Feb Trauma IEP

1. Trauma Admission Guidelines
M O N R O E C A R E L L J R . C H I L D R E N ’ S H O S P I T A L A T V A N D E R B I L T
Newsletter Date
Volume 4, Issue 2
Pediatric Trauma Service IEP
Special points of
interest:
 Any trauma patient
being admitted to the
PICU, whether from
the PED or the OR,
must be admitted to
the Peds PICU Trauma
Service under the on-
call trauma
attending’s name.
This keeps us in
compliance with ACS
rules and regulations.
 All trauma and burn
transfers must come
through the PED
before being admitted
to the hospital. This
allows the patient to
be triaged by our
activation system and
also allows providers
easy access to
additional radiological
work-up if needed.
The direct admit
process does not
apply to these
patients.
Inside this issue:
PICU Spinal Cord
Injury Admission
Pathway
2
Neurogenic Shock 2
Combined Pediatric
Trauma Response
Guidelines
3-4
Injured patient requiring admission
Patient requires admission to the
ICU (includes those admitted from
the OR)?
Does the patient have a multi-system
injury?
No
Yes
Admit to the Peds PICU Trauma Service
(PTA) under the trauma attending on call
No
Yes
Admit to the Trauma Service under the
trauma attending on call
Is the patient being admitted for
suspicion of abuse and is positive for
injuries/bruising?
No
Yes
Admit to the Trauma Service under the
trauma attending on call
Does the surgical sub-specialty re-
questing admission not admit to their
service (i.e. BURN, ENT, FACE,
NSGY, OPHTHO
Yes
Admit to the Trauma Service under the
trauma attending on call
No
Is the surgical sub-specialty involved
uncomfortable admitting to their
service?
No
Does the patient have a single-system
injury with a severe mechanism of
injury?
Admit to surgical sub-specialty
No
Yes
Admit to the Trauma Service under the
trauma attending on call
Yes
Admit to the Trauma Service under the
trauma attending on call

2. hypothermia.
Decreased systemic vascular resistance results
in relative hypovolemia due to the increased
venous capacity.
Treatment:
The hypotension that results from loss of
autonomic tone can precipitate further
secondary ischemic injury to the spinal cord.
To combat this, it should initially be treated
with crystalloid or colloid fluids until the
team is able to rule out the possibility of
hemorrhage. Hypotension due to
neurogenic shock often requires the addition
of vasopressors since it is often refractory to
Neurogenic shock is classified as a form of
distributive shock but should be used as a
diagnosis of exclusion in the early phases of
trauma resuscitation after hemorrhagic
shock is ruled out. (1)
Symptoms:
Patients classically exhibit hypotension and
relative bradycardia. This bradycardia is
often exacerbated by suctioning, turning,
and hypoxia.
Initially skin is often warm and flushed due
to profound vasodilation. Heat loss may
occur making the patient prone to
fluid resuscitation.
If bradycardia is present, patients may
respond to Atropine, Glycopyrrolate, or
vasoactive infusions with chronotropic,
vasoconstrictor, and inotropic properties
such as Dopamine or Norepinephrine.
Complications:
Complete injuries or higher grade injuries
often lead to more severe neurogenic
shock. In addition, the presence of
neurogenic shock has been shown to lead
to delays in operative management, which
may potentially worsen outcomes as well.
PICU Spinal Cord Injury Admission Pathway
Neurogenic Shock
Page 2
Pediatric Trauma Service IEP
Admission Service/
Attending
Peds PICU Trauma
Service
Trauma attending on call
Spine NSGY ORTHO
Labs CBC QAM (HCT>21%) BMP QAM
Radiological
Studies
MRI total spine Lateral c-spine (post halo
placement)
Monitoring Q1H: VS, Neuro,
Sensation checks
MAP goals x 5 days
<3yr; 60
3-12yr: 70
13-16yr: 75
>16yr: 80
Strict I/O
Normocapnia
Arterial BP monitoring
Accuchecks Q2H
(glucose between 80-
150)
Vasopressors Dopamine Epinephrine Norepinephrine Neosynephrine
Medications Fentanyl Versed Remifentanil
Fluids D5 1/2 NS with 20 mEq
KCL
D5 NS with 20 mEq KCL
Diet NPO (24hr) TF (advance to goal) Diet as tolerated
Activity Bedrest on KenAir
Mattress
Strict log rolling only, HOB flat Turn/reposition Q2H
DVT Prophylaxis SCD in place (on 2hr/
off 2hr)
TED hose in place
Bladder Indwelling catherter x
24-48hr
In and out cath Q6H
Consults PT/OT Speech (swallow) Rehab Services
1. Mack, E. (2013). Neurogenic Shock. The Open Pediatric Medicine Journal, 16-18.

3. With the recent update in trauma center criteria, ACS identified the need define specific response times based on the needs of the patient and
the trauma team. Below are the specific criteria that speaks to these additions:
 Neurotrauma care must be continuously available for all TBI and spinal cord injury patients and must be present and respond within 30
minutes based on institutional-specific criteria (CD 8–2).
 Ortho must be available in the trauma resuscitation area within 30 minutes after consultation has been requested by the surgical trauma
team leader for multiply injured patients (CD 9-7) based on institution-specific criteria.
 Response parameters for consultants addressing time-critical injuries (for example, epidural hematoma, open fractures, and hemodynami-
cally unstable pelvic fractures) must be determined and monitored (CD 5–16).
The Trauma Operational Process Performance Improvement Committee (TOPPIC) worked together in collaboration with their various services
to define our institutional-specific criteria at the end of 2015. The below guidelines are the result of this group’s work. They will be monitored
by our trauma registry and reported out as necessary.
Combined Pediatric Trauma Response Guidelines
Pediatric Trauma Service
1. The Pediatric Trauma Service (attending or fellow) will be available in the resuscitation area within 15 minutes of patient arrival for
Level I trauma activations.
 The attending or fellow serves as the team leader and directs the overall trauma resuscitation. All orders will come from the
team leader during the trauma resuscitation.
 It is expected that the attending or fellow surgeon will be in the emergency department on patient arrival, with adequate
notification from the field. The maximum acceptable response time is 15 minutes for the highest-level activation, tracked from
patient arrival.
 A resident in PGY 3/4 or a PEM attending who is part of the trauma team may be approved to begin initial resuscitation while
awaiting the arrival of the attending surgeon but cannot independently fulfill the responsibilities of, or substitute for, the
attending surgeon or fellow.
 The presence of such a resident or attending emergency physician may allow the attending or fellow surgeon to take call from
outside the hospital.
2. The Pediatric Trauma Service (PGY ≥1) will be available in the resuscitation area within 30 minutes of patient arrival for Level II trauma
activations.
 The PEM attending, PEM fellow, or Trauma senior resident serves as the team leader and directs the overall trauma
resuscitation. All orders will come from the team leader during the trauma resuscitation.
 It is expected that the surgery resident or NP/PA will be in the emergency department on patient arrival, with adequate
notification from the field. The maximum acceptable response time is 30 minutes for the midlevel-level activation, tracked
from patient arrival.
3. The Pediatric Trauma Service (PGY ≥1) will be available in the resuscitation area within 1 hour after consultation has been requested by
the PEM team leader for Level III activations and Trauma consults.
Pediatric Spine Service
1. The Pediatric Spine Service (PGY ≥2 or NP) will be available in the trauma resuscitation area within 30 minutes after consultation has
been requested by the surgical trauma team leader for the following situations:
 Increasing neurologic deficit
 Unstable cervical spine
CONTINUED ON FOLLOWING PAGE...
Page 3
Volume 4, Issue 2

4. Pediatric Neurosurgery Service
1. The Pediatric Neurosurgical Service (PGY 3/4, or NP) will be available in the trauma resuscitation area within 30 minutes after
consultation has been requested by the surgical trauma team leader for the following situations:
 Evidence of increased intracranial pressure as evidenced by a GCS≤8 with:
Unilateral blown pupil OR
Head CT with signs of impending or active herniation
2. The Pediatric Neurosurgical Service (PGY 3/4, or NP) will be available in the trauma resuscitation area within 30 minutes after
consultation has been requested by the surgical trauma team leader for the following situations:
 Acute epidural hematoma (EDH)
The optimal time for addressing EDH cases in need of surgical intervention is within four hours of injury.
The decision to operate on an acute EDH is based on the patient’s GCS score, pupillary exam, comorbidities, CT findings,
age, and, in delayed decisions, the patient’s ICP. Neurological deterioration over time is also an important factor
influencing the decision to operate.
Consultation should take place once a head CT has been obtained or uploaded from an outside facility.
 Acute subdural hematoma (SDH)
The optimal time for addressing SDH cases in need of surgical intervention is within four hours of injury.
The decision to operate on an acute SDH is based on the patient’s GCS score, pupillary exam, comorbidities, CT findings,
age, and, in delayed decisions, the patient’s ICP. Neurological deterioration over time is also an important factor
influencing the decision to operate.
Consultation should take place once a head CT has been obtained or uploaded from an outside facility.
Pediatric Orthopaedic Service
1. The Pediatric Orthopaedic Service (PGY2/3) will be available in the trauma resuscitation area within 30 minutes after consultation has
been requested by the surgical trauma team leader for the following situations:
 Acute limb compartment syndrome
 Pulseless extremity
2. The Pediatric Orthopaedic Service (PGY2/3) will be available in the trauma resuscitation area within 1 hour after consultation has been
requested by the surgical trauma team leader for the following situations:
 Open fractures
All open fractures irrespective of type require urgent irrigation and debridement (I&D). The optimal time for addressing
these cases is within eight hours from injury. If the patient cannot be taken to the OR within eight hours of injury due to
problems with clearance by trauma surgery or neurosurgery, a preliminary I&D will be performed at the bedside to decrease
the amount of gross contamination. Once medical clearance is obtained, the patient will then be taken to the Operating
Room for I&D of the open fracture.
The Orthopaedic resident on-call is responsible for performing the bedside I&D of the open fracture as well as splinting the
fracture for stabilization.
Antibiotics will be initiated by the resident per protocol.
 Hemodynamic instability related to long bone or pelvic fractures
Consultation should take place once fluid resuscitation has been initiated by the Pediatric Trauma Service.
Pediatric Surgical Specialties (ALL)
1. All surgical specialties will be available in the trauma resuscitation area within 30 minutes after consultation has been requested by the
surgical team leader for patients whose condition deteriorates.
Monroe Carell Jr. Children’s Hospital at Vanderbilt