Children s Trauma Center

Transcription

1 Children s Trauma Center PEDIATRIC TRAUMA MANUAL 2014 Department of Surgery Division of Pediatric Surgery Virginia Commonwealth University Health System

2 TABLE OF CONTENTS Part I- General Information Introduction Mission Statement Definition: Pediatric Trauma Patient Pediatric Trauma Service Organization Attendings Resident Staff Conferences Pediatric Trauma Program Manager Pediatric Trauma Information Coordinator Pediatric Trauma Response Important Contact Information Part II- ED Policy/Procedure Pediatric Trauma Team Activation Criteria Pediatric Trauma Team Activation Notification Pediatric Trauma Team Activation Personnel Response and Duties Pediatric Trauma Team Activation Studies Operating Room Massive Transfusion Protocol Pediatric Trauma Admission Policy Non-Surgical Admissions Policy Non-Accidental Trauma Consultation and Admission Policy PART III- Specific ED Management Two Tier Pediatric Trauma Team Alert Response Trauma Team Roles and Responsibilities Cervical Spine Clearance Adult and Pediatric Trauma Patient Arrival Communication Pediatric Trauma Patient Admission Pediatric Trauma Transfer Patient Evaluation and Admission Pediatric Trauma Alert Patient Evaluation in the Emergency Department Tetanus Prophylaxis and Immunization management Open fracture antibiotic guidelines Open skull fracture antibiotic guidelines Pediatric Massive Transfusion Protocol Surgical evaluation of non-accidental trauma in the ED Part IV- Inpatient Management Blunt Solid Organ Injury Management (non-operative) Solid organ injury grading scales Nursing Care of the patient in a rigid cervical collar. Screening, Brief Intervention and Referral to Treatment

3 Part V- Traumatic Brain Injury Closed Head Injury Management Repeat Inpatient Head Imaging Guidelines Catastrophic Head Injury Guidelines Pediatric Brain Death Guidelines Part VI Burn and Inhalation Evans-Haynes Burn Center Pediatric Inhalation Injury Part VII- Performance Improvement Quality Improvement and Monitoring Plan Definitions of PI levels of review Part VIII- Injury Prevention Safe Kids Virginia Child Safety Seat Resources Injury and Violence Prevention Program (IVPP) Part IX-Research

4 PART I- General Information Introduction Welcome to the Pediatric Trauma Service, the patient care component of Children s Trauma Center at VCU. As the only Level 1 Trauma Center in Central Virginia, we care for over 450 pediatric inpatient admissions annually and see many more in consultation. While this manual principally addresses direct patient care, Children s Trauma Center is actively involved in prevention, research, outreach and education as described in our Mission Statement. MISSION The Children s Trauma Center at Children s Hospital of Richmond at VCU will provide optimal resources and outcomes for all traumatically injured children in Central Virginia and beyond and will be a leader in injury prevention, research, education and advocacy. Definition: Pediatric Trauma Patient As a Children s Hospital within a Hospital, with a combined Level 1 pediatric and adult trauma center, we must define the pediatric trauma patient by age. The Pediatric Trauma Service will manage all children aged 14 years and younger. Patients aged 15 years and older will be managed by the Acute Care Surgery service. Please see below for organization of the Service and patient response Pediatric Trauma Service Organization The Pediatric Trauma Service is continually staffed by a Pediatric Trauma Attending, a Pediatric Surgery Chief Resident and a Pediatric Surgery Junior Resident. In addition, there may be an Intern, Acting Intern, and medical students on the Service. Pediatric Trauma Attending The Pediatric Trauma Service will be covered weekdays by the Pediatric Surgeon who is operating that day at VCUHS. While this may vary according to vacations and away times, in general the coverage on weekdays from 7AM- 4 PM will be: Monday- Dr. Patricia Lange Tuesday- Dr. Charles Bagwell Wednesday- Dr. Claudio Oiticica Thursday- Dr. David Lanning Friday- Dr. Jeffrey Haynes Please note that a continuously updated, day to day as well as monthly list of which Attending is on call for a given day and night, as well as a trauma backup Attending name, is available on the paging website on the hospital Intranet. These Attendings will be responsible for all trauma consultations, decisions and rounding during this time. After 4 PM weekdays until the following morning as well as on weekends, the Pediatric Trauma Service will be covered by the Pediatric Surgery Attending on call. This roster is instantly available on the paging website on the hospital intranet under ON CALL. In the unlikely event the attending on call does not respond or is not immediately available, the TRAUMA BACKUP Pediatric Surgery Attending as listed on the schedule should be contacted. All contacts are on the same intranet roster as well as listed below under Important Phone Numbers. The Trauma Attending will conduct daily bedside rounds on all pediatric trauma patients with available housestaff. Resident Staff

5 Chief Resident- the pediatric surgery chief resident (PGY-4) has final resident level authority for the pediatric trauma service patients. During the day, he is responsible for response to pediatric trauma in the ED as patient status and condition mandate. In the event of a less severely injured patient, he may delegate initial response to the junior resident, but must personally follow up on all consultations/admissions. See below for further information under Pediatric Trauma Response. The Chief Resident is responsible for conveying all information to the Pediatric Trauma Attending in a timely fashion unless delegated specifically to the junior resident. The Attending must be made aware of all DELTA alerts immediately and all ECHO alerts as patient condition mandates but generally within one hour. The Chief Resident is responsible for making daily rounds on all pediatric trauma patients, formulating treatment plans, and conveying them to the Attending on daily trauma rounds. The Chief Resident will be responsible for presenting cases at the pediatric surgical conference on the 1 st, 2 nd and 3 rd Wednesdays of the month at 4:30pm in Sanger 8. These may be trauma related or otherwise. He may assign presentations to junior residents. At a minimum a topic in pediatric trauma will be presented by the Chief Resident quarterly and will form the basis of the Internal Education Program, moderated by Dr. Haynes (see below). The Chief Resident is responsible for notifying all service staff, to include the Pediatric Trauma Nurse Coordinator, when the time for daily Attending rounds has been set. Junior Resident/Intern-The junior resident and or intern is responsible for responding to the ED during the day for pediatric trauma consultation. In the event of a DELTA or ECHO alert, he is to respond but is to also notify the Chief Resident of this response if the Chief is not already aware. He will relay all patient data and formulate the plan and convey it to the Chief Resident or Attending. The Junior Resident is responsible on the inpatient units for all minute to minute patient needs and the execution of plans made on rounds or at admission. He will notify senior housestaff and or the Attending as needed. He will attend daily Pediatric Trauma Rounds. He is responsible for all chart documentation to include history and physicals, consultations if seen and discharge summaries. All must be done in a timely fashion in compliance with hospital regulations Medical Students-During their rotation on the Pediatric Trauma Service, medical students are strongly encouraged to participate in all service related activities to include rounding, operating, responding to the ED for trauma consultation. If desired, they may have their pager placed on the Telepage list to receive Pediatric DELTA and ECHO Trauma Team alerts. Conferences The Pediatric Trauma Service will participate in all Departmental conferences to include Grand Rounds Thursdays at 7AM as well as a Death and Complications Conference to follow at 8AM. Selected trauma complications may be selected for Departmental discussion here. The Quarterly joint Pediatric Trauma conference takes place the 4 th Wednesday each quarter. Audience includes Peds Surgeons, Acute Care Surgeons, Peds EM, and nursing. The topic is inspired by Dr. Haynes from the PI Program. Nursing CE hours are available PTCC- Q3rd Wednesday monthly MAC- level 3 reviews, all deaths, system issues

6 Children s Trauma Center Staff Pediatric Trauma Medical Director - Dr. Jeffrey H. Haynes. Dr. Haynes is responsible for all aspects of the Pediatric Trauma Program. Clinical care is a shared responsibility between all of the pediatric surgeons. Any concerns regarding patient care, existing management recommendations, performance improvement issues, research or education should be brought to the attention of Dr. Haynes or Kelley Rumsey (see below). Pediatric Trauma Program Manager- The Pediatric Trauma Program Manager is Kelley Rumsey, MS, RN. She is responsible for all day to day administrative activities of the Children s Trauma Center. She should be paged daily for Attending Rounds. While clinical care of the pediatric trauma patient remains a resident responsibility, it is a team effort and any unmet needs of the patient will be handled in a collaborative fashion. The Pediatric Trauma Program Manager will frequently work with the resident staff to ensure these clinical needs are met. Pediatric Trauma Information Coordinator-The Pediatric Trauma Information Coordinator is a person who will be responsible for abstracting all patient data into the database as well as report generation from the trauma registry. This person will implement the Performance Improvement plan for pediatric trauma, assuring that all issues identified have been seen through to resolution. Should a research project or other query arise, the information coordinator or Dr. Haynes will be glad to discuss obtaining patient data from the extensive pediatric trauma database. Injury Prevention Coordinator- The Injury Prevention Coordinator is Corri Miller-Hobbs, BSN, RN. Children s Hospital of Richmond at VCU is the lead agency for Safe Kids Virginia. Ms. Miller-Hobbs is the state wide coordinator for Safe Kids Virginia. She leads a wide range of injury prevention activities focused on unintentional injuries in children aged 14 years and younger. This includes outreach, education and advocacy. Pediatric Trauma Response The vast majority of pediatric trauma patients will arrive either to the Trauma Resuscitation room in the event of DELTA/ECHO alerts or to the pediatric ED in less acutely injured patients. At present, all trauma transfers must go through an ED. As we are an adult and pediatric trauma center as well as a general surgery training program with resident work hour constraints, pediatric trauma ED response will depend on patient status as well as time of day. Pediatric Trauma response to DELTA/ECHO alerts will be fully delineated below under ED procedures. As a framework however the following general rules apply: ALL DELTA/ECHO ALERTS (criteria reviewed below) Attendings: Our Level 1 Trauma Center status is dependent on having on-site attendings to respond to these alerts 24/7. Accordingly, this function is carried out by the Acute Care surgical attendings on site who have privileges in pediatric trauma resuscitation. They will respond to all DELTA alerts regardless of time of day. ECHO alerts will be covered by the Pediatric Trauma Surgeon during weekday hours of 7AM- 4PM. Outside these hours, the Acute Care Surgeons will be the first responder. Once initial assessment of the patient is made, the Pediatric Trauma Surgeon will be contacted in a timely fashion depending on patient condition to assume management of the patient, unless they are already on site. Resident Staff: Again this coverage varies due to work hour restrictions. During weekdays, the resident assigned to the Acute Care Surgery staff will respond to all DELTA/ECHO alerts. That resident will contact the Pediatric Surgery Chief Resident once initial evaluation is done. The Pediatric Surgical Chief Resident will then

7 ensure immediate response to the trauma room personally or will delegate as the situation permits. In all cases of DELTA/ECHO alerts, the Pediatric Surgery Attending will be notified in a timely fashion. At night/weekends, the trauma resident on call will perform the above functions and will contact the Pediatric Surgery Attending on call in a timely fashion as patient condition mandates. Less severely injured patients will usually be triaged directly to the Pediatric ED for evaluation. Pediatric Trauma Consultation will be called by the Pediatric ED Attending. During the day, the Pediatric Surgery Junior Resident will respond to this consultation in such stable patients and promptly discuss the case with the Chief Resident or Attending. After hours, the trauma resident on call will see such consultations and discuss with the Pediatric Surgery Attending on call Important Contact Information Division of Pediatric Surgery Charles Bagwell MD Main Office Number Pager #3965 Cell Sanger Hall 8 th Floor Jeffrey Haynes MD Pager # 3242 Cell Rochelle Murtaza Claudio Oiticica MD Divisional Coordinator Pager # 3124 Cell David Lanning MD Nancy Thompson MS RN Pager #3099 Cell Nurse Practitioner Patty Lange MD Pager 2697 Pager #3562 Cell Cell Children s Trauma Center Kelley Rumsey MS, RN, CEN Corri Miller-Hobbs, BS, RN Pediatric Trauma Program Coordinator Safe Kids Virginia, Program Coordinator Pager 2133 Cell Office West Hospital, 4 th floor Office cmillerhobbs@mcvh-vcu.edu Office Sanger Hall 8 th floor P: (804) krumsey@mcvh-vcu.edu F: (804) Other Contacts Telepage PICU Blood Bank: PCU(Progressive Care Unit) CE Pediatric ED: E Trauma Room CW

8 PART II ED Policies and Procedures Pediatric Trauma Team Activation Criteria Pediatric Trauma Team Activation is a two tiered system based on set physiologic, anatomic, and mechanistic criteria, or at physician discretion. DELTA alerts are of the highest order while ECHO alerts are the next tier down. Activation Criteria as well as expected response times are outlined in the Pediatric Trauma Team Activation Document (see Appendix A). Among other functions, it is essential for participating physicians to sign in with time of their arrival as this parameter is tracked in the PIPS process as well as appropriate level of triage or level of alert. Pediatric Trauma Team Activation Notification Upon receipt of a pre-hospital report of an injured child, the Communication Room will reference DELTA/ECHO criteria and activate a level accordingly. A call will be placed to Telepage and a page will be placed to all members of the Pediatric Trauma Team with the following information: -age of patient -mechanism of injury -estimated time of arrival (ETA) Additionally, the Communication Room Staff will directly notify the Pediatric ED Attending as well as the on-site Acute Care Surgery Attending and associated Trauma Room Nursing Staff. Pediatric Trauma Team Activation Personnel Response and Duties The following diagram gives the general layout of responders around the arriving pediatric trauma patient as well as their responsibilities. These responders include: a) Trauma Attending b) Trauma Senior Resident c) Trauma Resident d) Pediatric Emergency Department Attending e) Emergency Medicine Resident f) Anesthesia Staff g) 2 ED Nurses; one from the Pediatric ED h) Registration clerk i) Radiology technician Ancillary Staff also available: a) Respiratory Therapist b) CT Scan technician c) Chaplain d) Social worker

9 Pediatric Trauma Team Activation Studies Laboratory studies drawn immediately may consist of: ABG with Hemoglobin and Lactate Type and Screen (x2) CBC and platelets Basic Metabolic Panel and LFT s, Lipase, Amylase PT/PTT/INR if clinically indicated or head injury ETOH/Drugs of abuse in children 12 years Pregnacy test if female of childbearing age XRAY Studies performed immediately may include: CXR Pelvis Xray if clinically indicated FAST in selected patients if clinically indicated Power Plans/ ordersets are being developed within Cerner for reference. Blood Bank/Massive Transfusion Protocol MTP in Cerner notifies the Blood Bank in lieu of an alert; a direct call to the blood bank is then made if the Massive Transfusion Protocol is clinically indicated.the Trauma Attending or Chief Resident are responsible for the decision to activate the Massive Transfusion Protocol. See Massive Transfusion Protocol Operating Room As a Level 1 Trauma Center, an operating room and team are always immediately available for care of the injured patient. The operating room will be notified of this need by phone as soon as it is known. The operating room will then prepare the OR suite and staff and notify anesthesia immediately. Additional direct anesthesia communication will occur by the anesthesia staff responding to the trauma team alert. Pediatric Trauma Admission Policy With few exceptions as outlined below, all pediatric trauma patients will be admitted to a surgical service. All poly-trauma patients will be admitted to the Pediatric Surgical Service with consultants as needed. Single system injury patients may be admitted to a specialty surgical service; consultation/clearance by Pediatric Surgery to confirm that this is indeed a single system injury can be requested by the pediatric ED staff during their evaluation as indicated. Examples: -An isolated forearm fracture may be admitted to Pediatric Orthopaedic Surgery. -A complex dog bite may be admitted to Plastic Surgery. -All burns will be admitted to Burn Surgery. Pediatric ICU (PICU) Trauma Admission Policy All pediatric trauma patients requiring admission to the PICU will be admitted to a surgical service, with PICU consultation as appropriate. Please see PICU Trauma Admission Policy: -All poly-trauma will be admitted to Pediatric Surgery -All burns will be admitted to Burn Surgery. -All isolated surgical head injuries will be admitted to Pediatric Neurosurgery or Pediatric Surgery if PICU admission is deemed necessary; poly-trauma in this group will be admitted to Pediatric Surgery with consultants as appropriate.

10 Non- Surgical Trauma Admissions The only approved pathway for a pediatric trauma admission to a non-surgical service is the isolated, non-surgical traumatic brain injury (concussions), after neurosurgical consultation. (Please see Isolated TBI Policy). These patients will be evaluated in the Peds ED and if their workup reveals an isolated TBI and admission is contemplated, Pediatric Neurosurgical consultation will be requested prior to admission. Additionally, if there is any suspicion of physical abuse, Pediatric Surgical Consultation will also be mandatory. If the surgical consultants clear the patient, they may be admitted for observation to the Pediatric Service with inpatient consultant follow-up. All charts of such patients are reviewed by the Pediatric Trauma Medical Director on a quarterly basis for appropriate management and compliance with this policy. Any deviation is further reviewed through the PIPS process and documented accordingly. Non-Accidental Trauma Consultation and Admission Suspected Non-Accidental Traumatic Brain Injuries may also be evaluated and admitted after surgical clearance as above. Additionally, any child evaluated in the peds ED and found to have suspicion of trauma to more than one system of a non-accidental nature will receive a mandatory Pediatric Surgical Consult for poly-trauma. If poly-trauma is found and admission is deemed necessary, the child will be placed on Pediatric Surgery service with pediatric and Child Protective Team Consultation as appropriate. Child Protection Team The Child Protection Team consists of physicians, nurses, nurse practitioners and social workers experienced in the field of child abuse and neglect. The team evaluates, diagnoses, and treats children who have been sexually or physically abused or neglected. The team works in cooperation with Child Protective Services and law enforcement to ensure the safety and wellbeing of our community s children. The team is available for consultations and may be contacted through the Pediatric Emergency Department. The Medical Director for the Child Protection Team is Dr. Robin Foster, Director of the Pediatric Emergency Department. Coping with Stress Reactions to Traumatic Events Working with children who have been seriously injured may evoke a strong emotional response among care providers. Stress is one of the greatest challenges threatening healthcare workers today. Stress negatively impacts our physical and emotional health; our performance, growth and contributes to burnout. Almost all people experience stress reactions to traumatic events, but most do not develop long-term disorders like PTSD. VCU Health System offers HELPLINK Employee Assistance Program for staff to address these stressful situations. Facilitated group debriefings or individual counseling is available to those who have a need. Debriefings may be coordinated by contacting the Pediatric Trauma Program Coordinator or EAP directly at

11 PART III- Specific ED Management Protocols A. Pediatric Trauma Team Alert Classification and Criteria Children s Trauma Center POLICY POLICY NUMBER: SUBJECT: Two Tier Pediatric Trauma Team Alert Response PURPOSE: Define patient guidelines for activation of Pediatric Trauma Team. PEDIATRIC TRAUMA TEAM ACTIVATION FOR PATIENTS 14 YEARS OF AGE AND YOUNGER Upon notification by prehospital care provider and/or identification that an injured patient meets Trauma Team Activation guidelines, the Communication room Medic/Nurse and/or Emergency Medicine Physician will implement the following: Contact the hospital page operator (telecommunications) at ext # *50, request a Trauma Team Activation and specify DELTA or ECHO ", based upon patient criteria and give the following information: 1) Age of patient 2) Mechanism of injury(e.g. burn, MVC, Struck by vehicle) 3) Estimated time of arrival The General/Trauma Surgeon will receive an alpha/numeric page and all other team members will receive a numeric page indicating a DELTA (11111) or ECHO (22222) Alert. DELTA TRAUMA TEAM ALERT: Tier I ALERT: 1. The Communications Room or Emergency Medicine Physician will activate the trauma team for a DELTA Alert - If prehospital care providers report or the patient presents to the Emergency Department with any of the following: Patient Status -Hypotension, age specific: Age 0-1: SBP < 60 mmhg Age 2-5: SBP < 70 mmhg Age 6-12: SBP < 80 mmhg Age > 12: SBP < 90 mmhg -Requiring fluid or blood to maintain SBP -Respiratory Compromise or Intubation: Age 0-1 RR: < 20 or > 40 Age 2-5 RR: < 20 or > 35

12 Age 6-12 RR: < 15 or > 30 Age > 12 RR: < 10 or > 30 -GCS 8 or less -EM Physician or Surgeon discretion Patient Injury -Any penetrating injury (BB, GSW, stab) to head, neck, chest or abdomen, regardless of hemodynamic status. -Flail Chest -Paralysis -Fractures: two or more proximal long bone -Burns greater than 15% TBSA -Inhalation Injury -Threatened limb or complete/partial amputation proximal to wrist/ankle Mechanism of Injury -EM physician or Surgeon discretion 2. Telecommunications will be responsible for activating the Trauma Team: DELTA Alert: Group Beeper: (Process of activation of Trauma Call Group) and Attending General Surgery/Trauma Surgeon (on call) - (see Trauma Call Calendar) 3. All team members alerted will respond immediately (within 15 minutes of notification) to Trauma Resuscitation Room. 4. Any patient presenting via the Pediatric Emergency Department Ambulatory entrance meeting DELTA alert criteria will be immediately transported to the Trauma Resuscitation Bay for complete evaluation. ECHO TRAUMA TEAM ALERT: Tier II ALERT: 1. The Communications Medic/Nurse or Emergency Medicine Physician will activate the trauma team for a ECHO Alert - If prehospital care providers report or the patient presents to the Emergency Department with any of the following(and the patient does not fit the guidelines for a DELTA Alert: Patient Status -GCS between 9 and 12 -Initial age specific hypotension responsive and stable after 20cc/kg isotonic fluid(not blood) -EM Physician or Surgeon discretion Patient Injury -Pelvic fracture -Open or depressed skull fracture, GCS 10 or greater -Combination burns and trauma -Any burn (thermal, chemical) 10% -15% TBSA -High voltage electrical burns (60mA of AC or mA of DC), including lightening injury.

13 -EM Physician or Surgeon discretion Mechanism of Injury -High Risk MVC: - > 40 MPH -Intrusion > 12 inches into passenger compartment -Ejection or Rollover -Death in same vehicle -Falls: 10 feet or 2-3 times height of child -Pedestrian or bicyclist vs Car: thrown, run over or significant impact (> 20 MPH, if speed is known) -Motorcycle/ATV crash > 20 MPH -GSW to extremities proximal to hands or feet. -EM physician or Surgeon discretion 2. Telecommunications will be responsible for activating the ECHO Trauma Team Alert: Group Beeper: (Process of activation of Trauma Call Group) and Attending General Surgery/Trauma Surgeon (on call) - (see Trauma Call Calendar) Additionally, the Pediatric Surgical Attending will be notified of ECHO alerts M-F from 7AM-4PM and will direct the workup. If not immediately available, the General/Trauma Surgeon will initiate treatment until the Pediatric Surgeon responds. 3. All team members alerted will respond immediately to Trauma Resuscitation Room. Attending General Surgery/Trauma Surgeon on call will be alerted for all Trauma Team Activations, but will respond to Trauma Resuscitation Room within 15 minutes of notification for DELTA ALERTS and upon request of other Trauma Team Members for ECHO ALERTS. As stated above the Pediatric Surgeon on call will respond to ECHO alerts and direct the workup M-F from 7AM -4PM. 4. Any patient presenting via the Pediatric Emergency Department Ambulatory entrance meeting ECHO alert criteria will be immediately transported to the Trauma Resuscitation Bay for complete evaluation. Reference: Committee on Trauma American College of Surgeons.(2014). Resources for Optimal Care of the Injured Patient: Author: Chicago, IL. Pediatric Trauma PC Committee Approval Date: Effective Date: Pediatric Trauma Medical Director: Signature on file Pediatric Trauma Program Coordinator: Signature on file Last Revision: 9/18/13 Annual Review:

14 TRAUMA SERVICE OPERATIONAL POLICIES NUMBER: SUBJECT: Trauma Team Roles and Responsibilities PURPOSE: To define the roles and responsibilities of personnel responding to a Trauma Activation, emphasizing clear, organized communication and team function. POLICY: A multidisciplinary team is notified to respond to the Emergency Department when a patient meets Delta or Echo trauma activation criteria. Each member of the team has specific roles and responsibilities. Through this organized approach, optimal care will be provided to the critically injured patient. I. General Principles A. Leadership: Good communication and leadership are keys to well-organized and efficient trauma resuscitations. It is imperative for the trauma team leader to ensure effective communication before, during, and after resuscitation. B. All PRIMARY Trauma Team members must report to the documenting nurse so that he/she can document the team member s time of arrival to the trauma. C. Noise Control: Individual conversations will not be permitted in the trauma resuscitation area. One voice should be heard by the entire trauma team. NO ONE should be talking while EMS is giving report. D. Pre-Brief: Prior to the patient arriving, a pre-brief is to be performed. This may be initiated by the Trauma Team Leader or the Recording Nurse. The pre-brief consists of the introduction of the team members (name, role, discipline) and concludes with a summary of available patient information and plan of care by the trauma Team Leader. E. Personal protective equipment (PPE): Individuals working inside the patient care zone of the resuscitation area or who have the potential for direct patient contact MUST OBSERVE STANDARD PRECAUTIONS and wear PPE. This geer consists of 1. Gown 2. Gloves 3. Head cover 4. Mask/eye shield

15 5. Shoe covers F. Sterile Procedures: Sterile technique should be used for all sterile procedures (e.g. chest tube and central line insertions, thoracotomy) and personnel should use sterile gloves, gowns, and drapes. II. Primary Trauma Resuscitation Team/Personnel and Responsibilities The Primary Trauma Team is involved in direct patient care A. EMS Personnel 1. Transports patient into the trauma/resuscitation area. 2. To the ENTIRE TRAUMA TEAM, gives a brief (30 seconds) report of the patient (Mechanism of injury, injuries identified, vital signs en route or changes in VS, procedures performed in the field). 3. Transfers patient to the ED stretcher and immediately steps back out of the primary care of the patient. 4. Further information (e.g. past medical history, allergies, family information) should be communicated in a quiet 1:1 report to the recording nurse as time/situation permits. B. Trauma Team Leader Trauma Senior/PGY 4 or 5 1. Stands at the foot of the bed. 2. Directs the overall resuscitation. 3. Responsible for the majority of the communication during the resuscitation. 4. Assumes responsibility for major invasive procedures and assists Trauma Attending as directed (e.g. central lines, chest tubes, thoracotomy). C. Trauma Attending 1. Must be present within 15 minutes of patient arrival for all Delta trauma activations. The trauma attending must see any echo trauma activations within 3 hours of patient arrival. 2. Assumes overall responsibility for the resuscitation and for supervising the Trauma Team Leader. 3. Serves as the triage officer responsible for directing flow of multiple patients to the OR, CT or inpatient units. 4. Remains in close communication with the STICU or OR charge nurses for bed allocation. D. Emergency Medicine Attending For Pediatric Trauma Activations, the Emergency Medicine Attending will be from Pediatric Emergency Medicine 1. Stands at the Head of the Bed a. May remain at the foot of the bed for echo trauma activations unless there is concern for need of airway management. 2. Responsible for supervising the Emergency Medicine Resident during the Primary Assessment of the airway. 3. Supervises or assumes management of the airway. 4. Supervises the initial assessment and management of ECHO trauma activations until the Trauma Attending arrives. 5. Assumes the role of the Trauma Attending when the Trauma Attending is not

16 available or in situations of multiple traumas. 6. Responsible for the EM Attending Trauma Note. E. Emergency Medicine Resident 1. Stands at the Head of the Bed. 2. Responsible for the primary assessment of the airway. 3. Performs the Neurological and HEENT component of the Secondary Assessment. 4. Obtains AMPLE history at the completion of the secondary assessment of the patient. 5. May be asked to manage/control bleeding from the scalp/head. 6. In the case of multiple traumas, may be asked to perform the primary and secondary survey of the patient. 7. Documents any procedures performed (e.g. intubation). F. Anesthesia 1. A resident (PGY3 or above) will respond to all delta and echo trauma activations a. Anesthesia attending will also respond to all Delta Traumas, if available. If the Anesthesia attending is present, they may assume responsibility for directing airway b. Prompt notification of the anesthesia attending if concerns of an echo trauma activation needing airway management 2. Stands at the head of the bed. a. Provides direction to the EM resident, in collaboration with the EM attending for appropriate ventilation, RSI medications and doses or use of alternative airways. b. An initial intubation attempt may be performed by the EM resident under the supervision of the EM attending and in collaboration with the anesthesia team. c. Any further attempts at intubation/securing the airway should be performed at the direction of the anesthesia team. 3. Remains available to the trauma team for airway management until released by the Trauma Attending. 4. Assumes management of the difficult airway (see separate policy). 5. Assists with communication to OR and anesthesia staff of potential need for OR. G. Junior Surgical Resident or EM2 rotating on the Trauma Service 1. Stands on the left side of the patient. 2. Completes the primary assessment (breathing & circulation). 3. Performs the secondary assessment (with the exception of the head and neck). 4. Performs procedures on the left side of the patient. 5. Assists SOCOM medics when they are rotating on Trauma Service. 6. Determines the medical plan of care in conjunction with the Trauma Team Leader and ensures communication to all involved caregivers. 7. Travels with the patient to CT, etc. 8. Obtains and is responsible for the follow through of any necessary consults.

17 9. Responsible for keeping the Trauma Attending, EM Attending and Senior Resident informed of patient s condition and any diagnostic findings. 10. Responsible for completion of the Trauma H&P. H. Surgical Intern or Medical Student rotating on the Trauma Service 1. Stands on the RIGHT side of the patient. 2. Assists with the secondary assessment. 3. Performs/assists with procedures on the right side of the patient. I. Respiratory Therapist 1. Responds to all DELTA trauma activations. 2. Ensures airway equipment, including mechanical ventilator, are ready for use. 3. Assists with airway management as required. 4. Monitors intubated patient s ventilator requirements. 5. Travels with the intubated patient to CT scan/or/inpatient units. J. Emergency Department Nurses (2) One will be the primary nurse and one will be the recording nurse. Two nurses will respond to all trauma activations. For ECHO activations, once the primary assessment has been completed and it is determined that the patient is stable or with no significant injuries, the second nurse may be released. For pediatric traumas, the Primary Nurse will be a nurse from the Pediatric ED. The second nurse may be a nurse from the Pediatric ED or the Adult ED 1. Primary Nurse a. Stands on the LEFT side of the patient. b. Places the patient on the monitor (SaO 2, EtCO 2, ECG, BP). c. Obtains peripheral IV s if not established by the prehospital providers. d. Assists in obtaining labs. e. Administers medications as ordered. f. Responsible for ongoing patient assessment. g. Accompanies patient to CT scan or other diagnostic areas. h. Responsible for placement of ID band. i. Places gastric tube and/or urinary catheters as ordered or delegates to the Trauma Tech or Patient Care Tech. 2. Recording Nurse/Scribe a. Initiates the TEAM PRE-BRIEF prior to patient arrival. b. Assists in crowd control and coordination of communication with the ancillary staff. c. Responsible for the documentation of team members present. d. Responsible for keeping a written record of the resuscitation on the trauma flow sheet. e. Assists with retrieval of equipment needed by the trauma team. f. Assists with sending blood/urine specimens to the lab. g. Calls pre-report to the receiving unit (e.g. OR as patient is leaving the trauma bay; ICU as patient is leaving for CT scan). K. Emergency Department Trauma Tech (Medic) 1. Stands on the right side of the patient.

18 III. 2. Obtains a manual blood pressure 3. Assists with placing patient on cardiac monitor (SaO 2, EtCO 2, ECG, BP). 4. Assists with establishing IV access when required. 5. Assists with obtaining labs when needed. 6. Assists with exposing the patient. 7. Assists with procedures as appropriate. 8. Assists with obtaining equipment needed for patient care. 9. Accompanies stable patients to CT scan and assists with transport to OR, ICU, etc. L. Patient Care Tech 1. Remains at the foot of the bed near the recording nurse. 2. Assists with exposure of the patient by removing shoes, socks and pants. 3. Assists with retrieving equipment and supplies for the trauma team. 4. Prepares the transport monitor PRIOR to patient arrival and places the patient on the transport monitor as soon as the secondary assessment is completed (under the direction of the primary or recording nurse). 5. Assists with transporting patients to CT scan/or/inpatient areas. M. Radiology tech 1. MUST comply with standard precautions. 2. Places x-ray film on stretcher prior to patient arrival for chest x-ray. 3. Remains near foot of bed until directed by Trauma Team Leader to obtain. Ancillary Support Staff: Ancillary staff respond to the trauma but remain outside the room until needed for direct patient contact. A. Respiratory Therapist 1. For ECHO trauma activations, remains on standby to respond when needed. 2. Assists with any ongoing airway or ventilator management of the trauma patient. B. Emergency Department Registration Clerk 1. Obtains any demographic information available and completes the patient registration. 2. Ensures that the patient ID band, labels and face sheet are delivered to the recording nurse. 3. AT NO TIME should the gathering of said information interrupt any part of the resuscitation. C. Social Worker 1. Responsible for notifying of next of kin. 2. Assists the team with any social issues that may be present. D. Chaplain 1. Assists with notification of next of kin. 2. Provides psychosocial support to patients, families and the trauma team. E. Trauma Nurse Practitioner 1. Responds to trauma activations when multiple patients are arriving simultaneously or when residents and interns may be in the OR. 2. Functions in the role of junior resident or intern, performing components of the primary and secondary assessment.

19 IV. 3. Performs or assists with procedures as indicated or delegated by the Trauma Team Leader or Trauma Attending. F. Trauma Case Manager 1. Responds to trauma activations whenever possible. 2. Assists with crowd control and communication. 3. May assume responsibility for the role of documenting nurse when necessary or in the case of multiple traumas arriving simultaneously. 4. Assists with retrieving supplies when necessary. 5. May assist with transporting patients to CT or other areas in the case of multiple traumas. G. Blood Bank notified of the incoming trauma but personnel do not respond to the ED H. Operating Room 1. Notified of incoming trauma but personnel do not respond to the ED. 2. Physicians utilize the red phone to let operating room staff know of trauma patients requiring immediate operative care. A brief report of the patient s status should be given using SBAR. Always notify the OR prior to leaving any resuscitation area with the patient. I. Security 1. Assesses for potential security risks related to incoming trauma patients. 2. Remains in communication with the ED Clinical Coordinators/Charge Nurse and/or Trauma Attending regarding security issues related to trauma patients. 3. Ensures lockdown procedures are followed when activated. 4. Collaborates with local/regional law enforcement agencies when appropriate to ensure protection of patients and staff or collection of evidence. Trauma Resuscitation Sequential Management A. Prior to patient arrival, the PRE-BRIEF will be completed. See section 1 for more details. B. Upon patient arrival, the room MUST be silent. Prehospital providers will give the MIVT report in LESS THAN 60 seconds while the patient is moved to the ED stretcher. C. The primary and secondary assessments are then completed. D. A manual blood pressure should be obtained on all trauma patients whenever possible unless the patient s condition or need for procedures precludes this (e. g. need for thoracotomy or initiation of CPR). E. Monitors should be applied by the primary nurse while the initial assessment is being performed. F. Warm blankets should be applied as soon as the patient is exposed. G. The PCT or Trauma Tech should connect patient to portable monitor as soon as the secondary survey is completed. H. THE GOAL TIME IN THE RESUSCIATION AREA IS 30 MINUTES. Initial disposition to CT scan must be completed within 30 minutes. 1. The goal LOS in the ED for Delta trauma activations is 1 hour. 2. The goal LOS in the ED for ECHO trauma activations is 2 hours.

20 V. Trauma Resuscitation Pearls A. Clear, concise communication is paramount. The Trauma Team Leader must lead and direct the team while verbalizing a plan. There must be a shared mental model between all team members at all times. B. Upon the patient entering the room, neither the Trauma Team Leader nor any other members of the trauma team should inhibit the EMS stretcher from coming all the way into the bay (e.g. NO STOPPING the patient prior to entering for a primary survey by anyone.) C. All patients should receive assessment for the presence of weapons, contraband or hazardous materials. D. All patients that require decontamination from hazardous/toxic materials must be decontaminated and all staff must ensure principles of staff protection and wear appropriate protective equipment. E. BEWARE OF SHARPS! If you utilize a sharp instrument or needle for a procedure, you own it until it has been deposited in an appropriate sharps container. F. NOISE DISCIPLINE is vital, extraneous noise should be minimized during procedures and critical phases of the resuscitation. This includes but is not limited to side conversation, phone calls, portable radio traffic, and talking in general. G. For Pediatric trauma patients, there must be clear documentation of the care provided by the adult trauma attending and that the care was transferred to Pediatric Surgery Trauma Medical Director: Michel Aboutanos, MD Effective Date: July 1, 2002 Trauma Program Director: Beth Broering, MSN, RN Trauma Patient Care Committee Approval Date: October, 2013 Last Revision: June, 2008 Annual Review: August 2016

21 TRAUMA TEAM POSITIONS AND RESPONSIBILITIES Respiratory Therapist AIRWAY MD EM Resident, EM Attending (Anesthesia when required) Trauma Tech Trauma Intern Trauma Junior Resident Primary Nurse Trauma Team Leader Trauma Attending Patient Care Technician Recording Nurse

22 Cervical Spine Clearance The unique anatomic characteristics of the pediatric cervical spine and distinct injury patterns manifest by age have led to the development of the following 2 algorithms by age and are evidence based. Both are also based on use of nexus criteria when appropriate without any x-rays, and the use of MRI when appropriate rather than CT scanning in the younger child, in an attempt to reduce radiation exposure. Pediatric Cervical Spine Clearance Recommendations Under 12 Years Nexus Criteria: -Midline Tenderness -Altered Consciousness -Intoxication -Distracting Injury -Neurologic Deficit NO YES Range of Motion Without Pain NO AP/Lat C- Spine YES Normal Abnormal Cervial Spine Cleared No Pain Re-examine CT if (+) Normal (Continued Pain Neurologic Deficit Prolonged Intubation) Neurosurgery Consult MRI Abnormal

23 Pediatric Cervical Spine Clearance Recommendations Ages Nexus Criteria: -Midline Tenderness -Altered Consciousness -Intoxication -Distracting Injury -Neurologic Deficit NO YES Range of Motion Without Pain Normal CT C-Spine YES NO Pain Abnormal Cervial Spine Cleared NO C-Collar; Re-examine Neurosurgery Consult Normal Normal but focal exam (+) prolonged intubation Abnormal MRI

24 Children s Trauma Center Clinical Practice Guidelines POLICY NUMBER: SUBJECT: Adult and Pediatric Trauma Patient Arrival Communication Communication Room EMS Reports to Communication Room Trauma Team Alert Notifies:Trauma Attending and Clinical Coordinato of Patient ETA Patient Transfer from Outside Hospital Call Received by Transfer Center Transfer Center Notifies: Adult (15yrs & older) * -OR- Peds (14yrs & younger) EM attending; coordinates recieving service * 15-17yrs: 3-way call; Transfer, Adult & Peds EM attending No Trauma Team Alert Notifies: Clinical Coordinator Trauma Team Alert Notifies: Trauma Attending, Clinical Coordinator, and activates Trauma Team Alert Patient Transport by EMS EMS Report to Communication Room No Trauma Team Alert To ED Trauma Team Alert To Trauma Bay; Activation of Trauma Team Alert To Adult ED Triage on Site Patient Arrives Unannounced No Trauma Team Alert Trauma Team Alert To ED To Trauma Bay; Activation of Trauma Team Alert To Pediatric ED Triage on Site No Trauma Team Alert To ED

25 Children s Trauma Center POLICY POLICY NUMBER: SUBJECT: Pediatric Trauma Patient Admission PURPOSE This policy guides the physician in the acceptance, evaluation, and admission process of a pediatric trauma patient. This policy is designed to aid in the prevention of missed injuries. PROCEDURE 1. All patients for whom a Trauma Team Alert is activated shall be taken to the resuscitation bay. 2. An evaluation of all Trauma Team Alert patients will occur in the resuscitation bay prior to any decisions to downgrade or transport to the Pediatric Emergency Department. 3. Trauma Team Alerts may not be cancelled prior to patient arrival and evaluation. 4. All patients, whether arriving direct from the scene or by transfer from a referring facility are subjected to Trauma Team Alert criteria. See policy on Pediatric Trauma Transfer for specific criteria. 5. Pediatric trauma patients being accepted in transfer from another hospital will be evaluated in the emergency department for stability of current condition, adequacy of evaluation at outside hospital, identification of appropriate consultants, and identification of proper admission unit and service. 6. All injured patients being admitted to the Pediatric Intensive Care Unit shall be admitted to the appropriate surgical service. REFERENCES Committee on Trauma, American College of Surgeons. (2014). Resources for Optimal Care of the Injured Patient: Author: Chicago, IL. Pediatric Trauma PC Committee Approval Date: February 19, 2014 Pediatric Trauma Medical Director: Effective Date: February 19, 2014 Last Revision: Pediatric Trauma Program Coordinator: Annual Review:

26 Children s Trauma Center Clinical Practice Guidelines POLICY NUMBER: SUBJECT: Two Tier Pediatric Trauma Team Alert Response PURPOSE: Define patient guidelines for activation of Pediatric Trauma Team. PEDIATRIC TRAUMA TEAM ACTIVATION FOR PATIENTS 14 YEARS OF AGE AND YOUNGER Upon notification by prehospital care provider and/or identification that an injured patient meets Trauma Team Activation guidelines, the Communication room Medic/Nurse and/or Emergency Medicine Physician will implement the following: Contact the hospital page operator (telecommunications) at ext # *50, request a Trauma Team Activation and specify Pediatric DELTA or Pediatric ECHO ", based upon patient criteria and give the following information: 3) Age of patient 4) Mechanism of injury(e.g. burn, MVC, Struck by vehicle) 3) Estimated time of arrival The Trauma Surgeon will receive an alpha/numeric page and all other team members will receive a numeric page indicating a DELTA (11111) or ECHO (22222) Alert. PEDIATRIC DELTA TRAUMA TEAM ALERT: Tier I ALERT: 3. The Communications Room or Emergency Medicine Physician will activate the trauma team for a PEDIATRIC DELTA Alert - If prehospital care providers report or the patient presents to the Emergency Department with any of the following: Patient Status -Hypotension, age specific: Age 0-1: SBP < 60 mmhg Age 2-5: SBP < 70 mmhg Age 6-12: SBP < 80 mmhg Age > 12: SBP < 90 mmhg -Requiring fluid or blood to maintain SBP -Respiratory Compromise or Intubation: Age 0-1 RR: < 20 or > 40 Age 2-5 RR: < 20 or > 35 Age 6-12 RR: < 15 or > 30 Age > 12 RR: < 10 or > 30 -GCS 8 or less

27 -EM Physician or Surgeon discretion Patient Injury -Any penetrating injury (BB, GSW, stab) to head, neck, chest or abdomen, regardless of hemodynamic status. -Flail Chest -Paralysis -Fractures: two or more proximal long bone -Burns greater than 15% TBSA (only 2 nd and 3 rd degree is calculated, NOT 1 st degree) -Inhalation Injury -Threatened limb or complete/partial amputation proximal to wrist/ankle Mechanism of Injury -EM physician or Surgeon discretion 4. Telecommunications will be responsible for activating the Trauma Team: PEDIATRIC DELTA Alert: Group Beeper: (Process of activation of Trauma Call Group) and Attending Trauma Surgeon (on call) - (see Trauma Call Calendar) 5. All team members alerted will respond immediately (within 15 minutes of notification) to Trauma Resuscitation Room. 6. Any patient presenting via the Pediatric Emergency Department Ambulatory entrance meeting PEDIATRIC DELTA alert criteria will be immediately transported to the Trauma Resuscitation Bay for complete evaluation. PEDIATRIC ECHO TRAUMA TEAM ALERT: Tier II ALERT: 2. The Communications Medic/Nurse or Emergency Medicine Physician will activate the trauma team for a PEDIATRIC ECHO Alert - If prehospital care providers report or the patient presents to the Emergency Department with any of the following(and the patient does not fit the guidelines for a PEDIATRIC DELTA Alert: Patient Status -GCS between 9 and 12 -Initial age specific hypotension responsive and stable after 20cc/kg isotonic fluid(not blood) -EM Physician or Surgeon discretion Patient Injury -Pelvic fracture -Open or depressed skull fracture, GCS 10 or greater -Combination burns and trauma -Any burn (thermal, chemical) 10% -15% TBSA(only 2 nd and 3 rd degree is calculated, NOT 1 st degree) -High voltage electrical burns (60mA of AC or mA of DC), including lightening injury.

28 -EM Physician or Surgeon discretion Mechanism of Injury -High Risk MVC: - > 40 MPH AND any of the below listed: -Intrusion > 12 inches into passenger compartment -Ejection -Rollover -Death in same vehicle -Falls: 10 feet or 2-3 times height of child -Pedestrian or bicyclist vs Car: thrown, run over or significant impact (> 20 MPH, if speed is known) -Motorcycle/ATV crash > 20 MPH -GSW to extremities proximal to hands or feet. -EM physician or Surgeon discretion 3. Telecommunications will be responsible for activating the PEDIATRIC ECHO Trauma Team Alert: Group Beeper: (Process of activation of Trauma Call Group) and Attending Trauma Surgeon (on call) - (see Trauma Call Calendar) Additionally, the Pediatric Surgical Attending will be notified of ECHO alerts M-F from 7AM-4PM and will direct the workup. If not immediately available, the Trauma Surgeon will initiate treatment until the Pediatric Surgeon responds. 5. Team members alerted will respond immediately to Trauma Resuscitation Room. The Attending Trauma Surgeon on call will be alerted for all Trauma Team Activations, and will respond upon request of other Trauma Team Members for ECHO ALERTS. As stated above the Pediatric Surgeon on call will respond to ECHO alerts and direct the workup M-F from 7AM -4PM. The Pediatric Surgeon will evaluate the patient within 6 hours of arrival or sooner as condition mandates. 6. Any patient presenting via the Pediatric Emergency Department Ambulatory entrance meeting PEDIATRIC ECHO alert criteria will be immediately transported to the Trauma Resuscitation Bay for complete evaluation. Reference: Committee on Trauma American College of Surgeons.(1998). Resources for Optimal Care of the Injured Patient: Author: Chicago, IL.

29 Children s Trauma Center POLICY POLICY NUMBER: SUBJECT: Pediatric Trauma Transfer Patient Evaluation and Admission PURPOSE This policy guides the physician in the acceptance, evaluation, and admission process of a transferred pediatric trauma patient. This policy is designed to aid in guiding patient flow, determining consultants and correct admission service and ultimately aid in the prevention of missed injuries. PROCEDURE 1. Pediatric Trauma Transfer patients (except burns) either through the transfer center or through direct outside hospital communication may not be directly admitted to the hospital despite outside workup. 2. All patients for whom a Trauma Team Alert is activated shall be taken to the resuscitation bay. 3. All pediatric trauma transfer patients are subject to Pediatric Trauma Team Alert criteria as follows and will be determined by the Communication Room. PEDIATRIC DELTA TRAUMA TEAM ALERT: Tier I ALERT Patient Status -Hypotension, age specific: Age 0-1: SBP < 60 mmhg Age 2-5: SBP < 70 mmhg Age 6-12: SBP < 80 mmhg Age > 12: SBP < 90 mmhg -Requiring fluid or blood to maintain SBP -Respiratory Compromise or Intubation: Age 0-1 RR: < 20 or > 40 Age 2-5 RR: < 20 or > 35 Age 6-12 RR: < 15 or > 30 Age > 12 RR: < 10 or > 30 -GCS 8 or less -EM Physician or Surgeon discretion

30 Patient Injury -Any penetrating injury (BB, GSW, stab) to head, neck, chest or abdomen, regardless of hemodynamic status. -Flail Chest -Paralysis -Fractures: two or more proximal long bone -Burns greater than 15% TBSA (only 2 nd and 3 rd degree is calculated, NOT 1 st degree) -Inhalation Injury -Threatened limb or complete/partial amputation proximal to wrist/ankle Mechanism of Injury -EM physician or Surgeon discretion 4. For transferred patients evaluated at outside hospitals and found to be stable and who then demonstrate continued physiologic stability at the time of Communication Room report, ECHO Trauma Team Alert will be based on the following criteria: PEDIATRIC ECHO TRAUMA TEAM ALERT: Tier II ALERT Patient Status -GCS between 9 and 12 -Initial age specific hypotension responsive and stable after 20cc/kg isotonic fluid (not blood) -EM Physician or Surgeon discretion Patient Injury -Pelvic fracture -Open or depressed skull fracture, GCS 10 or greater -Combination burns and trauma -Any burn (thermal, chemical) 10% -15% TBSA (only 2 nd and 3 rd degree is calculated, NOT 1 st degree) -High voltage electrical burns (60mA of AC or mA of DC), including lightening injury. -EM Physician or Surgeon discretion Mechanism of Injury -EM Physician or Surgeon discretion 5. Pediatric trauma transfers meeting Trauma Alert criteria may not be cancelled or downgraded prior to patient arrival and evaluation by the treating physician in the pediatric resuscitation bay. 6. Pediatric trauma transfer patients not meeting trauma alert criteria will be transported to the Pediatric ED and evaluated for stability of current condition, adequacy of evaluation at outside hospital, review of completed studies and ordering those needed, identification of appropriate consultants, and identification of proper admission unit and service. In general, this should always be a surgical service. Exceptions are usually the isolated mild traumatic brain injury without significant mechanism. After neurosurgical consultation, these patients may be admitted to pediatrics if cleared (see separate policy).

31 7. All transferred trauma patients being admitted to the Pediatric Intensive Care Unit must be admitted to the appropriate surgical service (see separate policy). REFERENCES Committee on Trauma American College of Surgeons.(2014). Resources for Optimal Care of the Injured Patient: Author: Chicago, IL. Pediatric Trauma PC Committee Approval Date: February 19, 2014 Pediatric Trauma Medical Director: Signature on file Pediatric Trauma Program Coordinator: Signature on file Effective Date: February 19, 2014 Last Revision: Annual Review:

32 Children s Trauma Center POLICY POLICY NUMBER: SUBJECT: Pediatric Trauma Alert Patient Evaluation in the Emergency Department PURPOSE This policy guides the physician in the required patient flow for Pediatric Trauma Alerts in the Emergency Department. This policy is designed to provide uniformity in evaluation and aid in the prevention of missed injuries. PROCEDURE 1. All patients for whom a Trauma Team Alert is activated shall be taken to the resuscitation bay. 2. An evaluation of all Trauma Team Alert patients will occur in the pediatric resuscitation bay prior to any decisions to downgrade or transport to the Pediatric Emergency Department. 3. Trauma Team Alerts may not be cancelled prior to patient arrival and evaluation by the treating physician as above. 4. All patients, whether arriving direct from the scene or by transfer from a referring facility are subject to the same Pediatric Trauma Team Alert criteria based on pre-hospital information provided to the Communication Room. Again, if an alert is called, it may not be downgraded or cancelled prior to patient evaluation by a physician in the pediatric trauma resuscitation bay. REFERENCES Committee on Trauma, American College of Surgeons. (2014). Resources for Optimal Care of the Injured Patient: Author: Chicago, IL. Pediatric Trauma PC Committee Approval Date: February 19, 2014 Pediatric Trauma Medical Director: Signature on file Pediatric Trauma Program Coordinator: Effective Date: February 19, 2014 Last Revision: Annual Review:

33 Pediatric Wound Management for Tetanus Tetanus Prophylaxis and Immunization Update Management Immunization History Unknown or < 3 doses 3 or more doses Clean Minor Wounds Give Vaccine No vaccine unless > 10 years since last vaccine Other Wounds (dirty,crush,burns) Vaccine and TIG (250u IM) No vaccine unless > 5 years since last vaccine Patient Age < 7 years 7-9 years years Vaccine To Give DTaP Td Tdap (If not previously given; If so give Td) Sources: CDC, AAP Red Book 2009

34 Open Fracture antibiotic guidelines: Antibiotic Prophylaxis for Open Pediatric Orthopedic Fractures Wound Classification Grade I Grade II/ Grade IIIA Grade IIIB/ Grade IIIC Definition Wound < 1 cm II:Wound <10cm IIIA:Wound>10cm Wounds >10cm and requiring soft tissue coverage Antibiotic Cefazolin* II: Cefazolin* IIIA: Cefazolin* and Gentamicin 48 hours: Duration 24 hours For 2 nd I and D, 48 more hours IIIB/IIIC: Cefazolin* and Gentamicin 48 hours: For 2 nd I and D, 48 more hours Cefazolin Gentamicin Clindamycin Aq Penicillin G 100 mg/kg/day Divided every 8-6 hr 7 mg/kg/day Single dose mg/kg/day Divided every 8-6hr 100, ,000 Units/kg/DAY Divided every 4-6 hr Prophylaxis Max single dose: 2000 mg Max single dose: 520 mg Max single dose: 900 mg Max single dose: 2 million units Usual MAX DAILY DOSE: 4000 mg Usual MAX DAILY DOSE: 2700 mg Usual MAX DAILY DOSE: 12 million units NOT TO EXCEED: 12 grams/day NOT TO EXCEED 800 mg/day NOT TO EXCEED 4.8 grams/day NOT TO EXCEED 24 million units/day Notes: * = Use Clindamycin if Penicillin allergic -All wounds should follow the Pediatric Tetanus Protocol. Notes (continued)-

35 -For barnyard injuries or gross organic contamination, add Penicillin (Clindamycin if Penicillin allergic) -It is the responsibility of the Orthopaedic Service to convey the grade of injury to the Pediatric Trauma Service or ED attending for initial dosing as appropriate. -It is the responsibility of the Orthopaedic Surgery Service to enter all postoperative antibiotic orders. -It is the responsibility of the Pediatric Trauma Service to ensure all inpatient antibiotic orders are appropriately continued and discontinued, unless a primary Orthopaedic patient. -Consider reduced dosing for renal/hepatic impairment - Gunshot injuries: simple extra-articular injuries to the extremities are not open fractures and do not require surgical intervention unless a major blast wound. -Bowel penetrating injuries: urgent ortho consult if fracture in area of bowel injury. Start Cefoxitin (or Clindamycin for penicillin allergy) for 48hrs at least and then continue dependent on debridement and amount of contamination of wound. -When flap coverage occurs within 48hrs of second debridement, an additional 48hrs of antibiotics are given after the flap is placed. - If wound coverage is delayed and it is left open but considered clean after the second debridement, 48hrs of antibiotics are given after the second debridement.

36 Open Pediatric Skull fracture Guidelines Antibiotic Prophylaxis for Open Skull Fractures Wound Classification Definition Antibiotic Clean or Clean/Contaminated No obv gross contamination, no dural penetration Cefazolin* Contaminated Gross contamination, GSW, bone fragments intracranially Nafcillin Ceftriaxone Contaminated (through sinuses or oral cavity) Nafcillin Ceftriaxone Metronidazole Duration 24 hours 5 days Poss I&D 5-7 days Poss I& D Antibiotic Prophylaxis for Open Skull Fractures (continued) Cefazolin Nafcillin Ceftriaxone Metronidazole 100 mg/kg/day mg/kg/day mg/kg/day 30 mg/kg/day Divided every 8-6 hr Divided every 6-4 hrs Divided every hr Divided every 8-6 hr Prophylaxis Max single dose: 2000 mg Max single dose: 2000 mg Max single dose: 2000 mg MAX single dose: 15 mg/kg or 1000 mg Usual MAX DAILY DOSE: 4000 mg NOT TO EXCEED: 12 grams/day Usual Max DAILY DOSE: 8000 mg NOT TO EXCEED 12 grams/day Usual Max DAILY DOSE 2000 mg NOT TO EXCEED 4 grams/day Usual Max DAILY DOSE 2000 mg NOT TO EXCEED 4 grams/day NOTES: * = Use Clindamycin if Penicillin allergic - All wounds should follow the Pediatric Tetanus Protocol. - GSW are considered contaminated - Contaminated/dirty wounds may involve dural penetration - No prophylaxis need for basilar skull fractures - Consider Vanc if suspected MRSA involvement with the dose being:

37 0-4.9 kg 1 st order/release Order 1 RBC Keep Ahead Release 1 RBC (non-irradiated RBC) Pediatric Massive Transfusion Protocol Pediatric Massive Transfusion Care Sets 2 nd order/release Order 1 Plasma Keep Ahead Order 2 Whole Blood Derived Platelets (individual units or pooled) Order 1 Cryo (individual unit) Release 1 Plasma Release 1 RBC (irradiated) Immediately Release 1 pre-thawed AB plasma kept in the Release Area refrigerator and 1 type O Rh specific RBC. Note: If patient Rh type is unknown, give Rh Negative RBC. Immediately begin irradiating the next RBC and thawing plasma. Do this even if the floor has not ordered the next protocol. 3 rd order/release Release 1 RBC (irradiated) Release 1 Plasma Release 2 Whole Blood Derived Platelets (individual or pooled) Release 1 Cryo (individual unit) 4 th order/release Order 2 Whole Blood Derived Platelets (individual or pooled) Order 1 Cyro (individual unit) Release 1 RBC (irradiated) Release 1 Plasma Release 1 Cryo (individual unit) Release 2 Whole Blood Derived Platelets (individual units or pooled) 5-10 kg 1 st order/release Order 1 RBC Keep Ahead Release 1 RBC (non-irradiated RBC) 2 nd order/release Order 1 Plasma Keep Ahead Order 1 dose Whole Blood Derived Platelets (pooled) Order 1 Cryo (individual unit) Release 1 Plasma Release 1 RBC (irradiated)

38 Immediately Release 1 pre-thawed AB plasma kept in the Release Area refrigerator and 1 type O Rh specific RBC. Note: If patient Rh type is unknown, give Rh Negative RBC. Immediately begin irradiating the next RBC and thawing plasma. Do this even if the floor has not ordered the next protocol. 3 rd order/release Release 1 RBC (irradiated) Release 1 Plasma Release 1 dose Whole Blood Derived Platelets (pooled) Release 1 Cryo (individual unit) 4 th order/release Order 1 dose Whole Blood Derived Platelets (pooled) Order 1 Cryo (individual unit) Release 1 RBC (irradiated) Release 1 Plasma Release 1 dose Whole Blood Derived Platelets (pooled) Release 1 Cryo (individual unit) kg 1 st order/release Order 2 RBC Keep Ahead Release 2 RBC 2 nd order/release Order 2 Plasma Keep Ahead Order 1 dose Whole Blood Derived Platelets (pooled) Order 1 dose Cryoprecipitate (pooled) Release 2 Plasma Release 2 RBC 3 rd order/release Release 2 RBC Release 2 Plasma Release 1 dose Whole Blood Derived Platelets (pooled) Release 1 dose Cryoprecipitate (pooled) 4 th order/release Order 1 dose Whole Blood Derived Platelets (pooled) Order 1 dose Cryoprecipitate (pooled) Release 2 RBC Release 2 Plasma Release 1 dose Whole Blood Derived Platelets (pooled) Release 1 dose Cryoprecipitate (pooled)

39 23-50 kg 1 st order/release Order 3 RBC Keep Ahead Release 3 RBC 2 nd order/release Order 2 Plasma Keep Ahead Order 1 dose Whole Blood Derived Platelets (pooled) Order 1 dose Cryoprecipitate (pooled) Release 2 Plasma Release 3 RBC 3 rd order/release Release 3 RBC Release 2 Plasma Release 1 dose Whole Blood Derived Platelets (pooled) Release 1 dose Cryoprecipitate (pooled) 4 th order/release Order 1 dose Whole Blood Derived Platelets (pooled) Order 1 dose Cryoprecipitate (pooled) Release 3 RBC Release 2 Plasma Release 1 dose Whole Blood Derived Platelets (pooled) Release 1 dose Cryoprecipitate (pooled) > 50 kg (use adult Massive Transfusion Protocol) Note: Red Blood Cell units should be 7 days for children less than 5 kg and < 14 days old for children > 5 and < 10 kg. Obtain Transfusion Medicine Attending approval if there are no RBCs < 14 days. AB patient s can receive type A RBCs if AB RBC stock is not adequate.

40 Part IV- Inpatient Management Protocols Blunt Solid Organ Injury Management (non-operative) A. Spleen SPLEEN INJURY GRADE I II III IV/V ADMIT TO Floor Bed Floor Bed PICU PICU PICU DAYS VITAL SIGNS Q4x4; then Q8 Q4x4;then Q8 PICU PICU CBC DIET Q12x2; d/c if stable Clears and advance Q12x2; d/c if stable Clears and advance Q6x2; then Q12 x 1 NPO x 24hrs then advance Q6x4; then q12x2 NPO x 24hrs then advance BED REST* 2 days* 3 days* 4 days* 5 days* RETURN TO SCHOOL 7-10 days 7-10 days 3 weeks 3 weeks RETURN TO SPORTS/PE OFFICE RETURN 4 weeks 4 weeks 6 weeks 8 weeks 2 weeks 2 weeks 2 weeks 2 weeks *= ambulate patient afternoon of last day of bed rest; Discharge next AM if stable. NOTES: -Progression dependent upon stable hemodynamics, exam and counts. -For multiple injuries within a spleen, increase grade by 1, up to Grade III -If patient is transfused, reset all parameters to beginning. -If splenic and hepatic injuries are present, manage according to highest grade of organ injury

41 Pediatric Non-Operative Hepatic Injury Management LIVER INJURY GRADE I II III IV/V/VI ADMIT TO Floor Bed Floor Bed PICU PICU PICU DAYS VITAL SIGNS Q4x4; then Q8 Q4x4;then Q8 PICU PICU CBC Q12x2; d/c if stable Q12x2; d/c if stable Q6x2; then Q12 x 1 Q6x4; then q12x2 DIET Clears and advance Clears and advance NPO x 24hrs then advance NPO x 24hrs then advance BED REST* 2 days* 3 days* 4 days* 5 days* RETURN TO SCHOOL RETURN TO SPORTS/PE OFFICE RETURN 7-10 days 7-10 days 3 weeks 3 weeks 4 weeks 4 weeks 6 weeks 8 weeks 2 weeks 2 weeks 2 weeks 2 weeks *= ambulate patient afternoon of last day of bed rest; Discharge next AM if stable. NOTES: -Progression dependent upon stable hemodynamics, exam and counts. -For multiple injuries within a liver, increase grade by 1, up to Grade III -If patient is transfused, reset all parameters to beginning. -If splenic and hepatic injuries are present, manage according to highest grade of injury organ

42 Pediatric Non-Operative Renal Injury Management C. Renal RENAL INJURY GRADE I II III IV V Admit to Floor Floor Floor GUconsult; Observe/OR PICU Days VS CBC GU Consult:OR Q4x4 thenq8 Q12x2; d/c if stable Q4x4 thenq8 Q12x2; d/c if stable Q4x4 then Q8 Q12x2; d/c if stable PICU Q6x2 then q12 x1; d/c if stable PICU X Diet Clears and advance Clears and advance Clears and advance NPO x 24 hrs then advance X Bed Rest* 1 day if stable 1day if stable 1 day if stable 2 days if stable X Re-Image No No No As Clinically Indicated X Return to School 7-10d 7-10d 7-10d 2 weeks X Return to Sports 4 weeks 4 weeks 6 weeks 6 weeks X Office Follow-up 2 weeks 2 weeks 2 weeks 2 weeks X *= ambulate patient afternoon of last day of bed rest; Discharge next AM if stable. NOTES: -Injury Grades 4 and 5 will receive GU consultation as well as any other injury at Attending discretion. -Progression to next step assumes clinical and laboratory stability -Some Grade 4 injuries may be managed operatively; these as well as Grade 5 injuries which are also operative, are excluded from these recommendations

43 Reference Grading Scales (AAST) Spleen injury scale (1994 revision) Grade* Injury type Description of injury ICD-9 AIS-90 I Hematoma Subcapsular, <10% surface area Laceration Capsular tear, <1cm parenchymal depth II Hematoma Subcapsular, 10%-50% surface area intraparenchymal, <5 cm in diameter Laceration Capsular tear, 1-3cm parenchymal depth that does not involve a trabecular vessel III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular or parecymal hematoma; intraparenchymal hematoma > 5 cm or expanding Laceration >3 cm parenchymal depth or involving trabecular vessels IV Laceration Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) 4 V Laceration Completely shattered spleen Vascular Hilar vascular injury with devascularizes spleen *Advance one grade for multiple injuries up to grade III. From Moore et al. [4]; with permission Kidney injury scale Grade* Type of injury Description of injury ICD-9 AIS- 90 I Contusion Microscopic or gross hematuria, urologic studies normal Hematoma Subcapsular, nonexpanding without parenchymal laceration II Hematoma Nonexpanding perirenal hematma confirmed to renal retroperitoneum Laceration <1.0 cm parenchymal depth of renal cortex without urinary extravagation III Laceration <1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravagation IV Laceration Parenchymal laceration extending through renal cortex, medulla, and collecting system Vascular Main renal artery or vein injury with contained hemorrhage 4 V Laceration Completely shattered kidney Vascular Avulsion of renal hilum which devascularizes kidney *Advance one grade for bilateral injuries up to grade III From Moore et al. [7]; with permission

44 Reference Grading Scales (AAST) continued Liver injury scale (1994 revision) Grade* Type of Injury Description of injury ICD-9 AIS-90 I Hematoma Subcapsular, <10% surface area Laceration Capsular tear, <1cm parenchymal depth II Hematoma Subcapsular, 10% to 50% surface area intraparenchymal <10 cm in diameter Laceration Capsular tear 1-3 parenchymal depth, <10 cm in length III Hematoma Subcapsular, >50% surface area of ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma > 10 cm or expanding 3 Laceration >3 cm parenchymal depth IV Laceration Parenchymal disruption involving 25% to 75% hepatic lobe or Couinaud s segments V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 5 Couinaud s segments within a single lobe Vascular Juxtahepatic venous injuries; ie, retrohepatic vena 5 cava/central major hepatic veins VI Vascular Hepatic avulsion 6 *Advance one grade for multiple injuries up to grade III From Moore et al. [4]; with permission

45 Children s Trauma Center Clinical Practice Guidelines POLICY NUMBER: SUBJECT: Nursing Care of the patient in a rigid cervical collar. PURPOSE: This policy guides the caregiver in the correct application and maintenance of a rigid cervical collar and in promoting skin integrity under the collar. DEFINITIONS: A. The purpose of rigid cervical collars is to provide support and restriction of movement in patients requiring cervical spine immobilization. Cervical spine immobilization is maintained until the patient has been fully evaluated clinically and/or radiographically and either 1.) Cleared of injury to the spine, or 2.) Known spinal injuries have been successfully treated, AND UNTIL there is a written (or electronic) physicians order to discontinue the collar. B. Cervical collars should not be removed for skin care if the patient is uncooperative and/or agitated. The RN will notify the physician if the patient is too uncooperative to have the collar removed for daily skin care. Cervical collar care should be planned around sedation and/or analgesia. Cervical immobilization is the primary goal and is not to be compromised for skin/wound care. PROCEDURE: 1. Preparation a. Check for any physician orders related to cervical collar removal. b. Determine the number of caregivers needed to safely perform the procedure. c. Assess the need for sedation. If the patient is restless and uncooperative, additional personnel including physician extenders (Physician, Physician s Assistant, Nurse Practitioner, or Trauma Nurse Clinician/Rounding Nurse) must be present to assist with care. d. Assemble equipment and supplies: 1. Skin cleansing supplies. 2. Clean pads and wound care supplies if required e. Explain the procedure to the patient with clear instructions not to attempt to move his/her head or neck during the procedure. f. Assess and document baseline sensory-motor function. g. Position the patient supine with arms to the sides. 2. Assessing proper fit of the collar a. Make sure that no plastic on the collar is touching the patient (plastic must overlap plastic)

46 b. The back panel should be centered: from front to back, the Velcro straps should be symmetrical. c. Insert index finger in front of the patient s ear and pull forward toward the chin. Finger should only go to mid-jaw. If it goes beyond, the collar is too loose. d. Too tight a fit may compromise circulation. No changes in skin color should be seen. 3. Care of the skin and changing pads a. Skin care, assessment for pressure breakdown, and changing pads on the collar should be completed a minimum of every 12 hours unless contraindicated (e.g. unstable cervical fracture) or if orders specify otherwise. b. One provider maintains the cervical spine in neutral position while a second provider performs skin care and collar maintenance. The head and neck are supported along the sides, with thumbs placed anterior to the patient s ears along the mandible and the fingers supporting the upper neck. c. Release Velcro straps and remove the anterior section of the collar. d. Wash the neck with soap and water and pat dry with towel. Inspect the skin any alteration of skin integrity. e. Clean the plastic part of the collar with alcohol. f. Replace soiled or moist foam pads with clean dry pads. Do not discard soiled foam pads. They will be washed with soap and water, rinsed thoroughly, squeezed out and hung to air dry; air drying normally takes 4-6 hours. g. Address alterations in skin integrity. If moisture is a problem or there is a red rash, especially in the neck creases, expect yeast/fungal and consider two options-either: Option #1. InterDry fabric (No Rx needed) -cut to size suitable to fit smoothly between skin and collar without bunching up. Option #2. Obtain a physician s order for Nystatin powder to be sprinkled on freshly washed and dried neck and creases during daily skin care. If a reddened, non-blanchable, Stage I pressure area is identified, notify physician. Contact the Wound Ostomy Care (WOC) nurse for recommendation. Re-assess and document daily. If there is an open pressure area beneath the collar, notify the physician, enter a referral to the WOC nurse, provide wound care as ordered. Re-asses and document daily. h. Replace the front section of the collar and refasten the Velcro. i. Supporting the head and neck, logroll the patient to side-lying position. Release the Velcro, remove the posterior section of the collar. j. Repeat the same process of care, steps d. through g. k. Replace the back portion of the collar. l. Logroll the patient back to supine position. m. Re-assess collar for fit and patient comfort. n. Re-assess and document sensory-motor function.

47 REFERENCES: Jacobson, T.M., Tescher, A.N., Miers, A.G, and Downer, L. (2008). Improving Practice. Efforts to reduce occipital pressure ulcers. Journal of Nursing care Quality., 23 (3), Powers, J, Daniels, D, McGuire, C., and Hilbish, C. (2006). The incidence of skin breakdown associated with use of cervical collars. Journal of Trauma Nursing, 13(4), Webber-Jones, J.E., Thomas, C.A., Bordeaux, R.E. (2002). The management and prevention of rigid cervical collar complications. Orthopedic Nursing,21(4), Madigan, K. (2009). Spinal Immobilization. Emergency Nursing Procedures 4 th ed Pediatric Trauma PC Committee Approval Date: 9/18/13 Pediatric Trauma Medical Director: Signature on file Pediatric Trauma Program Coordinator: Signature on file Effective Date: 9/18/13 Last Revision: Annual Review:

48 TRAUMA SERVICE OPERATIONAL POLICIES SUBJECT: Substance Abuse Structured Assessment, Brief Intervention, and Referral for Treatment (SBIRT) PURPOSE: VCU Medical Center is a Level 1 trauma center verified by the American College of Surgeons (ACS) and designated by the State. Verification surveys are conducted every 3 years by both the State and the ACS. The standards and criteria used to validate care and processes of care are published by the American College of Surgeons Resources for Optimal Care of the Injured Patient. Standard 18.5 and 18.6 in the Optimal Resources Guide (2006) state that a Level 1 Trauma Center: Must have a mechanism in place to identify problem drinkers and Must have the mechanisms in place to perform brief interventions and referral to treatment when appropriate POLICY: All patients 12 years old who present as trauma team activation will be screened for substance abuse. Those patients who are subsequently admitted to an inpatient unit for the treatment of a traumatic injury will be assessed using AUDIT/CRAFFT and, when indicated, have a brief intervention conducted and documented by a trained social worker. When indicated, a Substance Abuse Service consult will be initiated and/or a referral to treatment will be made. PROCEDURE: A. Trauma activations (Delta/Echo) who are 12 years of age and older are to have a serum blood alcohol content level (BAC) and urine drug screen (UDS) collected during their initial evaluation. B. Trauma service admissions will be identified by trauma service staff from the daily patient lists or sign outs by team members. C. Admitted patients will receive educational materials based on patient s learning needs. D. As part of the admission process, a Social Work consult for SBIRT should be ordered.

49 E. Social workers trained in the SBIRT process will assess each admitted patient prior to discharge using the CRAFFT ( 17 years of age) or AUDIT tool. a. Screening will be deferred for patients with persistent altered level of consciousness or who are discharged directly from the Emergency Department. F. Social workers will provide a brief intervention for any patient with a positive BAC or UDS, AUDIT score of 8-19 or CRAFFT score of 1 or higher. G. The Substance Abuse Team will be consulted on patients with an AUDIT score 20, a CRAFFT score of > 2, or with a known past medical history of acute alcohol withdrawal syndrome (aka DTs). H. Screening results and intervention referral will be documented on the SBIRT form and placed into the medical record (see attached). Social workers will also document in the Care Coordination clinical note that the SBIRT was conducted. a. Social workers will be responsible for providing the trauma service with monthly statistics on the number of patients screened, patients referred for treatment, those requiring Substance Abuse Service consults and the number of patients missed due to being discharged prior to screening. I. A physicians order is not required for referral for interventions. J. Information regarding substance use and or abuse is to be treated as confidential medical information. Results of alcohol and drug testing can be shared with parents or guardians of minor patients without their consent unless the patient is actively seeking treatment and articulates that he/she does not want the information shared. In this case, the information can still be shared with the parents/guardians when: a. Testing was done for medical purposes b. Lacks the capacity for rational choice c. Situation poses a substantial threat to live or physical well-being. Trauma PC Committee Approval Date: 7/2014 Effective Date: 7/2014 Trauma Medical Director: Last Revision: 5/2005 Trauma Program Manager: Annual Review: 7/2016 Pediatric Trauma Medical Director: Pediatric Trauma Program Coordinator:

50 Part V: Traumatic Brain Injury Traumatic Brain Injury Management POLICY NUMBER: Children s Trauma Center Clinical Practice Guidelines SUBJECT: Emergency Department Guidelines for Management of Severe Pediatric Traumatic Brain Injury Initial Treatment Assessment and Monitoring Diagnostic Treatments and Procedures Follow ATLS protocol, specifically noting the following in the setting of severe TBI: Initial Glasgow Coma Score on arrival, with individual component scores. If GCS < 4, notify LifeNet representative at (866) within 1 hour. Pupillary exam- size and reactivity Neurologic exam by Neurosurgical Resident prior to sedation/ paralytic Frequent vital signs every 15 minutes Respiratory rate and pattern Ear exam with documentation of hemotympanum or CSF leak, if present Presence of brainstem reflexes to gag reflex, cough, respiration over the ventilator Mechanism of injury and history since arrival Identify concurrent injuries Based on resuscitation status, emergent Head CT Orotracheal intubation while maintaining C-spine precautions Oxygenate/ ventilate to maintain paco mmhg and oxygen saturation >92% OG and foley catheter IVs Insert 2 large bore peripheral IVs. If unable to secure peripheral IV access within 5 minutes, insert IO NS bolus of 20ml/kg if hypotensive. May repeat Consider vasopressor support if hypotension does not respond to fluid therapy NS at maintenance Medications Consider: RSI medications

51 PRN sedation medications of midazolam 0.1mg/kg/dose and/or Fentanyl 1-2mcg/kg/dose PRN paralytic medication of vecuronium 0.1mg/kg/dose after adequate sedation administered If seizures noted, lorazepam 0.1mg/kg/dose up to 2mg perdose Seizure prophylaxis of fosphenytoin, loading dose mg/kg over 15 minutes. If given, check free phenytoin level 2 hours after infusion completed If persistent hypotension despite IV boluses, start vasopressor of Dopamine 5-10 mcg/kg/min to attain normotension Goals for BP: MAINTAIN SYSTOLIC BP above the following age related parameters (AACN; PALS): SBP: Term neonates > 60mm Hg 1mo- 12mos > 70mm Hg 1yr - 10 yrs > 70mm Hg + (age in years X 2) mm Hg > 10 years >90 mm Hg MAINTAIN MEAN ARTERIAL PRESSURE (MAP) according to following age related parameters to maintain appropriate CPP (PCCM, 2012; Hague & Zaritsky, 2007) (minimum MAP target higher if ICP thought to be high) MAP: Infants 0-12mos 35 mm Hg Children 1-12yrs 50 mm Hg Adolescents >12yrs 60 mm Hg Nursing If neurological deterioration, 3% saline bolus of 2-3ml/kg/dose If neurological deterioration continues, Mannitol 0.5 1gm /kg IV bolus. Patient must be well hydrated. Maintain head midline HOB elevated 30 IF no thoracic/ lumbar spine injury Avoid fevers. Hypo/ hyperthermia blanket to maintain normothermia Change C-collar to aspen collar prior to patient leaving ED NPO Pediatric Trauma PC Committee Approval Date: November 20, 2013 Pediatric Trauma Medical Director: Signature on file Pediatric Trauma Program Coordinator: Signature on file Effective Date: November 20, 2013 Last Revision: Annual Review:

52 Children s Trauma Center Clinical Practice Guidelines POLICY NUMBER: SUBJECT: Guidelines for the Care of Isolated Pediatric Traumatic Brain Injury (TBI) at CHoR In the Pediatric ED: 1. All children age 14 and under presenting with an isolated traumatic brain injury (TBI) will be seen by the Pediatric ED staff who will determine the workup, including the need for a CT scan. 2. If an admission is contemplated, either on the basis of persistent neurologic symptoms or CT scan findings, Pediatric Neurosurgical consultation will be mandatory. 3. After the Pediatric Neurosurgical consultation, a joint decision between the Pediatric ED staff and Pediatric Neurosurgery will be made as to the patient s admitting service and location: a. Isolated TBI which has been cleared by Pediatric Neurosurgery may be admitted to the General Pediatric service. Determination of a general floor bed or PPCU bed will be made in the Pediatric ED. b. Any case judged to be surgical will be admitted to the PICU on the Pediatric Neurosurgical service with PICU consultation (Please refer to the PICU Trauma Admission policy). 4. After the Pediatric ED evaluation as above, any patient found to have additional injuries (poly-trauma) will have Pediatric Surgical consultation in the Pediatric ED with admission to Pediatric Surgery service. 5. Any head injury suspected to be abuse related will also have Pediatric Surgical consultation in the Pediatric ED (Please refer to Pediatric Surgical Evaluation of Physical Abuse Policy). If cleared, the patient may be admitted to General Pediatric service as outlined above. At Admission: 6. Care on the General Pediatric service: a. Admission GCS b. Vital signs per unit protocol c. Neurochecks in PPCU: Q2hrs wean to Q4hrs as tolerated d. Neurochecks in Acute Care Pediatrics: Q4hrs e. No narcotics for pain f. Clear liquid diet and advance to regular diet as tolerated g. Pediatric neurosurgery and/or child neurology consultation if not done in pediatric ED

53 7. If clinical situation changes, immediately page the pediatric housestaff and/or pediatric neurosurgeon on call and consider PRRT for evaluation. Nursing can refer to Pediatric Nursing Algorithm for Escalating Care pathway for contacting appropriate personnel. 8. A TBI clinic appointment should be considered at discharge as clinically indicated. Rev. 7/16/12 Pediatric Trauma PC Committee Approval Date: 7/18/12 Pediatric Trauma Medical Director: Signature on file Pediatric Trauma ProgramCoordinator: Signature on file Effective Date: 7/18/12 Last Revision: Annual Review:

54 Children s Hospital of Richmond at VCU Traumatic Brain Injury Clinic The CHoR Multidisciplinary TBI/concussion clinic serves as a resource for patients who have been seen in the hospital, Emergency Department or physician s office for a brain injury. The multidisciplinary team includes: Certified brain injury specialists Physical medicine and rehabilitation physicians Certified ImPACT consultants Neuro-psychologists Sports medicine physicians Registered nurses Rehabilitation therapists Social workers Educational consultants Appointments and Location: To schedule an appointment, call Children s Hospital of Richmond at VCU- Brook Road Campus 2924 Brook Road Richmond, VA 23220

55 Traumatic Brain Injury Management Algorithm Traumatic Brain Injury Evaluation in Peds ED (To Accompany TBI Policy) Closed Head Injury Evaluation / Work Traumatic Brain Injury Evaluation / Workup per Peds ED Improved Persistent Neurologic Symptoms and/or Positive CT Findings Admission Considered by Peds ED Disposition per Peds ED Suspected NAT 1.) Neurosurgery Consult 1.) 2.) Neurosurgery Pediatric Surgery Consult 2.) Peds Consult Surgery Consult No Suspected NAT Neurosurgery Consult Neurosurgery Clears Neurosurgery Findings Surgical Neurosurgery clears Pediatric Surgery Clears Poly-trauma Admit to Peds Admit to Peds NSR / PICU Admit Peds Surgery / PICU Admit to Peds Admit to Peds NSR / PICU

56 Repeat Head Injury Imaging Guidelines ADMINISTRATIVE PROCEDURES/ POLICY NUMBER: CLINICAL PRACTICE GUIDELINES SUBJECT: Guidelines for repeat Head CT in trauma patients 1. Repeat CT scan ASAP for decline in neurologic status regardless of original findings on admission CT 2. For all patients diagnosed with epidural hematoma, repeat head CT within 6 to 8 hours if the neurologic examination is unobtainable. 3. Repeat in head CT in 24 hours if the patient is a Moderate or Severe Head Injury (Grade II or III) if the neurologic exam be unobtainable due to sedation. This will be evaluated on a case by case basis by Neurosurgery. 4. CT head should be repeated in 24 hours on any patient on anticoagulation medication, or abnormal coagulation profile or platelets on admission. 5. An ICP monitor should be placed if hourly neurological exam is not available and initial GCS was less than 8. Pediatric Trauma PC Committee Approval Date: 6/20/12 Pediatric Trauma Medical Director: Signature on file Pediatric Trauma Program Coordinator: Signature on file Effective Date: 6/20/12 Last Revision: Annual Review:

57 Pediatric Catastrophic Brain Injury Guidelines Catastrophic Brain Injury Guideline-Pediatric Admission A guideline is not intended to replace clinical management decisions. These suggestions must only be instituted when the Attending Physician has given permission to use all or part of these clinical interventions. PURPOSE: -To provide evidence based tools for the management of the pediatric patient with catastrophic brain injuries / neurologically devastating injuries with high potential for the declaration of brain death Contact LifeNet Health when one of the following clinical triggers is present: 1. GCS of 4 or less 2. Discussion of withdrawing mechanical ventilation or pharmacological measures 3. Discussion of brain death testing 4. Family brings up donation* * ATTENTION: Organ donation should not be mentioned to the next of kin by any member of the hospital healthcare team. The grave prognosis is given to the family by the Attending physician and patient care team. After this discussion has occurred, there is a collaborative decision made with the Attending physician and LifeNet Health regarding the proper timing of an organ donation discussion with the family. Age related parameters for systolic BP, MAP, CPP, ICP: MAINTAIN SYSTOLIC BP above the following age related parameters1: SBP: Term neonates > 60 mm Hg Infants 1-12months > 70 mm Hg Children 1-10 years > 70 mm Hg + (age in years X 2) mm Hg Adolescents > 10 years > 90 mm Hg MAINTAIN MEAN ARTERIAL PRESSURE (MAP) according to following age related parameters to maintain appropriate CPP 2,3 MAP: Infants 0-12 months 35 to 80 mm Hg Children 1-12 years 50 to 95 mm Hg Adolescents >12 years 60 to110 mm Hg If patient has an external ventricular or intraparachymal device, MAINTAIN CEREBRAL PERFUSION PRESSURE (CPP) according to following age related parameters to maintain perfusion to the brain tissue2,4 MAP- ICP = CPP. CPP: infants to 1 month > 40 mm Hg Infants 2 mo 1 year > 45 mm Hg Children 2 6 years > 50 mm Hg Children >7 years > 60 mm Hg

58 If patient has an external ventricular or intraparachymal device, TREAT ELEVATED INTRACRANIAL PRESSURE (ICP) according to following age related parameters or as directed by the Neurosurgeon5 ICP: Infant 0-12 months >10 mm Hg sustained greater than 10 minutes Child 1-12 years > 10 mm Hg sustained greater than 10 minutes Adolescent >12 years > 15 mm Hg sustained greater than 10 minutes Treatments: 1. Consider invasive hemodynamic monitoring 2. Adequate hydration: Ensure adequate hydration to maintain euvolemia 3. Vasopressor support: If hypotensive post adequate rehydration, may consider Epinephrine, Dopamine, Phenylephrine or Norepinephrine. CONTACT ATTENDING for patient individualized recommendation. MAINTAIN URINE OUTPUT > 1 ml/ kg/ hr 1. If Urine Output falls below 1ml / kg / hr, assess fluid status. Patient may need additional volume or BP support. 2. Consider Diabetes Insipidus (DI) if > 3mL/kg/hr over 2 hours and increasing serum sodium 6 3. Treat DI with Vasopressin drip if Urine Output remains > 3mL/kg/hr over 2 hours and serum sodium increasing. MAINTAIN pao2 > 80 and ph and paco Adequate ventilation may be maintained by: 1. Tidal volume of 6 8 ml/kg 2. Aggressive pulmonary hygiene, if not contraindicated by patient's condition (ie, suction and turn every 2 hours) 3. Respiratory treatments to prevent bronchospasm. **If end tidal CO2 (ETCO2) is available, may start with initial ABG to facilitate correlation with ETCO2. If correlated, may use ETCO2 for monitoring. ***Consider NIRS monitoring if available, with goal to maintain cerebral SvO2 >60. VENTRICULOSTOMY PLACEMENT; 1. Consider need for ventriculostomy placement for GCS <9; consult Neurosurgery 2. If EVD is placed, maintain ICP less than age appropriate parameters by opening (popping) ventriculostomy until ICP is less than 10 mm Hg, or at discretion of the Neurosurgeon. CRANIECTOMY Contact neurosurgery for consideration of craniectomy when maximal medical management is insufficient to decrease ICP, potential herniation or other signs of neuro deterioration 7 NORMOTHERMIA Maintain core body temperature between 36ºC and 37.5ºC or 96.8ºF and 99.5ºF 7,8 Order Set: Vital Signs/Monitoring Monitor VS every hour Intake and output every hour, Maintain urine output > 1mL/kg/hr and <3mL/kg/hr over two hours

59 Nursing HOB 30o and maintain head midline Keep temp between 36º C (96.8º F) and 37.5º C (99.5 ºF). Consider use of warming or cooling blanket as needed Strict I/O hourly. Notify provider if urine output < 1ml/kg/hr or > 3ml/kg/hr Suction: endotracheal PRN Notify Provider if glucose < 80 or >180 mg/dl Notify Provider if ICP > mmhg for > 5 minutes Notify Provider if lab values outside of normal limits Place Foley Place sump tube orally unless nasogastric placement is allowed per NSGY Monitor TOF (train of four) every 4 hours when patient on paralytic drip. Goal TOF is 1-3 out of 4 twitches. Do not attempt > 40 mamps Pop-off EVD for ICP > for > 5 minutes Notify provider of any seizure activity. If new onset seizure activity, notify Attending. Nutrition NPO Therapies Chest PT Desired goals: Aid mobilization & drainage of secretion, every 2 hours (even hr) Sport Bed Daily EEG SCDs for DVT prophylaxis Medications Intermittent PRN sedation orders Fentanyl for Moderate pain/sedation (Usual initial dose: 1 mcg/kg/dose) Fentanyl mcg, injectable, IV, every 1 hour, PRN moderate pain/sedation, initial therapy Fentanyl for Severe pain/sedation (Usual initial dose: 2-3 mcg/kg/dose) Fentanyl mcg, injectable, IV, every 1 hours, PRN severe pain/sedation refractory to initial therapy Midazolam (Usual dose: mg/kg/dose) Midazolam mg, injectable, IV, every 1 hours, PRN agitation/restlessness, initial therapy Intermittent PRN NMBA orders Vecuronium (Usual dose: 0.1 mg/kg/dose) Vecuronium mg, injectable, IV, every hour PRN ventilator dysynchrony ICP MANAGEMENT options in refractory elevated ICP Educational note: 3% Sodium Chloride is usually preferred over mannitol for acute ICP management.7 Sodium Chloride 3% may be given with serum Osm < 360 whereas mannitol can be given with serum Osm < 320. Maintain serum sodium between Sodium Chloride 3% CONTINUOUS INFUSION (Usual dose: ml/kg/hr Sodium Chloride 3%, 500 ml, IV, ml/hr, routine7,9 Sodium Chloride 3% BOLUS (Usual dose: 4 ml/kg/dose) Sodium Chloride 3% BOLUS (peds), ml, IV, injectable, once Dose in ml/kg

60 Mannitol 20% BOLUS (Usual dose: grams/kg/dose) Mannitol 20% (peds), grams, IV, injectable, once 7 SEIZURE PROPHYLAXIS may be considered; if initiated, monitor drug levels since TBI in children results in increased plasma levels. Monitor free phenytoin levels if fosphenytoin initiated Lorazepam recommended for acute treatment of seizures. Usual recommended dose: 0.1 mg/kg/dose up to max of 2 mg/dose Lorazepam mg, injectable, IV, unscheduled PRN seizures > 5 minutes. Fosphenytoin for seizure prophylaxis 7,9 Loading dose (Usual dose: mg/kg/dose) Fosphenytoin (peds) mg, injectable, IV, once, STAT ----Select an order sentence [Drop down box: 20, 25, 30, 40, 50, 60, 70, 80, , , 200, 250, 300, 350, 400, 500, 600, 700, 800, 900, 1000 mg] Maintenance dose (Usual dose: 5-10 mg/kg/day divided every 8-12 hours) Fosphenytoin (peds) mg, injectable, IV, every 12 hours, routine --- Select an order sentence [Drop down box: 1.4, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 15, 20, 25, 30, 40, 50, 60, 70, 80, 90, 100, 120, 150, 200 mg) MISCELLANEOUS MEDICATIONS STRESS ULCER PROPHYLAXIS Famotidine IV/PO (Usual dose: mg/kg/dose) Famotidine (peds) mg, injectable, IV, every 12 hours, routine (Drop down box: 0.8, 1.2, 2.4, 3.2, 4, 4.8, 6, 8, 10, 12, 16, 20, 30, 40 mg) OCULAR LUBRICANT ****All patients on neuromuscular blocking agents should also be on ocular lubricant for eye dryness. Lacrilube (adult/peds), 1 application, Ophth Oint, both eyes, every 4 hours, routine Comment while receiving neuromuscular blocking agents ELECTROLYTE REPLACEMENT- please refer to general PICU order set ORAL HYGIENE ****All patients should receive oral mouth care while intubated. Children and adolescents: Chlorhexidine 0.12% oral rinse, 15 ml, oral liquid, PO, every 12 hours, routine apply after routine oral cleaning for as long as patient is intubated. FLUIDS Maintenance Fluids NaCl 0.9% is preferred fluid for first 24 hours. Contact Neurosurgeon before adding dextrose to IVF. Sodium Chloride 0.9%, 1000 ml, IV, ml/hr, routine Lactated Ringers, 1000 ml, IV, ml/hr, routine A-line Sodium Chloride 0.9% 250 ml + heparin 250 units, IV, 3ml/hr, routine (A-line) CSF Replacement Sodium Chloride 0.9%, 1,000 ml, IV, See Order Details, Replace CSF output 1:1 (ml for ml) every 4 hours

61 SEDATION/ ANALGESIA CONTINUOUS INFUSIONS OPIATE FENTanyl is the opiate of choice for drip secondary to short duration of action Propofol is not recommended for continuous use in the pediatric population7 FENTanyl (Usual dose range: 1-6 mcg/kg/hr) Weight < 10 kg (1000 mcg/50 ml = 20 mcg/ml) FENTanyl 1 mg in Dextrose 5%, 50 ml, IV, ml/hr to give mcg/kg/hr (20 mcg/ml) (0.1 ml/kg/hr = 2 mcg/kg/hr) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight >10 kg (2000 mcg/100 ml = 20 mcg/ml) FENTanyl 2000 mcg in Dextrose 5%, 100 ml, IV, ml/hr to give mcg/kg/hr (20 mcg/ml) (0.1 ml/kg/hr = 2 mcg/kg/hr) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> UNDILUTED FENTanyl Weight < 10 kg (1000 mcg/20 ml = 50 mcg/ml) FENTanyl 1000 mcg, undiluted, 20 ml, ml/hr to give mcg/kg/hr (50 mcg/ml) (0.04 ml/kg/hr = 2 mcg/kg/hr) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight > 10 kg (2500 mcg/50 ml = 50 mcg/ml) FENTanyl 2500 mcg, undiluted, 50 ml, ml/hr to give mcg/kg/hr (50 mcg/ml) (0.04 ml/kg/hr = 2 mcg/kg/hr) BENZODIAZEPINE Midazolam is benzodiazepine of choice for drips secondary to shorter duration of action Midazolam (Usual dose range: mg/kg/hr) Weight < 10 kg (10mg/50 ml = 0.2 mg/ml) Midazolam 10 mg in Dextrose 5%, 50 ml, IV, ml/hr to give mg/kg/hr (0.2 mg/ml) (0.5 ml/kg/hr = 0.1 mg/kg/hr) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight kg (50 mg/50 ml = 1 mg/ml) Midazolam 50 mg in Dextrose 5%, 50 ml, c IV, ml/hr to give mg/kg/hr (1 mg/ml) (0.1 ml/kg/hr =0.1 mg/kg/hr) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight > 40 kg (100 mg/100 ml and 250 mg/250 ml = 1 mg/ml) Midazolam 100 mg in Dextrose 5%, 100 ml, IV, ml/hr to give mg/kg/hr (1 mg/ml) Midazolam 250 mg in Dextrose 5%, 250 ml, IV, ml/hr to give mg/kg/hr (1 mg/ml) (2 ml/hr = 2mg/hr) NEUROMUSCULAR BLOCKERS Notify Attending Prior to Initiating Continuous infusions Vecuronium (Usual dose range: mg/kg/hr) Weight < 10 kg (10 mg/50 ml = 0.2 mg/ml) Vecuronium 10 mg in Dextrose 5%, 50 ml, IV, ml/hr to give mg/kg/hr (0.2mg/mL) (0.5 ml/kg/hr =0.1 mg/kg/hr) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight kg (50 mg/50 ml = 1 mg/ml) Vecuronium 50 mg in Dextrose 5%, 50 ml, IV, ml/hr to give mg/kg/hr (1 mg/ml) (0.1 ml/kg/hr =0.1 mg/kg/hr) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight > 40 kg (100 mg/100 ml and 250 mg/250 ml = 1 mg/ml)

62 Vecuronium 100 mg in Dextrose 5%, 100 ml, IV, ml/hr to give mg/kg/hr (1 mg/ml) Vecuronium 250 mg in Dextrose 5%, 250 ml, IV, ml/hr to give mg/kg/hr (1 mg/ml) (0.05 ml/kg/hr = 0.05 mg/kg/hr) VASOPRESSORS Notify Attending Prior to Initiating Educational note: Phenylephrine or Norepinephrine may be considered in patients with adequate cardiac output Epinephrine or dopamine may be considered in patients with LOW cardiac output (s/p cardiac arrest, etc) 10 DOPamine (Usual dose range: 2-20 mcg/kg/min) Weight < 10 kg (40 mg/50 ml = 800 mcg/ml) DOPamine 40 mg in Dextrose 5%, 50 ml, IV, ml/hr to give mcg/kg/min (800 mcg/ml); Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 20 mcg/kg/min) (0.75 ml/kg/hr = 10 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight < 10 kg (80 mg/50 ml = 1600 mcg/ml) DOPamine 80 mg in Dextrose 5%, 50 ml, IV, ml/hr to give mcg/kg/min (1600 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 20mcg/kg/min) (0.4 ml/kg/hr = 10 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight kg (160 mg/100 ml = 1600 mcg/ml) DOPamine 160 mg in Dextrose 5%, 100 ml, IV, ml/hr to give mcg/kg/min(1600 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 20 mcg/kg/min) (0.4 ml/kg/hr = 10 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight kg (320 mg/100 ml = 3200 mcg/ml) DOPamine 320 mg in Dextrose 5%, 100 ml, IV, ml/hr to give mcg/kg/min(3200 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP > max dose 20 mcg/kg/min) (0.2 ml/kg/hr = 10 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight > 40 kg (400 mg/250 ml = 1600 mcg/ml) DOPamine 400 mg in Dextrose 5%, 250 ml, IV, ml/hr to give mcg/kg/min(1600 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 20 mcg/kg/min) (0.4 ml/kg/hr = 10 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight > 40 kg (800 mg/250 ml = 3200 mcg/ml) DOPamine 800 mg in Dextrose 5%, 250 ml,, IV, ml/hr to give mcg/kg/min (3200 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 20 mcg/kg/min) (0.2 ml/kg/hr = 10 mcg/kg/min) EPInephrine (Usual dose range: mcg/kg/min) Notify MD if dose > 2 mcg/kg/min. Weight < 10 kg (1 mg/50 ml = 20 mcg/ml)

63 EPInephrine 1 mg in 0.9% NaCl, 50 ml, IV, ml/hr to give mcg/kg/min (20 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 1 mcg/kg/min) (0.3 ml/kg/hr = 0.1 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight kg (6 mg/100 ml = 60 mcg/ml) EPInephrine 6 mg in 0.9% NaCl, 100 ml, IV, ml/hr to give mcg/kg/min (60 mcg/ml) Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 1 mcg/kg/min) (0.1 ml/kg/hr = 0.1 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight > 40 kg (15 mg/250 ml = 60 mcg/ml) EPInephrine 15 mg in 0.9% NaCl, 250 ml, IV, ml/hr to give mcg/min (60 mcg/ml). Titrate by mcg/min every 5 minutes for goal MAP > (max dose 40 mcg/min) (1 ml/hr = 1 mcg/min) PHENYLephrine (Usual dose range: mcg/kg/min) Weight < 10 kg (5 mg/50 ml = 100 mcg/ml) PHENYLephrine 5 mg in 0.9% NaCl, 50 ml, IV, ml/hr to give mcg/kg/min (100 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 3 mcg/kg/min) (0.06 ml/kg/hr = 0.1 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight kg (10 mg/100 ml = 100 mcg/ml) PHENYLephrine 10 mg in 0.9% NaCl, 100 ml, IV, ml/hr to give mcg/kg/min (100 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 3 mcg/kg/min) (0.06 ml/kg/hr = 0.1 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight > 40 kg (50 mg/500 ml = 100 mcg/ml) PHENYLephrine 50 mg in 0.9% NaCl, 500 ml, IV, ml/hr to give mcg/kg/min (100 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP > (max dose 3 mcg/kg/min) (0.06 ml/kg/hr = 0.1 mcg/kg/min) NORepinephrine (Usual dose range: mcg/kg/min OR 4-80 mcg/min if weight > 40 kg). Notify MD if dose > 0.6mcg/kg/min. Weight < 10 kg (0.8 mg/50 ml = 16 mcg/ml) NORepinephrine 0.8 mg in 0.9% NaCl, 50 ml, IV, ml/hr to give mcg/kg/min (16 mcg/ml). Titrate by mcg/kg/min every 5 minutes for goal MAP >.(max dose 2 mcg/kg/min ) (0.2 ml/kg/hr = 0.05 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight kg (4 mg/250 ml = 16 mcg/ml) NORepinephrine 4 mg in 0.9% NaCl, 250 ml, IV, ml/hr to give mcg/kg/min (16 mcg/ml) Titrate by mcg/kg/min every 5 minutes for goal MAP >.(max dose 2 mcg/kg/min ) (0.4 ml/kg/hr = 0.1 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight kg (8 mg/250 ml = 32 mcg/ml)

64 NORepinephrine 8 mg in 0.9% NaCl, 250 ml, IV, ml/hr to give mcg/kg/min (32 mcg/ml) Titrate by mcg/kg/min every 5 minutes for goal MAP >.(max dose 2 mcg/kg/min ) (0.2 ml/kg/hr = 0.1 mcg/kg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight > 40 kg (8 mg/250 ml = 32 mcg/ml) NORepinephrine 8 mg in 0.9% NaCl, 250 ml, IV, ml/hr to give mcg/min (32 mcg/ml). Titrate by mcg/min every 5 minutes for goal MAP >.(max dose 80 mcg/min ) (7.5 ml/hr = 4 mcg/min) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Weight > 40 kg (16 mg/250 ml = 64 mcg/ml) NORepinephrine 16 mg in 0.9% NaCl, 250 ml, IV, ml/hr to give mcg/min (64 mcg/ml). Titrate by mcg/min every 5 minutes for goal MAP >.(max dose 80 mcg/min ) (3.8 ml/hr = 4 mcg/min) BLOOD GLUCOSE MANAGEMENT Keep blood Glucose between mg/dl. Institute Insulin drip for persistent hyperglycemia. See PICU IV:Endocrine folder under Ordersets, Pediatric Critical Care, in Cerner for insulin drip orders if needed Laboratory. 1. Initial and PRN evaluation includes: Basic Metabolic, Magnesium, Phosphate, CBC, Arterial Blood Gas, Hepatic Panel, PT, PTT and Lactate (BG) a. Consider transfusion with Packed Red Blood Cells for Hgb < 7 g/dl. If SvO2 is < 65, NIRS is < 60, or patient is hypoxic, consider higher Hgb goal. b. If PT >18, give10 ml/kg (max 2 units) Fresh Frozen Plasma c. Replete electrolytes as needed d. Monitor glucose and treat with insulin drip if needed (keep glucose between mg/dl) 2. Sample to the Blood Bank for ABO typing 3. Draw STAT labs when Organ Donation Protocol is activated, as well Blood Bank sample 4. Consider Basic Metabolic and Osmolality after fluid bolus and/ or electrolyte replacement. 5. Consider daily blood culture and CBC if patient is hypothermic or hyperthermic 6. Free phenytoin level if patient is on fosphenytoin Stat Studies Blood gas, arterial, Specimen type: blood arterial, stat, lab reporting, stat X 1 Blood gas, venous, Specimen type: blood venous, stat, lab reporting, stat X 1 Lactate (BG), stat, lab reporting, stat X 1 Calcium, ionized, stat, lab reporting stat X 1 Magnesium ionized, stat, lab reporting stat, X 1 CBC, stat,, lab reporting priority stat, x 1

65 Basic Met, stat, lab reporting stat, x 1 Phosphorus, stat, lab reporting priority stat, x 1 Hepatic Panel, stat, lab reporting priority stat x 1 Osmolality, stat, lab reporting priority stat x 1 PT, stat, lab reporting priority stat x 1 PTT, blood, stat, lab reporting priority stat x 1 Fibrinogen, stat, lab reporting priority stat x 1 Blood Glucose: finger/heelstick (POCT) every 4 hours, Notify MD if: Blood Glucose < 80 or > 180 mg/dl Free phenytoin level, blood, stat now, lab reporting priority stat x1 Blood Culture Blood Bank For a 'type & crossmatch' order the following 3 tests: Type ABORh Blood, Stat, Lab Reporting Routine ABSC, Blood, Stat, Lab Reporting Routine Computer XM, Blood, Stat, Lab Reporting Routine Neuroimaging Consider repeat head CT if ICP > 20 and resistant to medical management 2 Educational Notes: Repeat Head CT scan ASAP for decline in neurologic status regardless of original findings on admission CT. For all patients diagnosed with epidural hematoma, repeat head CT within 6-8 hours if the neurologic examination is unobtainable. Neurosurgeon may request repeat head CT in 24 hours if the patient is a moderate or severe head injury (Grade II or III) and the neurologic exam is unobtainable due to sedation Head CT should be repeated in 24 hours for any patient on anticoagulation medication, or with an abnormal coagulation profile or platelets on admission CT: Head, w/o contrast, stat References: 1. Spencer B, Chacko J, Sallee D, American Heart A. The 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care: an overview of the changes to pediatric basic and advanced life support. Critical care nursing clinics of North America 2011;23: Scaife ER, Statler KD. Traumatic brain injury: preferred methods and targets for resuscitation. Current opinion in pediatrics 2010;22: Haque IU, Zaritsky AL. Analysis of the evidence for the lower limit of systolic and mean arterial pressure in children. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2007;8: Chambers IR, Kirkham FJ. What is the optimal cerebral perfusion pressure in children suffering from traumatic coma? Neurosurgical focus 2003;15:E3. 5. Cincinatti Children's Hospital. Clinical Guidelines for Major Head Injury

66 6. Cummins RO, Hazinski MF. Cardiopulmonary resuscitation techniques and instruction: when does evidence justify revision? Annals of emergency medicine 1999;34: Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2012;13 Suppl 1:S Zimmerman F. Pediatric Critical Care. 4th ed. Philadelphia, PA: Elsevier; Torre-Healy A, Marko NF, Weil RJ. Hyperosmolar therapy for intracranial hypertension. Neurocritical care 2012;17: Di Gennaro JL, Mack CD, Malakouti A, Zimmerman JJ, Armstead W, Vavilala MS. Use and effect of vasopressors after pediatric traumatic brain injury. Developmental neuroscience 2010;32: Resources: PICU medical team Pediatric Neurosurgery Pediatric Pharmacist PICU nursing leadership Clinical Director, Pediatric Palliative Care Approved by: Signature on file Signature on file Sue Sreedhar, MD Jeniece S. Roane MS,RN,NE-BC Associate Professor and Chief Nursing Director Division of Critical Care Medicine Women s and Children s Health Date of approval: January 3, 2013

67 Guidelines for declaring Brain Deat h ( Death by Ne uro lo gic Criteria ) in Pediatric Patients Patient Population: Patients aged 0-18 years old being treated in the PICU Reference: Guidelines for the determination of brain death in infants and children. Critical Care Medicine 2011, 39: Endorsed by the Society of Critical Care Medicine, American Academy of Pediatrics (Section on Critical Care and Section on Neurology), and the Child Neurology Society PLEASE NOTE: Declaring brain death is a clinical diagnosis. There are no objective tests or studies that can diagnosis this condition. 1. Assessment of neurologic function after CPR or other severe acute brain injuries should be deferred for >24 hours or if dictated by clinical judgment. Reduction in inter-exam observation interval can be done if ancillary tests are supportive. Ancillary studies are not required except in cases in which the clinical exam and apnea test cannot be completed. 2. What is required? a. 2 clinical exams and 2 apnea tests. i. Age: 37 weeks gestational age to 30 days old First exam may be performed 24 hours after CPR or other severe brain injury 1. Interval between exams must be at least 24 hours ii. Age: 31 days to 18 years -- First exam may be performed 24 hours following CPR or other severe brain injury 1. Interval between exams must be at least 12 hours b. Intervals between exams may be shortened if an ancillary test is performed and is consistent with brain death. i. Ancillary test: Cerebral Perfusion Scan (radionuclide cerebral blood flow or cerebral angiography) or EEG ii. These tests cannot substitute for a clinical exam c. The time of brain death is documented in the medical records. Time of death is the time the second examination and apnea test are completed. In patients with an aborted apnea test, the time of death is when the ancillary test is interpreted and when the components of the second examination that can be safely completed are completed. i. A complete neuro exam, ABGs conducted for the apnea test, and any other relevant information should be accurately documented with the correct timing d. Documentation: i. The form titled Brain Death Determination for Infants, Children, & Adolescents must be printed, completed, and signed by appropriate physicians. ii. The form can be found on the PICU Intranet website under Documents and Forms. iii. The form must be placed in Red Chart to be scanned into the medical record. e. 2 different attending physicians must perform the clinical exam. In the state of Virginia, 1 of these physicians must be from a neuroscience specialty either neurosurgery or neurology. i. Residents and fellows are encouraged to observe and participate in the clinical examination and testing process; however both neurologic exams should be

68 performed by an attending physician who is qualified and competent to perform the brain death examination. f. The same physician can perform both apnea tests. Each apnea test should be performed in proximity to clinical exams. 3. All reversible causes of encephalopathy should be ruled out before commencing brain death exams. 4. All sedative drugs must be discontinued and the patient should not have received any within 6 hours 5. Note: Atropine, if used in CPR, causes eye dilatation. Comments of pupils fixed and dilated are not accurate if the patient has received atropine or other anti-cholinergic drug. Appropriate time to allow metabolism of this drug must be given before starting brain death determination. 6. Severe electrolyte imbalances should be identified and treated if possible. a. Includes hyper- or hyponatremia, hyper- or hypoglycemia, severe ph disturbances, severe hepatic or renal dysfunction, and inborn errors of metabolism. b. If, in the clinicians judgment, reasonable efforts to correct imbalances are made, and the metabolic disturbance is judged to not be contributing to the coma, then brain death testing can proceed. 7. Toxic Drug Levels a. All sedative, analgesic, neuromuscular blockers, and anticonvulsants must be discontinued and have had sufficient time to be metabolized based on elimination halflife. (See attached table for elimination half-life guidelines) b. Serum levels to confirm that high or supra-therapeutic levels of anticonvulsants are not present should be obtained. These should be repeated as needed or until the levels are in low to mid-therapeutic range. 8. Blood Pressure Norms by age: a. For term neonates (0 to 28 days of age), SBP <60 mm Hg b. For infants from 1 month to 12 months, SBP <70 mm Hg c. For children >1 year to 10 years, SBP <70+(2 age in years) d. Beyond 10 years, hypotension is defined as an SBP <90 mm Hg **Note that these blood pressure thresholds will overlap with normal values, including the 5% of normal children who have an SBP lower than the 5th percentile for age. Reference: Circulation. 2000;102(suppl I):I-291 I-342.; Circulation. 2010; 122: S466- S Clinical Examination - The three cardinal findings of death by neurologic criteria are: a. Unresponsiveness, i. No cerebral motor response to pain in all extremities after nail-bed pressure and supraorbital pressure stimulus. Seizures, shivering and posturing must be absent, as they imply the presence of brain activity. Spontaneous body movements may be observed during the apnea test, at the time of abdominal incision, or in synchrony with the respirations of the mechanical ventilator. These body movements are generated by the spine and are not inconsistent with the diagnosis of death by neurologic criteria. b. Absence of brainstem reflexes,

69 i. Absence of pupil response to bright light in both eyes. Round, oval, or irregularly shaped pupils are compatible with death by neurologic criteria. Most pupils in death by neurologic criteria are in middle position (4 to 6 mm), but the size of the pupils may vary. ii. Absence of spontaneous eye movement, or in response to oculocephalic and oculovestibular testing. iii. Absence of bulbar musculature including facial and oropharyngeal muscles (corneal, gag, cough, sucking, and rooting reflexes) c. and Apnea i. Apnea Testing performed per Clinical Guideline d. When any of the three cardinal findings of death by neurologic criteria cannot be adequately assessed, confirmatory tests are required to diagnose death by neurologic criteria, as described in Section C below. e. Abnormal movements can occur in brain dead patients. These spinal reflexes should not be confused with brain activity. Some of the observed abnormal movements include: i. Spinal arc reflexes - arm movement, flexion at the waist ii. Spontaneous body movement with transport or procedures iii. Slow head turning iv. Facial twitching v. Babinski reflex vi. Abdominal & cremasteric reflexes 10. Family Support: a. While the Code of the Commonwealth of Virginia allows the physician to discontinue cardiorespiratory support at the time of death without consent from the next-of-kin or surrogate, the physician s choice of the appropriate moment for discontinuation of cardiorespiratory support may be influenced by family considerations, the possibility of organ donation, and other relevant ethical issues. b. Declaring a person brain dead can be very difficult for some families to accept. If this is the case or the family requests time for arrival of other family members it may be reasonable to temporarily continue cardiopulmonary support. c. If the family continues to have difficulty accepting the death, other medical professionals, hospital chaplains, and/or the Ethics Consultation Service should be contacted. d. Most importantly, BRAIN DEATH = DEATH. In future discussions regarding this patient, statements such as the body is being kept alive by the machines should not be made. This creates confusion for the family and often even for other health care providers. A way to make this statement to prevent such confusion is the heart and lungs are functional at present only because of the medical support being provided. From the moment the patient is pronounced, the patient is dead and the medical team should use the utmost caution with the spoken terminology to prevent any confusion for the family. Also, once a patient is pronounced brain dead, CPR does not need to be initiated for cardiac arrest because the patient is already dead. 11. Organ Procurement Organization a. At VCUHS/CHoR, LifeNet Health is our OPO.

70 b. Hospital policy states that they must be called for any patient who has a Glascow Coma Scale < 4 or who will have ventilator support withdrawn at the request of the family. A hospital staff member must contact LifeNet Health at (866) within 1 hour. i. The approach to the family for Organ/Tissue Donation will be the responsibility of the Donation Program professionals. ii. Consistent with the Center for Medicare/Medicaid Services (CMS) regulations, the regional Organ Procurement Organization (OPO) will be notified of every death that occurs at VCUHS within 1 hour. iii. Every patient who dies at VCUHS will be evaluated for organ, tissue and eye donation and the family of every potential donor will be informed of their option to donate organs and/or tissues. 12. Donor After Cardiac Death a. Organ recovery from a donor who does not meet the standard of brain death. b. These are patients who are medically devastated on ventilator support, from which ventilator support can be withdrawn with proper consent. Organ procurement can be predictably controlled and planned following withdrawal of ventilator support. i. See VCUHS Policy (updated April 10, 2010)

71 Pediatric Withdrawal of Mechanical Ventilation Guidelines Interdisciplinary Checklist Patient Name MR# Date Nurse Name Physician Name Time withdrawal process initiated: Time of extubation Check name of all the disciplines involved in withdrawal: MD RN RT CLS Chaplain Peds Palliative Care SW Pharm. Initial Decision Making Process Prior to withdrawal process, have following completed. Initial Family meeting; invite SW &/ or chaplain for psychosocial support Family wishes in chart Contact CLS for assistance with memory making activities DNR order in computer Consult Pediatric Palliative Care Team (via CIS or pager #4083) Ensure LifeNet informed of Withdrawal Process ( ) Determine if ME s case ( ) (MD responsibility) Orders are in place for withdrawal procedure and medications If patient has been receiving neuromuscular blockade, make sure has been turned off at least 2 hours prior to withdrawal or patient shows signs of spontaneous breathing Ensure presence of designated family members Notify respiratory therapist Nursing Considerations Prior to withdrawal process, have the following completed. Adequate staffing to allow nurse to coordinate appropriate care Provide a quiet environment Dim lights (omit overhead room lights) Turn off all alarms and consider disconnection from monitors Establish that the patient is comfortable Remove unnecessary medical equipment (NG tubes, venous compression devices, etc.) Maintain IV access for administration of palliation medications Discontinue vasopressors before beginning ventilator withdrawal Review with family the plan and process of ventilator withdrawal

72 Initial Initial Initial Establish Patient Comfort Follow Algorithm for Pharmacological Intervention During Pediatric Withdrawal of Life Support algorithm and document any medications given along with objective markers used Consider IV glycopyrrolate or IV/SC scopolamine if problems with secretions anticipated. If patient is experiencing pulmonary edema or excessive lung water (fine crackles on auscultation) consider diuresis or a topical vasodilator to reduce preload Ventilator Withdrawal Attending is present and has confirmed family wishes Premedicate, if indicated, and then begin a continuous infusion of the medication as ordered by MD. Wean PSV and PEEP to 5, FiO2 to 21%. Observe the patient continuously for signs of distress. Stop the process to re-bolus and titrate medication if signs of distress are apparent. Extubation: Suction any oropharyngeal secretions If present, deflate the endotracheal cuff Remove the tube (physician or respiratory therapy) Suction the mouth if necessary Turn off the ventilator and remove it from the room Place patient on room air After extubation: Provide comfort care i.e. mouth care, turn and reposition as tolerated Continue to monitor for discomfort and distress and treat according to Algorithm for Pharmacological Intervention During Pediatric Withdrawal of Life Support Treat stridor, with, in following order: re-bolus and titrate medication per CE algorithm, aerosol mask, racemic epinephrine aerosol treatments, an oral or nasal airway if family chooses to do so Documentation should include the following: Complete Pediatric Withdrawal of Life Support Guidelines Checklist Patient and family education on understanding of the withdrawal process and the anticipated outcome Initiation of withdrawal process Patient level of comfort Medication administered according to objective markers Additional interventions done

73 Brain Death Examination for Infants, Children, and Adolescents (Form must be completed when making the clinical diagnosis of brain death) Assessment of neurologic function after CPR or other severe acute brain injuries should be deferred for >24 hours or if dictated by clinical judgment. Reduction in inter-exam observation interval can be done if ancillary tests are supportive. Ancillary studies are not required except in cases in which the clinical exam and apnea test cannot be completed. Clinical assessments must be performed by two Attending Physicians. This brain death checklist is required at VCUHS for legal documentation of brain death. Age of Patient Timing of first exam Inter-exam interval Term Newborn > 37 weeks gestational age and up to 30 days old 13. First exam may be performed 24 hours after CPR or other severe brain injury 31 days old to 18 years old First exam may be performed 24 hours after CPR or other severe brain injury At least 24 hours OR Interval shortened because ancillary study (section 4) is consistent with brain death At least 12 hours OR Interval shortened because ancillary study (section 4) is consistent with brain death Section 1. PREREQUISITES for brain death examination and apnea test A. IRREVERSIBLE AND IDENTIFIABLE Cause of Coma (Please Check) Traumatic brain injury Anoxic brain injury Known metabolic disorder Other (Specify) B. CORRECTION of contributing factors that can interfere with neurologic exam Exam One: Attending s Initials: Exam Two: Attending s Initials: a. Core body temp > 35 C (95 F)? Yes No Yes No b. Systolic blood pressure or MAP in acceptable range (Systolic BP not less than 2 standard deviations below age appropriate norm) See companion guideline. Yes No Yes No c. Sedative/analgesic drug effect excluded as a contributing factor? - Pentobarbital Level must be < 10 mcg/ml to proceed with brain death declaration - Consider last dose of narcotics/benzos/anti-epileptic drugs - See attached table for elimination half-life guidelines Yes No Yes No d. Metabolic intoxication or severe disturbance excluded as a contributing factor? Yes No Yes No e. Neuromuscular blockade excluded as a contributing factor? Verification can be done using Train of Four Yes No Yes No If ALL prerequisites are marked YES, then proceed to sections 2 and 3, OR A confounding variable is present. An ancillary study, in addition to correlating clinical exam, is therefore required to document brain death (Section 4). Please List Confounding Variable: Section 2. PHYSICAL EXAMINATION (Please Check) Note: Spinal cord reflexes are acceptable Exam One: Date/time:_ Exam Two: Date/time: a. Flaccid tone, patient unresponsive to deep painful stimuli Yes No Yes No b. Pupils are midposition or fully dilated and light reflexes are absent Oculocephalic reflex or Doll s Eye : Eyes remain fixed in midposition. Yes No Yes No c. Corneal, cough, & gag reflexes are absent Sucking, rooting reflexes are absent (in neonates and infants) Yes No Yes No d. Oculovestibular reflexes are absent. ( Cold Caloric ) Yes No Yes No e. Spontaneous respiratory effort while on mechanical ventilation is absent Yes No Yes No The (specify) element of the exam could not be performed because. An ancillary study (EEG or radionuclide CBF) was performed to document brain death (Go to Section 4).

74 Section 3. APNEA TEST (Both apnea tests may be performed by the same physician) 1. Physician Present: Respiratory Therapist Present: 2. Pre-conditions are met: Patients with C-spine injury or CO2 retention (sleep apnea, COPD) should be diagnosed by cerebral blood flow studies. Exam One : Date/time: Normothermia (temperature > 35) Acceptable BP (See Section 1b) Euvolemia No C-spine injury suspected Exam Two: Date/time: Normothermia (temperature > 35) Acceptable BP (See Section 1b) Euvolemia No C-spine injury suspected 3. Pre-oxygenate with 100% oxygen for 5-10 minutes before beginning testing. 4. Obtain baseline values and alert ABG lab that apnea testing for brain death exam is beginning. 5. Procedure: Done Baseline ABG Time: ph: PaO2: PaCO2: HCO3: O2 sat: HR: BP: Temp: Pulse ox: Done Baseline ABG Time: ph: PaO2: PaCO2: HCO3: O2 sat: HR: BP: Temp: Pulse ox: Be sure to have manual resuscitation bag with 100% oxygen source. Use suction catheter (French diameter) sized no greater than double the size of the artificial airway (ex: 14 Fr. catheter for 7.0 ETT or tracheostomy Place tape over suction engagement port of catheter to divert oxygen to patient s lower airway Remove patient from ventilator Attach prepared catheter to 6-10 lpm O2 source and place catheter in artificial airway (tip placed just above the carina) ABG Time: ABG Time: ph: ph: PaO2: PaO2: PaCO2: PaCO2: HCO3: HCO3: Draw ABG at 5-8 minutes: O2 sat: O2 sat: HR: HR: BP: BP: Temp: Temp: Pulse ox: Pulse ox: ABG Time: ABG Time: ph: ph: PaO2: PaO2: PaCO2: PaCO2: Draw ABG at 8-10 minutes: HCO3: HCO3: (Not required if target PaCO2 already reached) O2 sat: O2 sat: HR: HR: BP: BP: Temp: Temp: Pulse ox: Pulse ox: 6. Monitor for: Spontaneous respirations or respiratory effort present Cardiac ectopy present Pulse oximetry < 85 % present Hypotension present (See companion guideline) **Stop test and draw an ABG if yes is checked at any time. Hyperventilate and consider optional confirmatory test.** Yes Yes Yes Yes No No No No Yes Yes Yes Yes No No No No

75 7. If the PaCO2 does not reach 60mmHg and the patient remains stable, the test may be extended to minutes and a third ABG obtained. **If PaCO2 does not meet brain death criteria after 15 minutes, place patient back on ventilator and consider repeating apnea test after a suitable time interval.** Performed Document Result: Not Performed Performed 8. Hyperventilate and place patient back on oxygen for 15 minutes at end of test Done Done Document Result: Not Performed 9. No spontaneous respiratory efforts were observed despite final PaCO 2 60mm Hg and a 20mm Hg increase above baseline. Physician Signature: Date & Time: Yes: The apnea test supports the diagnosis of brain death. The apnea test is contraindicated or could not be performed to completion because. An ancillary study (EEG or radionuclide CBF) was therefore performed to document brain death. (Go to Section 4). No Yes: The apnea test supports the diagnosis of brain death. No Section 4. ANCILLARY TESTING Ancillary testing is required when: (1) any components of the examination or apnea testing cannot be completed; or (2) ) if there is uncertainty about the results of the neurologic examination. Date/Time Test Interpreted: Ancillary testing may be performed to reduce inter-examination period; however, in this circumstance, a second neurologic exam is still required (including apnea test). Components of neurologic exam that can be performed safely should be completed in close proximity to ancillary test. Electroencephalogram (EEG) report documents electrocerebral silence OR Yes No Cerebral Blood Flow (CBF) study report documents no cerebral perfusion. - Pentobarbital must be < 10 mcg/ml Yes No Section 5. Signatures Legal Time of Death is the time PaCO2 reached target value during second apnea test or official interpretation of ancillary test. Examiner One: I certify that my exam and/or ancillary test report is consistent with cessation of function of the brain and brainstem. Printed Name Signature MD # Specialty Date mm/dd/yyyy Time Examiner Two: I certify that my exam and/or ancillary test report confirms unchanged and irreversible cessation of function of the brain and brainstem. The patient is declared brain dead at this time. Date & Time of death:_ Printed Name Signature MD # Specialty Date mm/dd/yyyy Time References: Nakagawa TA, Ashwal S, Mathur M, Mysore MR, Bruce D, Conway EE Jr, Duthie SE, Hamrick S, Harrison R, Kline AM, Lebovitz DJ, Madden MA, Montgomery VL, Perlman JM, Rollins N, Shemie SD, Vohra A, Williams-Phillips JA, Society of Critical Care Medicine, Section on Critical Care and Section on Neurology of the American Academy of Pediatrics, Child Neurology Society. Guidelines for the determination of brain death in infants and children: an update of the 1987 Task Force recommendations. Crit Care Med Sep;39(9): National Guideline Clearinghouse (NGC). Guideline Summary: Guidelines for the determination of brain death in infants and children: an update of the 1987 Task Force recommendations. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [cited 2013 Sep 16]. Available:

76 VCU Health System Guideline: Withholding and/or Withdrawing Life-Sustaining Treatment for Pediatric Patients 14. Purpose The purpose of this document is to provide guidance for clinical staff regarding initiating discussions about the withholding and/or withdrawal of life-sustaining treatments for pediatric patients. In addition, this document provides treatment guidelines during the withholding and withdrawal of care to help clinicians reduce the physical, psychological, and emotional distress of the pediatric patient and family. (Note: this guideline does not apply when Clinical Brain Death has been determined (see VCUHS policy ) 15. Definitions a. Life-sustaining treatment: clinical care such as, but not limited to, mechanical ventilation, cardiopulmonary resuscitation, use of vasopressors, administration of blood and blood products, hemodialysis, enteral or parenteral nutrition, antibiotic administration, which, when withdrawn will result in the death of a patient due to their underlying disease process. b. Legally authorized representative (LAR): person(s) authorized by the Code of Virginia to make health care decisions on behalf of the patient; in most cases, this will be the patient s parent(s) or guardian. c. Terminal weaning: the gradual withdrawal of mechanical ventilation prior to extubation as part of the withdrawal of life-sustaining treatment. The principle advantage of terminal weaning is the reduction of signs and symptoms of upper airway obstruction and hypoxia through the administration of sedatives and analgesics, thereby reducing patient distress. The terminal weaning process not only promotes the comfort of the patient but also reduces anxiety of family and caregivers. d. Terminal extubation: the removal of an endotracheal tube as part of the withdrawal of life-sustaining treatment. Extubation in such a situation avoids the prolongation of the dying process and allows the patient to be free from an "unnatural" endotracheal tube at the end of life. The process of terminal extubation also is morally transparent, i.e. the intentions of the clinicians are clear, and the process cannot be confused with a therapeutic wean. e. Opiate naïve patient: a patient who has not received continuous opiates for more than five days, nor have they shown evidence of physical tolerance to opiates during this time. 16. General Considerations Before initiating discussions with the patient and/or LAR regarding the withdrawal of lifesustaining treatment, the patient care team should consider the following: a. Decisions to withhold and/or withdraw life-sustaining treatment and allow death to occur are never easy for the pediatric patient, family or health care providers. An environment of mutual respect and collaboration that fosters open and continuous communication between members of the health care team, LAR, patient, and family

77 will increase the overall effectiveness of the process and reduce anxiety and stress for participants. b. Various members of the health care team (physician, nurse, chaplain, social worker, child life specialist) should be involved in the pre-planning process when withdrawal of life-sustaining treatment is being considered. All members of the team should understand the patient s condition before initiating discussions with the LAR regarding the withdrawal of life-sustaining treatment. c. Once a decision has been made to withdraw care, the health care team should step back and reflect on how the focus has shifted from life-sustaining measures to providing end of life care and ensure that the care plan is revised accordingly to meet the new goal. d. During the final moments of a child s life, the pediatric care team can make a positive difference at a crucial time for the patient and family. 17. Decision-making Process: Meeting with the Legally Authorized Representative A well-planned and executed meeting with the child s LAR and other key family members is critical when the withholding/withdrawal of life sustaining treatment is a potential option for the patient. The goal of such a meeting is to discuss the child s condition and prognosis, ascertain the patient s wishes, if known, regarding treatment, and make decisions regarding treatments to be continued or withheld/withdrawn. The Pediatric Palliative Care Consult Team may be contacted for assistance in arranging and preparing for the meeting. a. The meeting should occur in a quiet, private setting to avoid interruptions. Everyone should be seated during the meeting to provide for the comfort of the participants. Appropriate members of the patient care team should be present including the bedside nurse, social worker, child life specialist, chaplain, and physician. The patient s LAR must be present. Other individuals, e.g. family members and friends, may be present at the discretion of the LAR. b. The health care team should describe the patient s condition and prognosis in a compassionate but clear and concise manner, avoiding medical jargon. The option to withhold/withdraw life sustaining treatment should be presented. c. To the extent known and appropriate for the age of the child, the LAR s decisions regarding the withholding/withdrawal of care should be guided by their knowledge of what the patient would want. d. If the LAR agrees to proceed with withholding/withdrawing life-sustaining treatment, the health care team should be prepared to address questions and offer suggestions regarding timing of implementation of the plan, what specific treatments will/will not be provided, the patient s comfort and likelihood that the patient will experience distress or pain, and steps to be taken to minimize patient discomfort and distress. e. The team should ensure that the LAR, patient, and family are aware that the amount of time from completion of the withdrawal process until the patient s death is unpredictable. The team should reassure them that if the death does not occur immediately, it does not mean that the decision to withdraw care was inappropriate. f. The health care team should inform the LAR, patient, and family that transfer to the Comfort Room or to another room on the acute care floor is a possibility if there is a prolonged interval after withdrawal.

78 g. The healthcare team should express interest in making the experience meaningful for the patient and the family. In particular, the team should invite input regarding who will be present at the bedside during the withdrawal of care. If others are identified who have not yet arrived, the team should determine how long it might take for them to arrive, and whether the timing of the implementation of the withdrawal plan can be adjusted to accommodate this. h. The team should invite the family to express concerns, reassure them that the patient s comfort and symptom management will be the primary goals of treatment, and reiterate that withdrawal of life sustaining treatment does not mean withdrawal of all care. i. The team should offer family time alone with the patient to provide opportunity for expression of cultural and religious beliefs throughout the withdrawal and dying process. j. The Child Life Specialists should offer assistance with memory making activities. k. The Pediatric Palliative Care Consult Team should be contacted as needed to assist with staff support and participate in discussions about possible transfer to the Comfort Room on Acute Care Pediatrics. l. Following the Meeting i. The health care team should develop a comprehensive step-wise plan for the process of withholding/withdrawing life-sustaining treatment once the decision has been made. ii. The attending physician should document in the medical record the nature of the meeting, the names of participants (specifically the name of the LAR), the information relayed regarding the patient s condition and prognosis, and decisions reached regarding the goals of the patient s treatment including the continuation or withholding/withdrawal of care. iii. The physician will need to determine if the Medical Examiner (ME) should be contacted ( ). (Information regarding when to call the ME is available within VCUHS policy ). iv. Life Net should be contacted ( ) prior to withdrawal of any lifesustaining therapies including medical or pharmacological support. v. A Do Not Resuscitate order must be placed in the medical record prior to the withdrawal or withholding of any treatment (see VCUHS policy ) 18. Nursing Considerations a. General Considerations i. The bedside nurse is an indispensable resource to the patient and family during the dying process, thus his/her presence at the bedside is critical to reduce anxiety and provide timely interventions as needed. Nursing assessment and presence are particularly important: 1. during and immediately after withdrawal of life support 2. when titrating medications 3. after changes are made in ventilator settings by the Respiratory Therapist 4. any time there is a significant change in the patient s status 5. while the patient is actively dying ii. The nurse should be prepared to spend extra time with the family discussing questions/concerns and should use this opportunity to invite family to share information about the patient and his/her interests. iii. The bedside nurse should assess and respect cultural differences of family response to the situation and the grieving process.

79 iv. Throughout the dying process including before, during, and after the withdrawal of life-sustaining care, the patient and family should be given the opportunity to be alone, if so desired. v. As appropriate, the family should be encouraged to hold the patient s hand and talk to the patient. vi. Attention to the environment of care and attending to small details such as lowering the side rails and bed and having facial tissues, chairs and water available for family are important to creating a comfortable and supportive setting. b. Prior to Initiating the Withholding or Withdrawal of Life-Sustaining Treatment i. Adequate staffing should be provided to allow the nurse to coordinate the appropriate care and support for the patient. ii. The bedside nurse should review with the physician the step-wise plan developed by the health care team for the withdrawal of care and ensure that the plan encompasses all relevant treatments being provided to the patient such as mechanical ventilation, pacemakers, ECMO, vasopressors, enteral/parenteral nutrition, intravenous hydration, antibiotics, and dialysis. iii. Prior to the withholding or withdrawal of any care or treatment, the nurse should ensure that a DNR order has been placed in the medical record. iv. The nurse should ensure that memory making activities have been initiated, when appropriate, and should communicate with the Child Life Specialist to ensure the coordination of such efforts in the overall treatment plan. v. Medications should be readily available to treat signs and symptoms of pain, dyspnea, and secretions. (See: Guidelines for Pharmacologic Intervention During Pediatric Withdrawal of Life-Sustaining Treatment). vi. The nurse should evaluate the setting in which care is being delivered 1. Provide a quiet environment. 2. Dim lights (omit overhead room lights) 3. Alarms and monitors: Evaluate the utility of continuing EKG or other monitoring in the patient s room, and at the nurses station. Consider whether information is needed from the monitor during the withdrawal of care process and also consider the families needs/preferences regarding monitoring. If preferable and consistent with the treatment plan, obtain orders for discontinuing monitoring. vii. Removal of medical devices and equipment: Prior to initiating the withdrawal of care, the nurse should review with the physician the use of medical devices and equipment, e.g. nasogastric tubes, venous compression devices, restraints, to determine if their continued use is consistent with the treatment plan and goals. Orders should be obtained for the removal of such care as needed. Note that certain devices cannot be removed if the case is being referred to the Medical Examiner (discuss with physician for guidance/clarification). If devices and equipment are removed, the nurse should reassure the patient and family that removal is consistent with the overall goal of patient comfort. viii. Intravenous access should be established/maintained for the administration of palliative medications if needed. Patients who are uncomfortable or experiencing respiratory distress should be pre- medicated before ventilator withdrawal and then placed on a continuous infusion as ordered by the physician. (See: Guidelines for Pharmacologic Intervention During Pediatric Withdrawal of Life-Sustaining Treatment)

80 ix. Patients who are comatose are unlikely to experience distress. They should be monitored for signs of distress and medicated during or after withdrawal of care as needed. c. During ventilator withdrawal, the bedside nurse should i. Ensure that orders are entered for ventilator withdrawal and medications to manage discomfort and distress. ii. Ensure that paralytic medications are discontinued at least two hours prior to discontinuation of ventilator support. iii. Notify the Respiratory Therapist who should be present at the bedside iv. Titrate sedation and pain medication as ordered by the physician. v. The FIO 2 should be weaned to 21% over 5-10 minutes. vi. The patient should be observed continuously for signs of distress including: 1. Dyspnea/ Shortness of Breath: nasal flaring, use of accessory muscles, agitation, restlessness, grunting, gasping 2. Heart rate increase > 20% above baseline 3. Mean arterial pressure increase > 20% above baseline 4. Grimacing, clutching 5. Patient self-report of pain or clinical signs of pain (using recommended pain assessment tool) vii. If signs of distress are noted, the weaning process should be stopped in order to rebolus and titrate medications (See: Guidelines for Pharmacologic Intervention During Pediatric Withdrawal of Life-Sustaining Treatment). viii. Patients who are comatose are unlikely to experience distress. They should be monitored for signs of distress and medicated during or after withdrawal of care as needed. d. During extubation, the bedside nurse should i. Suction any oropharyngeal secretions ii. Deflate the endotracheal tube cuff, if present iii. Remove the tube (physician or respiratory therapist) iv. Suction as necessary v. Turn off the ventilator and remove it from the room (respiratory therapist) vi. Place patient on room air e. Following extubation, the bedside nurse should i. Provide comfort care, e.g. mouth care, turn and reposition the patient as needed. ii. Continue to monitor the patient for discomfort and distress and treat according to the Pediatric Guidelines for Pharmacologic Intervention During Withdrawal of Life- Sustaining Treatment. iii. Obtain orders to treat stridor as needed ( recommendations addressed in Pediatric Withdrawal of Life Support Bedside Checklist) f. Should the patient stabilize, consider transferring the patient to the Palliative Care Unit or another appropriate alternate location where continued comfort care can be provided according to the agreed upon plan.

81 g. See VCUHS policy for Proper Care of Deceased Patients and Interaction with Their Families i. Patients who are comatose are unlikely to experience distress. They should be monitored for signs of distress and medicated during or after withdrawal of care as needed. h. During ventilator withdrawal, the bedside nurse should i. Ensure that orders are entered for ventilator withdrawal and medications to manage discomfort and distress. ii. Ensure that paralytic medications are discontinued at least two hours prior to discontinuation of ventilator support. iii. Notify the Respiratory Therapist who should be present at the bedside iv. Titrate sedation and pain medication as ordered by the physician. v. The FIO 2 should be weaned to 21% over 5-10 minutes. vi. The patient should be observed continuously for signs of distress including: 1. Dyspnea/ Shortness of Breath: nasal flaring, use of accessory muscles, agitation, restlessness, grunting, gasping 2. Heart rate increase > 20% above baseline 3. Mean arterial pressure increase > 20% above baseline 4. Grimacing, clutching 5. Patient self-report of pain or clinical signs of pain (using recommended pain assessment tool) vii. If signs of distress are noted, the weaning process should be stopped in order to rebolus and titrate medications (See: Guidelines for Pharmacologic Intervention During Pediatric Withdrawal of Life-Sustaining Treatment). i. During extubation, the bedside nurse should i. Suction any oropharyngeal secretions ii. Deflate the endotracheal tube cuff, if present iii. Remove the tube (physician or respiratory therapist) iv. Suction as necessary v. Turn off the ventilator and remove it from the room (respiratory therapist) vi. Place patient on room air j. Following extubation, the bedside nurse should i. Provide comfort care, e.g. mouth care, turn and reposition the patient as needed. ii. Continue to monitor the patient for discomfort and distress and treat according to the Pediatric Guidelines for Pharmacologic Intervention During Withdrawal of Life- Sustaining Treatment. iii. Obtain orders to treat stridor as needed ( recommendations addressed in Pediatric Withdrawal of Life Support Bedside Checklist) k. Should the patient stabilize, consider transferring the patient to the Palliative Care Unit or another appropriate alternate location where continued comfort care can be provided according to the agreed upon plan. l. See VCUHS policy for Proper Care of Deceased Patients and Interaction with Their Families.

82 2. Physician Considerations a. Prior to the patient/guardian meeting, the attending physician should discuss the patient s condition and prognosis with relevant colleagues and consultants to ensure consensus. b. The attending physician should discuss the patient s condition and prognosis with patient care team, the plan to discuss the withdrawal of life support with the LAR, solicit input and feedback from team members, and address any issues or concerns raised. c. Following the meeting with the LAR, the attending physician should work with the health care team to develop a detailed treatment plan to achieve the goals established during the meeting, including a step-by-step process for the withdrawal of care as appropriate (including but not limited to mechanical ventilation, pacemakers, ECMO, vasopressors, enteral/parenteral nutrition, intravenous hydration, antibiotics, dialysis), and strive to ensure that all team members are clear regarding the treatment goals and plan. d. Following the meeting with the LAR, the attending physician should document in the medical record the nature of the meeting, the names of participants (in particular the name of the LAR), the information relayed regarding the patient s condition and prognosis, and decisions reached regarding the goals of the patient s treatment including the continuation or withholding/withdrawal of care. e. The physician should ensure that neuromuscular blocking agents are stopped at least two hours before proceeding with withdrawal of ventilator support. f. The physician should ensure that a Do Not Resuscitate order is entered in the medical record prior to the withdrawal or withholding of any treatment. g. The physician should enter orders to support the withdrawal of care process as needed including the following Delete orders that are no longer needed or are inconsistent with the new treatment plan Activate the order set Palliative Treatment of Pediatric Patient During Withdrawal of Life-Sustaining Treatment Activate the order set for Treatment of Stridor in the Extubated Patient Consider orders for intravenous glycopyrrolate (10mcg/kg/dose every 3 hours) or intravenous or subcutaneous scopolamine(6mcg/kg/dose IV/SC every 6 hours; max = 0.65mg OR may use scopolamine 1.5 mg transdermal patch for children > 12 years) if problems with secretions are anticipated h. A physician should be accessible at all times following the meeting with the LAR and during the withdrawal of care/dying process to provide orders as needed and to support the staff, patient, and family. Documentation: The physician and nurse s documentation should include the following: Pediatric Withdrawal of Life-Sustaining Treatment Bedside Checklist Patient and LAR education and understanding of the withdrawal process and the anticipated outcome. Initiation of withdrawal process Results of patient assessments including vital signs and level of comfort Medications administered Additional interventions done

83 References: American Association of Critical Care Nurses. (2005). AACN procedure manual for critical care (5th ed.). St. Louis: Elsevier. Campbell, M. L. & Coyne, P. (2006). Compendium of Treatment of End Stage Non-Cancer Diagnoses: Pulmonary. Hospice and Palliative Nurses Association. (pp ). Kendall/Hunt Publishing Co. Consultation with Margaret Campbell June National Guideline Clearinghouse. Recommendation for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. (March 30, 2005). Wiegand, D.L. & Mahon, M. M. (2005). Withholding and Withdrawing Life-Sustaining Therapy. In AACN: Procedure Manual for Critical Care. (5th ed., pp St. Louis: Elsevier. Troug R (2008) Recommendations for end-of-life care in the ICU: A consensus statement by the American Academy of Critical Care Medicine Crit Care Med, 36, 953. Munson D (2007) Withdrawal of mechanical ventilation in pediatric and neonatal intensive care units. Pediatric Clinics of North America. 34, Taketomo, C.K., Hodding, J.H. & Kraus, D.M. (2008) Pediatric Dosage Handbook (15 th ed. ) Lexi-Comp: Hudson, OH. REVIEWED BY: PICU Evidence Based Practice Council VCUHS Ethics Committee VCUHS Risk Management Pediatric Palliative Care & Pain Management Team APPROVED BY: DATE: John J. Mickell, M.D. Director, Pediatric Intensive Care Unit Virginia Commonwealth University Health System Jeniece Roane, MS, RN, NE-BC Nurse Manager, Pediatric Intensive Care Unit

84 Guidelines for Pharmacological Intervention During Pediatric Withdrawal of Life Support Goal Comfo If experiencing fear/anxiety If benzodiazapine naïve, IV bolus with: midazolam 0.1mg/kg (4mg max) or lorazepam 0.05mg/kg (2 mg max) If experiencing dyspnea or pain If opiate naïve, IV bolus with: morphine IV 0.1mg/kg IV (5mg max) OR Fentanyl IV bolus 1mcg/kg IV (50 mcg max) If currently on benzodiazapines, give IV bolus = current hourly infusion rate and increase infusion rate by 50% [ex: midazolam infusing at 2mg/hr, bolus Depending on patient response using objective markers 1, may repeat every 10 min Continue current meds for comfort Reassess frequently Proceed If currently on opioids, give IV bolus = current infusion rate and increase hourly infusion rate by 50% [ex: morphine infusing at 2mg/hr, bolus = 2mg, increase infusion to 3mg/hr] Continuing dyspnea Continuing pain 1. Give an IV bolus = current hourly infusion rate 2. Increase infusion rate by 50% of bolus dose [ex: morphine infusing at 3mg/hr, bolus = 3mg, increase infusion to 4.5mg/hr] 3. Depending on patient response using objective markers 1, may repeat every 10 min See Pediatric Withdrawal of Life Support Guidelines For each dose, document reason for giving the medication and reassess for effect. 1 See page 3 for objective signs for dose titration. The following information is intended for use by clinicians to assist in determining dosages of medications to be used in various clinical settings. Actual dosages required for a given patient may be influenced by a number of variables including but not limited to recent exposure to the drug, cardiovascular, hepatic, renal and other major organ function, underlying disease state(s), concomitant use of other medications, etc. As a result, clinicians must adjust initial and subsequent medication dosages based on the needs of each individual patient and the patient s treatment plan and therapeutic goals. Patients with compromised renal or hepatic function should be monitored and the dose carefully titrated to avoid accumulation of these agents. Clinicians should document the indications for and response to therapy in all cases, particularly those in which dosages exceed the recommended maximum.

85 Table 1. Opioid analgesic agents Drug Typical Typical Morphine Equiva lent Dose, 10 mg Onset to Peak Effect, Duratio n of Effect, 3 4 Adult Dose, 2 10 IV mg Pediatric Dose, IV 0.1 mg/kg Typical Infus ion Fentanyl IV 100 [a] μg mins 2 5 hrs μg/kg mg/kg/hr Rate μg/kg μg/kg//hr a Equivalent doses are approximations and are of limited value due to differences in onset and duration - of effect Table 2. Sedative agents Drug Lorazepa m Midazola m Onset to Peak Effect, mins Durat ion of Effect, hrs Typical Initial Adult Dose, IV Typical Initial Infusion Dose, Adult Typical Initial Pediatric Dose, IV Typical Initial Infusion Dose, Pediatric mg mg/hr 0.05 mg/kg mg/kg/hr mg/kg 1 5 mg/hr 0.1 mg/kg μg/kg//hr - Truog, R et al, Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine, 2008, Crit Care Med, 36, 3, 953. Objective Markers for Upward Adjustment of Medications Dyspnea = c/o breathlessness (distressful subjective sensation)* Respiratory distress = use of accessory muscles, flaring, restlessness, grunting, possible increase in RR, HR or BP, agitation* Pain = c/o pain OR behavioral signs of pain including: facial grimace, restlessness, agitation, cry, difficult to console* * The above objective signs of discomfort are appropriate rationale for symptom management upward dose titration

86 References Munson D (2007) Withdrawal of mechanical ventilation in pediatric and neonatal intensive care units. Pediatric Clinics of North America. 34, Partridge, JC, and Wall, SN (1997). "Analgesia for dying infants whose life support is withdrawn or withheld. " Pediatrics76(4). Zawistowski, CA & DeVita, MA (2004) A descriptive study of children dying in the pediatric intensive care unit after withdrawal of life-sustaining treatment. Pediatr Crit Care Med; 5(3): Chan, JD, Treece PD, Engelberg RA, et al. (2004) Narcotic and benzodiazepine use after withdrawal of life support: association with time to death? Chest.;126: VCUMC Pediatric Patient Care Guidelines: Withdrawal of Life Support - Link American Academy of Pediatrics (2000). Committee on Bioethics and Committee on Hospital Care. Palliative Care for Children. Pediatrics, 106(2 Pt 1): Troug R (2008) Recommendations for end-of-life care in the ICU: A consensus statement by the American Academy of Critical Care Medicine Crit Care Med, 36, 953 Taketomo, CK, Hodding, Jh, & Kraus, Dm (2008) Pediatric Dosage Handbook. Lexi- Comp: Hudson, OH.

87 VI- Burn and Inhalation Pediatric Burn and Inhalation Injury Management The Children s Trauma Center partners closely with the Evans-Haynes Burn Center (EHBC), treating approximately 100 pediatric burn patients annually. The EHBC is verified by the American Burn Association for both adult and pediatric burn care. Children who present to the Emergency Department with severe burns or inhalation injury requiring airway management or fluid resuscitation will initially be cared for in the Pediatric Intensive Care Unit. Once stabilized, these patients are transferred to the EHBC. Our teams partner for outreach, prevention, and provider education events.