tag:blogger.com,1999:blog-31344279187984500022024-03-04T12:22:27.084-08:00UK Trauma Protocol Manualuktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comBlogger166125tag:blogger.com,1999:blog-3134427918798450002.post-4397646818505005312023-09-04T12:39:00.005-07:002023-11-07T05:41:46.331-08:00Short Bowel Syndrome (Short Gut) <p> <span></span></p><a name='more'></a><p></p><p class="MsoNoSpacing">Below are recommendations and tips in the management of patients with symptoms related to relatively short small intestinal length (short bowel syndrome, short gut). Management should include multidisciplinary care and may require referral to a specialty center. Many thanks to Dr. Abigail Martin, UK Pediatric Surgery, for sharing this document. </p><p class="MsoNoSpacing"><b>Short Gut Syndrome
Overview: <o:p></o:p></b></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Patients with short gut have improved outcomes
when being followed by an interdisciplinary, consistent team at an intestinal
rehabilitation center <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Patients with chronic/irreversible short gut
syndrome will be dependent on parenteral nutrition for the remainder of their
lives <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Long term comorbidities include: <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Parenteral
nutrition associated liver disease (PNALD) <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Intestinal
failure associated liver disease (IFLAD) <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Complications
from need for long term central venous access (mainly infectious, thrombotic) <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Teduglutide may be used to treat short gut
syndrome and possibly reduce dependence on parenteral nutrition by promoting
mucosal growth and possibly restoring gastric emptying and secretion. This is
easier to obtain when working with an intestinal rehabilitation center <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Indications for intestinal transplant: <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Presence
of liver failure from parenteral nutrition <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Significant
line complications including frequent CLABSIs or loss of central access due to
thrombosis of veins <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Frequent
hospitalizations to control the sequela of short gut syndrome (such as
dehydration or electrolyte imbalances)<o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Early involvement of Palliative Care will help
with long term decision making and to discuss the long term issues that pertain
to short gut syndrome <o:p></o:p></p><p class="MsoNoSpacing"><o:p> </o:p></p><p class="MsoNoSpacing"><b>Care Team Planning
for Newly Diagnosed Short Gut</b>: <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Recommend GI consult while inpatient <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Identify which team will manage home
parenteral/enteral nutrition <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Ensure case management and social work is
notified to prepare for home health nursing and home parenteral nutrition <o:p></o:p></p><p class="MsoNoSpacing"><o:p> </o:p></p><p class="MsoNoSpacing"><b>Anatomy</b>: <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Undergo UGI/SBFT study in one year from
diagnosis to establish baseline anatomy <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->If concerned for IFALD/PNALD or if patient is
having any other abdominal surgery in the future, perform needle biopsy using
18 Ga needle of the liver <o:p></o:p></p><p class="MsoNoSpacing"><o:p> </o:p></p><p class="MsoNoSpacing"><b>Parenteral
Nutrition</b>: <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Cycle parenteral nutrition as soon as possible
to decrease risk of PNALD, better QOL <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Goal
of 12-16 hour cycling schedule before discharge home (most patients end up
discharging on 16 hour cycling schedule) <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Goal
over time of 10-12 hour cycling schedule<o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Consider Omegaven in Peds and SMOF in Adults if
developing evidence of IF associated cholestasis (Dbili >2 for 2+ weeks)<o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->In newly diagnosed patients, all estimated
nutritional needs should be provided via parenteral nutrition until weight
maintenance is demonstrated <o:p></o:p></p><p class="MsoNoSpacing"><o:p> </o:p></p><p class="MsoNoSpacing"><b>Gastric Feeds</b>:
<o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Benefits of tube feeds (especially continuous
low volume feeds):<o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Stimulation
of intestinal mucosa to improve growth/absorption <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Allows
for more total enteral calories and less parenteral calories <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Sometimes
better tolerated for stool volume or potential dumping <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Discuss NGT vs gastrostomy tube with patient<o:p></o:p></p><p class="MsoNoSpacing"><o:p> </o:p></p><p class="MsoNoSpacing"><b>Oral Feeds</b>: <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Volume limited by titration to goal of 4-6 soft,
formed stools daily <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Do not continue a clear liquid diet other than
water and no-sugar drinks <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Consult with dietician about education for short
gut syndrome diet <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Plan on 6-8 small meals per day <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Limit fluids to <4 ounces per meal <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Take soluble fiber preferentially, avoid
insoluble fiber <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Avoid sugary and sugar-substitute containing
foods as this may worsen diarrhea <o:p></o:p></p><p class="MsoNoSpacing"><o:p> </o:p></p><p class="MsoNoSpacing"><b>Nutritional
Supplementation</b>: <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Will need life long monitoring for
micronutrients, vitamins, minerals <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Evaluated at 6 month mark by home infusion plan
and TPN modified accordingly <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Consider starting Juven BID once PO is allowed,
unless it contributes to dumping syndrome <o:p></o:p></p><p class="MsoNoSpacing"><o:p> </o:p></p><p class="MsoNoSpacing"><b>Stooling</b>: <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Goal of 4-6 soft but formed stools daily <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Daily fluids should be adjusted to meet stooling
goals <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Add pectin and/or fiber to help bulk up stools
and prevent diarrhea <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Start Imodium to help thicken stools, many
patients require high doses daily <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Consider cholestyramine of pectin, fiber, and
Imodium do not help solidify stools <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Cholestyramine
will benefit patients without a terminal ileum or intact colon most<o:p></o:p></p><p class="MsoNoSpacing"><o:p> </o:p></p><p class="MsoNoSpacing"><b>Bacterial
Overgrowth</b>: <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Primary IF care providers should monitor for
need of cycling oral antibiotics <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]-->-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span><!--[endif]-->Probiotics should be used with caution as may
cause CLABSI/bacteremia <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Administer
probiotics separately from parenteral nutrition <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;"> </span></span><!--[endif]-->Ideally
a different person that does not care for and hang the parenteral nutrition
should be administering the probiotics <o:p></o:p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 13.5pt;">-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]-->Consider famotidine 80mg in parenteral nutrition
to help decrease level of gastric acid secretion, as this can sometimes make
stooling worse. IV PPI is not compatible in the TPN, and PPI tablets may not be
absorbed as well. <span style="font-size: 13.5pt;"><o:p></o:p></span></p><p class="MsoNoSpacing"><o:p> </o:p></p><p class="MsoNoSpacing"><o:p>Published Sept 4, 2023 (Abby Martin-PedSurg, Andrew Bernard)</o:p></p><p></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-43178759096620593912023-09-04T12:03:00.002-07:002023-11-07T06:43:31.041-08:00Neurogenic Shock in Spinal Cord Injury (SCI)<span><a name='more'></a></span><p class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;"><b><span style="font-family: "Times New Roman",serif; font-size: 18.0pt; line-height: 115%;">Hemodynamic management of acute
spinal cord injury</span></b></p><p class="MsoNormal"><span style="line-height: 107%;">1. Patients
with traumatic aSCI (cervical or thoracic ASIA A-D) and central cord syndrome</span><span style="line-height: 107%;"><o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 0in; mso-add-space: auto; tab-stops: .5in;"><span style="font-family: Calibri, sans-serif;">2. MAP ≥ 85
mmHg for 5 days</span><o:p></o:p></p><p style="margin: 0in; tab-stops: .5in;"><span style="font-family: Calibri, sans-serif;">3.
Vasopressor agent:</span><o:p></o:p></p><p class="MsoListParagraphCxSpFirst" style="margin-left: .25in; mso-add-space: auto; mso-list: l0 level1 lfo1; tab-stops: .5in; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Arial, sans-serif;">•<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: Calibri, sans-serif;">Norepinephrine
(most patients)</span><o:p></o:p></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: .25in; mso-add-space: auto; mso-list: l0 level1 lfo1; tab-stops: .5in; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Arial, sans-serif;">•<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: Calibri, sans-serif;">Dopamine
(pts w bradycardia)</span><o:p></o:p></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: .25in; mso-add-space: auto; mso-list: l0 level1 lfo1; tab-stops: .5in; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Arial, sans-serif;">•<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: Calibri, sans-serif;">Phenylephrine
(more potential for harm in patients with bradycardia or heart failure)</span><o:p></o:p></p><p class="MsoListParagraphCxSpLast" style="margin-left: .25in; mso-add-space: auto; mso-list: l0 level1 lfo1; tab-stops: .5in; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Arial, sans-serif;">•<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: Calibri, sans-serif;">Epinephrine/vasopressin
(use in refractory response only)</span><o:p></o:p></p><p style="margin: 0in; tab-stops: .5in;"><span style="font-family: Calibri, sans-serif;">4. Arterial
line if indicated</span><span style="font-size: 20.0pt;"><o:p></o:p></span></p><p class="MsoNormal"><span style="font-size: 20.0pt; line-height: 107%;"> </span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Hemodynamic management of acute
spinal cord injury<o:p></o:p></span></b></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Statement of Need<o:p></o:p></span></b></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Perfusion
& oxygen delivery is integral to prevent worsening of acute spinal cord
injuries (aSCI). Some patients with aSCI
may exhibit hemodynamic instability due to damage to autonomic/sympathetic
innervation pathways. The published
literature is weak in this area, which may result in variations in therapy.<o:p></o:p></span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Background<o:p></o:p></span></b></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">A
mean arterial pressure (MAP) target of 85-90mmHg is suggested by guidelines to
ensure adequate spinal perfusion after aSCI.</span><!--[if supportFields]><span
style='font-size:12.0pt;line-height:115%;font-family:"Times New Roman",serif'><span
style='mso-element:field-begin'></span> ADDIN EN.CITE <span style='mso-element:
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Proactive hemodynamic management also reduces the risk of fluctuations
in blood pressure, which may be deleterious after aSCI (particularly
hypotension).</span><!--[if supportFields]><span style='font-size:12.0pt;
line-height:115%;font-family:"Times New Roman",serif'><span style='mso-element:
field-begin'></span> ADDIN EN.CITE <span style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.CITE.DATA <![if gte mso 9]><xml>
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Isotonic fluid resuscitation and the use of vasopressors may be needed
to meet the target blood pressure in some individual. Overall, the scientific support for the MAP
target of >85mmHg is weak, consisting of under-powered, retrospective
studies. However, there is some
consistency in these studies in that patients who consistently have a MAP
>85mmHg seem to have better neurologic outcomes.</span><!--[if supportFields]><span
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field-begin'></span><span style='mso-spacerun:yes'> </span>ADDIN EN.CITE.DATA <![if gte mso 9]><xml>
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</xml><![endif]--></span><!--[if supportFields]><span style='font-size:12.0pt;
line-height:115%;font-family:"Times New Roman",serif'><span style='mso-element:
field-end'></span></span><![endif]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">
Based on animal and human evidence, the level of evidence would be
characterized as low to very low based on GRADE criteria.</span><!--[if supportFields]><span
style='font-size:12.0pt;line-height:115%;font-family:"Times New Roman",serif'><span
style='mso-element:field-begin'></span> ADDIN EN.CITE <span style='mso-element:
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</xml><![endif]--></span><!--[if supportFields]><span style='font-size:12.0pt;
line-height:115%;font-family:"Times New Roman",serif'><span style='mso-element:
field-end'></span></span><![endif]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">
The literature primarily pertains to patients with traumatic injuries,
rather than exacerbations of chronic spinal problems, though some of the same
perfusion concerns may be applicable in these situations.<o:p></o:p></span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Recommendations<o:p></o:p></span></b></p><ol start="1" style="margin-top: 0in;" type="1">
<li class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-bottom: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: 8.0pt; mso-margin-top-alt: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Patients with
traumatic aSCI<o:p></o:p></span></li>
<ol start="1" style="margin-top: 0in;" type="a">
<li class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-bottom: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level2 lfo2; mso-margin-bottom-alt: 8.0pt; mso-margin-top-alt: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Acute
cervical or thoracic<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-bottom: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level2 lfo2; mso-margin-bottom-alt: 8.0pt; mso-margin-top-alt: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">ASIA A-D<o:p></o:p></span></li>
</ol>
<li class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-bottom: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: 8.0pt; mso-margin-top-alt: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Patients who exhibit
a MAP < 85mmHg may require fluid management and/or vasopressors for
hemodynamic support<o:p></o:p></span></li>
<ol start="1" style="margin-top: 0in;" type="a">
<li class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-bottom: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level2 lfo2; mso-margin-bottom-alt: 8.0pt; mso-margin-top-alt: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Isotonic
fluids to ensure euvolemia should be initiated promptly (conditional
recommendation, low level of evidence)<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-bottom: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level2 lfo2; mso-margin-bottom-alt: 8.0pt; mso-margin-top-alt: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Vasopressors
may be considered to maintain MAP >85mmHg (conditional recommendation,
low level of evidence)<o:p></o:p></span></li>
</ol>
</ol><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-left: 1.5in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span>i.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">There is no literature to support a
primary vasopressor of choice<o:p></o:p></span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-left: 1.5in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span>ii.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Norepinephrine is a reasonable option for
most patients with aSCI (conditional recommendation, low level of evidence)<o:p></o:p></span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-left: 1.5in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span>iii.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Dopamine may be necessary in patients with
bradycardia who need more chronotropic support (conditional recommendation, low
level of evidence)<o:p></o:p></span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-left: 1.5in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span>iv.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Phenylephrine is also reasonable to use as
a primary or adjunct agent (conditional recommendation, low level of evidence) <o:p></o:p></span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-left: 2.0in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level4 lfo2; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Phenylephrine has more potential for harm
in patients with bradycardia or patients with heart failure<o:p></o:p></span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-left: 1.5in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span>v.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variation-settings: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Epinephrine, vasopressin should be used in
situations of refractory response only (conditional recommendation, very low
level of evidence)<o:p></o:p></span></p><ol start="2" style="margin-top: 0in;" type="1">
<ol start="3" style="margin-top: 0in;" type="a">
<li class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-bottom: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level2 lfo2; mso-margin-bottom-alt: 8.0pt; mso-margin-top-alt: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">The duration
of MAP targeting has commonly been described as 7 days (not to exceed)
(conditional recommendation, low level of evidence)<o:p></o:p></span></li>
</ol>
<li class="MsoNormal" style="line-height: 115%; margin-bottom: 0in; margin-bottom: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l1 level1 lfo2; mso-margin-bottom-alt: 8.0pt; mso-margin-top-alt: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Consider continuous
arterial blood pressure monitoring, particularly in the acute phases of
care (good practice statement)<o:p></o:p></span></li>
</ol><p class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;"> </span></p><p class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">References<o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><!--[if supportFields]><span
style='font-size:12.0pt;font-family:"Times New Roman",serif;mso-no-proof:yes'><span
style='mso-element:field-begin'></span><span
style='mso-spacerun:yes'> </span>ADDIN EN.REFLIST <span style='mso-element:
field-separator'></span></span><![endif]-->1. Schroeder GD, Vaccaro
AR, Welch WC. Best Practies Guidelines:
Spine Injury: NEUROGENIC SHOCK
AND SYSTEMIC PRESSURE-DIRECTED THERAPY. In: American College of Surgeons; 2022.
p. 46-48.<o:p></o:p></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2. Early
acute management in adults with spinal cord injury: a clinical practice
guideline for health-care professionals. 2008;31(4):403-479.<o:p></o:p></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">3. Cozzens
JW, Prall JA, Holly L. The 2012 Guidelines for the Management of Acute Cervical
Spine and Spinal Cord Injury. 2013;72 Suppl 2:2-3.<o:p></o:p></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">4. Kong
CY, Hosseini AM, Belanger LM, et al. A prospective evaluation of hemodynamic
management in acute spinal cord injury patients. 2013;51(6):466-471.<o:p></o:p></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">5. Weinberg
JA, Farber SH, Kalamchi LD, et al. Mean arterial pressure maintenance following
spinal cord injury: Does meeting the target matter? 2021;90(1):97-106.<o:p></o:p></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">6. Vale
FL, Burns J, Jackson AB, et al. Combined medical and surgical treatment after
acute spinal cord injury: results of a prospective pilot study to assess the
merits of aggressive medical resuscitation and blood pressure management.
1997;87(2):239-246.<o:p></o:p></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">7. Hawryluk
G, Whetstone W, Saigal R, et al. Mean Arterial Blood Pressure Correlates with
Neurological Recovery after Human Spinal Cord Injury: Analysis of High
Frequency Physiologic Data. 2015;32(24):1958-1967.<o:p></o:p></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">8. Levi
L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical
cord trauma: description, intervention, and prediction of outcome.
1993;33(6):1007-1016; discussion 1016-1007.<o:p></o:p></p><p>
<!--[if supportFields]><span style='font-size:12.0pt;line-height:107%;
font-family:"Times New Roman",serif;mso-fareast-font-family:Calibri;mso-fareast-theme-font:
minor-latin;mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:
AR-SA'><span style='mso-element:field-end'></span></span><![endif]--></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 10.0pt;"><span style="mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-hansi-font-family: Calibri; mso-no-proof: yes;">9.<span style="mso-tab-count: 1;"> </span>Andrews
JC, Schunemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence
to recommendation-determinants of a recommendation's direction and strength.
2013;66(7):726-735.<o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 10.0pt;"><br /></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 10.0pt;">Posted 9-4-23 Authors: Aaron Cook, PharmD, C Reynolds RN, A Bernard MD</p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-7162093760000139562023-08-13T13:44:00.003-07:002023-11-07T05:57:53.392-08:00Interfacility OR Transfer<p> </p><span><a name='more'></a></span><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><div style="text-align: left;">This process was developed by the Periop Management Team to facilitate smooth transfer between GSH and Chandler for operative intervention.</div><div style="text-align: left;"><span style="color: #0000ee; text-decoration-line: underline;"><br /></span></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2an3uuvuMXP92t3QhzVeR9C84K6O3hL6BrC8uAcC79nv4flxKbOjDpH0BIqiU-9UsfhY5JcWSRSngGgQLXmYtWi-O6_OsyW_DSFQrJYjcXAlm8eOAxCgqdD8KQbffIvFTL8W0Rq2lZ5hqVICL6T09qgzAnQUNyE0EQmSRWiYCBmnHVVPVCk5heSXe381e/s1632/Interfacility%20OR%20Transfer%20Algorithm_VISIO%20v2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1056" data-original-width="1632" height="207" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2an3uuvuMXP92t3QhzVeR9C84K6O3hL6BrC8uAcC79nv4flxKbOjDpH0BIqiU-9UsfhY5JcWSRSngGgQLXmYtWi-O6_OsyW_DSFQrJYjcXAlm8eOAxCgqdD8KQbffIvFTL8W0Rq2lZ5hqVICL6T09qgzAnQUNyE0EQmSRWiYCBmnHVVPVCk5heSXe381e/s320/Interfacility%20OR%20Transfer%20Algorithm_VISIO%20v2.jpg" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">8-13-23 A Bernard/Periop Mgmt Team</div><p></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-40042369692413125652023-02-27T11:20:00.005-08:002023-11-07T05:58:03.190-08:00Muscle Biopsy Process<p> <span></span></p><a name='more'></a><p></p><p align="center" class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;">Histology Department<o:p></o:p></b></p>
<p align="center" class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;">(859)257-1822</b><b><o:p> </o:p></b></p>
<p align="center" class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;">PROCEDURE FOR SKELETAL MUSCLE BIOPSIES</b></p>
<p class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">1.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]-->Schedule muscle biopsies <span style="background: yellow; mso-highlight: yellow;">24 hours in advance</span> by calling the
Histology laboratory at (859)257-1822. Please call the lab ASAP if a biopsy is
cancelled or re-scheduled.</p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">2.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]-->Specimens must be received by 12:00pm to allow
for same day processing.<span style="mso-spacerun: yes;"> </span><span style="background: yellow; mso-highlight: yellow;">No muscle biopsy specimens will
be accepted on Fridays.</span><span style="mso-spacerun: yes;"> </span>Please
schedule cases so the specimen(s) will be received in the histology department
Monday-Thursday.</p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">3.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]-->An appropriately completed test requisition,
including patient history, must accompany the tissue.</p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">4.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]-->The surgeon should divide the specimen into 3
portions.</p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">a.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]-->1.5 cm in length x 0.5 cm in diameter – prior to
excision, secure each end to a splint (a wooden throat swab or tongue blade is
satisfactory) to prevent contraction artifact in the muscle fibers. Submit in a
Petri dish on saline-soaked gauze sponge. <b style="mso-bidi-font-weight: normal;">Please
do not oversaturate or float in saline</b>. <span style="mso-spacerun: yes;"> </span><u>DO NOT FREEZE SPECIMEN</u>. Ship specimen
with a cold pack that includes enough ice or cold packs to keep specimen cool
until arrival.<o:p></o:p></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">b.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]-->1.5 cm in length x 0.5 cm in diameter – prior to
excision, secure each end to a splint to prevent contraction artifact in the
muscle fibers. Submit this tissue in 10% neutral buffered formalin.<o:p></o:p></p>
<p class="MsoListParagraphCxSpLast" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">c.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]-->A tiny specimen (0.3 cm x 0.3 cm x 0.3cm) should
be immersed immediately in 2% glutaraldehyde for possible electron microscopy.</p>
<p class="MsoNormal"><i style="mso-bidi-font-style: normal;">*If the patient is an
infant or child, the quantity of muscle may be decreased. Please contact the
laboratory to discuss absolute minimal requirements prior to biopsy.</i></p>
<p class="MsoNormal">Ship specimens to:<span style="mso-tab-count: 2;"> <span> </span></span>University
of Kentucky Medical Center<o:p></o:p></p>
<p class="MsoNormal"><span style="mso-tab-count: 4;"> <span> </span></span>800
Rose St<o:p></o:p></p>
<p class="MsoNormal" style="margin-left: 1.5in; text-indent: 0.5in;">Histology
Department<o:p></o:p></p>
<p class="MsoNormal" style="margin-left: 1.5in; text-indent: 0.5in;">Pavilion H, 4<sup>th</sup>
floor, Room HL409<o:p></o:p></p>
<p class="MsoNormal" style="margin-left: 1.5in; text-indent: 0.5in;">Lexington, KY
40536</p>
<p class="MsoNormal">Please contact the laboratory at (859)257-1822 for packing
and shipping arrangements or questions.<o:p></o:p></p><p class="MsoNormal">2-27-23 A Bernard/Teresa Kaenzig (teresa.kaenzig@uky.edu)</p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-16921459007390331822023-01-29T17:03:00.010-08:002023-11-07T06:43:49.476-08:00Clinic Follow-up After Trauma (Who Needs Follow-up)<p></p><span></span><div class="separator" style="clear: both; text-align: left;"><span><a name='more'></a></span><div><br /></div><div>Patients with the following diagnoses should be considered for follow-up in the Trauma Clinic (Fridays). </div><ol style="text-align: left;"><li>Concussion</li><li>Multiple ribs</li><li>Chest tube</li><li>Abnormal CXR at discharge (return with a film)</li><li>Drains</li><li>s/p ICU</li><li>Postop lap/thor</li><li>Embolization</li><li>Wounds</li><li>Antibiotics </li><li>Victims of violence</li><li>PTSD screen +</li></ol></div>Posted Jan 2023/A Bernard/C Reynolds<br /><span><div class="separator" style="clear: both; text-align: center;"><br /></div><br /></span>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-57854679960035039202023-01-01T13:54:00.006-08:002023-11-07T05:56:45.410-08:00Ortho Contact Decision Tree<p><span><br /></span></p><a name='more'></a><div class="separator" style="clear: both; text-align: left;">Orthopedic surgery uses pagers as their primary contact method. The following algorithm lays out this process. </div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHhtlZhDhGTRALdVj7Wlxd29QU67P_sahejT4RI-gkLM9MrCYFKmA96Twn5ANJgE5rHGrDgZvICYw77_0vR6gn-r1A3sHNnMsUrMK6OFlyAONQtw_brrP-rPTWsgoWMQy-dGagBnOBhXfymdyHJBt3wzte_c8ku0EaGCUOiuZi9JuE00q4-7NRQKUIJQ/s937/Ortho%20Contact%20Decision%20Tree.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="722" data-original-width="937" height="247" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHhtlZhDhGTRALdVj7Wlxd29QU67P_sahejT4RI-gkLM9MrCYFKmA96Twn5ANJgE5rHGrDgZvICYw77_0vR6gn-r1A3sHNnMsUrMK6OFlyAONQtw_brrP-rPTWsgoWMQy-dGagBnOBhXfymdyHJBt3wzte_c8ku0EaGCUOiuZi9JuE00q4-7NRQKUIJQ/s320/Ortho%20Contact%20Decision%20Tree.png" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><div>Posted Nov 2022/Reviewed Jan 2023 (Shannon Johnson/C Reynolds/A Bernard)</div>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-68345965513825690972023-01-01T10:21:00.004-08:002023-11-07T05:59:34.783-08:00Ortho Discharge Instructions (.Phrases)<p> <span></span></p><a name='more'></a><p></p><p class="MsoNormal"><b><span style="font-size: 12pt; line-height: 107%;">ORF (Ortho Trauma) Discharge .Phrases:<o:p></o:p></span></b></p><p class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span></p><p class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 107%;"><br /></span></p><p class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-family: Symbol; font-size: 12pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"></span></span><!--[endif]--><span style="font-size: 12pt; line-height: 107%;">Bandage
Care:<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; font-size: 12pt; line-height: 107%; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 12pt; line-height: 107%;">ACE
Wrap - ACE wrap may be removed 72 hours following surgery, and then re-applied
daily for swelling as needed, taking care not to remove the sterile OR dressing
underneath. If they are becoming rolled up and are creating strictures or
tourniquet like pressure areas, they can be removed earlier and re-wrapped as
needed. (Smartphrase: .ACE)<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; font-size: 12pt; line-height: 107%; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 12pt; line-height: 107%;">Surgical
Dressings - Surgical bandage should remain clean, dry, and intact and
should not be removed until follow-up appointment. If bandage becomes wet,
soiled, or falls off it may be replaced with a clean dry gauze or covaderm
dressing as needed. (Smartphrase: .BAN)<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; font-size: 12pt; line-height: 107%; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 12pt; line-height: 107%;">Old
Pin Site Dressings - May remove bandages from old traction pin and/or ex-fix
pin sites 2-3 days after surgery; if dry, may then leave open to air or place
additional dry dressing as needed. (Smartphrase: .TR)<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 12pt; line-height: 107%;">Traction/Pin
Site Care:<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; font-size: 12pt; line-height: 107%; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 12pt; line-height: 107%;">Traction/Ex-Fix
Pin Sites - Leave pin site gauze clean dry and intact. If pin site gauze
becomes soiled, remove soiled gauze and clean pin sites with mild soap and
water with hygiene or as needed. May re-wrap pin with clean dry gauze as needed
for drainage. (Smartphrase: .PIN)<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12pt; line-height: 107%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 12pt; line-height: 107%;">Brace/Splint
Care:<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; font-size: 12pt; line-height: 107%; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 12pt; line-height: 107%;">Remove
brace at least once per shift for skin check and hygiene. While brace is
removed, keep limb in neutral (flat) position. For information regarding how to
remove/apply specific braces, please access the Wound Care Handbook under
Woundcare Resources on CareWeb. (Smartphrase: .BRA)<o:p></o:p></span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; font-size: 12pt; line-height: 107%; mso-fareast-font-family: "Courier New";">o<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 12pt; line-height: 107%;">Plaster
splints must remain clean, dry, and intact at all times. If there are concerns
regarding the splint, please page the orthopedic resident. (Smartphrase: .SP)</span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><span style="font-size: 12pt; text-indent: -0.25in;"><br /></span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><span style="font-size: 12pt; text-indent: -0.25in;">Posted Dec 2022 (Shannon Johnson, C Reynolds/A Bernard)</span></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-59502598263644702762022-10-09T07:22:00.012-07:002023-11-07T06:01:55.307-08:00Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document<br /><span><a name='more'></a></span><div>The following guideline was developed by the American Association for the Surgery of Trauma Critical Care Committee and published as a Clinical Consensus Document in Trauma Surgery and Acute Care Open (TSACO). </div><div><br /></div><div><a href="https://tsaco.bmj.com/content/7/1/e000936?utm_source=alert&utm_medium=email&utm_campaign=tsaco&utm_content=latest&utm_term=10082022">https://tsaco.bmj.com/content/7/1/e000936?utm_source=alert&utm_medium=email&utm_campaign=tsaco&utm_content=latest&utm_term=10082022</a><br /></div><div><br /></div><div>Posted Oct 2022 (A Bernard)</div><div><br /></div>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-62090741669481806882022-10-08T10:15:00.005-07:002023-11-07T10:11:07.708-08:00Acute Pancreatitis-Treatment and Admission Location/Service<p> <span><br /></span></p><a name='more'></a><div class="separator" style="clear: both; text-align: left;">This guideline represents collaborative work by Emergency Medicine, Acute Care Surgery, Interventional GI, IR and Pulmonary Medicine/Critical Care. </div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEja5f9o2r7eRLDOkCLS6vFOLCr9D12dhM1yVCFv6SUX45YqOnLvrfp1_SNd41MKHqhwXRdbfUyAEsYFAiq0CVkhURKMD7ljGoUCa5HtOnxFD2_uqdvm3neAbAT2Td6blagLtJpOGsvOuI6gVACGDkyO8F0XJ8DYgjOM6jibMJ1UzBDwx6ChAQCw8X0d7w" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1128" data-original-width="1462" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEja5f9o2r7eRLDOkCLS6vFOLCr9D12dhM1yVCFv6SUX45YqOnLvrfp1_SNd41MKHqhwXRdbfUyAEsYFAiq0CVkhURKMD7ljGoUCa5HtOnxFD2_uqdvm3neAbAT2Td6blagLtJpOGsvOuI6gVACGDkyO8F0XJ8DYgjOM6jibMJ1UzBDwx6ChAQCw8X0d7w" width="311" /></a></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEj-TT2Mf4SaLSwYsptIWW0ZeSEVhREgkZBHJuYHYb0IcRLn0Dw_smgF0SHy1uIImijXO2jiYJQWGJHhe6bkliN217D9Rp5HebwjVCgk1tEp5FQZbBYKsGM58xduD_jYfJm_9R7d58n4tXTCOipEWzEg7ZVdf6g4Wlj2IkDVfUpAVSVC3Wq4dTdg7_0WKA" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="494" data-original-width="1297" height="122" src="https://blogger.googleusercontent.com/img/a/AVvXsEj-TT2Mf4SaLSwYsptIWW0ZeSEVhREgkZBHJuYHYb0IcRLn0Dw_smgF0SHy1uIImijXO2jiYJQWGJHhe6bkliN217D9Rp5HebwjVCgk1tEp5FQZbBYKsGM58xduD_jYfJm_9R7d58n4tXTCOipEWzEg7ZVdf6g4Wlj2IkDVfUpAVSVC3Wq4dTdg7_0WKA" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><span style="text-align: left;">Published by Sion and Davis in TSACO, 2019</span><span style="font-family: interfaceregular; font-size: 13.5pt; text-align: left;">-000308</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: interfaceregular; font-size: 13.5pt; text-align: left;"><br /></span></div><div class="separator" style="clear: both; text-align: center;">Drainage Tree (Drafted Fall 2017 by GI, ACS and IR)</div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNQl5p02gulNJcCtILx5m0pDcnQpuM-Qg4OAsE9f8f5DkiIlFzH3ekE78XEsq4TsBZtXlsgZucHY38pw5RO44YApVFR6SYp4Tu8Mre3pkEwvBxBhYZXPsNM-OulaNh56BxQgcuIg3agwQ8/s1600/Algorithm.png" style="margin-left: 1em; margin-right: 1em; text-align: left;"><img border="0" data-original-height="609" data-original-width="899" height="270" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNQl5p02gulNJcCtILx5m0pDcnQpuM-Qg4OAsE9f8f5DkiIlFzH3ekE78XEsq4TsBZtXlsgZucHY38pw5RO44YApVFR6SYp4Tu8Mre3pkEwvBxBhYZXPsNM-OulaNh56BxQgcuIg3agwQ8/s400/Algorithm.png" width="400" /></a></div><br /><div style="text-align: left;">Posted 2017; Revised Oct 2022 (A Bernard/Driss Raissi/S Mardini/Julie Hay); Revised Nov 2023</div></div><p></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-52428168875864383922022-10-08T09:04:00.003-07:002023-11-07T06:10:01.927-08:00Guideline for the Use of Prophylactic Tranexamic Acid for Blood Loss Prevention and Transfusion Conservation in Adult Non-Cardiac Surgery<p> <span></span></p><a name='more'></a><p><b>Background </b></p><p>Bleeding that occurs after noncardiac surgery has emerged as a significant contributor to postoperative morbidity
and mortality. A study of over 40,000 patients undergoing noncardiac surgery found that major bleeding affected
15% of patients, and was independently associated with 30-day mortality [1]. These results are consistent with
previously published studies that showed perioperative bleeding increased morbidity, mortality, and resource
utilization [2-4]. This association of perioperative bleeding and major adverse events may be associated with a
drop in perioperative hemoglobin, producing a decrease in arterial oxygen content. This pathology suggests that
preventing perioperative blood loss may translate to fewer postoperative complications in noncardiac surgery.
Tranexamic acid (TXA) is an antifibrinolytic approved for the prevention and treatment of bleeding in numerous
clinical settings. </p><p>These include cardiac surgery with cardiopulmonary bypass, joint arthroplasty, acute trauma, and
in obstetrics to prevent post-partum hemorrhage [5, 6, 7,8]. TXA acts as a synthetic lysine analog, inhibiting the
conversion of plasminogen to plasmin by blocking the lysine-binding sites on the plasminogen molecule. This
creating a reversable reduction in plasminogen-fibrin activity, decreasing fibrinolysis and clot degradation.
TXA has shown blood loss prevention and blood transfusion avoidance in numerous noncardiac surgery
populations, including joint arthroplasty [9], spine surgery [10], gynecological [11], and urological surgery [12].
While efficacy has clearly demonstrated in many noncardiac surgery populations, clinical trials of TXA in noncardiac
surgery have been insufficiently powered to evaluate both efficacy and safety, limiting its use in a broader range of
noncardiac surgery population. </p><p><b>POISE-3 Trial </b></p><p>The Perioperative Ischemic Evaluation-3 (POISE-3) study was a multicenter, international randomized controlled
trial of TXA vs placebo in noncardiac surgery patient ages 45 and older. [13] Primary outcomes of the study
included both efficacy and safety endpoints. These included; </p><p>• Efficacy: Composite 30-day incidence of; life-threatening bleeding, major bleeding, and bleeding into a
critical organ (Assessed via superiority with 2-sided confidence interval of 95% (p< 0.05))</p><p> • Safety: Composite 30-day incidence of; myocardial injury after noncardiac surgery (MINS), nonhemorrhagic stroke, peripheral arterial thrombosis, and symptomatic proximal venous thromboembolism
(Assessed via non-inferiority with 1-sided CI of 97.5%, (p<0.025))
Patients included were ≥45 years of age with, or at risk of, atherosclerotic disease, and undergoing major
noncardiac surgery. Included comorbidities were a history of coronary artery disease, peripheral vascular disease,
a history of stroke, a history of TIA, a history of diabetes, or a history of smoking within 2 years.
Excluded populations were patients with; a hypersensitivity to TXA, CrCl <30mL/min or chronic dialysis, a history of
seizures, recent (<3 months) stroke, MI, arterial or venous thrombosis, subarachnoid hemorrhage within 30 days,
or a fibrinolytic condition following consumptive coagulopathy. </p><p><b>Dosing:</b> 1000mg IV over 10 minutes, prior to incision and 1000mg IV over 10 minutes at wound closure</p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhrt5STBq_PElU5CV8TeScI5jXphd-ZwBQL_qiUxaqTaoggH5cHmKRrDAJ46lEZ4dSgsiYHSTU_MZe9aT40Yx0n02-dQcq0N7AW8NltG4bQcQKbXmA-jqvKZLjLJuObP7Al5AIdKrUn_rzhaUR20zWlxgrwHEZS839fOV_PKLfxi09rO5qNkfbhGxYzzw" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="627" data-original-width="646" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEhrt5STBq_PElU5CV8TeScI5jXphd-ZwBQL_qiUxaqTaoggH5cHmKRrDAJ46lEZ4dSgsiYHSTU_MZe9aT40Yx0n02-dQcq0N7AW8NltG4bQcQKbXmA-jqvKZLjLJuObP7Al5AIdKrUn_rzhaUR20zWlxgrwHEZS839fOV_PKLfxi09rO5qNkfbhGxYzzw" width="247" /></a></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><b>Interpretation of POISE-3 Results </b></div><div class="separator" style="clear: both; text-align: left;">POISE-3 demonstrated a statistically significant reduction in the composite efficacy outcome with Major Bleeding
being the primary endpoint driver. The composite safety endpoint was evaluated via non-inferiority, and failed to
meet the pre-specified endpoint (p-value <0.025). These finding warrant the judicious use of TXA in the noncardiac
surgery population. While POISE-3 shows a clear benefit with an absolute difference of -2.6% and an NNT=38 to
prevent one bleed, a 0.3% increase in composite cardiovascular events was seen, translating to a NNH=333. </div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><b>Considerations and Dosing of Prophylactic TXA at UK HealthCare </b></div><div class="separator" style="clear: both; text-align: left;">The following chart is a consolidated reference of prophylactic tranexamic acid use in noncardiac surgery. Listed
services are not exclusive, and represent the practice of surgical services that have established use of TXA, and
other services that intend to incorporate use into practice at UK Healthcare for. Newly established practices are
designated with (*). Inclusion/exclusion criteria specified by service surgeons</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEh2qID7qmhRLZ5lr2bkKpXqLty6adPF695PGfCCwh9xyRwToCOucqhhyTCDqBdiNr2umGLv6DsgSd_Ol9NF54Bam1HEyjyfMZYmZ43hsVYi14dXMpDTYn7OQxzCPDlZKvV2q6FxjMrYztvbbB1w-Zg8BvxU4r9WpLkRsZOZhVcH_by3a5uozQiYJqNUUg" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="755" data-original-width="637" height="240" src="https://blogger.googleusercontent.com/img/a/AVvXsEh2qID7qmhRLZ5lr2bkKpXqLty6adPF695PGfCCwh9xyRwToCOucqhhyTCDqBdiNr2umGLv6DsgSd_Ol9NF54Bam1HEyjyfMZYmZ43hsVYi14dXMpDTYn7OQxzCPDlZKvV2q6FxjMrYztvbbB1w-Zg8BvxU4r9WpLkRsZOZhVcH_by3a5uozQiYJqNUUg" width="202" /></a></div><br /><p><b>Administration of Tranexamic acid </b></p><p>Maximum infusion rate: 100mg/min </p><p>• For weight-based bolus doses that are not able to be rounded to 1000mg, consider using tranexamic acid
vial (1000mg/10mL). Tranexamic acid may be administered undiluted by IV injection max rate 100mg/min </p><p>• For continuous infusion administration, use 1000mg/100mL stock bag </p><p><b>Hospital Committee Endorsements </b></p><p>• Pharmacy & Therapeutics Committee (September 2022) </p><p>• Perioperative P&T Subcommittee (August 2022)</p><p> • Antithrombosis Stewardship P&T Subcommittee (September 2022) </p><p><b>References </b></p><p>1. Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators, Spence J,
LeManach Y, Chan MTV, et al. Association between complications and death within 30 days after
noncardiac surgery. CMAJ. 2019 Jul 29;191(30):E830-E837. doi: 10.1503/cmaj.190221. </p><p> 2. Obi AT, Park YJ, Bove P, et al. The association of perioperative transfusion with 30-day morbidity and
mortality in patients undergoing major vascular surgery. J Vasc Surg 2015; 61: 1000. 9.e1 </p><p>3. Smilowitz NR, Oberweis BS, Nukala S, et al. Association between anemia, bleeding, and transfusion with
long-term mortality following non-cardiac surgery. Am J Med 2015; 129: 315e23. e2 </p><p>4. Wu WC, Smith TS, Henderson WG, et al. Operative blood loss, blood transfusion, and 30-day mortality in
older patients after major noncardiac surgery. Ann Surg 2010; 252: 11e7 </p><p>5. Fergusson DA, Hébert PC, Mazer CD, Fremes S, MacAdams C, Murkin JM, Teoh K, Duke PC, Arellano R,
Blajchman MA, Bussières JS, Côté D, Karski J, Martineau R, Robblee JA, Rodger M, Wells G, Clinch J,
Pretorius R; BART Investigators. A comparison of aprotinin and lysine analogues in high-risk cardiac
surgery. N Engl J Med. 2008 May 29;358(22):2319-31 </p><p>6. Fillingham YA, Ramkumar DB, Jevsevar DS, et al. Reg Anesth Pain Med 2019;44:7–11. </p><p>7. CRASH-2 trial collaborators Effects of tranexamic acid on death, vascular occlusive events, and blood
transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized placebo-controlled
trial. , Lancet. 2010;376(9734): 23–32. </p><p>8. Shakur H, Roberts I, Fawole B, Chaudhri R, El-Sheikh M, Akintan A, et al. Effect of early tranexamic acid
administration on mortality, hysterectomy, and other morbidities in women with post-partum
haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet.
2017 May;389 (10084):2105–16. </p><p>9. Zhou XD, Tao LJ, Li J, Wu LD. Do we really need tranexamic acid in total hip arthroplasty? A meta-analysis
of nineteen randomized controlled trials. Arch Orthop Trauma Surg 2013;133:1017–27. </p><p>10. Li ZJ, Fu X, Xing D, Zhang HF, Zang JC,Ma XL. Is tranexamic acid effective and safe in spinal surgery? A
meta-analysis of randomized controlled trials. Eur Spine J and the European Section of the Cervical Spine
Research Society 2013;22:1950–7. </p><p>11. Martin-Hirsch PP, Bryant A. Interventions for preventing blood loss during the treatment of cervical
intraepithelial neoplasia. Cochrane Database Syst Rev 2013; 12:CD001421. </p><p>12. Zaid HB, Yang DY, Tollefson MK, Frank I, Winters JL, Thapa P, Parker WP, Thompson RH, Karnes RJ,
Boorjian SA. Efficacy and Safety of Intraoperative Tranexamic Acid Infusion for Reducing Blood
Transfusion During Open Radical Cystectomy. Urology. 2016 Jun;92:57-62 </p><p>13. Devereaux PJ, Marcucci M, Painter TW. Tranexamic Acid in Patients Undergoing Noncardiac Surgery. N
Engl J Med. 2022 May 26;386(21):1986-1997. doi: 10.1056/NEJMoa2201171. Epub 2022 Apr 2. PMID:
35363452.BJA 172-8</p>Published 10/8/22 Eric Johnson/A Bernard<p></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-7724530942231617262022-06-20T06:54:00.007-07:002023-12-15T07:36:11.867-08:00Trauma Alert/Stroke Alert-DUAL Activation <p> <span></span></p><a name='more'></a><span style="font-size: 16pt;">Patients with acute stroke who then fall or otherwise become
injured may arrive at the trauma center as a trauma team activation. Though
many of these patients are minimally injured and require no sophisticated
trauma care, the timely evaluation and management of the acute stroke can have
enormous impact on clinical outcome. In order to assure the timely performance
of head CT and activation of the stroke team, following guideline should be
considered:</span><p></p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; font-size: 16pt; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">1.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="color: black; font-size: 16pt; mso-fareast-font-family: "Times New Roman";">IF the trauma alert patient shows NO or MINIMAL
external signs of injury, AND<o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; font-size: 16pt; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">2.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="color: black; font-size: 16pt; mso-fareast-font-family: "Times New Roman";">Radiology WET READ of CT head is negative for
hemorrhage, THEN<o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; font-size: 16pt; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">3.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="color: black; font-size: 16pt; mso-fareast-font-family: "Times New Roman";">CALL STROKE ALERT<o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; font-size: 16pt; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">4.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="color: black; font-size: 16pt; mso-fareast-font-family: "Times New Roman";">Follow up final imaging ASAP (Stroke Team will
review head CT/CTA imaging at the time of response)<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 16pt;">If the patient is deemed to have
had a stroke and is not injured, the trauma activation charge will be cancelled
and the patient will not be entered into the trauma registry. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-size: 16pt;"><br /></span></p><p class="MsoNormal"><span style="font-size: 16pt;">June 20, 2022 A Bernard/C Reynolds; reviewed 12-15-23</span></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-4540543083091145402022-04-18T07:55:00.009-07:002023-12-15T07:36:56.669-08:00GI Hemorrhage<p></p><span><a name='more'></a></span><div class="separator" style="clear: both; text-align: left;">These guidelines reflect organization-wide collaboration among Emergency Medicine, Acute Care Surgery, IR and GI. </div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">GI Bleed Overall Algorithm</div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMQngnOoH8U6NEqudUvoN-YhDJNpyZZ5d-pVzfJEDoSdlwPDd_cSYAvhToHnay-aBabFX1oh5IOVVXTuTzNXBCCE-yYwCD3m6sAhx5UBbbvqEAenBTfuPfKNMXSimpc2ec4mU55QZTmQNF-UeDQ_4wVD6bv-EZciEb-F5s7KibK2wdMlTGQtUotrFhew/s886/Upper%20GI%20Hemorrhage%20Overall.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="553" data-original-width="886" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMQngnOoH8U6NEqudUvoN-YhDJNpyZZ5d-pVzfJEDoSdlwPDd_cSYAvhToHnay-aBabFX1oh5IOVVXTuTzNXBCCE-yYwCD3m6sAhx5UBbbvqEAenBTfuPfKNMXSimpc2ec4mU55QZTmQNF-UeDQ_4wVD6bv-EZciEb-F5s7KibK2wdMlTGQtUotrFhew/s320/Upper%20GI%20Hemorrhage%20Overall.png" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc_xOQYQPhFLsMxJaeKEwE5hu_0Lnnuy4svU6YluNNLp54B1rLg4MHAWSsr_isEa6RwWNmgb9mE-abNRYfODZgFzb3E0Dg82Qv7TutCGNCQYh5yqxTHfT1J_bF9UWKbK9W4CE3etQXwl5v0AIfsbjLiKKiBLHL05txkhXOjm841XQIrcNwf7qDJno9dg/s396/Glasgow%20Blatchford%20Score.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="396" data-original-width="309" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc_xOQYQPhFLsMxJaeKEwE5hu_0Lnnuy4svU6YluNNLp54B1rLg4MHAWSsr_isEa6RwWNmgb9mE-abNRYfODZgFzb3E0Dg82Qv7TutCGNCQYh5yqxTHfT1J_bF9UWKbK9W4CE3etQXwl5v0AIfsbjLiKKiBLHL05txkhXOjm841XQIrcNwf7qDJno9dg/s320/Glasgow%20Blatchford%20Score.png" width="250" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">GI Bleed Resuscitation</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiE3qhkVETLQ1cgLTVW7pFIRpPX0xua4sra-tWvK99O46tTcO2dWWoucaCpgGm_iqtgN08UCbw4V6eRFDqQPZKlS8S9TbH20dVvziLKs_o34TF4AQhkYF79ewovyd5iguMGzhOM0eUb0mmW0PGmcTfRWVeKRJiOsA-sWu2fW8zBG2wT1ypAU6swOuN-uA/s887/GI%20Bleed%20Resuscitation.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="536" data-original-width="887" height="193" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiE3qhkVETLQ1cgLTVW7pFIRpPX0xua4sra-tWvK99O46tTcO2dWWoucaCpgGm_iqtgN08UCbw4V6eRFDqQPZKlS8S9TbH20dVvziLKs_o34TF4AQhkYF79ewovyd5iguMGzhOM0eUb0mmW0PGmcTfRWVeKRJiOsA-sWu2fW8zBG2wT1ypAU6swOuN-uA/s320/GI%20Bleed%20Resuscitation.png" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">Variceal Bleed</div><br /><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEik3nQ0prD71MN5pp0PPDHL2HHpT4WV4jCdz5ianWONR-CFkrrR6UWi4Snvn60Ew9xkveOnF4SCgzim9pbI1ftNDlMFzSNKW7JqhVIDHZOA5aq_oqMdKiJ_-SUS0R2RIt58traxihwgVYzb_7Rnm1GlrOTYsckUukeku3rLok-sAk_OBnPT9zqqOH2O2A" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="888" data-original-width="1388" height="205" src="https://blogger.googleusercontent.com/img/a/AVvXsEik3nQ0prD71MN5pp0PPDHL2HHpT4WV4jCdz5ianWONR-CFkrrR6UWi4Snvn60Ew9xkveOnF4SCgzim9pbI1ftNDlMFzSNKW7JqhVIDHZOA5aq_oqMdKiJ_-SUS0R2RIt58traxihwgVYzb_7Rnm1GlrOTYsckUukeku3rLok-sAk_OBnPT9zqqOH2O2A" width="320" /></a></div><br /><br /></div>Revised April 20, 2022 AB/CR; reviewed 12-15-23<br /><span><br /></span><p></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-55432177757169541662022-03-13T12:06:00.006-07:002023-12-15T07:38:03.079-08:00Documentation for Death Without Imaging-Achieving Accurate ISS Coding <span><a name='more'></a></span><div class="separator" style="clear: both; text-align: center;"><br /></div><div>Patients who die early after arrival sometimes have low injury severity score (ISS) in the database. Accurate ISS coding is important because it established the predicted mortality and helps accurately reflect trauma center performance. Thorough physical exam and careful documentation is the best way to ensure adequate ISS coding. </div><br />ANY OBVIOUS HEAD INJURY<div><ul style="text-align: left;"><li>LOC SINCE INJURED OR DURATION OF LOC KNOWN? </li><li>CONCUSSION GETS UP TO AN AIS OF 3</li><li>CSF LEAK? OBVIOUS FRACTURE? OBVIOUS SKULL BASE IS AIS 3, OPEN DEPRESSED SKULL FRACTURE CAN BE UP TO AN AIS 4</li><li>PENETRAING INJURY TO HEAD OBVIOUSLY DEEPER THAN 2 CM IS AN AIS 5</li></ul><div><br /></div><div>ANY THORACIC / ABDOMINAL OBVIOUS TRAUMA</div><div><ul style="text-align: left;"><li>SUCKING CHEST WOUND WITHOUT ANY OTHER INFO IS AIS 4</li><li>PNEUMOTHORAX WITHOUT DESCRIPTION IS AIS 2, IF PERSISTENT AIR LEAK OR MASSIVE AIS 4, IF TENSION AIS 5</li><li>AORTIC LACERATION IS AIS 4, IF MAJOR / 20% BLOOD LOSS IT’S AIS 5 AND IF HEMORRHAGE IS NOT CONTAINED TO THE MEDIASTINUM IT’S AIS 6</li><li>MOST VASCULAR INJURIES UPGRADE ONE AIS POINT FOR BLOOD LOSS >20%</li><li>DIAPHRAGM LACERATION IS AIS 2-4 DEPENDING ON SIZE</li><li>TRAUMATIC ASPHYXIATION IS AIS 3-5, WITH 5 FOR DOCUMENTED ARREST</li><li>HEART LACERATION NFS IS AIS 3, ANY PERFORATION OR ATRIAL RUPTURE IS AIS 5 AND ATRIAL RUPTURE OR MULTIPLE LAC’S IS AN AIS 6</li></ul></div><div><br /></div><div>ORGAN INJURIES CAN BE SCORED IF YOU HAVE ANY DETAIL WITH AT LEAST AIS 2</div><div><br /></div><div>ANY EXTREMITY TRAUMA CAN BE CODED AT SOME LEVEL IF YOU DOCUMENT “OBVIOUS FRACTURE”. THIS ADDS USUALLY AN AIS 2 OR 3 TO THEIR ISS CALCULATION</div><div><br /></div><div>**CONDITIONS LIKE SHOCK, COAGULOPATHY, ETC. CAN INFLUENCE REIMBURSEMENT SO THOSE SHOULD ALSO BE DOCUMENTED BUT WILL NOT AFFECT ISS SCORES.</div><div><br /></div><div>March 13, 2022 (Trish Cooper/C Reynolds/A Bernard); reviewed 12-15-23</div><p></p><div class="separator" style="clear: both; text-align: center;"></div><p></p></div><span><!--more--></span><span><!--more--></span>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-6692536188236934252022-03-11T18:25:00.006-08:002023-12-15T07:38:38.414-08:00Hospice Scatterbed<p> <span></span></p><a name='more'></a><div class="separator" style="clear: both; text-align: left;">Optimal end-of-life care is facilitated by patient-centered communication that involves the patient, family, and all caregivers. The Palliative Care Team can be a valuable resource. An additional resource that provides support to families at the end of life is the Hospice Scatterbed Program. This program permits patients for whom death is imminent to receive formal hospice care through Bluegrass Care Navigators without changing their geographical location). An added advantage of the Hospice Scattered Program is that families receive long-term bereavement support. </div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMtAVo14SFKWXCQclsRDly0bm2eClz5wdVEn2LEix-CLUbkuoJlAOf1H9LtkFUpQ1MzVovPxVlHcTsbwZ6nfyvDyNCFvczrxvtSWJLA5uFTPmjWi6H_CV80SnLjUQkJBrdp6WPnN12OmVVtkcGotHgH5WldZTsbMe2k95ys942tbc1cSYxtWIj0Hjk1g/s1570/Scatterbed%20Update%20Sept%202022.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1212" data-original-width="1570" height="247" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMtAVo14SFKWXCQclsRDly0bm2eClz5wdVEn2LEix-CLUbkuoJlAOf1H9LtkFUpQ1MzVovPxVlHcTsbwZ6nfyvDyNCFvczrxvtSWJLA5uFTPmjWi6H_CV80SnLjUQkJBrdp6WPnN12OmVVtkcGotHgH5WldZTsbMe2k95ys942tbc1cSYxtWIj0Hjk1g/s320/Scatterbed%20Update%20Sept%202022.png" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: left;">March 11, 2022 (Crystal Rogers/C Reynolds/A Bernard/Manpreet Datta-Pulmonary Medicine); Reviewed 12-15-23</div><p></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-50377755133079621852021-12-19T15:07:00.003-08:002023-12-15T07:39:18.668-08:00Mesenteric Ischemia-Diagnosis and Treatment<p> <span></span></p><a name='more'></a><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjoijCjtxJ7g5NoksrXC96FpmWS7Ypl_-67zXcwHASjl1uRlMzR8sBlZsQuQIcmaiGnFh9-VLDcbCqAlvYJzxYSwg7Lzdt90qRTP9FjXCi448TItWCw9OtdxzhqoHMmdO6AuGJsEKoruRcdpQm-29LUGujT7GDAe_Yg8h1hkgqjBEyYrTLMtpIvudGWvA=s1824" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1238" data-original-width="1824" height="217" src="https://blogger.googleusercontent.com/img/a/AVvXsEjoijCjtxJ7g5NoksrXC96FpmWS7Ypl_-67zXcwHASjl1uRlMzR8sBlZsQuQIcmaiGnFh9-VLDcbCqAlvYJzxYSwg7Lzdt90qRTP9FjXCi448TItWCw9OtdxzhqoHMmdO6AuGJsEKoruRcdpQm-29LUGujT7GDAe_Yg8h1hkgqjBEyYrTLMtpIvudGWvA=s320" width="320" /></a></div><br /><span><br /></span><p></p><div><span><div style="background-color: white; border: 0px; font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; font-stretch: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><b><u>For Fluorescence Angiography:</u></b></div><div style="background-color: white; border: 0px; font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; font-stretch: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><b><u><br /></u></b></div><div style="background-color: white; border: 0px; font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; font-stretch: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><b><u>What to request</u></b>:</div><div style="background-color: white; border: 0px; font-family: Calibri, Arial, Helvetica, sans-serif; font-size: 12pt; font-stretch: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><ul><li>Laparotomy:</li><ul><li>Spy Kit (OR materials)</li><li>SPY tower (lives outside of OR 10)</li><li>+/- Stryker rep </li></ul><li>Laparoscopy:</li><ul><li>Spy Kit (OR Materials)</li><li>Stryker rep (to provide SPY compatible scope)</li></ul></ul><div style="border: 0px; color: inherit; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><u style="font-weight: bold;">Step-by-step Instructions:</u> These will be on the cart and are also on the PDF attached.</div><div style="border: 0px; color: inherit; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><ul><li><span color="inherit" style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Turn SPY tower on (back of monitor)</span></li><li><span color="inherit" style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Connect the SPY head to the monitor (color coded cords)</span></li><li><span color="inherit" style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Drape camera head </span></li><li><span color="inherit" style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">White balance (button on front panel of tower)</span></li><li><span color="inherit" style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Administer 2.5cc ICG (takes 30-60s until can scan bowel)</span></li><li><span color="inherit" style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Press green button on camera and start scanning</span></li></ul></div><div style="border: 0px; color: inherit; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><br aria-hidden="true" /></div><div style="border: 0px; color: inherit; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><b><u>Resources:</u></b></div><div style="border: 0px; color: inherit; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><ul><li><span color="inherit" style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">SPY quick guide (attached) *** </span></li><li><span color="inherit" style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">YouTube- operational video: <a data-auth="Verified" data-linkindex="0" href="https://nam04.safelinks.protection.outlook.com/?url=https%3A%2F%2Fyoutu.be%2F85053bEXJgs&data=04%7C01%7Candrew.bernard%40uky.edu%7Ce29926e901cf4ad4c77e08d9e34b295b%7C2b30530b69b64457b818481cb53d42ae%7C0%7C0%7C637790734392370920%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=xDMKUmeCLN6NZOxUEW06fv2QbaZHa%2FLa7O0%2FI7d4y48%3D&reserved=0" originalsrc="https://youtu.be/85053bEXJgs" rel="noopener noreferrer" shash="Hoe310vePldwOKhVDKdFWBvbIRDorg4ARQVlKIzZa9TzDcmc49ph9poQqKJEx4Px+Iy5V4V7Z1Xwnhcve0t1ZGQykLCZ5/U4CFz7sDOiRfGnGU68WRX2YX/BZ4PyC4ZLC4TkkSIp+eaKZM3BgURaJnM9Noio5LBu2Cv9nU9Cpv0=" style="border: 0px; font-family: inherit; font-size: 15px; font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;" target="_blank" title="Original URL: https://youtu.be/85053bEXJgs. Click or tap if you trust this link.">https://youtu.be/85053bEXJgs</a><span style="border: 0px; color: #201f1e; font-family: inherit; font-size: 15px; font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"> </span></span></li><li>YouTube- draping video: <a data-auth="Verified" data-linkindex="1" href="https://nam04.safelinks.protection.outlook.com/?url=https%3A%2F%2Fyoutu.be%2FFkDY6hUAB2g&data=04%7C01%7Candrew.bernard%40uky.edu%7Ce29926e901cf4ad4c77e08d9e34b295b%7C2b30530b69b64457b818481cb53d42ae%7C0%7C0%7C637790734392370920%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=1HhZ94us2fA%2FyWFx4NCPW3v3ypKWW%2BdfzaTYWE8ja34%3D&reserved=0" id="LPlnk541106" originalsrc="https://youtu.be/FkDY6hUAB2g" rel="noopener noreferrer" shash="XrTQAbUgV0imFgFCxi8B0fJf+LSHBxOlvPQprMYZg4gAEjeyFPSeZEORtKjDaePjJzUHMqgFn7xU+eFRQvuETm0zEXrNKJ7vo2JQh9IM3guNan0Yvjfsnn0ZuBChZNuZTL2fy9hWUaiO3wIqq96azNkJDu935lwa2Ep5fVWXV/k=" style="border: 0px; font-family: inherit; font-size: 15px; font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;" target="_blank" title="Original URL: https://youtu.be/FkDY6hUAB2g. 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The posting process also allows one to designate a certain operating table type (angio, Jackson, Berchtold), other surgical teams needed, equipment/supplies and other special requests. The smoothest operation is a well-planned and set-up operation. </div><div class="separator" style="clear: both; text-align: left;">In addition, a briefing among team members ahead of the case sets the stage for a smooth and deliberate operation. And also provides the best educational environment. See BID Teaching method in the references. </div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLlNWkaLXV8y7x8ihKcahkva-pN1expthiEu2T8Pmh1h1HN07j7wHeKPWMf09QbLVclvk3PBSUnhCrkyd9_kwCLDqq3oZdNIyx5ieKG4vPXwQJ4SyupC6eqiIHjqGsHkffvm0goZy8hcdM/s1162/Case+Posting+Checklist+v4.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1162" data-original-width="981" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLlNWkaLXV8y7x8ihKcahkva-pN1expthiEu2T8Pmh1h1HN07j7wHeKPWMf09QbLVclvk3PBSUnhCrkyd9_kwCLDqq3oZdNIyx5ieKG4vPXwQJ4SyupC6eqiIHjqGsHkffvm0goZy8hcdM/s320/Case+Posting+Checklist+v4.png" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;"><div class="page" title="Page 1"><div class="layoutArea"><div class="column">Case Posting: Rules of Engagement <span style="font-family: Arial; font-size: 12pt; font-weight: 700;">Case Posting Basics</span><p></p><p><span style="font-family: ArialMT; font-size: 12pt;">The OR desk phone number is </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">3-5631</span><span style="font-family: ArialMT; font-size: 12pt;">. We are here for you 24/7. We are your allies in providing quadruple aim, expedient care to our patients. We have compiled some miscellaneous tips to simplify OR access.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Please call the scheduling office at </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">3-6954 </span><span style="font-family: ArialMT; font-size: 12pt;">to post cases Monday through Friday 8am to 5 pm.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Please post cases through the OR desk for all same-day postings and for next-day postings if it is after 5pm.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">If it is Friday after 5p through Monday at 8 am and you need to post a case for Saturday, Sunday, or Monday, please call the OR desk.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">If calling the scheduling office to post cases during off-hours, please leave the p</span><span style="font-family: ArialMT; font-size: 12pt;">atient’s </span><span style="font-family: ArialMT; font-size: 12pt;">posting information, including any special items/equipment needed, on their answering machine. They will post the cases in the order received</span><span style="font-family: ArialMT; font-size: 12pt;">, so the patient’s place in line will </span><span style="font-family: ArialMT; font-size: 12pt;">be preserved. Leave your contact number and any time constraints on the message.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">To book an anesthesia sedation case:</span></p><ul style="list-style-type: none;"><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">All sedation cases must be NPO.</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> Y</span><span style="font-family: ArialMT; font-size: 12pt;">ou must discuss the patient with </span><span style="font-family: ArialMT; font-size: 12pt;">the anesthesia board runner (</span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">8-0082</span><span style="font-family: ArialMT; font-size: 12pt;">).</span></p></li></ul><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">For all other anesthesia sedation bookings, please call scheduling.</span></p><p><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">Things to Know (and Ways to Help Us Help You)</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: ArialMT; font-size: 12pt;">Attending surgeons may only run two ORs at once. If a third room must be opened, an alternate attending must engage.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Attending surgeons may never have cases running simultaneously in different buildings. For example, one attending cannot cover a case at the VA or CAS while covering a case at Chandler.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Do not engage the OR before your attending is aware of and agrees to the case or before the patient has consented unless it is a class A emergency. This will prevent wastes of time and resources.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Aside from some A emergencies, all patients must be consented and have an updated H&P. Inpatient consents are good for 48 hours. Outpatient consents are good for 30 days. H&Ps are good for 24-hours and must include a statement regarding the plan to bring the patient to OR on that date. Anesthesia must also consent every patient. Please keep this in mind if there are language barriers or social issues- sometimes a phone call to OR to let us know the power of attorney is available, for example, can avert a delay of your case.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">When 2+ services plan coinciding procedures on a patient, each service must post their portion of the case with the scheduler</span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">. Posting cases correctly and with all involved parties included in the booking at the time of posting allows the OR to provide the correct supplies, estimate surgical time, and allows each service access to chart on the operative record. </span><span style="font-family: ArialMT; font-size: 12pt;">Adding procedures later will cause many avoidable problems and inevitable delays.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">At the time of posting, please give the scheduler a list of special items/equipment needed for the case. The more the OR knows before the patient is in the room, the smoother the case will go. If there are extenuating circumstances regarding your patient (i.e. they are on ECMO), please inform the OR when posting.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">While situations and provider preferences differ, the general rules for NPO status are as follows:</span></p><ul style="list-style-type: none;"><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">2 hours: clears, including clear juices, black coffee, and tea</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">4 hours: breast milk</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">6 hours: plain toast, non-breast milks, coffee with cream</span></p></li></ul></div></div></div><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px;"><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">8 hours: most solid foods, juices with pulp</span></p></div></div></div></blockquote><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: ArialMT; font-size: 12pt;">If the patient has NG tube feeds that have not been turned off, it may be possible for the case to go without waiting 8 hours if the tube is post-pyloric (with day-of-surgery imaging to verify tube placement).</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">On Saturdays, there is one room for scheduled elective cases from 7:30 am </span><span style="font-family: ArialMT; font-size: 12pt;">– </span><span style="font-family: ArialMT; font-size: 12pt;">3 pm. Any service can book into this room. Aside from this block, all other weekend cases are </span><span style="font-family: ArialMT; font-size: 12pt;">considered elective or TSA cases (time/space available) and will be taken care of in the order they are scheduled.</span></p></div></div></div><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: ArialMT; font-size: 12pt;">Please, refrain from making repeated calls to the desk regarding estimated start times for TSA cases. The schedule is ever evolving and is always only a phone call away from the next change in plans. This makes it difficult to forecast when a non-emergent case might go. Please know we are aligned with you in getting all surgical patients timely </span><span style="font-family: ArialMT; font-size: 12pt;">care. When we send for your service’s patient</span><span style="font-family: ArialMT; font-size: 12pt;">, the desk will call the resident listed on the posting.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">If the OR is ready to start your case and the patient is not ready for surgery (i.e. lacks consent and POA not present or the patient is waiting for scan or labs, etc.), the case will go to the bottom of the list. Please avoid engaging the OR if your patient or team is not ready.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Please make every effort to post cases correctly. A great deal of time and resources are wasted if, for example, a case is posted as an open case when it is actually a laparoscopic case.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Cases cannot be posted as place holders- meaning that as long as any other cases are in the queue, a service cannot cancel a case and replace it with another. If a case cancels, the time slot goes to the next waiting patient. There are times we may be able to accommodate, but this is the general rule.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">If you need OR supplies for an off-site procedure, please call OR Materials at </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">3-8080</span><span style="font-family: ArialMT; font-size: 12pt;">. They might even be able to tube supplies to you if you provide them with the closest pneumatic tube station number. Other helpful contacts:</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Central Sterile (instruments) </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">3-6026 </span><span style="font-family: ArialMT; font-size: 12pt;">Hospital Materials </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">3-5645 Emergent Cases</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">There are formal rules of engagement for posting emergent cases to OR under </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">Policy #OR01-07</span><span style="font-family: ArialMT; font-size: 12pt;">, but here is the gist:</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Please do not post an emergency to OR until the surgeons are available and the patient is consented and ready for surgery. Cases are considered active emergent postings only once both patient and service are 100% ready for OR. For example, a case cannot jump the list by being posted as an emergency 4 hours before the attending will actually be available. Likewise, if the OR is available and a viable emergent case is posted, it will go as quickly as possible; so, case </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">cannot </span><span style="font-family: ArialMT; font-size: 12pt;">be posted at 0530 as a B emergency with the expectation of waiting to go to OR until 0730 as a first start.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Emergent case status is related to patient status alone and has nothing to do with convenience or availability. For example, a case cannot be posted as an emergency to </span><span style="font-family: ArialMT; font-size: 12pt;">follow the last case in a line. Additionally, a service cannot post a case today with the intention of it going as an emergency tomorrow because that is when the attending will be available. The attendings of every service convened to decide what sorts of cases would be considered emergent for their respective services. The OR desk is happy to provide copies of these case listings.</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: ArialMT; font-size: 12pt;">The categories of emergent cases are as follows:</span></p><p><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">Trauma Red:</span></p><ul style="list-style-type: none;"><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">Requires immediate access to OR</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">Never bring a trauma red up to OR without first calling the OR. The desk </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">MUST</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">have a medical record number, at the very least. Imagine how much better the care your team can provide when you know a trauma patient is on the way rather than having them just show up unannounced in the trauma bay. Similarly, OR needs notice in order to provide both our best care for the patient as well as optimal support for you. The more notice and information shared, the more prepared we can be.</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">A full posting is not required if time does not allow, but it helps the OR to help you if we know the general area of the surgery and/or the mechanism of injury</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">If there is a trauma red page, the OR will hold a room/team for 1 hour- until someone from the trauma service calls the desk to either post or clear the red, or extend the hold time. </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">This communication is key</span><span style="font-family: ArialMT; font-size: 12pt;">. SGB must call the desk to either engage or release the OR. Telling anesthesia personnel DOES NOT negate your responsibility to communicate with the desk.</span></p><p><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">Class A Emergency:</span></p></li></ul><ul style="list-style-type: none;"><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">Life or limb-threatening condition requiring immediate surgery</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">Will take precedence over and bump any other case</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">OR has a 1 hour time limit to get an A emergency patient in the room</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">If the patient needs to come to OR immediately, please discuss using the trauma</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">room with the desk.</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">A emergencies cases can post without consent if required by the acuity of the</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">patient</span></p><p><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">Class B Emergency:</span></p></li></ul><ul style="list-style-type: none;"><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">Life or limb threatening condition requiring surgery within 4 hours</span></p></li><li><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">B emergencies become A emergencies after 3.5 hours</span></p></li></ul></div></div><span style="font-family: Arial; font-size: 12pt; font-weight: 700;"><div class="page" title="Page 4"><br /></div>Class T Emergency:</span></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">Non-life-threatening condition which may lead to severe complications without surgical intervention within 24 hours</span></p><p><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">Administrative T Emergency:</span></p><p><span style="font-family: SymbolMT; font-size: 12pt;"> </span><span style="font-family: ArialMT; font-size: 12pt;">Cases after which the patient can be discharged home, facilitating throughput</span></p><p><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">Case Bumping</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Emergent cases go ahead of (or “bump”) TSA or scheduled cases.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">If you have TSA patients who have been bumped for one or more days, please make OR charge aware. We will try our best to make them a priority. If a patient declines, the posting can be upgraded to emergent status. Please know that it is not considered a bump if the service chooses to takes the case off the schedule because it is late in the day.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">If you add an emergency, it will bump </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">your service’s </span><span style="font-family: ArialMT; font-size: 12pt;">other cases. Unless both OR and Anesthesia can open an additional room, the added emergency will go before your </span><span style="font-family: ArialMT; font-size: 12pt;">service’s schedul</span><span style="font-family: ArialMT; font-size: 12pt;">ed line. If a case is posted as an emergency and the service chooses to do a non-emergent case first, the emergent posting loses its status.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">If your attending believes your case is more emergent than that of another service, the </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">attendings </span><span style="font-family: ArialMT; font-size: 12pt;">must decide between them who will go and let the OR desk know. This is a conversation between the service attendings (the anesthesia attending may be involved as well) and </span><span style="font-family: Arial; font-size: 12pt; font-weight: 700;">does not </span><span style="font-family: ArialMT; font-size: 12pt;">include </span><span style="font-family: ArialMT; font-size: 12pt;">the room’s </span><span style="font-family: ArialMT; font-size: 12pt;">nursing or anesthesia staff, or the OR desk. If consensus is not reached, the matter will be escalated to the Medical Director who will make the final decision.</span></p><p><span style="font-family: ArialMT; font-size: 12pt;">Whether bumping a partner or another service, it is your responsibility to talk to the attending/service being bumped.</span></p></div></div></div></div><div class="separator" style="clear: both; text-align: left;"><b><br /></b></div><div class="separator" style="clear: both; text-align: left;"><b>Reference</b></div><div class="separator" style="clear: both; text-align: left;">https://crlt.umich.edu/sites/default/files/NFO19_Concurrent_Session_Materials/BID%20Model.pdf</div><div class="separator" style="clear: both; text-align: left;"><a href="https://crlt.umich.edu/sites/default/files/NFO19_Concurrent_Session_Materials/BID%20Model.pdf">BID Teaching Method</a></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: ArialMT; font-size: 16px;">8/29/2020 (Michal Brooks), Revised </span>June 2, 2021 A Bernard; Reviewed 12-15-23</div><p></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-40091134211954738522021-01-03T03:05:00.006-08:002023-12-15T07:48:08.289-08:00Medical Student Night Duties-Trauma/Emergency General Surgery Call<p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><br /></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="border: 1pt none windowtext; color: #201f1e; font-size: 16pt; padding: 0in; text-indent: -0.25in;">Meet the night team in the 7-100 resident workroom and </span><span style="border: 1pt none windowtext; color: #191919; font-size: 16pt; padding: 0in; text-indent: -0.25in;">obtain a trauma pager from the workroom</span><span style="border: 1pt none windowtext; color: #201f1e; font-size: 16pt; padding: 0in; text-indent: -0.25in;">. </span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #201f1e; font-size: 16pt; text-indent: -0.25in;"><br /></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #201f1e; font-size: 16pt; text-indent: -0.25in;">Attend evening ICU hot rounds at 1800 for surgical and trauma ICU exposure. </span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #201f1e; font-size: 16pt; text-indent: -0.25in;"><br /></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #201f1e; font-size: 16pt; text-indent: -0.25in;">Respond to all Trauma Alert Reds. Ask the chief how to be most useful during them. Be an active participant. </span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="font-size: 16pt; text-indent: -0.25in;"><span style="color: #201f1e;"><br /></span></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="font-size: 16pt; text-indent: -0.25in;"><span style="color: #201f1e;">P</span></span><span style="color: #191919; font-size: 16pt; text-indent: -0.25in;">articipate in operative cases or bedside procedures.</span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #191919; font-size: 16pt; text-indent: -0.25in;"><br /></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #191919; font-size: 16pt; text-indent: -0.25in;">Spend as much time as possible with the junior or chief resident-i.e. in the emergency room-participating in the acute evaluation and intervention of emergency surgery patients. You should follow the progress of the patient throughout their hospital experience. If the patient goes to the OR, you should scrub the case and practice writing postop orders and notes.</span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="border: 1pt none windowtext; color: #191919; font-size: 16pt; padding: 0in; text-indent: -0.25in;"><br /></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="border: 1pt none windowtext; color: #191919; font-size: 16pt; padding: 0in; text-indent: -0.25in;">Assist the Blue Junior in the evaluation and workup of consults. Send notes to the Blue Junior for feedback. Cosign the nighttime attending. Utilize the “Blue Surgery History and Physical Note” for </span><span style="border: 1pt none windowtext; color: #201f1e; font-size: 16pt; padding: 0in; text-indent: -0.25in;">Trauma Alert Reds</span><span style="border: 1pt none windowtext; color: #191919; font-size: 16pt; padding: 0in; text-indent: -0.25in;"> and </span><span style="border: 1pt none windowtext; color: #201f1e; font-size: 16pt; padding: 0in; text-indent: -0.25in;">Trauma Alerts</span><span style="border: 1pt none windowtext; color: #191919; font-size: 16pt; padding: 0in; text-indent: -0.25in;">. </span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #191919; font-size: 16pt; text-indent: -0.25in;"><br /></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #191919; font-size: 16pt; text-indent: -0.25in;">On “slow” nights, consider helping the ICU and/or floor intern on inpatients, including rounding and responding to pages.</span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #191919; font-size: 16pt; text-indent: -0.25in;"><br /></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #191919; font-size: 16pt; text-indent: -0.25in;">Refer to the UK Trauma Protocol Manual in making clinical and operational decisions.</span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #191919; font-size: 16pt; text-indent: -0.25in;"><br /></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #191919; font-size: 16pt; text-indent: -0.25in;">Learn the evaluation and management of common general surgery diseases.</span></p><p class="MsoNormal" style="margin-left: 0.25in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-align: left; text-indent: -0.25in;"><!--[if !supportLists]--></p><p class="MsoNormal" style="margin-left: 0.25in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--></p><p class="MsoNormal" style="margin-left: 0.25in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--></p><p class="MsoNormal" style="margin-left: 0.25in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--></p><p class="MsoNormal" style="margin-left: 0.25in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--></p><p class="MsoNormal" style="margin-left: 0.25in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--></p><p class="MsoNormal" style="margin-left: 0.25in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--></p><p class="MsoNormal" style="margin-left: 0.25in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;"><!--[if !supportLists]--></p><p class="MsoNormal" style="margin-left: 0.25in; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -0.25in;">November 12, 2023 (A Bernard/A Nickols)</p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-28904290092046389302021-01-02T08:32:00.001-08:002023-12-15T07:48:26.426-08:00Colon SSI Checklist<p> <br /><span></span></p><a name='more'></a><div class="separator" style="clear: both; text-align: left;">Checklist for SSI Prophylaxis in EGS Colon Cases </div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><ul style="text-align: left;"><li>Were antibiotics ordered Preop?</li><li>Were antibiotics given within 1 hour of incision?</li><li>What antibiotic?</li><li>When should re-dosing occur?</li><li>Did re-dosing occur?</li><li>Was a wound protector used?</li><li>Was the wound irrigated with fresh saline?</li><li>Was a closing tray used?</li><li>Suction tip changed?</li><li>Gloves changed?</li><li>Case type dictated-clean, clean/cont, cont, dirty/infected (including 'peritonitis' if present)?</li></ul></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi67446Hard9bY7SMNhj5u8C-6Sa3lHds6sEXJi24PH-HskUTUg9Opj01si9gVLAQg14L-qXoYjqPf9oYzenbWvAjCpXKHYCNPfjTraqSZlRMbJw8_rGqs-9GuqdftJyzxcrSSn9Np4icrr/s1618/Colon+SSI+Checklist.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1210" data-original-width="1618" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi67446Hard9bY7SMNhj5u8C-6Sa3lHds6sEXJi24PH-HskUTUg9Opj01si9gVLAQg14L-qXoYjqPf9oYzenbWvAjCpXKHYCNPfjTraqSZlRMbJw8_rGqs-9GuqdftJyzxcrSSn9Np4icrr/s320/Colon+SSI+Checklist.png" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">January 2, 2021 Candice Travers/A Bernard; Reviewed 12-15-23</div><p></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-26788293163319268862020-12-29T17:08:00.004-08:002023-12-15T07:48:53.033-08:00Equity-How to Encourage it in a Healthcare Team<p> </p><span><a name='more'></a></span><p><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgK-ykboxu56f6R38bDvwoGn6djfVMhxiDw3uMhyphenhyphenPMEnw1FVbxa0Wu74en1srAsmdPEcgyGHDFRNXA26PqoB8AV0QuPARMHRSs-MrzQR05igZbDrUSumDn7EP5Y_1QP_pbJTbFIqoZgcBvd/s2048/Screen+Shot+2020-12-29+at+8.01.42+PM.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1158" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgK-ykboxu56f6R38bDvwoGn6djfVMhxiDw3uMhyphenhyphenPMEnw1FVbxa0Wu74en1srAsmdPEcgyGHDFRNXA26PqoB8AV0QuPARMHRSs-MrzQR05igZbDrUSumDn7EP5Y_1QP_pbJTbFIqoZgcBvd/s320/Screen+Shot+2020-12-29+at+8.01.42+PM.png" width="320" /></a></div><br /><p></p><p>These and other resources are available on the EAST Equity, Quality and Inclusion in Trauma Surgery Practice web site at:</p><p><a href="https://www.east.org/career-management/equity-quality-and-inclusion-in-trauma-surgery-practice">https://www.east.org/career-management/equity-quality-and-inclusion-in-trauma-surgery-practice</a><br /></p><p>A Bernard/Reviewed 12-15-23</p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-32143931682966184912020-12-29T17:06:00.001-08:002023-12-15T07:49:52.531-08:00Microaggression-How to Respond<p> <span></span></p><a name='more'></a><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivVL0ajo_GdLkBsBi6Aa9QYa_Gozz_48mRg6TLpF24Sxr7adHh-GqcYQqVLOAaGnUdHlGkUJyojP_QTMLBYjGkpHz7gAW-vGe5e6e0VkQLeZ3Xn3NcYeHO63KopzvC4vuWhXWm5aqVhVTR/s2048/Screen+Shot+2020-12-29+at+8.00.27+PM.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1163" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivVL0ajo_GdLkBsBi6Aa9QYa_Gozz_48mRg6TLpF24Sxr7adHh-GqcYQqVLOAaGnUdHlGkUJyojP_QTMLBYjGkpHz7gAW-vGe5e6e0VkQLeZ3Xn3NcYeHO63KopzvC4vuWhXWm5aqVhVTR/s320/Screen+Shot+2020-12-29+at+8.00.27+PM.png" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKw4KOcJx_aNwEGZXovycFWI-vEi10PgkWdvAIK_82G8X3ahJ3LewEXJYqVV7sSH95oy5tHo0vaQsE9do9SenB5CCUCFipdof2fclOoOaBuxiG6nX56Jor373ilLHJGlrZze7-rkr3N1Nb/s2048/Screen+Shot+2020-12-29+at+8.00.44+PM.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1160" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKw4KOcJx_aNwEGZXovycFWI-vEi10PgkWdvAIK_82G8X3ahJ3LewEXJYqVV7sSH95oy5tHo0vaQsE9do9SenB5CCUCFipdof2fclOoOaBuxiG6nX56Jor373ilLHJGlrZze7-rkr3N1Nb/s320/Screen+Shot+2020-12-29+at+8.00.44+PM.png" width="320" /></a></div><br /><span>These and other resources are available on the EAST Equity Quality and Inclusion in Trauma Surgery Practice web page at: </span><p></p><p><a href="https://www.east.org/career-management/equity-quality-and-inclusion-in-trauma-surgery-practice">https://www.east.org/career-management/equity-quality-and-inclusion-in-trauma-surgery-practice</a></p><p>Reviewed A Bernard Dec 15, 2023</p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-33909212621503787902020-11-29T17:42:00.007-08:002023-01-31T04:55:56.346-08:00Trauma Service Consultation Guideline<p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><b><u><span></span></u></b></p><a name='more'></a><b><u><span style="color: black; font-family: Cambria, serif;"><br /></span></u></b><p></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><b><u><span style="color: black; font-family: Cambria, serif;">TRAUMA SERVICE CONSULTATION GUIDELINE:</span></u></b><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black; font-family: Cambria, serif;"> </span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black; font-family: Cambria, serif;">INJURY WARRANTS TRAUMA EVALUATION<sup>1</sup><span class="xapple-converted-space"> </span>or RECOGNIZED NEED FOR TRAUMA SERVICE ADMISSION<sup>2</sup><span class="xapple-converted-space"></span></span><span class="xapple-converted-space"><span style="color: black; font-family: Wingdings;"><span>à</span></span></span><span class="xapple-converted-space"><span style="color: black; font-family: Cambria, serif;"> </span></span><b><span style="color: black; font-family: Cambria, serif;">CALL SGT IMMEDIATELY<o:p></o:p></span></b></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><i><span style="color: black; font-family: Cambria, serif;">Trauma service consultation does NOT represent completed transition of care</span></i><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><i><span style="color: black; font-family: Cambria, serif;">Trauma admission order represents transition of care, unless workup ongoing OR admission order entered at time of consultation, which will be directly communicated between trauma and emergency resident</span></i><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black; font-family: Cambria, serif;"><o:p> </o:p></span></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black; font-family: Cambria, serif;">INJURY WARRANTS TRAUMA EVALUATION<sup>1</sup>:</span><span class="xapple-converted-space"><span style="color: black; font-family: Cambria, serif; font-size: 7pt;"><o:p></o:p></span></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span class="xapple-converted-space"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Documented or concern for:<span class="xapple-converted-space"> </span></span><span class="xapple-converted-space"><span style="font-family: Cambria, serif;"><o:p></o:p></span></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">solid organ injury</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">hollow viscous injury</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">bladder or kidney injury (includes gross hematuria)</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">vascular injury (includes ischemic limb, abnormal API, documented injury on imaging)</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1.5in; mso-list: l3 level3 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">See<span class="xapple-converted-space"> </span><i>Extremity Vascular Injury</i><span class="xapple-converted-space"> </span>guideline</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">cardiac or pulmonary injury</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">rib fracture</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">pneumothorax or hemothorax</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">complex wound without underlying fracture or open joint</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">mangled extremity</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1.5in; mso-list: l3 level3 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">See<span class="xapple-converted-space"> </span><i>Mangled Extremity<span class="xapple-converted-space"> </span></i>guideline</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">compartment syndrome without underlying fracture</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: Cambria, serif;">penetrating thoracic injury with pleural violation<o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: Cambria, serif;">penetrating abdominal or pelvic injury with peritoneal violation<o:p></o:p></span></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="font-family: Cambria, serif;"><o:p> </o:p></span></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black; font-family: Cambria, serif;">INJURY WARRANTS TRAUMA ADMISSION<sup>2</sup>:<o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Multisystem (“polytrauma”)</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Multiple service line involvement</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Multiple injuries not covered by the same surgical specialist</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Any individual injury requires trauma service management</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">High-mechanism fracture at risk of additional injury</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">See attached<span class="xapple-converted-space"> </span><i>Fracture Admission Guideline </i><span>for high-risk injuries</span></span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l3 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Low-mechanism fracture with additional injuries or multiple fractures</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 1in; mso-list: l3 level2 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">See attached<span class="xapple-converted-space"> </span><i>Fracture Admission Guideline </i><span>for special considerations</span></span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="font-family: Cambria, serif;"><o:p> </o:p></span></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black; font-family: Cambria, serif;">DIRECT SERVICE CONSULTATION (in lieu of or in addition to SGT consultation):<o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Ortho: extremity fracture, compartment syndrome with associated fracture, pelvic fracture</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Hand (Ortho, PLA): distal upper extremity fracture, compartment syndrome, soft tissue, tendon or nerve injury</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Neurosurgery: traumatic brain injury with altered mental status (GCS<8), BIG 3</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Spine: spine fracture other than processes</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Maxillofacial Trauma (OMFS, PLA, ENT): facial fracture, facial laceration</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l1 level1 lfo3; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="color: black; font-family: Cambria, serif;">Ophthalmology: globe rupture, elevated intraocular pressure, need for lateral canthotomy</span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; margin: 0in 0in 0in 0.5in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="font-family: Cambria, serif;"><o:p> </o:p></span></p><p><style class="WebKit-mso-list-quirks-style">
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</style></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo4; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings;">è<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: Cambria, serif;">NO direct Interventional Radiology, Urologic, Cardiac, Thoracic or Vascular service consultation<span class="xapple-converted-space"> </span><b>unless requested by SGT based on need for urgency of communication</b></span><span style="font-family: Cambria, serif;"><o:p></o:p></span></p><p class="xxmsonormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo4; text-indent: -0.25in;"><span style="font-family: Cambria, serif;"><b>Posted Nov 2020; Reviewed Jan 2023</b></span></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-42115855651482587482020-11-29T03:26:00.003-08:002023-12-15T07:54:02.650-08:00Feeding the Hemodynamically Unstable Adult Patient <p> <span></span></p><a name='more'></a><p></p><p><b style="font-family: Calibri, sans-serif; font-size: 11pt;"><span style="font-size: 12pt; line-height: 17.12px;">Summary and Background </span></b></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><span style="font-size: 12pt; line-height: 17.12px;">The gastrointestinal (GI) tract plays an important role in regulating the body’s inflammatory response and immune function, in addition to the absorption of nutrients. In critical illness, patients can experience a massive pro-inflammatory response from the gut, leading to oxidative tissue damage, apoptosis, and an impaired immune response towards infectious pathogens. Additionally, increased mucosal permeability can occur, increasing the risk of infection via bacterial translocation into the bloodstream. 30-50% of ICU patients are malnourished upon admission, a factor that can further predispose patients to these consequences of GI impairment.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><span style="font-size: 12pt; line-height: 17.12px;">Early initiation of enteral nutrition (EN) can be greatly beneficial in supporting proper GI function in critically ill patients. Providing as little as 20% of a patient’s total nutritional goals enterally can lower inflammation, reduce oxidative stress, support the humoral immune response, restore microbiome composition, and decrease insulin resistance. The 2016 ASPEN/SCCM guidelines state, “In setting of hemodynamic compromise or instability, EN should be withheld until patient is fully resuscitated and/or stable,” due to the risk of nonocclusive bowel necrosis (NOBN). The largest study supporting the concern for NOBN stems is the NUTRIREA-2 study that investigated 2410 mechanically ventilated patients requiring vasopressor support, randomized to early enteral nutrition or parenteral nutrition. Patients in the enteral nutrition group experienced increased bowel ischemia over the parenteral nutrition group. Of note, the study’s patient population had an elevated mean vasopressor requirement of 0.53 ug/mg/min of norepinephrine.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><span style="font-size: 12pt; line-height: 17.12px;">The effect of vasopressors on gut perfusion and the risk of NOBN seems to be dose-related. Thus, recommendations for a safe dose range and vasopressor selection for initiation of enteral nutrition would be of utility. These guidelines seek to increase the administration of early enteral nutrition in appropriate clinical scenarios, as well as provide guidance in higher-risk situations where enteral nutrition should be restricted to a reduced rate or withheld.<o:p></o:p></span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><b><span style="font-size: 12pt;">Prior to initiation of EN, assess patient for resuscitation and hemodynamic stability markers:<o:p></o:p></span></b></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><span style="font-size: 12pt;"> -Lactate normalized (≤ 2.0) or correcting rapidly <o:p></o:p></span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><span style="font-size: 12pt;"> -Mean arterial pressure (MAP) maintained >65 (with or without vasopressors)<o:p></o:p></span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><span style="font-size: 12pt;"> -Vasopressor requirements decreasing or stable (e.g.: Norepi @ 0.2mcg/kg/min with other stable parameters listed here) <o:p></o:p></span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><span style="color: red; font-size: 12pt;"> </span><span style="font-size: 12pt;">-Fluid requirements stabilizing (patient is not actively requiring boluses for blood pressure maintenance) <o:p></o:p></span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in; text-indent: 0.5in;"><span style="font-size: 12pt;">-No ongoing or active bleeding <o:p></o:p></span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><span style="font-size: 12pt;"> </span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><span style="font-size: 12pt;">-The primary team will initiate the tube feeding based on resuscitation and hemodynamic stability markers and using the guidelines below (Table 1)<o:p></o:p></span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><span style="font-size: 12pt;">-The RD will be responsible for completing a Nutrition Evaluation note with tube feeding recommendations within 24 hr of the placement of the Nutrition Consult order </span><span style="color: red;"><o:p></o:p></span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><span style="font-size: 12pt;"><br /></span></p><p class="MsoNoSpacing" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuaVXC9L47q7UTrUugRca5QJHBHBCf8RaMDdHCloN3p9O3xRcLpLMJjRDum7BQpgNf8PpLlrJlWUP3JwdrEIk6Hswbac5ZJQV6xTPbQKlMANvvuopca_MbRQ-MzFNP-K-bWmVRaLF2x6La/s2316/Vasopressors+and+Nutrition-Table+1+2020.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1132" data-original-width="2316" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuaVXC9L47q7UTrUugRca5QJHBHBCf8RaMDdHCloN3p9O3xRcLpLMJjRDum7BQpgNf8PpLlrJlWUP3JwdrEIk6Hswbac5ZJQV6xTPbQKlMANvvuopca_MbRQ-MzFNP-K-bWmVRaLF2x6La/s320/Vasopressors+and+Nutrition-Table+1+2020.png" width="320" /></a></div><br /><p></p><p class="MsoPlainText" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><b><span style="font-size: 12pt;">References<o:p></o:p></span></b></p><p class="MsoPlainText" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><b><span style="font-size: 12pt;"> </span></b></p><p class="MsoPlainText" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;">Wischmeyer PE. Enteral Nutrition Can Be Given to Patients on Vasopressors. Crit Care Med. 2020 Jan;48(1):122-125. <o:p></o:p></p><p class="MsoPlainText" style="font-family: Calibri, sans-serif; font-size: 11pt; margin: 0in;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Revelly JP, Tappy L, Merger MM, et. al: Early metabolic and splanchnic responses to enteral nutrition in postoperative cardiac surgery patients with circulatory compromise. <i>Intensive Care Med</i> 2001; 27: 540-547.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Bruns BR, Kozar RA: Feeding the postoperative patient on vasopressor support: Feeding and pressor support. <i>Nutr Clin Pract</i> 2016; 31: 14-17.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Meier-Hellmann A, Reinhart K, Bredle DL, et al: Epinephrine impairs splanchnic perfusion in septic shock. <i>Crit Care Med</i> 1997; 25: 399-404. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Nygren A, Thorén A, Ricksten SE: Vasopressors and intestinal mucosal perfusion after cardiac surgery: Norepinephrine vs. phenylephrine. <i>Crit Care Med</i> 2006; 34: 722-729.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Merchan C, Altshuler D, Aberle C, et al: Tolerability of enteral nutrition in mechanically vented patients with septic shock who require vasopressors. <i>J Intensive Care Med </i>2017; 32: 540-546.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Khalid I, Doshi P, DiGiovine B: Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. <i>Am J Crit Care</i> 2010; 19: 261-268. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Patel JJ, Kozeniecki M, Biesbore A, et al. Early trophic enteral nutrition is associated with improved outcomes in mechanically ventilated patients with septic shock: A retrospective review. <i>J Intensive Care Med</i> 2016; 31: 471-477.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Ohbe H, Jo T, Matsui H, et al: Differences in effect of early enteral nutrition on mortality among ventilated adults with shock requiring low-, medium-, and high-dose noradrenaline: A propensity-matched analysis. <i>Clin Nutr</i> 2019 Feb 15 [Epub ahead of print]<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Ohbe, H., et. al. Early Enteral Nutrition for Cardiogenic or Obstructive Shock Requiring Venoarterial Extracorporeal Membrane Oxygenation: A Nationwide Inpatient Database Study. <i>Intensive Care Med</i> (2018) 44:1258–1265<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><br /></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">November 29, 2020 (K Fedder/B Woodward/A Bernard); Reviewed 12-15-23</p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-5649465602096180152020-11-28T18:21:00.003-08:002023-11-07T08:36:05.946-08:00Open Skull Fracture Antibiotic<p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><br /></p><span><a name='more'></a></span><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><span style="font-size: 11pt;">Background:</span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">The incidence of meningitis occurring after head trauma ranges from 1.4 to 10.6% in patients who receive antimicrobials. However, the efficacy of antimicrobial prophylaxis to prevent meningitis remains controversial due to low-quality clinical data. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">A recent multicenter trial evaluated infection after penetrating brain injury<sup>5</sup>. Patients were stratified into two categories, those who received prophylactic antibiotics for penetrating brain injury, and those who did not. Antibiotic regimens and duration of prophylaxis was not well defined. Infection rate was 7% in patients who received antibiotics, compared with 6% in those who did not. The use of prophylactic antibiotics did not impact the rate of infection in the results of this study. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;">Meta-analyses describing the use of prophylactic antibiotics in the setting of basilar skull fractures failed to show a decrease in the incidence of meningitis compared to no antibiotics.<span style="font-size: 7pt; line-height: 9.98667px;"> </span>However, clinical data suggests that the presence of a CSF leak is an additional risk factor for developing meningitis, and patients who present with a CSF leak may benefit from antibiotic prophylaxis.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><i>This document is intended to serve only as a guideline based on current review of medical literature, and not intended to replace clinical judgment, physician/surgeon discretion, or special circumstances. <o:p></o:p></i></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><i><br /></i></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBZm99APkzHGM1uce8CsSvk0vMqy6S6TvVSmhWfrQp0x6eY1V3IG6DAoIWgDhVL57hbbiXe1K_I8ZBOBdQ94bv3l2grPYcm6NBIgUzOsm0NDc15XJ44yesbZkkLCxetkzDg0TJW11mBHqo/s1474/Open+Skull+Antibiotic+2020.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="882" data-original-width="1474" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBZm99APkzHGM1uce8CsSvk0vMqy6S6TvVSmhWfrQp0x6eY1V3IG6DAoIWgDhVL57hbbiXe1K_I8ZBOBdQ94bv3l2grPYcm6NBIgUzOsm0NDc15XJ44yesbZkkLCxetkzDg0TJW11mBHqo/s320/Open+Skull+Antibiotic+2020.png" width="320" /></a></div><br /><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-size-adjust: auto; widows: auto;">Resources:<o:p></o:p></p><p class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 9pt; line-height: 12.84px; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">1.<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;"> </span></span></span><!--[endif]--><span style="font-size: 9pt; line-height: 12.84px;">Ratilal BO, Costa J, Pappamikail, et al. Antibiotic prophylaxis for preventing meningitis in patient with basilar skull fractures. <i>Cochrane Database Sys Rev. </i>2015 Apr 28;(4): CD004884. doi: 10.1002/14651858.CD004884.pub4.<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 9pt; line-height: 12.84px; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">2.<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;"> </span></span></span><!--[endif]--><span style="font-size: 9pt; line-height: 12.84px;">May AK, Fleming SB, Carpenter RO et al. Influence of broad-spectrum antibiotic prophylaxis on intracranial pressure monitor infections and subsequent infectious complications in head-injured patients. Surg Infect (Larchmt) 2006; 7:409-417.<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 9pt; line-height: 12.84px; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">3.<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;"> </span></span></span><!--[endif]--><span style="font-size: 9pt; line-height: 12.84px;">Villalobos T, Arango C, Kubilis P et al. Antibiotic prophylaxis after basilar skull fractures: a meta-analysis. Clin Infect Dis 1998; 27:364-369.<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 9pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">4.<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 7pt; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;"> </span></span></span><!--[endif]--><span style="color: #131413; font-size: 9pt;">Yellinek S, Cohen A, Merkin V, Shelef I, Benifla M. Clinical significance of skull base fracture in patients after traumatic brain injury. J Clin Neurosci. 2016;25:111–5.</span><span style="font-size: 9pt;"><o:p></o:p></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; font-size: 11pt; line-height: 15.6933px; margin: 0in 0in 8pt;"><style class="WebKit-mso-list-quirks-style">
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</style></p><p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-size: 9pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">5.<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #232323; font-size: 9pt;">Harmon LA, Haase DJ, Kufera JA, et al. Infection after penetrating brain injury—an Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15–19, 2019, in Austin, Texas. <em>J Trauma Acute Care Surg</em>. 2019;87(1):61–67.</span><span style="font-size: 9pt;"><o:p></o:p></span></p><div><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #232323; font-size: 9pt;"><br /></span></div><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><br /></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;">November 28, 2020 (Dina Ali, A Bernard, Steph Priest); Review Ali/Olney 11-7-23</p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><br /></p><p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: -0.25in;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #232323; font-size: 9pt;"><br /></span></p><p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: -0.25in;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #232323; font-size: 9pt;">No</span></p><p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: -0.25in;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #232323; font-size: 9pt;"><br /></span></p><p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: -0.25in;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #232323; font-size: 9pt;"><br /></span></p><p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l0 level1 lfo1; text-autospace: none; text-indent: -0.25in;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #232323; font-size: 9pt;"><br /></span></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-1523278650935674142020-11-11T13:22:00.007-08:002023-12-17T03:47:27.104-08:00Hospital-based Violence Intervention Program-Project Peace<span></span><p align="center" class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: center; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><b style="font-size: 11pt; text-align: start;"><span></span></b></p><a name='more'></a><p></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: center; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><b style="font-size: 11pt; text-align: start;"><span style="color: black;">Background:</span></b></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: left; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black;">Project Peace is an initiative based in the LFUCG Mayor’s Office intended to reduce the incidence of firearm injury and the impact of firearm violence by providing support for victims and families who are vulnerable to injury. Hospital-based violence intervention programs (HVIPs) have been used throughout the United States with great success. Program constructs vary but often involve an assessment by hospital trauma team members and referral to the program followed by case workers in the community engaging and providing a broad menu of support options.<span> </span></span></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black;"><span><br /></span></span></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><b><span style="color: black;">Eligibility:</span></b></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="text-indent: -0.25in;">Gunshot wound victims ages 12 – 29 (primarily, though anyone in need may be referred)</span></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0px; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="text-indent: -0.25in;">Patients of UK Hospital who live in Fayette County </span></p><p class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo3; text-align: left; text-indent: -0.25in;"></p><ol style="text-align: left;"><p> <b style="caret-color: rgb(0, 0, 0); font-family: Calibri, sans-serif; font-size: 11pt; text-indent: 0px;"><span style="color: black;">Process:</span></b></p></ol><p></p><p class="MsoListParagraphCxSpFirst" style="mso-list: l1 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-themecolor: text1;"><span style="mso-list: Ignore;">1.<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant-caps: normal; font-weight: normal; font: 7pt "Times New Roman"; line-height: normal;"> </span></span></span><span style="font-size: 11pt; text-indent: -0.25in;">Social Worker (<b>or trauma providers is being discharged from ED</b>) will meet with patient and family at bedside to conduct Initial Assessment. Goal is within 24 hours as scheduling and neurologic status allow. If the patient is to be discharged before SW can see them, the Trauma Attending will make the approach.</span></p><p class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-themecolor: text1;"><span style="mso-list: Ignore;">2.<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant-caps: normal; font-weight: normal; font: 7pt "Times New Roman"; line-height: normal;"> </span></span></span><!--[endif]--><span style="color: black;">After assessment information obtained, SW will ask about circumstances regarding admission (safety concerns, high risk behaviors, safe discharge planning.</span></p><p class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-themecolor: text1;"><span style="mso-list: Ignore;">3.<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant-caps: normal; font-weight: normal; font: 7pt "Times New Roman"; line-height: normal;"> </span></span></span><!--[endif]--><span style="color: black;">Social Worker will continue to check in with patient and family on a consistent basis to discuss discharge needs and plans.<o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 1.5in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-themecolor: text1;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant-caps: normal; font-weight: normal; font: 7pt "Times New Roman"; line-height: normal;"> </span></span></span><!--[endif]--><span style="color: black;">SW: Explain Project Peace's initiative to patient.<span> </span>The Project Peace is a program that connects a street outreach worker (SOW) to patients involved in gun-related violent crimes to point them to resources for their safety and success. A SOW is an individual whose lived experiences may give them a greater insight into what the patient is going through.<span> </span></span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 1.5in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-themecolor: text1;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant-caps: normal; font-weight: normal; font: 7pt "Times New Roman"; line-height: normal;"> </span></span></span><!--[endif]--><span style="color: black;">SW will go over the SOW bios with patient. SW will then ask patient if they would consent to their name and phone being provided to Project Peace for purposes of pairing them with SOW. <span> </span></span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 1.5in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-themecolor: text1;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant-caps: normal; font-weight: normal; font: 7pt "Times New Roman"; line-height: normal;"> </span></span></span><!--[endif]--><span style="color: black;">SW will explain that being connected to a SOW is free, that they are not connected to law enforcement and that SOW are someone who they can talk to about resources and opportunities they may need post discharge.<span> </span></span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 1.5in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span style="color: black; font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-themecolor: text1;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant-caps: normal; font-weight: normal; font: 7pt "Times New Roman"; line-height: normal;"> </span></span></span><!--[endif]--><span style="color: black;">If the patient does not provide consent. Brochure and community resources will be left with patient, should they choose to make contact post-discharge. <o:p></o:p></span></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0.5in; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black;"><o:p> </o:p></span></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0.5in; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black;">*Word for word script not appropriate as each patient situation will vary.*<o:p></o:p></span></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0.5in; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black;"><o:p> </o:p></span></p><p class="MsoNormal" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 8pt; orphans: auto; text-align: start; text-decoration: none; text-indent: 0.5in; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><b><span style="color: black;">Process for Referrals:<o:p></o:p></span></b></p><p class="MsoListParagraphCxSpFirst" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="color: black;">Step 1:<span> </span><span> </span>Hospital receives patient verbal consent, documents in medical record. <o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="color: black;">Step 2:<span> </span><span> </span>Case manager notifies Project Peace. </span><span face="Calibri, sans-serif" style="caret-color: rgb(0, 0, 0); font-size: 11pt; text-indent: 0px;"> </span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="color: black;">Step 3:<span> </span><span> </span>Project Peace will reply once message is received to close referral loop on <o:p></o:p></span></p><p class="MsoListParagraphCxSpMiddle" style="-webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; caret-color: rgb(0, 0, 0); color: black; font-family: Calibri, sans-serif; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-weight: normal; letter-spacing: normal; line-height: 15.6933px; margin: 0in 0in 0in 1.25in; orphans: auto; text-align: start; text-decoration: none; text-indent: 0.25in; text-size-adjust: auto; text-transform: none; white-space: normal; widows: auto; word-spacing: 0px;"><span style="color: black;">hospital end.<o:p></o:p></span></p><p class="MsoListParagraphCxSpFirst" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -0.25in;"><style class="WebKit-mso-list-quirks-style">
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</style></p><p class="MsoListParagraphCxSpLast" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;">Step 4: Project Peace will work with Street Outreach Workers to make contact.<o:p></o:p></p><p class="MsoListParagraphCxSpLast" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;">November 11, 2020 (A Bernard/L Hatfield/S Priest); Revised: Alexis Nickols/C Reynolds/A Bernard/Julius Johnson 12-17-23</p><p class="MsoListParagraphCxSpLast" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><br /></p><p class="MsoListParagraphCxSpLast" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><o:p></o:p></p><p class="MsoNormal" style="line-height: 15.6933px; margin-left: 1.5in;"><o:p></o:p></p><p class="MsoListParagraphCxSpLast" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><o:p></o:p></p><p class="MsoNormal" style="line-height: 15.6933px; margin-left: 1.5in;"><o:p></o:p></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><o:p></o:p></p><p class="MsoListParagraphCxSpLast" style="line-height: 15.6933px; margin-left: 1.25in; text-indent: 0.5in;"><o:p></o:p></p><style class="WebKit-mso-list-quirks-style">
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</style>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.comtag:blogger.com,1999:blog-3134427918798450002.post-71005549225710420092020-10-20T21:18:00.005-07:002023-12-17T07:27:57.474-08:00Tracheostomy-Bedside in ICU<p> <span></span></p><a name='more'></a><a name="_Toc352655190"><span style="font-family: arial; font-size: small;">Introduction</span></a><p></p><h1><span style="font-family: arial; font-size: small;"><a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/tracheostomy" title="Learn more about Tracheostomy from ScienceDirect's AI-generated Topic Pages"><span color="windowtext" style="text-decoration: none;">A tracheostomy</span></a> is often performed on critically ill patients, those requiring prolonged <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/artificial-respiration" title="Learn more about Artificial Respiration from ScienceDirect's AI-generated Topic Pages"><span color="windowtext" style="text-decoration: none;">mechanical ventilation</span></a> in the intensive care unit (ICU). Bedside tracheostomy is often helpful for avoiding transferring an unstable patient to the OR and/or to help minimize the cost. The aim of this guideline is to standardize and outline the steps necessary to safely perform an open tracheostomy at the bedside in adult ICU patients.</span></h1><h1><span style="font-family: arial; font-size: small;">Policy<o:p></o:p></span></h1><p class="MsoNoSpacing" style="margin-left: 0in; text-indent: 0in;"><span style="font-family: arial;">Blue surgery (trauma and emergency general surgery) may perform open tracheostomy procedures in the intensive care setting with the required staffing, safety procedures and equipment. **Note: <b>The DCN needs 24hrs </b>to make suer the OR tray and DCN are available. </span></p><h1><span style="font-family: arial; font-size: small;"><a name="_Toc352655191">Procedure</a><o:p></o:p></span></h1><p class="MsoListParagraph" style="margin-left: 0.5in; mso-list: l2 level1 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]--><b>1.<span style="font-stretch: normal; font-weight: normal; line-height: normal;"> </span></b><!--[endif]-->Staffing for the tracheostomy must include:<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->a.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Attending blue surgery faculty<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->b.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Blue Surgery assistant x2 (fellow, resident, APP): assist procedure-performing provider<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->c.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Trauma Surgical Services Divisional Charge Nurse (DCN): circulating, and cautery safety ** <b>no patient care, this is a safety supervision role</b>**<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->d.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Respiratory Therapist: airway, ventilator management<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->e.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->ICU nurse: sedation and patient monitoring only<o:p></o:p></span></p><p class="MsoNormal" style="margin-left: 1in;"><span style="font-family: arial;">*Procedures must include <b><u>all </u></b>required staffing in order to proceed. If the DCN is unable to be pulled from staffing, the case cannot proceed.</span></p><p class="MsoListParagraph" style="margin-left: 0.5in; mso-list: l2 level1 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]--><b>2.<span style="font-stretch: normal; font-weight: normal; line-height: normal;"> </span></b><!--[endif]--> Equipment and supplies required: (equipment, trays, consumable supplies)<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->a.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Equipment includes:<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1.5in; mso-list: l2 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><span style="font-family: arial;"><!--[if !supportLists]--><span style="font-stretch: normal; line-height: normal;"> </span>i.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Electrosurgical unit (ESU)<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1.5in; mso-list: l2 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><span style="font-family: arial;"><!--[if !supportLists]--><span style="font-stretch: normal; line-height: normal;"> </span>ii.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Headlights<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1.5in; mso-list: l2 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><span style="font-family: arial;"><!--[if !supportLists]--><span style="font-stretch: normal; line-height: normal;"> </span>iii.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Mayo stand/bedside table x 2<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1.5in; mso-list: l2 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><span style="font-family: arial;"><!--[if !supportLists]--><span style="font-stretch: normal; line-height: normal;"> </span>iv.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Suction w/ suction tubing<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1.5in; mso-list: l2 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><span style="font-family: arial;"><!--[if !supportLists]--><span style="font-stretch: normal; line-height: normal;"> </span>v.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Tracheostomy tray (resident/fellow/APP/DCN to obtain tray from Central Sterile (CS) department)<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->b.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Supplies (Appendix 1)</span></p><p class="MsoListParagraph" style="margin-left: 0.5in; mso-list: l2 level1 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]--><b>3.<span style="font-stretch: normal; font-weight: normal; line-height: normal;"> </span></b><!--[endif]-->Confirm the presence of a completed consent prior to the procedure. Inpatient consents <u>must be done</u> within 48 hours. Refer to policy <a href="https://ukhealthcare.mc.uky.edu/policies/enterprise/_layouts/15/WopiFrame.aspx?sourcedoc=/policies/enterprise/Enterprise/A06-000%20Consent%20to%20Treatment.docx&action=default&DefaultItemOpen=1">#A06-000, Consent to Treatment</a>.</span></p><p class="MsoListParagraph" style="margin-left: 0.5in; mso-list: l2 level1 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]--><b>4.<span style="font-stretch: normal; font-weight: normal; line-height: normal;"> </span></b><!--[endif]-->All sharps and x-ray detectable sponges shall be counted prior to the procedure and upon skin closure in a consistent and visual manner. The DCN will keep a running total of the counted items on the designated count board or a count sheet. All counts are audibly and visually performed by the DCN and the blue surgery assistant or scrubbed team member. Refer to policy <a href="https://ukhealthcare.mc.uky.edu/policies/enterprise/_layouts/15/WopiFrame.aspx?sourcedoc=/policies/enterprise/Enterprise/A08-190%20%20Procedural%20Counts.docx&action=default&DefaultItemOpen=1">#A08-190, Procedural Counts</a>.</span></p><p class="MsoListParagraph" style="margin-left: 0.5in; mso-list: l2 level1 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]--><b>5.<span style="font-stretch: normal; font-weight: normal; line-height: normal;"> </span></b><!--[endif]-->Adhere to proper and safe use of the ESU per UK policy, <a href="https://ukhealthcare.mc.uky.edu/policies/departmental/_layouts/15/WopiFrame.aspx?sourcedoc=/policies/departmental/Perioperative%20Services/OR%2004-03%20Electrosurgery.docx&action=default">#OR 04-03, Electrosurgery</a>. To include safe use of the active electrode, and dispersive electrode during monopolar electrosurgery, and required Electronic Medical Record (EMR) documentation.</span></p><p><span style="font-family: arial;">Caution should be used during surgery on the head and neck when using an active electrode in the presence of a combustible anesthetic gas and oxygen-enriched environments such as the ICU. <b><i>Use the lowest possible concentration of oxygen that provides adequate patient oxygen saturation prior to manipulation of trachea. Note: The respiratory therapist (RT) will pre-oxygenate the patient at 100% FiO2, and sustain the oxygenation at 100% during the dissection. RT will then decrease to 21% FiO2 at the instruction of the provider, if the patient is able to tolerate, once proximity to the trachea is reached. This must happen prior to manipulation of the trachea by tracheal hook, sutures or tracheostomy. </i></b><u># RC08-03 Tracheostomy at beside</u> <b><i><o:p></o:p></i></b></span></p><p class="MsoNormal"><o:p><span style="font-family: arial;"> </span></o:p></p><p class="MsoListParagraph" style="margin-left: 0.5in; mso-list: l2 level1 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]--><b>6.<span style="font-stretch: normal; font-weight: normal; line-height: normal;"> </span></b><!--[endif]-->Follow fire safety measures when electrosurgery is in use according to local, state, and federal regulations, and UK policy <a href="https://ukhealthcare.mc.uky.edu/policies/enterprise/_layouts/15/WopiFrame.aspx?sourcedoc=/policies/enterprise/Enterprise/A10-090%20Surgical%20Fire%20Safety.docx&action=default&DefaultItemOpen=1">#A01-090, Surgical Fire Safety</a>.<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->a.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->The DCN conducts a fire prevention assessment in collaboration with the surgical team, communicates results, and initiates the fire risk protocol accordingly (Appendix 2); documents assessment score in the EMR<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->b.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Verify nonflammable materials (wet towel, sterile water, or saline) are available on the field to extinguish a fire should one occur, and monitor that moistened sponges are used near the active electrode tip<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->c.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Use a water-soluble gel to cover the patient’s facial hair and use water-soluble eye lubricants<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->d.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Adhere to fire safety strategies related to skin prep, policy <a href="https://ukhealthcare.mc.uky.edu/policies/departmental/_layouts/15/WopiFrame.aspx?sourcedoc=/policies/departmental/Perioperative%20Services/OR%2003-06%20Procedural%20Skin%20Prep.docx&action=default&DefaultItemOpen=1=">#OR 03-06, Procedural Skin Prep</a><o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1.5in; mso-list: l2 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><span style="font-family: arial;"><!--[if !supportLists]--><span style="font-stretch: normal; line-height: normal;"> </span>i.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Allow skin antiseptic agents to dry completely before sterile drapes are applied and prior to the use of the ESU<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1.5in; mso-list: l2 level3 lfo2; mso-text-indent-alt: -9.0pt; text-indent: -1.5in;"><span style="font-family: arial;"><!--[if !supportLists]--><span style="font-stretch: normal; line-height: normal;"> </span>ii.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Adhere to manufacturer’s recommendations for dry time of antiseptic agent. Maintain strict adherence to recommended dry time of skin preparation; the DCN to use a timer to measure adequate prep dry time prior to activation of the ESU<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 0.5in; mso-list: l2 level1 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]--><b>7.<span style="font-stretch: normal; font-weight: normal; line-height: normal;"> </span></b><!--[endif]-->Refer to policy <u>#OR 10-02, Smoke Evacuation</u>. The thermal destruction of tissues from the ESU creates a smoke byproduct called plume and must be evacuated with proper smoke evacuation equipment.<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 0.5in; mso-list: l2 level1 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]--><b>8.<span style="font-stretch: normal; font-weight: normal; line-height: normal;"> </span></b><!--[endif]-->Instrument decontamination/sterilization<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->a.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Reusable trays and instrumentation will be covered and transported to the Central Sterile (CS) department for proper cleaning and sterilization as soon as possible after use, by the DCN.<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->b.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->In preparation for transport to the decontamination area, sharp instruments must be segregated from other instruments and confined in a puncture-resistant container; to prevent sharps injury, disposable blades will be used and should be discarded appropriately after sharps counts have been completed at the end of the procedure.<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->c.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Keep instruments moist until cleaned.<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->d.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->Soiled instruments are to be transported to OR CS in a closed, leak-proof container, and identified with biohazard label.<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 0.5in; mso-list: l2 level1 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]--><b>9.<span style="font-stretch: normal; font-weight: normal; line-height: normal;"> </span></b><!--[endif]-->Training and education requirements<o:p></o:p></span></p><p class="MsoListParagraph" style="margin-left: 1in; mso-list: l2 level2 lfo2;"><span style="font-family: arial;"><!--[if !supportLists]-->a.<span style="font-stretch: normal; line-height: normal;"> </span><!--[endif]-->The DCN/APP will complete facility-required education and competency verification activities related to electrosurgery and fire safety/fire reduction strategies, initially and annually thereafter. </span></p><p class="MsoNormal"><b><span style="font-family: arial;">References<o:p></o:p></span></b></p><p class="MsoNormal"><span style="font-family: arial;">Association of periOperative Registered Nurses (AORN). (2020). Guidelines for electrosurgical safety. In: <i>Guidelines for Perioperative Practice</i>. Denver, CO: AORN, Inc.</span></p><p class="MsoNormal"><span style="font-family: arial;">Association of periOperative Registered Nurses (AORN). (2020). Guidelines for environment of care. In: <i>Guidelines for Perioperative Practice</i>. Denver, CO: AORN, Inc.</span><o:p></o:p></p><p class="MsoNormal"><span style="font-family: arial;"><br /></span></p><p class="MsoNormal"><span style="font-family: arial;">Published 10/21/20 (A Bernard/Sue Taylor/Steph Priest/Henrik Berdel); Reviewed 12-17-23</span></p><h1 style="margin-left: 0in; mso-list: l0 level1 lfo1; text-indent: 0in;"></h1><p></p>uktraumaprotocolhttp://www.blogger.com/profile/12883224188596770964noreply@blogger.com