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Welcome to the online home of the University of Arizona General Surgery Handbook. This handbook is a peer-reviewed, yearly-updated, publicly available resource for residents.

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About This Handbook

This resource serves as the repository for the University of Arizona General Surgery practice management guidelines. It is designed for quick reference, evidence-based decision support, and consistency across all surgical services.

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Appendices

In-House Directory

(Dial “4” before extension unless otherwise noted)

Patient & Family Services

Adult Family Room – 5456
Gift Shop – 4330
Cafeteria – 6156 / 4670
Cashier – 8457
Chaplain / Spiritual Care – 6826 / (2109)
Patient Relations – 6281 / (3668)
Resource Center – 6335

Admissions & Registration

Admitting – 7605
Admitting MD Pager – 5908
Direct Admit (08:00–18:00) – 7485
Ambulatory Surgery Waiting Room – 4232

Emergency & Critical Care

ED Case Manager – 5072
Electrocardiogram (EKG) – 7444 / (3568)
Telemetry – 6365 / (5818)
Emergency Pager (PICU Pager) – 4220 / (7956)

Clinical Departments

Audiology – 5013
Blood Bank – 6920 / (5037)
Blood Gas Laboratory – 9250
Cath Lab – 6537
Diagnostic Cardiology – 6750
Dialysis – 7776
Dialysis Technician – 1249 / (4394)
Gastrointestinal (GI) Lab – 6665
Interventional Radiology – 2379
Microbiology – 6209
Nutrition – 1249 / (4394)
Pain Team (Epidural) – 1660
Palliative Care – 7486
Phlebotomy / Lab Draw – 6291 / (5660)
Speech Therapy – (1892)
Urology – 6709
Virology – 6338
Wound Referral – 1810 / 2150-4170

Surgical & Perioperative Services

Operating Room Desk (OR Desk) – 5908
Operating Room Pharmacy (OR Pharmacy) – 5868
Sterile Processing – 6316
Total Parenteral Nutrition (TPN) – 6316 / (2143)

Imaging & Radiology

CT Scan – 6755 / 6922
Film Library – 7409
Radiology Main – 5027 / 7491 / (1579)
Ultrasound (US) – 6918 / (5531)

Pharmacy Services

Inpatient Pharmacy – 5868
IV Room – 6890

Rehabilitation & Therapies

Physical Therapy / Occupational Therapy (PT/OT) – 5910 / (2410)

Operations & Support

Battery Pickup/Recycle – 591-7005
Bio-Medical Engineering (Bio-Med) – 7500
Bulk Item (Water) – 4481
Facilities / Maintenance – 7409
Food Service – 3603
Help Desk (IT) – 7514 / (6766)
Housekeeping (EVS) – 2194
Human Resources – 2173
Infection Control – 7601
Transport Services – 8726 / 6511
Transfer Services – 5868
Security – 6538

Emergency (In-House Only)

Code Blue – Call 5000
Rapid Response – 4777
Stroke Team – 7876
Security – 6538
Anything Else – 5000

Pharmacy

Inpatient Pharmacy

Ante Room – 4-6556
Diamond Satellite Pharmacy (D4W) – 4-6780 / 4-2801
Inpatient Pharmacy Main Line – 4-6589
Investigational Drugs (Jennifer / Elena) – 4-6127 / 4-6589
Intravenous (IV) Room – 4-6589
Manufacturing Area – 4-6581
Nutrition Support Pharmacist (TPN Pharmacist) – 4-7658
Oncology Pharmacist – 4-7835 / 4-7838
Operating Room (OR) Pharmacy – 4-6590
Order Entry Area – 4-6579 / 4-6580
Transplant Pharmacy (Katie / Ruhani) – 4-6555
Pharmacy Vault – 4-6554
Fax – 4-2138

Unit-Based Clinical Pharmacy Coverage

Unit	RPh	Primary	Secondary
1NW	—	4-7520	—
3E	4-7619	4-5247	—
3NE	4-6549	4-7166	4-7167
3NW (BMT)	4-9293	4-7656	4-7657
4NE	4-4253	4-7371	—
4W	4-4253	4-9378	—
5EW (Ante/Postpartum)	—	4-7060	4-5774
5NS (Labor & Delivery)	—	4-7047	—
6EW (Cardiac Stepdown)	4-4739	4-2680	—
6NS (CTICU)	4-4117	4-7660	—
7EW (Cardiac PCU)	4-4739	4-4228	—
7NS (MICU)	4-5078	4-0099	—
8EW (Trauma Stepdown)	4-2812	4-3260	—
8NS (Trauma ICU)	4-5321	4-3290	—
9EW (Specialty IMC)	4-5566	4-6886	—
9NS	—	4-7371	—
D2N	4-3297	4-3400	—
D3N	—	4-6035	—
D3W	—	4-7395	—
D4N (NICU)	4-3899	4-7578	—
D5N	4-8255	4-7453	4-8297
D5W	4-8255	4-7453	4-8297
D6N (PICU)	4-3820	4-7376	—
D6W	4-6999	4-7612	—
ED Central	4-9815	4-9582	—
ED North (Peds)	—	4-9583	—
ED South	—	4-9581	—
ED Trauma	—	4-9580	—
ED Triage	—	4-9816	—
PACU / OR	—	4-7510	—
Urgent Care	—	4-4750	4-6272

Medication History Team

Med Hx Interns (Weekdays Only) – 4-9283
Medication History Technician (ED / Inpatient Pharmacy) – 4-3694 / 4-6784

Outpatient & Specialty Pharmacies

Banner Family Pharmacy – 4-7949 / Fax 2-3563
Center Pharmacy – 4-7403 / Fax 2-2600
Orange Grove Pharmacy – 3-7212 / Fax 3-9608
South Campus Pharmacy – 874-2553 / Fax 8-8020
South Campus Retail Services – 874-2000
Specialty Pharmacy – 4-6193 / Fax 4-6204

Emergency & Security Contacts

FEMA – Emergency Supply Coordination – 1-602-364-3940
FEMA Backup – 1-602-364-3941
Security (Campus) – 621-3273
University of Arizona Police – 621-8273

Medical Imaging – Useful Numbers

Reading Rooms

Body Imaging – 47053, 47065, 47068
Cardiac Imaging – 48730, 40146
Chest Imaging – 42566, 46832
Fluoroscopy – 45153
Interventional Radiology (IR) – 42102, 42106
Musculoskeletal (MSK) Imaging – 42272, 46828
Neuroradiology (Neuro) – 46811, 45157
Nuclear Medicine (Nuc) – 47400
Pediatric Radiology (Ped) – 46843, 46845
Ultrasound (US) – 46761, 47235

Technologists

Computed Tomography – Emergency Department (CT ED) – 49777
Computed Tomography – Main (CT Main) – 46755, 46722
Magnetic Resonance Imaging (MRI) – 44889
Fluoroscopy (Fluoro) – 47420
Interventional Radiology – Main (IR Main) – 42379
Interventional Radiology – Holding Area (IR Holding) – 44245
Nuclear Medicine (Nuc) – 44894
X-ray – Main Department (X-ray Main) – 45027
X-ray – Emergency Department (X-ray ED) – 49867
Ultrasound (US) – 46918

Post-Operative Check — Workflow

Step 1. Chart Check (before entering the room)

Immediate post-op/procedure note
Procedure type, laterality, anastomosis present, drains/tubes (where is the drain placed intraoperatively?), intra-op complications.
Estimated blood loss and transfusion given. If PEG placed: note bumper distance at skin.
Vitals trends (since OR/PACU)
Tachycardia: may signal pain, hypovolemia, bleeding, PE, infection.
Hypotension: consider bleeding, sepsis, anesthetic effect, hypovolemia.
Hypertension: uncontrolled pain, urinary retention, missed home meds.
Tachypnea/SpO₂ <92%: atelectasis, PE, pneumonia, volume overload.
Fever: <48h atelectasis, most likely physiological after surgery.
Labs
CBC: drop in Hgb/Hct (bleeding).
BMP: electrolytes (Na, K, Ca, Mg, Phos), renal function (UO correlation).
LFTs: if HPB or biliary surgery.
Coags: if bleeding or liver disease.
Glucose: hyperglycemia post-op, diabetics, stress response.
Intake/Output
Adequate urine output? (goal ≥0.5 mL/kg/hr).
Drain outputs: character (serosanguinous vs bilious vs feculent) and volume.
Comorbidities
Cardiac: CAD, CHF, arrhythmias → influences fluids, pain, beta-blocker use.
Pulmonary: COPD/OSA → higher risk of hypoxia/retention.
Renal: CKD → careful fluids, drug dosing.
Hepatic: cirrhosis → coagulopathy, ascites, encephalopathy risk.
Endocrine: diabetes (glucose control), thyroid/adrenal meds.
Home medications
beta-blocker (avoid rebound tachycardia), statin, thyroid meds, seizure meds, antidepressants.
anticoagulants, antiplatelets, ACEi/ARB, SGLT2 inhibitors, metformin (renal risk), insulin (adjusted).
Pain regimen baseline (opioid-tolerant vs opioid-naïve).

Step 2. Patient Examination + Nursing Check

Airway: Patent, voice clear, aspiration risk addressed.
Breathing: SpO₂ _% on _ (RA/NC/NRB/HFNC); RR ____. Incentive spirometer at bedside with goal set.
Circulation: HR _ BP /_ MAP . Telemetry rhythm ____. Cap refill/warmth. Check dressings/drains for bleeding/hematoma.
Neuro (Disability): Mental status at baseline? Focal deficits? Pain/sedation documented.
Exposure/Wound: Incisions intact/dry, no erythema/crepitus. Do not remove sterile dressing unless ordered; reinforce if needed.
Foley/Fluids: Foley present? Y/N. UO _ mL/hr (goal ≥0.5 mL/kg/hr). IV fluids running at ; assess need for bolus.
GI: Abdomen soft/firm? Distension, tenderness, peritonitis? N/V? Anti-emetic plan. NG/OG/stoma function; drain character.
Hematology/VTE: SCDs in place and functioning.
Extremities/Integument: Pulses/motor/sensation distal to operative site; compartments soft.
Lines, Tubes, Drains:
IVs/central lines.
Chest tube(s): suction/water seal; output ___ mL; air leak? Y/N.
Surgical drains: number ___; last-hour output ___ mL; character.
Foley: keep/remove per protocol; bladder scan if low UO.
Prevena/wound vac if present.
Check with nurse: Ask for concerns re: pain, urine output, N/V, hemodynamics.

Step 3. Post-Op Orders and Documentation

Write/post-op check note (S/O/A/P).
Update orders if needed: labs (CBC, BMP, Mg/Phos, lactate if needed, glucose), meds, diet advancement, IVF adjustments.

Procedure-Specific Add-Ons:
- Colorectal/anastomosis: Monitor for leak (rising pain/tachycardia/fever, drain amylase/bilirubin).
- HPB: Check bile in drains, trend LFTs.
- Vascular: Doppler distal pulses, compartments, antiplatelet/anticoag plan.
- Thoracic: Chest tube management, daily CXR, air-leak check.
- Endocrine/Thyroid: Calcium/hypocalcemia symptoms, voice, airway.
- Hernia/Abdominal wall: Binder use, seroma/hematoma watch.

Step 4. Red Flags — Call Senior Immediately

SpO₂ < 92% on O₂, escalating work of breathing, new chest pain.
SBP < 90 or MAP < 65, HR > 120 sustained, new arrhythmia.
UO < 0.5 mL/kg/hr, anuria, or dark/bloody urine.
Rapidly expanding hematoma or soaked dressings; bright-red drain output.
Rigid abdomen, peritonitis, or pain out of proportion.
Fever ≥ 38.5°C with peritonitis, severe tachycardia, or hypotension.
New focal neuro deficit, delirium, or severe agitation.

Common Post Operative Issues

Post-Operative Pain Management

Definition

Acute pain arising after surgery, resulting from tissue injury, inflammation, and nociceptive/neuropathic pathways.

Numeric Rating Scale (NRS 0–10) for verbal adults.
Critical Care Pain Observation Tool (CPOT) or FLACC scale for non-verbal or pediatric patients.
Uncontrolled pain worsens outcomes: delayed ambulation, pulmonary complications, delirium, and chronic pain syndromes.

I. Principles

Multimodal therapy is standard: combine non-opioids, opioids, and regional techniques.
Oral > IV whenever feasible.
Start least invasive, escalate stepwise.
Always rule out dangerous causes of pain: peritonitis, bleeding, anastomotic leak, compartment syndrome, ischemia.
Regular reassessment: q2–4h depending on setting.
Prevent complications: constipation, oversedation, delirium, respiratory depression.
Tailor to special populations: frail, elderly, renal/hepatic impairment, pediatrics, opioid-tolerant patients.

II. Stepwise Framework

Step 1: Scheduled Non-Opioids (baseline for all unless contraindicated)

Acetaminophen
650 mg PO q6h OR 1 g PO/IV q6–8h
Max: 4 g/day (≤3 g in frail, liver disease, alcohol use).
NSAIDs (avoid in renal impairment, GI ulcer, coagulopathy, or fresh anastomosis)
Ketorolac 15–30 mg IV q6h (max 5 days).
Ibuprofen 400–600 mg PO q6h.
Adjuncts
Gabapentin 100–300 mg PO qHS (titrate to 300 TID; renal adjust).
Robaxin (methocarbamol) 500–1000 mg PO/IV q8h PRN.
Flexeril (cyclobenzaprine) 5–10 mg PO TID PRN.
Lidocaine patches (12h on/12h off) for incisional pain.

Step 2: PRN Oral Opioids (breakthrough pain)

Oxycodone IR 5–10 mg PO q4–6h PRN.
Hydromorphone PO 2–4 mg PO q4–6h PRN.
Hydrocodone/APAP (Norco 5/325 mg) 1–2 tabs PO q6h PRN (track acetaminophen total).
Tramadol 50 mg PO q6h PRN (max 400 mg/day; serotonin syndrome risk with SSRIs/SNRIs).

Step 3: IV Opioids (if NPO, severe pain, or unable to tolerate PO)

Hydromorphone 0.2–0.5 mg IV q2–3h PRN.
Morphine 1–2 mg IV q2–3h PRN (avoid in renal impairment).
Fentanyl 25–50 mcg IV q1–2h PRN (short acting).

Step 4: Escalation / Severe or Refractory Pain

PCA (Patient-Controlled Analgesia):
Hydromorphone: 0.2 mg demand, lockout 8–10 min, no basal in opioid-naïve.
Morphine: 1 mg demand, lockout 8–10 min.
Add basal infusion only if opioid-tolerant or ICU monitored.
Acute Pain Service consult for uncontrolled pain, opioid tolerance, or consideration of regional/epidural techniques.
Regional / Neuraxial:
Epidural infusion (thoracic/lumbar).
TAP block or wound infusion catheter.
Coordinate with anesthesia/pain service.

III. Monitoring & Safety

Assessment frequency:
Floor: q4h.
ICU: q2h (NRS or CPOT if non-verbal).
Side effect management:
Nausea → ondansetron 4 mg IV/PO q8h PRN.
Constipation → senna scheduled ± miralax.
Pruritus → diphenhydramine or nalbuphine.
Respiratory depression → naloxone 0.1–0.2 mg IV q2–3 min PRN (max 0.8 mg).
Special populations:
Elderly/frail → lower doses, slower titration.
Renal impairment → avoid morphine, adjust gabapentin, avoid ketorolac.
Hepatic impairment → acetaminophen max ≤2–3 g/day.

IV. Pediatric Considerations

Pain assessment tools: FLACC (Face, Legs, Activity, Cry, Consolability), Wong-Baker FACES, Numeric scale (if verbal).
Non-pharmacologic adjuncts: parental presence, distraction (music, video), comfort positioning.
Stepwise regimen (weight-based):
Acetaminophen: 10–15 mg/kg PO/IV q6h (max 75 mg/kg/day, not exceeding 4 g).
Ibuprofen: 5–10 mg/kg PO q6–8h (avoid <6 months or renal/GI risk).
Opioids:
- Morphine 0.05–0.1 mg/kg IV q2–4h PRN.
- Hydromorphone 0.01–0.02 mg/kg IV q3–4h PRN.
- Oxycodone 0.05–0.15 mg/kg PO q4–6h PRN.
Avoid codeine & tramadol (variable metabolism, black box warning).
Regional techniques: caudal block, epidural, nerve blocks often used safely in pediatrics.
Cautions: infants <6 months at higher risk of respiratory depression.

V. Red Flags / Urgent Triggers

Disproportionate pain to expected course.
Sudden severe pain with instability → consider hemorrhage, anastomotic leak, perforation.
New focal deficits → compartment syndrome, ischemia, nerve injury.
Opioid-induced oversedation or respiratory depression.

VI. Intern Pearls

Always schedule acetaminophen + NSAID unless contraindicated.
Opioids should be PRN, not scheduled.
Always reassess vitals and pain after each escalation step.
Disproportionate pain = work up for complication, not just medicate.
In ICU: prioritize analgesia over sedation.
If delirium develops: reduce opioids/benzos, add delirium precautions.

VII. Summary Tables

Non-Opioids

Drug	Dose / Route	Notes / Cautions
Acetaminophen	650 mg PO q6h OR 1 g IV q6–8h	Max 4 g/day (≤3 g in liver dz)
Ketorolac	15–30 mg IV q6h (≤5 days)	Avoid renal/GI/bleeding risk
Ibuprofen	400–600 mg PO q6h	Avoid GI ulcer, renal impairment
Gabapentin	100–300 mg PO qHS → TID	Renal adjust
Robaxin	500–1000 mg IV/PO q8h PRN	Limit IV ≤3 days, avoid severe renal impairment
Flexeril	5–10 mg PO TID PRN	Oversedation risk
Lidocaine patch	Apply over incision, 12h on/12h off	Useful for incisional pain

Opioids

Drug	Dose / Route	Notes / Cautions
Oxycodone IR	5–10 mg PO q4–6h PRN	1st-line oral opioid
Hydromorphone PO	2–4 mg PO q4–6h PRN	Stronger oral option
Hydrocodone/APAP	1–2 tabs PO q6h PRN	Track total APAP dose
Tramadol	50 mg PO q6h PRN (max 400 mg/day)	Risk serotonin syndrome
Hydromorphone IV	0.2–0.5 mg IV q2–3h PRN	Preferred IV opioid
Morphine IV	1–2 mg IV q2–3h PRN	Avoid in renal impairment
Fentanyl IV	25–50 mcg IV q1–2h PRN	Short acting
PCA (Hydromorphone)	0.2 mg demand, lockout 8–10 min	No basal if opioid-naïve
PCA (Morphine)	1 mg demand, lockout 8–10 min	Basal only if opioid-tolerant

VIII. References

Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the ICU. Crit Care Med. 2013;41(1):263–306.
Devlin JW, Skrobik Y, Gélinas C, et al. PADIS Guidelines (Pain, Agitation/Sedation, Delirium, Immobility, Sleep). Crit Care Med. 2018;46(9):e825–e873.
El Moheb M. Use of Opioids in the Postoperative Period. In: Current Surgical Therapy, 14th ed. Elsevier, 2023.
Washington Manual of Surgery, 9th ed. LWW, 2024.
American Pediatric Surgical Association (APSA) & American Pain Society pediatric recommendations (consensus-based).

Post-Operative Bradycardia

Definition

Bradycardia = HR < 60 bpm, clinically significant when < 50 bpm or associated with symptoms.
Causes may be physiologic (vagal tone, athletic conditioning, sleep) or pathologic (ischemia, conduction disease, drugs, metabolic derangements).

Symptoms: syncope, presyncope, hypotension, dyspnea, chest pain, altered mental status.
Differentiate:
Sinus node dysfunction (pacing defect)
Atrioventricular [AV] block (conduction defect)

I. Principles

Not all bradycardia requires intervention — treat the patient, not the number.
Always exclude reversible causes first.
Use ACLS framework: Airway, Breathing, Circulation → Identify Rhythm → Intervene.
High-grade AV block or unstable bradycardia = emergent pacing.

II. Etiologies

Reversible / Transient

Vagal stimulation (pain, suctioning, intubation)
Medications: β-blockers, CCBs, digoxin, antiarrhythmics, anesthetics
Electrolyte derangements: K⁺, Mg²⁺, Ca²⁺
Hypothermia, hypothyroidism, sleep apnea

Pathologic

Ischemia (inferior MI)
Infection (endocarditis with abscess, sepsis)
Infiltrative/inflammatory: amyloidosis, sarcoidosis
Post-cardiac surgery: valve, CABG, congenital repair

III. AV Block Classification

First-degree: prolonged PR, 1:1 conduction
Mobitz I (Wenckebach): progressive PR lengthening, dropped QRS
Mobitz II: constant PR, intermittent dropped QRS — unstable, needs pacing
Third-degree (complete block): no atrial conduction, ventricular escape rhythm

IV. Evaluation

Confirm rhythm: EKG, telemetry
Assess hemodynamics: BP, mental status, O₂ sat, urine output
Labs: electrolytes, troponin, thyroid function if indicated
Echocardiogram if infiltrative/structural suspicion
Ambulatory monitoring if recurrent outpatient symptoms

V. Management

A. Stable, Asymptomatic

Observation + continuous monitoring
Correct reversible causes
Avoid AV nodal blockers (β-blockers, CCBs, digoxin, adenosine)

B. Symptomatic or High-Grade Block (Mobitz II, Complete HB)

Call senior + cardiology/EP immediately
Treat reversible causes
Prepare for permanent pacemaker evaluation

C. Unstable (hypotension, AMS, ischemia, shock)

Follow ACLS 2025 algorithm:
1. Atropine 1 mg IV q3–5 min (max 3 mg)
- Avoid in heart transplant patients → go directly to pacing/pressors.
2. If ineffective:
- Transcutaneous pacing (TCP) (sedate if able)
- Dopamine infusion: 5–20 µg/kg/min
- Epinephrine infusion: 2–10 µg/min
3. If refractory:
- Transvenous pacing, CCU transfer, cardiology/EP consult

VI. ACLS Algorithm (ASCII Flowchart)

VII. Quick Reference: Drugs & Doses

Medication	Dose / Route	Notes / Cautions
Atropine	1 mg IV q3–5 min (max 3 mg)	Avoid in heart transplant patients
Dopamine	5–20 µg/kg/min IV infusion	Titrate to HR & BP; vasopressor effects
Epinephrine	2–10 µg/min IV infusion	Potent; monitor closely for tachyarrhythmias
TCP	Start at 60–80 bpm, sedation if time allows	First-line if atropine ineffective
TVP	Transvenous pacing	Definitive bridge until permanent pacemaker

VIII. Red Flags – Call Senior Immediately

HR < 40 bpm sustained
Symptomatic bradycardia (syncope, hypotension, AMS, chest pain)
Mobitz II or Complete Heart Block
New bradycardia post-cardiac surgery
Bradycardia with sepsis or suspected perivalvular abscess

IX. Intern Pearls

Not all bradycardia needs treatment—asymptomatic and stable often safe to monitor.
Always review the med list for nodal blockers.
If unstable: Atropine → TCP/Pressors → TVP.
Pacemaker is definitive therapy for high-grade AV block.
Treat underlying causes in parallel, don’t delay.

X. References

Kusumoto FM, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Bradycardia and Cardiac Conduction Delay. JACC. 2019;74(7):e51–e156.
American Heart Association. ACLS Bradycardia Algorithm. 2025 Provider Manual Updates & FAQs. cpr.heart.org.
Neumar RW, et al. Part 8: Adult ACLS: Bradycardia with a Pulse. Circulation. 2015;132:S444–S464.
Fulton MR II. Advanced Cardiac Life Support (ACLS). StatPearls. 2025.

Key Takeaways

Differentiate sinus bradycardia vs AV block.
Stable + asymptomatic → monitor and treat causes.
Symptomatic/high-grade AV block → urgent pacing, consider pacemaker.
Unstable bradycardia = ACLS algorithm: Atropine → TCP/Pressors → TVP.
Always search for reversible causes in parallel.

Post-Operative Fever

I. Principles

Fever = temperature > 38.0°C (100.4°F) in the immediate post-operative setting.
May be benign (inflammatory response, blood products) or pathologic (infection, thromboembolic, ischemic).
Always stratify by time since surgery, severity, and patient stability.
Unstable patient with fever = sepsis until proven otherwise.

II. Timeline-Based Differential

Post-Op Timing	Common Etiologies	High-Risk / Dangerous Causes
< 48 hours	Inflammatory response, hematoma, aspiration, transfusion reaction, atelectasis	Early pneumonia, intra-op contamination, line infection
48–72 hours	Pneumonia, UTI, phlebitis, catheter infection	Anastomotic leak, sepsis
3–7 days	Surgical site infection, pneumonia, UTI, C. difficile colitis	Intra-abdominal abscess, anastomotic leak, empyema
> 7 days	DVT/PE, line sepsis, drug fever	Deep abscess, septic pelvic thrombophlebitis

III. Stepwise Evaluation

Step 1 – Confirm Fever

Verify measurement and source, repeat if uncertain.
Review trend, maximum temperature, and fever pattern (isolated vs persistent vs spiking).

Step 2 – Assess Stability

Vitals: HR, BP, O2 sat, RR.
Sepsis screen: hypotension, tachypnea, altered mental status, oliguria.

Step 3 – History and Exam

History: cough, sputum, dysuria, wound pain/drainage, diarrhea, calf pain/swelling, meds/blood products.
Exam: chest, surgical wounds, drains, Foley, IV/central lines, extremities.

Step 4 – Initial Workup

Basic set (almost always):
CBC with differential
BMP
Blood cultures ×2
Urinalysis ± urine culture
Chest X-ray
Targeted testing (if indicated):
Sputum culture (productive cough)
Stool toxin/PCR (diarrhea, recent antibiotics)
CT abdomen/pelvis with IV contrast (abdominal tenderness, tachycardia, leak/abscess concern)
Duplex ultrasound (suspected DVT)
Line cultures (if catheter infection suspected)

IV. Management

Stable patients
Complete evaluation before empiric antibiotics
Supportive care: antipyretics, pulmonary toilet, incentive spirometry, ambulation, hydration
Unstable patients
Treat as sepsis
Cultures, broad-spectrum antibiotics, IV fluids
Search for and initiate source control (abscess drainage, remove infected line, debride wound)
Source-directed therapy
Abscess → drainage
SSI → open wound, culture, drainage
Pneumonia/UTI → targeted antibiotics
C. difficile → oral vancomycin or fidaxomicin
Line sepsis → line removal

V. Red Flags – Call Senior Immediately

Hemodynamic instability (hypotension, tachycardia, hypoxia)
Peritonitis or rigid abdomen
Fever with chest pain, arrhythmia, or sudden hypoxia (possible PE/MI)
Purulent, feculent, or bilious drainage from wound or drains
Temperature > 39°C without clear source

VI. Intern Pearls

First 24h fevers often non-infectious, but rule out aspiration, transfusion reaction, necrotizing infection.
Always inspect lines, drains, Foley, wounds.
Drug fever is rare and a diagnosis of exclusion.
Remember: Sepsis = Source control + Antibiotics + Resuscitation.

VII. Quick Reference Table

Initial Workup

Test	Indication
CBC with diff	Almost always
BMP	Baseline and renal function
Blood cultures ×2	Unexplained fever or unstable
Urinalysis ± UCx	Foley or dysuria
Chest X-ray	POD >2, cough, hypoxia
CT A/P with IV contrast	Abdominal tenderness, leak/abscess concern
Duplex US	Suspected DVT
Stool toxin/PCR	Diarrhea, recent antibiotics
Line cultures	Suspected line sepsis

VIII. References

Bartlett JG, et al. Postoperative fever: clinical evaluation and management. Clin Infect Dis. 2002;34(4):512–518.
Berríos-Torres SI, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection. JAMA Surg. 2017;152(8):784–791.
Calandra T, Cohen J. International Sepsis Forum Consensus Conference on Definitions of Infection in the ICU. Crit Care Med. 2005;33(7):1538–1548.
Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2013;41(2):580–637.

Key Takeaways

Always verify fever, assess stability, and apply timeline-based differential.
Early fevers often benign; late fevers usually infectious.
Workup should be systematic and source-driven.
Unstable post-op patient with fever = treat as sepsis until proven otherwise.

Post-Operative Hypertension

I. Definitions

Asymptomatic Elevated BP (new AHA term):
SBP >130 mmHg or DBP >80 mmHg in the inpatient setting, often transient and not requiring acute intervention.
Markedly Elevated BP (replaces "urgency"):
SBP ≥180 mmHg or DBP ≥110 mmHg without acute end-organ damage.
Avoid reflexive IV treatment. Address measurement accuracy and reversible causes first.
Hypertensive Emergency:
SBP ≥180 mmHg or DBP ≥110–120 mmHg with evidence of acute end-organ damage (neurologic, cardiac, renal, aortic, pulmonary).

II. Evaluation

Step 1 – Confirm

Repeat BP manually; ensure proper cuff size, positioning, rest.
Confirm with arterial line if present.

Step 2 – Assess for End-Organ Damage

Neurologic: encephalopathy, delirium, seizures, focal deficits, vision change.
Cardiac: chest pain, ACS, ischemic ECG, elevated troponin.
Aortic: tearing chest/back pain → dissection.
Pulmonary: dyspnea, pulmonary edema, hypoxia.
Renal: oliguria, elevated creatinine.

Step 3 – Targeted Workup

BMP, LFTs, CBC.
Troponin, BNP.
ECG, chest X-ray.
CT brain (neuro deficits).
CTA chest/abdomen (if dissection suspected).

III. Management Principles

A. Asymptomatic Elevated or Markedly Elevated BP (No Organ Damage)

Do not treat acutely/reflexively with IV antihypertensives. (Evidence shows this increases risk of AKI, ICU transfer, and mortality).
A-I-M strategy:
A – Assess: confirm accurate measurement.
I – Identify: fix triggers (pain, anxiety, urinary retention, hypoxia, withdrawal, missed meds).
M – Modify: restart/adjust chronic regimen, plan outpatient follow-up.

B. Hypertensive Emergency (With End-Organ Damage)

Admit to ICU, place arterial line if needed.
BP targets:
Lower MAP by ≤25% in first hour.
Then to ~160/100 in next 2–6h.
Normalize over 24–48h.

Exceptions (Organ-Specific)

Aortic Dissection: SBP 100–120 within minutes; HR 60–80 with IV β-blocker before vasodilator.
Acute Ischemic Stroke:
If reperfusion candidate: treat if >185/110.
If not reperfusion: treat only if >220/120.
Pregnancy (pre-/eclampsia): labetalol, hydralazine, or nicardipine; avoid ACEi/ARB, nitroprusside; give MgSO₄ for eclampsia.

IV. Stepwise Management

Step 1 – Fix Reversible Causes

Pain, anxiety, bladder distension, hypoxia, missed antihypertensives, missed dialysis.

Step 2 – Oral Therapy (for marked elevation, stable patients)

Captopril PO: 12.5–25 mg q8h.
Hydralazine PO: 10–20 mg q6h.
Isosorbide dinitrate PO: 5–20 mg TID.
Nifedipine XL PO: 30 mg daily (avoid short-acting).
Clonidine PO: 0.1–0.2 mg, repeat 0.05–0.1 mg q1–2h (max 0.6–0.7 mg); caution sedation/rebound.

Step 3 – IV Therapy (for emergencies)

Labetalol IV: 10–40 mg q20–30 min; infusion 1–2 mg/min.
Nicardipine infusion: start 5 mg/h; titrate q5–15 min; max 15 mg/h.
Clevidipine infusion: 1–2 mg/h; double q90s; max 32 mg/h.
Esmolol infusion: 500–1000 mcg/kg bolus → 50–200 mcg/kg/min.
Nitroglycerin infusion: 5–10 mcg/min (ACS, pulmonary edema).
Enalaprilat IV: 1.25 mg q6h (avoid in AKI/hyperkalemia).

Step 4 – Transition

Switch to long-acting oral regimen (amlodipine, ACEi/ARB, β-blocker, thiazide).
Ensure continuity of outpatient therapy.

V. Quick Reference

Category	Action	Notes
Asymptomatic Elevated BP	No IV meds; AIM strategy	Avoid overtreatment
Markedly Elevated BP	Same as above	Treat only if persistent + documented chronic HTN
Hypertensive Emergency	ICU, IV antihypertensives	Target MAP ↓ ≤25% in 1h

VI. Red Flags — Call Senior / ICU

SBP ≥180 or DBP ≥120 with symptoms or organ damage.
Concern for aortic dissection, stroke, ACS, pulmonary edema.
Pregnant/postpartum patient with severe hypertension.
Refractory BP despite multiple IV meds.

VII. Intern Pearls

AHA 2024 update: avoid PRN IV antihypertensives in asymptomatic patients.
Treat the cause, not just the number.
Early post-op hypertension is often pain, anxiety, or missed meds.
Emergencies only → IV therapy.
Restart home meds early; adjust dosing to prevent rebound.

VIII. References

Bress AP, Anderson TS, Flack JM, et al. The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the AHA. Hypertension. 2024;81(8):e94–e106.
Whelton PK, Carey RM, et al. 2017 ACC/AHA Guideline on High Blood Pressure. J Am Coll Cardiol. 2018;71(19):e127–e248.
Aronow WS. Treatment of Hypertensive Emergencies. Ann Transl Med. 2017;5(14):320.
Hiratzka LF, et al. 2010 ACCF/AHA Guidelines for Thoracic Aortic Disease. Circulation. 2010;121(13):e266–e369.
Powers WJ, et al. Acute Ischemic Stroke Guidelines. Stroke. 2019;50:e344–e418.
Magee LA, et al. Hypertensive Disorders of Pregnancy. Pregnancy Hypertens. 2014;4(2):105–145.

Key Takeaways

Do not reflexively treat asymptomatic BP elevations
Always search for reversible causes in post-op patients first.
Markedly elevated BP without organ damage → optimize chronic/home meds, address triggers, treat with IV medications only when persistent.
Emergencies only → ICU + IV titratable therapy.

Post-Operative Hypotension

I. Definition

Hypotension =
SBP < 90 mmHg OR
MAP < 65 mmHg OR
Drop > 40 mmHg from baseline
Clinical significance depends on organ perfusion: altered mental status, oliguria, lactic acidosis, or chest pain indicate shock regardless of the number.

II. Principles

Post-op hypotension may be benign (residual anesthesia, mild hypovolemia) or life-threatening (hemorrhage, cardiogenic shock, sepsis, anaphylaxis).
Think in categories:
Tank (volume problem): hemorrhage, hypovolemia, third spacing
Pump (cardiac problem): MI, arrhythmia, tamponade, cardiomyopathy, PE
Pipes (resistance problem): sepsis, anaphylaxis, adrenal insufficiency, epidural vasodilation
Unstable patient with hypotension = shock until proven otherwise.
Restart chronic antihypertensives early when safe, especially beta-blockers and clonidine, to avoid rebound instability. Hold ACEi/ARB if ongoing hypotension.

III. Stepwise Evaluation

Step 1 – Confirm

Recheck BP manually, ensure correct cuff.
Review trends and correlate with HR, SpO₂, urine output.
Confirm with arterial line if available.

Step 2 – Assess Stability

ABCs first.
Check mental status, urine output, cap refill, extremity temperature.
If unstable → call senior/ICU and start resuscitation immediately.

Step 3 – Focused History & Exam

History: blood loss, fluid balance, epidural use, missed antihypertensives.
Exam:
Surgical site, drains, dressings → bleeding/hematoma
JVP, heart sounds, lungs → CHF, tamponade, pneumothorax
Abdomen → distension, rigidity, leak
Extremities → warm vs cold, mottling, DVT signs

Step 4 – Immediate Workup

Continuous vitals and strict I/O.
CBC (H/H), BMP, lactate.
Coagulation profile if bleeding suspected.
ECG (ischemia, arrhythmia).
CXR (pneumothorax, pulmonary edema).
POCUS: IVC, LV/RV function, tamponade, pericardial effusion.
CT chest/abdomen/pelvis if bleeding or leak suspected and patient stable.

IV. Management

General Measures

Airway, Breathing, Circulation.
O₂, 2 large-bore IVs, monitor.
Type & crossmatch if bleeding suspected.

Stepwise by Category

1. Tank (Volume/Hemorrhage/Third Spacing)

500–1000 mL crystalloid bolus → reassess.
Repeat bolus or escalate to blood products if inadequate.
Search for bleeding (surgical site, chest, abdomen, retroperitoneum).
Massive transfusion protocol if active hemorrhage.

2. Pump (Cardiac Dysfunction)

EKG, troponin, echo.
Arrhythmia → treat per ACLS.
MI/cardiogenic shock → cardiology, inotropes (dobutamine, milrinone).
Tamponade → pericardiocentesis or surgical decompression.

3. Pipes (Vasodilation/Maldistribution)

Sepsis → cultures, broad antibiotics, source control, fluids.
Anaphylaxis → epinephrine, antihistamines, steroids.
Adrenal insufficiency → stress-dose hydrocortisone.
Epidural-induced vasodilation → pause infusion, fluids, vasopressors.

4. Persistent Hypotension Despite Fluids

Start vasopressors: norepinephrine = first-line.
Add vasopressin or epinephrine if refractory.
ICU transfer for invasive monitoring and advanced support.

V. Red Flags – Call Senior Immediately

Hypotension unresponsive to 1–2 L crystalloid.
Suspected active bleeding or falling hemoglobin.
Hypotension with chest pain, arrhythmia, or new ST changes.
Hypotension with hypoxia or respiratory distress (PE, tamponade, pneumothorax).
Hypotension with altered mental status or rising lactate.
MAP < 60–65 mmHg sustained despite fluids.

VI. Intern Pearls

Hypotension is never normal post-op — always find the cause.
Use Tank → Pump → Pipes to stay systematic.
Heart rate clues:
Tachycardia → volume loss, sepsis.
Bradycardia → meds, conduction block, vagal.
Response to fluids is diagnostic: improvement = tank problem.
Persistent hypotension despite fluids → pressors + ICU.
Always consider occult bleeding (retroperitoneum, hemothorax, intra-abdominal).
Restart chronic antihypertensives early if safe to prevent rebound.

Key Takeaways

Define hypotension clinically: MAP < 65 or SBP < 90 with poor perfusion.
Tank, Pump, Pipes framework organizes causes.
Stepwise: Confirm → Assess stability → Focused exam → Workup → Resuscitate.
MAP < 60–65 is dangerous and requires prompt action.
Early senior/ICU involvement is critical — hypotension is never benign post-op.

Post-Operative Hypoxia and Dyspnea

I. Definition

Hypoxemia: SpO₂ <92% or PaO₂ <60 mmHg on room air.
Dyspnea: subjective sensation of breathlessness, often correlating with abnormal oxygenation, ventilation, or increased work of breathing.
In the post-op setting, hypoxia/dyspnea may reflect benign causes (atelectasis, mild hypoventilation) or life-threatening complications (PE, pneumonia, ARDS, pneumothorax, anastomotic leak with sepsis).

II. Framework

Think V–Q–D:

Ventilation problems: hypoventilation (opioids, sedation), airway obstruction, OSA, COPD/asthma, atelectasis, pneumothorax.
Perfusion problems: PE, right heart dysfunction, hypovolemia/shock.
Diffusion problems: pneumonia, pulmonary edema, ARDS.

III. Stepwise Evaluation

Step 1 – Confirm & Assess Stability

Recheck SpO₂, correlate with waveform.
Vital signs: RR, HR, BP, O₂ sat, temp.
If SpO₂ <92% or acute distress → see patient immediately.
Assess airway patency, mental status, work of breathing.

Step 2 – Focused History

New chest pain, pleuritic pain, cough, sputum, hemoptysis.
Timing: immediate post-op (residual anesthesia, aspiration) vs later (pneumonia, PE).
Risk factors: immobility, OSA, COPD, obesity, smoking, prior PE/DVT, major surgery.

Step 3 – Focused Exam

Airway: obstruction, stridor, snoring.
Chest: breath sounds (wheezing, crackles, absent breath sounds, asymmetry).
CV: tachycardia, JVD, edema, new murmur.
Abdomen: distension → splinting, aspiration risk.
Extremities: swelling/asymmetry → possible DVT/PE.

Step 4 – Initial Workup

Pulse oximetry (continuous if unstable).
ABG (if altered, severe distress, or rising CO₂ suspected).
CXR: atelectasis, pneumonia, pulmonary edema, effusion, PTX.
ECG ± troponin: rule out ACS.
Labs: CBC (infection), BMP, BNP if heart failure suspected.
Consider CTA chest (PE protocol) if hypoxemia unexplained and risk factors present.
Bedside echo/POCUS: RV strain (PE), LV dysfunction, effusion, B-lines (pulmonary edema).

IV. Management

Immediate Stabilization

Ensure airway, give supplemental O₂ (nasal cannula → non-rebreather → HFNC/BiPAP → intubation if needed).
Sit patient upright, encourage incentive spirometry, deep breathing.
Call senior early if SpO₂ <90% despite O₂ or increased work of breathing.

Treat Underlying Cause

Ventilation:
Opioid/sedative depression → reduce meds, consider naloxone.
Atelectasis → IS, ambulation, CPAP/HFNC.
Bronchospasm (COPD/asthma) → albuterol nebs, steroids if severe.
Pneumothorax → chest tube if large/symptomatic.
Perfusion:
Suspected PE → CTA chest, anticoagulation if stable, escalate if unstable.
Shock/hypovolemia → fluids, blood, pressors as indicated.
Diffusion:
Pneumonia → cultures, empiric antibiotics.
Pulmonary edema → diuretics, NIPPV, afterload reduction if hypertensive.
ARDS → lung-protective ventilation, ICU transfer.

V. Oxygen Delivery Devices – Summary Table

Device	Usage	Flow Rate	Delivered FiO₂	Advantages	Disadvantages
Simple Face Mask	Moderate-to-severe hypoxia, initial treatment	5–10 L/min (≥5 to flush CO₂)	35–50%	Higher FiO₂ than NC, easy to use	Dry mucosa (needs humidification), interferes with eating/talking
Reservoir Cannula (Oxymizer)	Chronic or ambulatory use, higher FiO₂ without high flow	Up to 16 L/min	Up to 90%	Conserves O₂, higher delivery efficiency, mustache/pendant styles	Bulky, cosmetic concerns
Partial Rebreather Mask	Moderate-to-severe hypoxia	6–10 L/min (bag must not collapse)	50–70%	Higher FiO₂ than simple mask	Bag monitoring required, interferes with ADLs
Non-Rebreather Mask	Acute, severe hypoxia	10–15 L/min (≥10 to keep bag inflated)	85–90%	Very high FiO₂ delivery	Interferes with ADLs, risk of CO₂ retention if inadequate flow
Double Trunk Mask	Patients with high inspiratory flow demand	Same as NC (low/high flow)	Up to 100%	Improves PaO₂ compared to NC alone	Requires assembly, cumbersome
Venturi Mask	Precise FiO₂ delivery in moderate-to-severe hypoxia	2–15 L/min (depends on adapter color)	24–60%	Fixed, accurate FiO₂	Bulky, less accurate at high FiO₂, interferes with ADLs
High-Flow Nasal Cannula (HFNC)	Severe hypoxia, step before NIV/intubation	10–60 L/min	Up to 100%	Heated, humidified, comfortable, provides mild PEEP	Requires equipment, cannula may be uncomfortable
Continuous Positive Airway Pressure (CPAP)	OSA, pulmonary edema	Device-dependent	21–100%	Keeps airway open, reduces preload/afterload	Requires tight mask, poorly tolerated in some
Bilevel Positive Airway Pressure (BiPAP)	Hypercarbia (COPD, ARDS), avoids intubation	Device-dependent	21–100%	Inspiratory/expiratory pressure support	Risk of aspiration, requires cooperation
Invasive Mechanical Ventilation	Severe/critical hypoxia, perioperative support	Device-dependent	21–100% with PEEP	Precise control of FiO₂, tidal volume, PEEP	Requires intubation, sedation, ICU-level support

VI. Red Flags – Call Senior/ICU Immediately

SpO₂ <88% or persistent <92% on supplemental O₂.
Increased work of breathing, accessory muscle use, altered mental status.
Hemodynamic instability (hypotension, tachycardia, shock).
Suspected PE with instability.
New large pneumothorax, tension physiology.
Post-op patient requiring escalation to BiPAP/HFNC or intubation.

VII. Intern Pearls

Always think atelectasis vs pneumonia vs PE in post-op hypoxia.
Don’t forget opioid/sedation-induced hypoventilation early post-op.
If unilateral decreased breath sounds post central line → rule out pneumothorax.
Incentive spirometry and early ambulation are the best prevention.
Hypoxia + tachycardia out of proportion to exam = PE until proven otherwise.

VIII. References

Washington Manual of Surgery, 9th ed., 2023 – Postoperative pulmonary complications.
Cameron JL, Cameron AM. Current Surgical Therapy. 13th ed. Elsevier, 2023 – Pulmonary complications after surgery.
Sessler CN, et al. Complications in the postoperative period: pulmonary complications. Crit Care Clin. 2006;22(2):329–349.
Konstantinides SV, et al. 2019 ESC Guidelines for pulmonary embolism. Eur Heart J. 2020;41(4):543–603.

Key Takeaways

Hypoxia <92% = evaluate immediately.
Use V–Q–D framework: Ventilation, Perfusion, Diffusion.
Always stabilize first (airway, O₂, positioning).
Escalate oxygen devices stepwise (NC → mask → NRB → HFNC → NIV → intubation).
Call senior early for persistent hypoxemia, distress, or instability.

Post-Operative Nausea & Vomiting

I. Scope & Definitions

PONV: nausea and/or vomiting within 24–48 h of anesthesia/surgery.
Post-op N/V may be benign (PONV, medication-related) or indicate complication (ileus, SBO, anastomotic leak, aspiration, intracranial process).
Goals: stabilize → identify driver (PONV vs obstructive/pathological) → treat using class-based antiemetics and prokinetics → prevent recurrence.

II. First-Principles Framework (etiology buckets)

CNS/vestibular: anesthetics, opioids, migraine, motion sensitivity.
GI motility/obstruction: ileus, SBO, delayed gastric emptying; anastomotic complications if toxic.
Chemical/metabolic: opioids, antibiotics, iron, uremia (missed dialysis), DKA, pregnancy.
Risk factors for PONV (Apfel): female, non-smoker, prior PONV/motion sickness, post-op opioids (0–4 points ≈ 10/20/40/60% risk).

III. Stepwise Evaluation

Step 1 – Rapid stabilization - Upright position; NPO if active emesis; bedside suction. - O₂ if SpO₂ < 92%; protect airway if aspiration risk. - IV crystalloid; correct electrolytes (targets: K⁺ ≥ 4.0, Mg²⁺ ≥ 2.0).

Step 2 – Focused Hx/Exam - Timing (PACU vs POD 2–3), emesis character (gastric/bilious/feculent), distension/tenderness, last flatus/BM, prior PONV, migraine/vestibular symptoms, opioid dose.

Step 3 – Targeted Workup (as indicated) - Labs: BMP (K/Mg/Ca), glucose; ± lactate if ill; pregnancy test when relevant. - Imaging: upright/supine KUB for ileus/SBO → CT A/P with IV contrast if concerning. - ECG if multiple QT-prolonging meds or baseline risk.

IV. Universal Early Actions

NPO, IV fluids, electrolyte repletion to targets.
Opioid-sparing analgesia (acetaminophen, regional, NSAIDs if safe).
IS and early mobilization when safe; aspiration precautions.

V. Antiemetic & Prokinetic Options (choose by class; avoid duplicating the same class if already used)

5-HT3 antagonist - Ondansetron 4–8 mg IV/PO q8h PRN
Avoid high total IV doses; do not use 32 mg IV single dose. QT caution—correct K/Mg; ECG if high-risk.

D2 antagonists - Prochlorperazine 5–10 mg IV/PO q6h PRN
- Haloperidol 0.5–2 mg IV/IM q6–8h PRN (QT/TdP caution)
- Droperidol 0.625–1.25 mg IV once (boxed warning for QT; use lowest effective dose with ECG and corrected K/Mg)

Antihistamine/anticholinergic - Promethazine 12.5–25 mg PO/IM/IV q6h PRN (sedation, anticholinergic; avoid IV extravasation)
- Scopolamine 1.5 mg TD patch q72h (apply pre- or early post-op in high risk)

Steroid - Dexamethasone 4–8 mg IV (best as prophylaxis at induction; can use if not already given)

NK-1 antagonist - Aprepitant 40 mg PO (often prophylaxis; consider refractory per institutional protocol)

Prokinetic - Metoclopramide 10 mg IV/PO q6h PRN (avoid if mechanical obstruction; EPS/QT caution)
- Erythromycin 250 mg IV/PO q6–8h (short course) for foregut dysmotility (QT/cytochrome interactions; local practice varies)

VI. PONV Prophylaxis (use Apfel risk)

0–1 risk factor: 1 agent (e.g., ondansetron or dexamethasone).
2 risk factors: 2 different classes.
3–4 risk factors: ≥2 classes (often three: dexamethasone + 5-HT3 + scopolamine or droperidol).
Rescue rule: if N/V occurs despite prophylaxis, treat with a different class than those already given.

VII. Rescue Ladder (when symptoms occur or persist)

If no prophylaxis was given:
Start one agent (e.g., ondansetron 4 mg IV). Reassess in 30–60 min.
If persistent symptoms:
Add a second agent from a different class (e.g., promethazine 12.5–25 mg IV or prochlorperazine 5–10 mg IV).
If still symptomatic:
Add a third class (e.g., dexamethasone 4–8 mg IV if not yet given, or droperidol 0.625–1.25 mg IV with ECG and corrected K/Mg).
If impaired motility suspected and no mechanical obstruction:
Add metoclopramide 10 mg IV q6h (prokinetic), continue electrolyte optimization, minimize opioids.
Refractory/high-risk:
Consider NK-1 antagonist (aprepitant 40 mg PO) per formulary; review for drug interactions.
At any step, if red flags appear (see Section X):
Escalate evaluation for ileus/SBO/leak and proceed to decompression pathway.

VIII. Ileus / SBO Decompression Pathway

Ileus likely (distension, minimal pain, no flatus/BM): NPO, IV fluids, correct K/Mg, minimize opioids, chew gum, early ambulation, metoclopramide if no contraindication.
High-grade obstruction or persistent large-volume emesis: NG tube to low continuous suction, resuscitate, possible CT A/P with IV contrast,

IX. Special Situations

Missed dialysis / uremia: antiemetics are symptomatic only—nephrology for urgent dialysis.
Pregnancy possible: test prior to certain meds; tailor regimen.
Migraine phenotype: add migraine therapy (e.g., triptan/NSAID) when safe.
QT safety: avoid stacking QT-prolonging agents; correct K/Mg before droperidol/haloperidol/high-dose 5-HT3; obtain ECG in at-risk patients.

X. Red Flags — Call Senior / Escalate Early

Bilious or feculent emesis; severe distension; peritonitis; fever/tachycardia.
No flatus/BM with worsening distension/pain (ileus/SBO).
Hematemesis; aspiration; SpO₂ < 92% despite O₂.
Refractory N/V despite ≥2 different antiemetic classes.
Severe electrolyte derangements, AKI, or dehydration not improving.

XI. Quick Reference — Antiemetic/Prokinetic Doses

Class	Medication	Typical Dose & Route	Key Safety Notes
5-HT3	Ondansetron	4–8 mg IV/PO q8h PRN	Do not use 32 mg IV; QT caution; correct K/Mg
D2	Prochlorperazine	5–10 mg IV/PO q6h PRN	EPS/sedation; QT caution
D2	Haloperidol	0.5–2 mg IV/IM q6–8h PRN	QT/TdP risk; ECG if high-risk
D2	Droperidol	0.625–1.25 mg IV once	Boxed QT warning; ECG + electrolyte correction
H1/ACh	Promethazine	12.5–25 mg PO/IM/IV q6h PRN	Sedation/anticholinergic; IV tissue injury risk
ACh	Scopolamine patch	1.5 mg TD q72h	Avoid narrow-angle glaucoma; delirium risk
Steroid	Dexamethasone	4–8 mg IV	Best prophylaxis at induction; hyperglycemia
NK-1	Aprepitant	40 mg PO	CYP interactions; formulary-dependent
Benzamide	Metoclopramide	10 mg IV/PO q6h PRN	Avoid if obstruction; EPS/QT caution
Macrolide	Erythromycin	250 mg IV/PO q6–8h (short course)	QT/cytochrome interactions

XII. Intern Pearls

Treat airway/oxygenation and dehydration/electrolytes first.
Use risk-based prophylaxis and rescue from a different class.
Pair N/V + distension + no flatus with imaging and early NG rather than stacking antiemetics.
Minimize opioids; mobilize early.

XIII. References

Gan TJ, et al. Fourth Consensus Guidelines for the Management of PONV (2020). Anesth Analg. 2020;131:411–448.
Apfel CC, et al. A simplified risk score for predicting PONV. Anesthesiology. 1999;91:693–700.
FDA Drug Safety Communications: Ondansetron – removal of 32 mg IV dose; QT/TdP risk.
Droperidol safety and QT guidance — contemporary reviews and labeling.

Post-Operative Oliguria (Enhanced Evidence-Based Protocol, 2025)

I. Definition & Goals

KDIGO definition (gold standard): urine output (UO) < 0.5 mL/kg/hr for ≥ 6 hours.
Refined thresholds: UO < 0.3 mL/kg/hr may better predict post-op AKI in high-risk patients.
Obese patients: Use ideal body weight (IBW) for calculation.
IBW (men) = height (cm) – 100.
IBW (women) = height (cm) – 110.
Goal: Maintain UO ≥ 0.5–1 mL/kg/hr, individualized.

II. First-Principles Framework

Pre-renal (Tank/Pipes): hypovolemia, bleeding, sepsis/vasodilation, low EABV, inadequate pre-op optimization (PrevAKI, BigpAK trials).
Intra-renal (Parenchymal): ischemic ATN, nephrotoxins, rhabdo, AIN, pneumoperitoneum-induced renal hypoperfusion after laparoscopy.
Post-renal (Obstruction): Foley obstruction, clots, retention/BPH, ureteral obstruction; intra-abdominal hypertension/ACS (bladder pressure ≥20 mmHg + organ dysfunction).

III. Stepwise Evaluation

Step 1 — Verify & Check the Line

Confirm I/Os, review hourly charting.
Inspect Foley for kinks/loops; flush or replace if obstructed.
Bladder scan: > 200–300 mL in post-op patients = significant → treat as retention.

Step 2 — Advanced Bedside Assessment

Vitals, MAP (≥65), mentation, perfusion exam.
POCUS with VExUS: distinguishes hypovolemia vs venous congestion.
If tense abdomen/vent pressures rising: measure bladder pressure.
IAH ≥12 mmHg, ACS ≥20 mmHg with organ dysfunction.

Step 3 — Focused Workup

Labs: CBC, BMP, Cr, K, Mg/Phos, lactate, CK, UA ± microscopy.
Biomarkers: NGAL, TIMP-2*IGFBP7 (if available) detect injury earlier than Cr.
Indices:
FENa: best in oliguric pts without diuretics/CKD (<1% = pre-renal, >2% = ATN).
FEUrea: <35% = pre-renal, more reliable with diuretic use.
Imaging: renal/bladder US if obstruction suspected.

IV. Stepwise Management

A. Fix the Easy Stuff First

Ensure Foley patency or replace.
Stop nephrotoxins (NSAIDs, ACEi/ARB, aminoglycosides); delay contrast if possible.
Adjust dosing of renally cleared meds.

B. Fluid & Hemodynamic Strategy

Balanced crystalloids first-line (LR, Plasma-Lyte). Large RCTs show improved outcomes vs saline without increased hyperkalemia.
Goal-directed fluids: 500–1000 mL bolus with reassessment (MAP, UO, POCUS). Avoid rigid restriction (RELIEF trial: restrictive fluids ↑ AKI risk).
Sepsis bundle: \~30 mL/kg crystalloid within 3h if septic, guided by dynamics.
Pressors: Norepinephrine first-line (MAP ≥65). Add vasopressin if NE >15 µg/min.
Avoid dopamine (no renal benefit, potential harm).

C. If Volume Overloaded / Cardiorenal

Loop diuretic trial (furosemide 20–40 mg IV; higher if CKD).
Furosemide Stress Test (FST):
Timing: within 24–48h of AKI.
Dose: 1 mg/kg IV (1.5–2 mg/kg if chronic loop use).
UO <200 mL in 2h = predicts progression → early nephrology + RRT planning.

D. Treat Post-Renal Causes

Retention/clots: large-bore Foley, irrigation/continuous bladder irrigation.
Upper tract obstruction: renal US/CT + urgent urology (stent/nephrostomy).

E. Intra-Abdominal Hypertension / ACS

IAH: IAP ≥12 mmHg; ACS: IAP ≥20 mmHg with organ dysfunction.
Medical management first: NG/rectal tube decompression, sedation/NMB, judicious fluids, diuresis.
Surgery: decompression if refractory ACS persists.

F. Dialysis / KRT

Indications (AEIOU): Acidosis, Electrolyte (K+), Ingestions, Overload, Uremia.
Timing: Early initiation does not improve mortality vs standard triggers → follow standard indications.
CRRT preferred if unstable.

V. Red Flags — Escalate Immediately

UO <0.5 mL/kg/hr × 6h → immediate eval + FST consideration.
UO <0.3 mL/kg/hr × 12h → nephrology consult mandatory.
Anuria ≥6h or rapid Cr rise → ICU escalation.
Hypotension/sepsis with oliguria despite resuscitation.
ACS with IAP ≥20 mmHg and organ dysfunction.
Pulmonary edema, refractory hypoxemia.
Persistent obstruction not relieved.

VI. Care Bundles & QI

KDIGO AKI bundle: maintain MAP ≥65, avoid nephrotoxins, monitor Cr/UO closely, maintain normoglycemia (<180 mg/dL), structured fluid plans.
ERAS considerations: Do not over-restrict fluids—periop oliguria still ↑ AKI risk.
E-alerts & AKI response teams: improve adherence, reduce nephrotoxin use, ↑ early nephrology involvement.

VII. Intern Pearls

Check the Foley first.
Use VExUS/POCUS to separate hypovolemia from venous congestion.
FENa unreliable in diuretics/CKD → use FEUrea.
FST is a powerful bedside prognostic tool.
Avoid HES (hydroxyethyl starch) for resuscitation → renal harm.

VIII. References

KDIGO AKI Guideline, 2012 (current standard).
PrevAKI & BigpAK trials – perioperative risk optimization.
RELIEF Trial, 2018 – restrictive vs liberal fluid therapy.
Furosemide Stress Test studies – predictive tool for AKI progression.
WSACS Consensus, 2021 – intra-abdominal hypertension & ACS.
Tallarico R, McCoy IE, Dépret F, Legrand M. Perioperative Oliguria. Anesthesiology, 2024.

Key Takeaways

Oliguria = hypoperfusion or obstruction until proven otherwise.
Refine thresholds: <0.3 mL/kg/hr is more predictive in high-risk surgical patients.
Always verify Foley and scan bladder first.
Prefer balanced crystalloids, avoid excessive restriction.
FST, biomarkers, and POCUS improve risk stratification.
Call senior/nephrology early for persistent oliguria or red flags.

Post-Operative Tachycardia

I. Principles

Tachycardia = HR > 100 bpm sustained.
Can be a normal physiologic response (pain, fever, hypovolemia) or a sign of serious pathology (bleeding, sepsis, PE, arrhythmia).
Always distinguish sinus tachycardia from non-sinus tachyarrhythmia using EKG.
Persistent unexplained tachycardia = assume complication until proven otherwise.

II. Sinus vs Non-Sinus Tachycardia

Sinus Tachycardia (most common post-op)

P waves present, upright in II, III, aVF.
Gradual onset/offset.
Etiologies = physiologic stress:
Pain, agitation, anxiety
Fever, sepsis, SIRS
Hypovolemia, hemorrhage, third-spacing
Hypoxemia, hypercarbia
Anemia
Medications (beta-blocker withdrawal, albuterol, pressors)

Non-Sinus Tachycardia (pathologic arrhythmia)

Atrial fibrillation/flutter – irregularly irregular, no consistent P waves, rapid ventricular response.
SVT (AVNRT, AVRT, atrial tachycardia) – abrupt onset/termination, narrow complex, no visible P waves.
Ventricular tachycardia – wide complex, life-threatening.
Multifocal atrial tachycardia (MAT) – irregular rhythm with ≥3 P wave morphologies, often in COPD.

III. Differential Diagnosis

Volume / Circulatory

Hemorrhage (surgical site, drains, hematoma)
Hypovolemia (NPO, inadequate resuscitation, third spacing)
Sepsis

Pulmonary

Hypoxia, hypercarbia (atelectasis, pneumonia, pulmonary edema)
Pulmonary embolism
Pneumothorax

Cardiac

Myocardial ischemia or infarction
Arrhythmia (AFib, SVT, VT, MAT)
CHF exacerbation

Other

Pain, anxiety, agitation
Fever
Endocrine (thyrotoxicosis, pheochromocytoma, withdrawal states)
Medications (albuterol, pressors, anticholinergics)

IV. Stepwise Evaluation

Step 1 – Confirm

Recheck vitals manually.
Obtain EKG to distinguish sinus vs arrhythmia.

Step 2 – Assess Stability

Hemodynamics: BP, mentation, urine output.
Oxygenation and ventilation.
If unstable: ACLS, call senior/ICU, resuscitate.

Step 3 – Focused History & Exam

Chest pain, dyspnea, palpitations, bleeding, abdominal pain.
Inspect wounds, drains, dressings for hemorrhage.
Examine chest, lungs, extremities.

Step 4 – Workup

Continuous telemetry, EKG.
CBC (hemoglobin/hematocrit), BMP (lytes).
Troponin if chest pain or ischemia concern.
Lactate and cultures if febrile or septic features.
CXR (pneumonia, effusion, pneumothorax).
CT chest (PE protocol) if hypoxia or unexplained tachycardia with risk factors.

V. Management

Sinus Tachycardia (secondary to physiologic stress)

Treat underlying cause:
Pain → multimodal analgesia.
Fever/sepsis → cultures, antibiotics, source control.
Hypovolemia/hemorrhage → IV fluids, blood products.
Hypoxia → O2, pulmonary toilet, bronchodilators.
Anemia → transfusion if indicated.

Non-Sinus Tachycardia (primary arrhythmia)

Atrial fibrillation/flutter with RVR
Stable: metoprolol 5 mg IV q15 min (max 15 mg) OR diltiazem 10–20 mg IV.
Unstable: synchronized cardioversion; call cardiology.
SVT
Vagal maneuvers → adenosine 6 mg IV push → 12 mg if no effect.
Ventricular tachycardia
ACLS protocol, amiodarone, cardioversion/defibrillation.
MAT
Treat underlying cause (often hypoxia), rate control with verapamil or beta-blocker if tolerated.

VI. Red Flags – Call Senior Immediately

HR > 130 sustained.
Hypotension, hypoxia, altered mental status.
Chest pain or ST changes on EKG.
Evidence of bleeding (falling H/H, bloody drains, hemodynamic instability).
Persistent tachycardia without clear explanation after initial workup.

VII. Intern Pearls

Always get an EKG — don’t assume sinus tachycardia.
In post-op patients, tachycardia is often the first sign of hemorrhage, sepsis, or PE.
Don’t reflexively give beta-blockers for sinus tachycardia — treat the cause.
Tachycardia + fever = infection until proven otherwise.
Tachycardia + falling H/H = bleeding until proven otherwise.

VIII. References

Sessler CN, et al. Mechanisms and management of tachycardia in critically ill patients. Crit Care Med. 2015;43(12):2641–2650.
Devereaux PJ, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307(21):2295–2304.
Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2013;41(2):580–637.
January CT, et al. 2019 AHA/ACC/HRS guideline for the management of atrial fibrillation. Circulation. 2019;140(2):e125–e151.

Key Takeaways

Step 1: Confirm and get an EKG.
Step 2: Assess stability (ABCs).
Sinus tachycardia = physiologic stressor → treat cause.
Non-sinus tachycardia = arrhythmia → follow ACLS, cardiology consult.
Persistent unexplained tachycardia is a red flag — bleed, sepsis, PE, ischemia until ruled out.

Phone Directory

9EW

9EW Directory

Teams and Services

Transplant: 446-4063

Transplant Case Manager: 694-6040

Hepatobiliary (HPB): 446-3237

ENT (NOC/Weekend Operator): 445-1952

Colorectal/Soft Tissue (CREST): 446-3241

Urology (Uro): 446-3131

Gyn/Onc & OB/GYN: 446-0737 / 446-0742

Breast / Endocrine: 446-3246

Trauma (A/B/C): 446-3162 / 446-3164 / 446-3168

Nursing and Clinical Support

9EW Charge RN: 694-8693

Global Charge: 694-3021

Global H.U.C.: 694-3048

A.D.: 694-6349

Security: 694-6533

Discharge RN: 694-5050

Case Manager Desk: 694-4368

SWAT RN: 694-8299

House Supervisor (Call Global First): 694-9887

Phlebotomy: 694-6291

Ancillary and Diagnostic Services

Lab / Pharmacy / RT: 694-6601 / 694-6577 / 694-2844

Materials / EVS / Housekeeping: 694-6575 / 694-4111

MRI / X-Ray / CT: 694-4889 / 694-5027 / 694-6755

EKG Tech: 694-7444

Tele: 694-7581 / 7582

CXR Pager: 446-4462

Admission and Placement

For Direct Admit: Call Patient Placement

694-4600

694-6539 (Nights)

694-4607

Administrative and Logistics

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Consult and Allied Health Services

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Case Management – [extension not listed]

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Interpreter – 3456

Employee Health – 7616

Diagnostic and Procedural Areas

Radiology / X-Ray – 5027 / 7401 (1579)

CT Scan – 6755 / 6922

MRI – 4889

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Emergency and Critical Services

Code Blue: Call 5000

Rapid Response: 4777

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Anything Else / Operator: 0

ED Main: 7547 / 9813

ED Lost and Found: 3792

ED Radiology: 7458

ICU and Step Down Units

ICU and Step-Down Units

3E Medical IMC – 5247 / 3677

6EW Cardiac IMC – 2680 / 8770

6NS Cardiac ICU – 7660 / 8724

5NW Neuro ICU – 7395 / 4093

8NS Trauma ICU – 6035 / 8780

D4N NICU – 7358

D6N PICU – 7450

D6W Peds Onc – 7536

Inpatient and Surgical Units

3NE Med/Surg – 7156 / 8772

3NW Heme/Onc/BMT – 7660 / 8724

5EW Cardiac Med/Surg – 4228 / 8778

8EW Trauma – 3260 / 8734

D2N Ortho – 3400 / 8770

D5 Peds – 7436

South Campus – 874-2000

Laboratory and Clinical Support

Main Laboratory – 6601

Infection Prevention – 4446 (2847)

Bio-Med – 7500

Diagnostic Cardiology – 6132

Respiratory Therapy – 6365 (3151)

RT Charge – 2844

Red Cross / Plasma – 7325

Phlebotomy Draw – 6291 / 6866

PICC Pager – 2906

Pharmacy (Outpatient) – 6110

Specialty Pharmacy – 7262

Pharmacy

Inpatient Pharmacy

Ante Room – 4-6556
Diamond Satellite Pharmacy (D4W) – 4-6780 / 4-2801
Inpatient Pharmacy Main Line – 4-6589
Investigational Drugs (Jennifer / Elena) – 4-6127 / 4-6589
Intravenous (IV) Room – 4-6589
Manufacturing Area – 4-6581
Nutrition Support Pharmacist (TPN Pharmacist) – 4-7658
Oncology Pharmacist – 4-7835 / 4-7838
Operating Room (OR) Pharmacy – 4-6590
Order Entry Area – 4-6579 / 4-6580
Transplant Pharmacy (Katie / Ruhani) – 4-6555
Pharmacy Vault – 4-6554
Fax – 4-2138

Unit-Based Clinical Pharmacy Coverage

Unit	RPh	Primary	Secondary
1NW	—	4-7520	—
3E	4-7619	4-5247	—
3NE	4-6549	4-7166	4-7167
3NW (BMT)	4-9293	4-7656	4-7657
4NE	4-4253	4-7371	—
4W	4-4253	4-9378	—
5EW (Ante/Postpartum)	—	4-7060	4-5774
5NS (Labor & Delivery)	—	4-7047	—
6EW (Cardiac Stepdown)	4-4739	4-2680	—
6NS (CTICU)	4-4117	4-7660	—
7EW (Cardiac PCU)	4-4739	4-4228	—
7NS (MICU)	4-5078	4-0099	—
8EW (Trauma Stepdown)	4-2812	4-3260	—
8NS (Trauma ICU)	4-5321	4-3290	—
9EW (Specialty IMC)	4-5566	4-6886	—
9NS	—	4-7371	—
D2N	4-3297	4-3400	—
D3N	—	4-6035	—
D3W	—	4-7395	—
D4N (NICU)	4-3899	4-7578	—
D5N	4-8255	4-7453	4-8297
D5W	4-8255	4-7453	4-8297
D6N (PICU)	4-3820	4-7376	—
D6W	4-6999	4-7612	—
ED Central	4-9815	4-9582	—
ED North (Peds)	—	4-9583	—
ED South	—	4-9581	—
ED Trauma	—	4-9580	—
ED Triage	—	4-9816	—
PACU / OR	—	4-7510	—
Urgent Care	—	4-4750	4-6272

Medication History Team

Med Hx Interns (Weekdays Only) – 4-9283
Medication History Technician (ED / Inpatient Pharmacy) – 4-3694 / 4-6784

Outpatient & Specialty Pharmacies

Banner Family Pharmacy – 4-7949 / Fax 2-3563
Center Pharmacy – 4-7403 / Fax 2-2600
Orange Grove Pharmacy – 3-7212 / Fax 3-9608
South Campus Pharmacy – 874-2553 / Fax 8-8020
South Campus Retail Services – 874-2000
Specialty Pharmacy – 4-6193 / Fax 4-6204

Emergency & Security Contacts

FEMA – Emergency Supply Coordination – 1-602-364-3940
FEMA Backup – 1-602-364-3941
Security (Campus) – 621-3273
University of Arizona Police – 621-8273

Surgical and Perioperative Services

OR Desk – 6120

OR Pharmacy – 6208

Pain Team (Epidural) – (1868)

Palliative Care – 6645

Pre-Op Ready Room – 7276

PACU – 6202

TPN – 6216 / 2143

Telemetry (Original in IDR) – 7413

Interventional Radiology / Special Procedures – 2379 / 2632

Sterile Processing – 6316

Trauma

ATLS

Pre-Arrival

Principles

Trauma resuscitation begins before patient arrival.
The objective is a safe, organized, and fully prepared environment that allows immediate lifesaving intervention.
Preparation saves lives — ensure that equipment, personnel, and the environment are ready before starting the primary survey.
Do not delay critical actions once the patient enters the room.

Team Organization and Leadership

Identify the team leader before arrival.
Assign and confirm roles:
Airway: prepare for intubation.
Breathing: chest access, oxygen setup, thoracostomy readiness.
Circulation: IV access, blood draw, MTP setup.
Monitor: ECG, SpO₂, BP, temperature.
Recorder: document vitals, interventions, and times.
Runner: manage supplies, coordinate x-ray, labs, and blood products.
Establish closed-loop communication and confirm understanding (“copy” / “understood”).
Reinforce teamwork and safety: “If anyone identifies a safety issue, speak up.”

Safety and Environment

All team members must wear PPE (gloves, gown, mask, face protection).
Maintain room temperature ≥26 °C to prevent hypothermia.
Ensure adequate lighting and a clear workspace.
Verify sharps containers and spill management availability.
Prepare warm blankets and active warming devices.
Maintain a safe environment for staff and patient at all times.

Equipment and Supply Readiness

Airway

Confirm suction is functional and canister empty.
Ensure oxygen source >1000 psi and flowmeter operational.
Prepare bag-valve-mask with reservoir and tubing.
Check laryngoscope light, and prepare ETTs (7.0–8.0 mm) with stylet and CO₂ detector.
Keep cricothyroidotomy set open and visible.
Draw up RSI medications (sedative, paralytic, flushes).

Breathing

Open chest-tube tray (36–40 Fr) and attach drainage system.
Prepare 14 G needle for decompression at 5th ICS AAL.
Place occlusive dressings and scissors nearby.
Confirm ventilator or O₂ circuit readiness.

Circulation

Insert two large-bore (14–16 G) IVs or have ready.
Ensure rapid infuser, pressure bags, and fluid warmers functional.
Prime and hang warmed Ringer’s lactate.
Place pelvic binder and tourniquets at bedside.
Confirm IO access kit and MTP cooler available.
Warm all fluids and blood to avoid hypothermia/coagulopathy.

Monitoring and Adjuncts

Attach ECG, SpO₂, BP cuff, temperature probe.
Power on FAST ultrasound.
Prepare Foley and NG/OG tubes.
Ensure portable x-ray and lead aprons ready.
Set up point-of-care testing (ABG, glucose, lactate).

Pre-Arrival Brief (Team Huddle)

Conduct 2–3 minutes before arrival.
Team leader summarizes:
Mechanism and expected injuries.
Anticipated interventions (airway, MTP, thoracostomy).
Individual task assignments and sequence.
Confirm readiness verbally:

“Suction on, oxygen on, IV fluids warmed, chest tray open.”
Reinforce communication:

“I will call out ABCDE — speak up with critical findings.”
A brief, structured huddle ensures a shared mental model and readiness for high-risk interventions.

Final Cross-Checks Before Entry

Suction functional and within reach.
Oxygen flowing and visible.
Bag-valve-mask assembled and tested.
Chest-tube tray open with sterile gloves available.
Warmed fluids running through warmer.
Pelvic binder at bedside.
Ultrasound probe clean with gel ready.
Defibrillator powered and charged.

Medications and Blood Products

RSI agents:
Etomidate 0.3 mg/kg or Ketamine 1.5 mg/kg.
Succinylcholine 1.5 mg/kg or Rocuronium 1 mg/kg.
Vasopressors available (norepinephrine / epinephrine).
TXA 1 g IV in 100 mL NS over 10 min (if < 3 hr from injury).
Tetanus prophylaxis drawn and labeled.
Analgesics (morphine, fentanyl) ready post-stabilization.

Handoff Reception (MIST)

Assign one person to receive the prehospital report.
Use MIST format:
M: Mechanism of injury
I: Injuries found or suspected
S: Signs (vital parameters)
T: Treatment provided and time of injury
Confirm time of injury and fluids given.
Direct transfer to bed and begin primary survey.

Leader statement:

“Thank you. Team ready, patient to bed.
Beginning primary survey — Airway and cervical spine protection.”

Quality and Safety

Remove backboard promptly once spine precautions are secured.
Keep the patient and room warm.
Maintain clear equipment access and staff pathways.
Document arrival time, first vitals, interventions immediately.
Dispose of sharps safely after use.

Transition to Primary Survey

Leader confirmation:

“Monitors on, suction and oxygen functional, team in PPE, MIST received.
Beginning primary survey — Airway and cervical spine protection.”

References

Advanced Trauma Life Support (ATLS®) 10th Edition, American College of Surgeons Committee on Trauma.
Vanderbilt University Medical Center Trauma PMG Format.

Primary Survey and Resuscitation

Principles

The primary survey is a structured, rapid assessment to identify and manage immediately life-threatening injuries.
Assessment and resuscitation occur simultaneously, following the ABCDE sequence.
Treat the greatest threat to life first and do not delay lifesaving interventions for diagnostic tests.
Reassess continuously—if deterioration occurs, repeat the entire primary survey.

Airway with Cervical Spine Protection

Assessment

Determine if the patient can speak; the ability to talk implies a patent airway.
Look for stridor, gurgling, noisy respirations, blood, vomitus, or facial trauma.
Assume cervical spine injury until proven otherwise.

Interventions

Maintain manual inline stabilization (MILS) at all times.
Suction blood and vomitus immediately.
Perform chin lift or jaw thrust (avoid head tilt).
Insert airway adjuncts as indicated:
Oropharyngeal airway: if unresponsive and without gag reflex.
Nasopharyngeal airway: if gag present and no basilar skull fracture.

Definitive Airway Indications

GCS ≤ 8.
Airway obstruction or severe facial/neck trauma.
SpO₂ < 90% despite high-flow oxygen.
Apnea or hypoventilation.

Definitive Airway Techniques

Orotracheal intubation with inline stabilization (preferred).
If unable to intubate or ventilate, perform surgical or needle cricothyroidotomy.

Key Principle: Always maintain cervical spine protection during airway management.

Breathing and Ventilation

Assessment

Inspect for symmetrical chest expansion, wounds, and deformities.
Auscultate both lungs for air entry.
Percuss for dullness or hyperresonance.
Observe respiratory rate, effort, and SpO₂.

Immediate Life-Threatening Conditions

Tension pneumothorax: needle decompression (14 G at 5th ICS AAL or 2nd ICS MCL) → chest tube.
Open pneumothorax: apply three-sided occlusive dressing → chest tube.
Massive hemothorax: chest tube; if >1500 mL initial output or >200 mL/hr × 4 hr → thoracotomy.
Flail chest: oxygen, analgesia, and ventilatory support as needed.
Cardiac tamponade: pericardiocentesis and urgent surgical exploration.

Oxygenation Targets

SpO₂ ≥ 94%, RR 10–30/min, PaCO₂ 35–40 mmHg.
Avoid prophylactic hyperventilation.

Key Principle: Diagnose and treat tension pneumothorax clinically—do not delay for imaging.

Circulation with Hemorrhage Control

Assessment

Palpate central pulses and assess skin color, temperature, and capillary refill (<2 sec).
Control external bleeding with direct pressure or tourniquet if needed.
Consider internal bleeding in chest, abdomen, pelvis, or long bones.

Access and Monitoring

Insert two large-bore (14–16 G) IVs or IO access.
Draw blood for type and cross-match.
Initiate continuous ECG, BP, SpO₂, temperature, and urine output monitoring.

Resuscitation

Class I (<15% loss): monitor; fluids usually not required.
Class II (15–30%): give 1 L warmed isotonic crystalloid → reassess.
Class III (30–40%): initiate massive transfusion (1:1:1 PRBC:FFP:platelets).
Class IV (>40%): immediate transfusion and operative control.

Targets

SBP ≥ 100 mmHg (<65 yr) or ≥110 mmHg (≥65 yr).
MAP ≥ 65 mmHg.
Urine output ≥ 0.5 mL/kg/hr (adult), 1 mL/kg/hr (child).
Lactate < 2 mmol/L and Base deficit > –6 mEq/L indicate adequate perfusion.

Adjuncts

Apply pelvic binder if pelvic instability suspected.
Perform FAST or DPA for internal hemorrhage assessment.

Key Principle: Assume hypotension is due to hemorrhage until proven otherwise.

Disability (Neurologic Evaluation)

Assessment

Determine GCS (E4 / V5 / M6).
Examine pupils for size, symmetry, and reactivity.
Evaluate motor and sensory function in all extremities.

Management

Prevent hypoxia and hypotension; maintain SBP >100 mmHg.
Treat seizures promptly.
If GCS ≤ 8, secure a definitive airway and maintain PaCO₂ 35–40 mmHg.

Red Flags

Unequal pupils or lateralizing signs suggest intracranial mass lesion → urgent neurosurgical consultation.

Key Principle: A single episode of hypotension or hypoxia worsens outcomes in TBI—prevent both.

Exposure and Environmental Control

Actions

Fully expose the patient; inspect front, back, axillae, perineum.
Prevent hypothermia:
Use warm blankets or forced-air warmer.
Warm IV fluids and blood products.
Maintain ambient temperature >26 °C.

Key Principle: Hypothermia contributes to coagulopathy—actively prevent heat loss.

Adjuncts to the Primary Survey

Continuous ECG, SpO₂, and EtCO₂ monitoring.
Obtain portable chest and pelvic x-rays and FAST as indicated.
Insert urinary catheter unless urethral injury suspected (blood at meatus, perineal bruising, high-riding prostate).
Insert gastric tube (orogastric if facial trauma).
Draw baseline labs: CBC, type & cross, lactate, base deficit, ABG, coagulation profile.

Reevaluation

Repeat ABCDE after each major intervention or change in status.
If deterioration occurs, restart at Airway.
Document all findings and responses.

Transfer and Communication

Stabilize airway, breathing, and circulation before transfer.
Maintain oxygen, IV access, and monitoring during transport.
Communicate physician-to-physician with the receiving trauma center.
Do not delay transfer for imaging that will not alter immediate management.

Documentation

Record time and response for every intervention.
Document vital signs, GCS components, airway procedures, fluids, blood products, and reassessments.

References

Advanced Trauma Life Support (ATLS®) 10th Edition, American College of Surgeons Committee on Trauma.
Vanderbilt University Medical Center Trauma PMG Format.

Secondary Survey

Principles

The secondary survey begins after completion of the primary survey and initial resuscitation once the patient is hemodynamically stable.
Its purpose is to perform a head-to-toe evaluation, identify all injuries, and initiate definitive management.
If deterioration occurs at any point, return immediately to the primary survey (ABCDE).

Preparation

Confirm that vital signs are stable and resuscitation is ongoing.
Ensure analgesia and sedation are adequate.
Maintain spinal precautions throughout.
Continue monitoring: ECG, SpO₂, BP, temperature, and urine output.
Warm the patient and maintain a normothermic environment.

History and Mechanism of Injury

AMPLE History

A – Allergies
M – Medications (including anticoagulants, insulin, beta-blockers, etc.)
P – Past medical history (comorbidities, pregnancy status, tetanus immunization)
L – Last meal (important for anesthesia)
E – Events / Environment leading to injury (mechanism, time, extrication, associated hazards)

Mechanism of Injury (MOI)

Evaluate for energy transfer and injury pattern correlation: - Blunt trauma: MVC, fall, assault, blast.
- Penetrating trauma: knife, firearm — note trajectory and object characteristics.
- Blast injuries: consider primary (barotrauma), secondary (shrapnel), tertiary (impact), and quaternary (burn/inhalation) effects.
Understanding mechanism predicts hidden injuries and guides imaging.

Systematic Head-to-Toe Examination

Head and Scalp

Inspect and palpate for lacerations, hematomas, deformities, depression, or CSF leak.
Examine eyes: pupils (size/reactivity), conjunctiva, orbital integrity.
Assess ears: hemotympanum, CSF otorrhea.
Examine nose: septal hematoma, CSF rhinorrhea.
Evaluate mouth and jaw: loose teeth, malocclusion, facial fractures, bleeding.
Control scalp bleeding with direct pressure; avoid blind clamping.

Neck

Maintain cervical immobilization during exam.
Inspect for bruising, seatbelt marks, hematoma, or tracheal deviation.
Palpate for subcutaneous emphysema, laryngeal crepitus, tenderness.
Assess JVD (tamponade vs. tension physiology).
Evaluate for neurologic deficit or hoarseness suggesting laryngeal/tracheal injury.
Do not remove cervical collar until cleared by clinical and radiographic criteria.

Chest

Inspect for abrasions, contusions, penetrating wounds, or flail segments.
Palpate for tenderness, deformity, subcutaneous emphysema, rib instability.
Percuss for dullness or hyperresonance.
Auscultate both lungs and heart.
Reassess chest tube function if present.
Obtain portable chest x-ray and monitor oxygenation.

Abdomen

Inspect for ecchymosis (seatbelt sign), distension, penetrating wounds.
Palpate gently for tenderness, guarding, rigidity, masses.
Percuss for dullness or tympany; auscultate for bowel sounds.
Evaluate for pelvic stability with gentle pressure once.
Perform FAST; if positive and unstable → laparotomy.
Consider CT abdomen/pelvis with contrast if stable.

Pelvis and Perineum

Inspect for lacerations, ecchymosis, bleeding from urethra, vagina, or rectum.
Check pelvic stability once only; if unstable, apply pelvic binder immediately.
Examine perineum for hematoma or laceration.
Rectal exam: assess tone, presence of blood, bony fragments, high-riding prostate.
Vaginal exam in females with pelvic fractures or suspected vaginal injury.

Extremities

Inspect for deformity, wounds, bleeding, or amputation.
Palpate for tenderness, crepitus, distal pulses, and capillary refill.
Assess motor, sensory, and perfusion status (5 P’s: pain, pallor, paresthesia, paralysis, pulselessness).
Immobilize fractures and dislocations with splints.
Control external bleeding with pressure or tourniquet if necessary.
Consider compartment syndrome in crush or long-bone injuries.

Back and Posterior Surface

Logroll with four-person technique maintaining spinal alignment.
Inspect the entire back, buttocks, and posterior thighs.
Palpate spine for tenderness, step-offs, or deformity.
Examine posterior wounds carefully before re-positioning.

Adjuncts to the Secondary Survey

Diagnostic imaging as indicated: CT head/neck/chest/abdomen/pelvis, spine films.
Laboratory evaluation: CBC, electrolytes, renal function, coagulation, lactate, ABG.
Urinalysis: check for hematuria.
Toxicology screen if indicated.
Foley catheter (unless urethral injury suspected).
NG/OG tube for gastric decompression (OG if facial trauma).
Pain control and tetanus prophylaxis as required.

Special Considerations

Pediatric Patients

Use weight-based resuscitation (Broselow tape).
Pediatric anatomy increases risk of airway obstruction and intra-abdominal injury without external signs.

Geriatric Patients

Limited physiologic reserve; normal vitals may mask shock.
High risk for intracranial hemorrhage on anticoagulants.

Pregnant Patients

Evaluate both mother and fetus.
Use left lateral uterine displacement after 20 weeks to relieve IVC compression.
Fetal monitoring if viable gestational age.
Administer Rh immunoglobulin to all Rh-negative mothers with torso trauma.

Reevaluation

Continuously reassess vital signs and mental status.
Repeat focused exams after every intervention or if condition changes.
Any deterioration requires immediate return to primary survey.

Definitive Care and Disposition

Identify injuries requiring operative intervention or specialist consultation.
Coordinate transfer or admission based on injury pattern and facility capability.
Provide clear handoff using SBAR or MIST format.
Continue resuscitation, monitoring, and warming measures during transfer.
Document all findings, diagnostics, and interventions performed.

Documentation

Record all examination findings, imaging results, and interventions.
Note vital trends, neurologic status, wound locations, and definitive management plans.
Document tetanus status, analgesia given, and consultations obtained.

References

Advanced Trauma Life Support (ATLS®) 10th Edition, American College of Surgeons Committee on Trauma.
Vanderbilt University Medical Center Trauma PMG Format.

Fluids, Electrolytes and Nutrition

Bowel Regimen Recommendations

For Patients With a Functioning Gastrointestinal Tract

Pharmacologic Classes

Miralax – Osmotic laxative
Sennokot – Stimulant laxative
Milk of Magnesia – Osmotic laxative
Bisacodyl Suppository – Stimulant laxative
Lactulose – Osmotic laxative

Initial Regimen (At Admission)

Start:
Sennokot 2 tablets BID
Miralax 17 g daily

Escalation Based on Time Without Bowel Movement

After 48 Hours

Normal Renal Function:
Add Milk of Magnesia 15 mL PO TID
Impaired Renal Function:
Add Lactulose 20 g PO TID

After 72 Hours

Normal Renal Function:
Increase Milk of Magnesia to 30 mL PO TID
Add Bisacodyl Suppository 10 mg PR ×1
Impaired Renal Function:
Add Bisacodyl Suppository 10 mg PR ×1

After 96 Hours

Add SMOG Enema 120 mL PR ×1
Consider abdominal imaging (KUB)

Monitoring: Red Flags for Ileus or Obstruction

If constipation is accompanied by any of the following symptoms, obtain a KUB to assess for ileus or obstruction:

Abdominal distention, discomfort, or firmness
Decreased or absent flatus
Increased belching or hiccups
Nausea or vomiting

Bowel Regimen for Non-Functioning Gastrointestinal Tract

Use this section if an ileus is present on clinical exam or imaging.

Initial Management

Place NG tube to low wall suction
Make patient NPO
Initiate IV fluids
Monitor electrolytes as needed
Continue per rectal bowel regimen
Encourage ambulation (if appropriate)
Repeat KUB PRN to monitor gas pattern
Discontinue or minimize:
Opioids
Anticholinergics
Dopamine agonists
Anti-serotonergics

Advanced Pharmacologic Interventions

Ogilvie’s Syndrome (Confirmed on Imaging)

Neostigmine
Can only be given on 10N
Use caution in patients with anastomosis

Postoperative Ileus or Opioid-Induced Constipation

Oral Naloxone

Initial dose: 2 mg PO TID
Max dose: 4 mg PO TID
Max duration: 48 hours
Monitor for opioid reversal, especially in liver disease

Methylnaltrexone

Dose: 12 mg SQ ×1
May repeat after 24 hours if no resolution
Use only if:
Imaging confirms no obstruction
Oral naloxone has failed
Must discuss with attending before ordering
Use caution in patients with an anastomosis

Management of Diarrhea

Initial Steps

Stop all bowel regimen agents
Monitor electrolytes

If C. difficile Negative

Imodium: 4 mg q6h PRN
Fiber supplementation:
Without feeding tube:
- Psyllium: 2 caps daily (max 5 caps QID)
With feeding tube:
- Nutrisource Fiber: 1 packet daily (max 6 packets/day; order under tube feeds)
Titrate dose and frequency as needed

References

Yang A, Lam T, Jierjian E, et al. An Evaluation of docusate monotherapy and the prevention of opioid-induced constipation after surgery. J Pain Palliat Care Pharmacother. 2022; 36(1):18–23.
Gathers K, Fawad K, Petros K. Evaluation of methylnaltrexone bromide for the treatment of postoperative ileus. Crit Care Med. 2013;41(12):929.
Chamie K, Golla V, Lenis AT, et al. Peripherally Acting μ-Opioid Receptor Antagonists in the Management of Postoperative Ileus: a Clinical Review. J Gastrointest Surg. 2020. https://doi.org/10.1007/s11605-020-04671-x
Valle RG, Godoy FL. Neostigmine for acute colonic pseudo-obstruction: a meta-analysis. Ann Med Surg (Lond). 2014;3(3):60–64.
Dudi-Venkata NN, Kroon HM, Bedrikovetski S, et al. Impact of STIMUlant and osmotic LAXatives (STIMULAX trial) on gastrointestinal recovery after colorectal surgery: randomized clinical trial. Br J Surg. 2021 Jul 23;108(7):797–803.
Beavers J, Orton L, Atchison L, et al. The Efficacy and Safety of Methylnaltrexone for the Treatment of Postoperative Ileus. Am Surg. 2022; 88(3):409–413.
Gibson CM, Pass SE. Enteral naloxone for the treatment of opioid-induced constipation in the medical intensive care unit. J Crit Care. 2014; 29(5):803–807.
Merchan C, Altshuler D, Papadopoulos J. Methylnaltrexone Versus Naloxone for Opioid-Induced Constipation in the Medical Intensive Care Unit. Ann Pharmacother. 51(3):203–208.
Liu M, Wittbrodt E. Low-dose oral naloxone reverses opioid-induced constipation and analgesia. J Pain Symptom Manage. 2002; 23(1):48–553.

Reviewed November 2024 By

Caroline Banes, DNP, APRN, ACNP-BC
Jennifer Beavers, PharmD, BCPS
Jennifer Emerson, PharmD
Bethany Evans, MSN, ACNP-BC
Chelsea Tasaka, PharmD, BCCCP
Caroline Jackson, PharmD

Electrolyte Replacement Guidelines

Division of Acute Care Surgery

Exclusions

Do not use this protocol for patients with:

Hemodialysis / Peritoneal dialysis
Acute kidney injury (AKI)
Creatinine clearance < 30 mL/min
Chronic adrenal insufficiency
Electrical burns
Rhabdomyolysis
Diabetic ketoacidosis (DKA)
Crush injury
Hypothermia
Active transfer orders out of the ICU / Step Down Unit

Potassium Replacement

Always check phosphorus level to determine appropriate potassium product.

Replacement Based on Serum Potassium

Serum K⁺ (mEq/L)	Replacement	Recheck Level
3.3 – 3.9	40 mEq KCl PO/PT/IV (enteral preferred)	With next AM labs
3.0 – 3.2	20 mEq KCl PO/PT/IV × 3 doses (IV preferred)	Immediately and with next AM labs
2.6 – 2.9	80 mEq KCl IV and NHO	Immediately and with next AM labs
< 2.6	100 mEq KCl IV and NHO	Immediately and with next AM labs

*** Consider PO/PT replacement if GI tract available ***

Infusion Guidelines:

If central line and continuous cardiac monitoring:
Infuse at 20 mEq/hr (max = 40 mEq/hr)
If peripheral access only:
Infuse at 10 mEq/hr
Serum potassium may increase by ~0.25 mEq/L per 20 mEq IV KCl infused.

Magnesium Replacement

Replacement Based on Serum Magnesium

Serum Mg (mg/dL)	Replacement	Recheck Level
1.3 – 1.9	4 g IV over 4 hours	With next AM labs
≤ 1.2	8 g IV over 8 hours	6 hours after replacement

IV Administration:

One-time doses using 4 g/100 mL premixed piggybacks
Infuse at 1 g per hour

Oral Administration:

Elemental magnesium (magnesium oxide) or Milk of Magnesia may be used
Note: Oral magnesium is poorly absorbed; diarrhea may limit effectiveness
Separate EPIC order must be entered for oral replacement

Phosphorus Replacement

Always look at phosphorus level to determine appropriate potassium product.

Product Reference

Product	Phosphate	Potassium	Sodium
K-Phos Neutral Tablet	250 mg (8 mmol)	1.1 mEq	13 mEq
K Phos Injection (per mL)	3 mmol	4.4 mEq	—
Na Phos Injection (per mL)	3 mmol	—	4 mEq

Replacement Based on Serum Phosphorus

Serum Phos (mg/dL)	Replacement	Recheck Level	Approx. K⁺ if KPhos Used
2.0 – 2.5	15 mmol KPhos or NaPhos
or
K-Phos Neutral 2 tabs PO/PT q4h × 3 (enteral preferred)	With next AM labs	~22 mEq
1.6 – 1.9	30 mmol KPhos or NaPhos
or
K-Phos Neutral 2 tabs PO/PT q4h × 4 (IV preferred)	With next AM labs	~44 mEq
< 1.6	45 mmol KPhos or NaPhos	6 hours after replacement	~66 mEq

Notes:

Use K Phos if K⁺ < 4.0 mEq/L
Use Na Phos if K⁺ ≥ 4.0 mEq/L
Pharmacy will dilute in 250–300 mL NS
Infuse over 2–6 hours

Calcium Replacement

Replacement based on ionized calcium (iCa⁺⁺):

Ionized Ca (mg/dL)	Replacement	Recheck Level
3.5 – 3.9	4 g Calcium Gluconate	With next AM labs
3.0 – 3.4	6 g Calcium Gluconate	4 hours after replacement
2.5 – 2.9	8 g Calcium Gluconate	4 hours after replacement
< 2.5	10 g Calcium Gluconate and NHO	4 hours after replacement

Infuse at 2 g per hour

References

Zaloga GP, K.R., Bernards WC, Layons AJ. Fluids and Electrolytes. In: Civetta TR, Kirby JM, eds. Critical Care. Vol 1. Philadelphia: Lippincott-Raven; 1997:23.63
Panello JE, Delloyer RP. Critical Care Medicine. 2nd ed. St. Louis: Mosby, Inc.; 2002:1169
Polderman et al. Critical Care Medicine. 2000 Jun; 28(6):2022–2025
Polderman et al. Journal of Neurology. 2001 May; 94(5):697–70

Authors

Brad Dennis, MD
LeAnne Atchison, PharmD
Jennifer Beavers, PharmD

Revisions

April 2020
April 2022
February 2024

Trauma Critical Care Nutrition Guidelines

Division of Trauma and Surgical Critical Care
Clinical judgment may supersede guidelines as patient circumstances warrant

1. Nutrition Assessment and Planning

All patients admitted to the Trauma ICU require:
Nutrition risk assessment within 24 hours
Nutrition care plan within 48 hours
Consult Nutrition Services as needed for:
Tube feeding formulations
Oral supplements
Inadequate oral intake
Patient/caregiver education

2. Nutrition Administration Strategy

A. General Recommendations

Enteral Nutrition (EN) is preferred over Parenteral Nutrition (PN)
Minimize aspiration risk by:
Reducing sedation
Elevating HOB to 30–45°
Following VAP oral care protocols
Limiting non-essential transport from ICU

B. Oral Nutrition

Preferred if patient is able to safely eat by mouth
Start with a regular diet and advance as tolerated
Add oral nutrition supplements to optimize intake

C. Enteral Nutrition (EN)

Initiation

Begin EN within 24–48 hours of critical illness onset and ICU admission
Ensure hemodynamic stability and resuscitation completed

Advancement

Advance feeds toward goal within 48–72 hours as tolerated

Transitioning to Oral Intake

Initiate 12-hour EN cycling (7 PM–7 AM) to provide ~50% of caloric needs during transition
Discontinue EN once patient consistently consumes ≥ 50% of meals

Access Considerations

Post-pyloric feeding is preferred in patients at high aspiration risk
Do not delay nutrition if only gastric access is available

Feeding Tube Access Types:

Route	Short-Term Options	Long-Term Options
Gastric	OGT, NGT, DHT	PEG, laparoscopic gastrostomy
Post-pyloric	DHT (confirm via abdominal radiograph)	PEG-J for failed post-pyloric tube access

D. Parenteral Nutrition (PN)

Low Nutrition Risk

Initiate PN if unable to meet >60% of energy/protein requirements via EN by day 7–10

High Nutrition Risk

Initiate PN as soon as feasible (after resuscitation) if:
Malnutrition present on admission (per AND/ASPEN criteria)
Inability to use GI tract expected for >3–5 days

Weaning PN

Begin weaning once patient meets ≥ 60% of caloric needs via enteral or oral intake
Decrease PN rate and components per PN team orders

If LOS > 7 days and patient has not met ≥ 60% of estimated needs, consider combined PO/EN/PN approach

3. Dosing Guidelines

A. Dosing Weight

If BMI < 30: Use actual or usual body weight
If BMI ≥ 30: Use upper ideal body weight (IBW)

Hamwi Method for IBW:

Men: 106 lb (48 kg) + 6 lb (2.7 kg) per inch > 5 ft ±10%
Women: 100 lb (45 kg) + 5 lb (2.3 kg) per inch > 5 ft ±10%

Use actual weight if it is less than IBW

B. Energy Requirements

25 kcal/kg/day based on dosing weight
If BMI ≥ 30: Use 25 kcal/kg upper IBW

C. Protein Requirements

Condition	Protein Goal
General (non-obese)	1.2–2.0 g/kg/day
BMI 30–39.99	2.0 g/kg upper IBW/day
BMI ≥ 40	2.5 g/kg upper IBW/day
Hemodialysis (HD)	1.5–2.0 g/kg/day
Continuous Renal Replacement Therapy (CRRT)	1.5–2.5 g/kg/day
Hepatic Failure	1.2–2.0 g/kg/day (dry/actual wt)
Spinal Cord Injury	2.0 g/kg/day
Traumatic Brain Injury	1.5–2.0 g/kg/day
Open Abdomen	Add 2.9 g protein per liter of exudate loss

4. Monitoring and Special Considerations

A. Laboratory Monitoring

Serum protein markers (e.g., prealbumin, CRP) are not recommended for assessing nutrition status or adequacy

B. Gastrointestinal Intolerance

Routine GRV monitoring not recommended
Assess tolerance using:
Physical exam
Symptoms
Abdominal radiographs

If GRV > 500 mL → consider holding tube feeds

Prokinetic Agents

Use for suspected intolerance or high aspiration risk
Erythromycin 200 mg IV or per tube q6h × 3 days
Metoclopramide 10 mg IV q6h × 3 days
Naloxone 8 mg q8h × 3 days, then 8 mg q6h PRN

Persistent Diarrhea (C. diff negative)

Initiate Nutrisource Fiber 4 packets over 24 hours

C. Refeeding Syndrome

Before EN initiation, correct electrolytes and administer:
Thiamine
Folic acid
Multivitamin
For at-risk patients:
Begin trophic feeds (≤ 25% of caloric goal)
Monitor BMP, phosphorus, magnesium daily
Advance EN slowly over 3–4 days

D. Open Abdomen Management

Initiate early EN within 24–48 hours post-injury if no evidence of bowel injury

E. Hyperglycemia and Tube Feeds

VUMC EN formulary does not include diabetic-specific formulas

Use Impact Peptide 1.5 or Peptamen Intense VHP to minimize carbohydrate load

5. Associated MDSCC Protocols

Glycemic Control Protocol
GI Stress Ulcer Prophylaxis
Ventilator-Associated Pneumonia (VAP) Prevention Protocol

6. Revisions

April 2021
April 2023

7. Authors

Beth Mills, MS, RD, CNSC, LDN
Laurie Ford, APNP-BC
Stephen Gondek, MD

Preoperative Enteral Nutrition Protocol

For Patients with a Protected Airway (Tracheostomy or Oral Endotracheal Tube)
Division of Trauma and Surgical Critical Care

Clinical judgment should guide application of this protocol based on patient-specific factors.

1. Non-Abdominal Surgery

Turn off enteral nutrition (EN) immediately before operating room (OR) departure or bedside procedure
Flush and aspirate gastric tube prior to OR transport

2. Abdominal Surgery or Prone-Position Procedures

Turn off enteral nutrition 6 hours prior to planned anesthesia
Flush and aspirate gastric tube prior to OR departure

3. Upper Gastrointestinal (GI) Endoscopy

Discontinue enteral nutrition 1 hour before elective upper endoscopy
Place nasogastric tube (NGT) to suction

4. Additional Perioperative Considerations

Discontinue insulin infusions before OR transport
If subcutaneous (SQ) insulin was given within 2 hours of transport:
Notify anesthesia to perform perioperative point-of-care glucose (accucheck) in the OR
Resume tube feedings postoperatively unless instructed to hold
For patients with confirmed post-pyloric feeding access, consider continuing continuous tube feeds intraoperatively in coordination with:
Anesthesiology
Surgical team

5. Sources for Guideline Development

Boullata JI, Carrera AL, Harvey LH, Hudson L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN. 2017; 41(1):15–103.
McClave SA, Taylor BE, Martindale RG, Warren MM, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN. 2016; 40(2):159–211.
Taylor BE, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Crit Care Med. 2016; 44(2):390–438.
Kohn JB. Adjusted or Ideal Body Weight for Nutrition Assessment? JAND. 2015. http://dx.doi.org?10.1016/j.jand.2015.02.007
Andrews AM, Pruziner AL. Using Adjusted vs. Unadjusted Body Weights in Clinical Evaluations. JAND. 2016. http://dx.doi.org/10.1016/j.jand.2016.07.003
Wade C, Wolf SE, Reuben S, et al. Loss of Protein, Immunoglobulins, and Electrolytes in Exudates from Negative Pressure Wound Therapy. Nutr Clin Pract. 2010; 25(5):510–516.
Compher C, Bingham AL, McCall M, et al. Guideline for the Provision of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN. 2022; 46:12–41. DOI:10.1002/jpen.2267
Schwartz DB, Barrocas A, Annetta MG, et al. Ethical Aspects of Artificially Administered Nutrition and Hydration: ASPEN Position Paper. JPEN. 2021; 35(2):254–267. DOI:10.1002/ncp.10633
Bechtold ML, Brown PM, Escuro A, et al. When Is Enteral Nutrition Indicated? JPEN. 2022; 46:1470–1496. DOI:10.1002/jpen.2364
Singer P, Blaser AR, Berger MM, et al. ESPEN Guideline on Clinical Nutrition in the ICU. Clin Nutr. 2019; 38:48–79. https://doi.org/10.1016/j.clnu.2018.08.037
Academy of Nutrition and Dietetics. Adult Nutrition Care Manual: Critical Illness. 2021 update. Accessed 9/10/2022. http://www.nutritioncaremanual.org

6. Revisions

April 2021
April 2023

Trauma Glycemic Control Protocol

Division of Acute Care Surgery

1. Initial Glycemic Assessment

Is the patient a known diabetic?

No:
If blood glucose (BG) ≤ 150 mg/dL → No further action
If BG > 150 mg/dL:
- Check hemoglobin A1c (HbA1c)
- Initiate correctional insulin using a sliding scale (SSI)
- If HbA1c > 6.5%:
- Add type 2 diabetes mellitus (T2DM) to the problem list
- Initiate basal insulin: Glargine 0.15 units/kg/day
- Consult Endocrinology
Yes (Established diabetes):
Proceed to Section 2.

2. Management in Known Diabetics

A. Insulin-Dependent Diabetes Mellitus (IDDM)

Check HbA1c
Initiate:
Sliding Scale Insulin (SSI)
Basal insulin: Resume 50% of home Glargine dose
If BG > 200 mg/dL:
If HbA1c > 6.5%:
- Confirm diagnosis on problem list (if not already present)
- Increase Glargine to 0.15 units/kg/day
- Consult Endocrinology

B. Non–Insulin-Dependent Diabetes Mellitus (NIDDM)

Check HbA1c
Initiate:
Sliding Scale Insulin (SSI)
Basal insulin: Glargine 0.15 units/kg/day

3. Persistent Hyperglycemia

If BG remains > 180 mg/dL despite SSI and basal insulin:

Add prandial insulin (Lispro) with meals
or
Initiate scheduled Lispro q4–6h in patients receiving continuous enteral nutrition

4. General Principles and Safety Considerations

Avoid SSI monotherapy in type 2 diabetes mellitus (T2DM)
Continue basal insulin even if the patient is NPO
Ensure the hypoglycemia protocol is activated with all insulin orders
Endocrinology consultation is recommended for:
Type 1 diabetes mellitus (T1DM)
Patients using insulin pumps
Newly diagnosed T2DM (HbA1c > 6.5%)
Known diabetics with HbA1c > 9%

Use caution in:

Patients with chronic kidney disease (CKD)
Older adults
Patients with significant fluid shifts
Consider pharmacy consultation in these cases

5. Discontinuation of Glycemic Monitoring

Consider stopping BG checks and insulin therapy if ALL criteria are met:

BG remains ≤ 150 mg/dL
Patient has met tube feeding goal for > 24 hours
Patient is off vasopressors

Insulin Infusion Protocol (TICU Only)

6. Initiation Criteria

Consider initiating an insulin infusion per TICU protocol if:

Two consecutive BG readings ≥ 250 mg/dL

Nutritional Support Required

Ensure a glucose source is provided via one of the following:

D10 infusion at 30 mL/hr
D5LR or D5NS at ≥ 50 mL/hr
Enteral nutrition at ≥ 50% of target goal rate
Parenteral nutrition (PN) infusing

7. Transition Off Insulin Infusion

When to discontinue insulin infusion:

Infusion rate is ≤ 5 units/hr for ≥ 4 hours
Patient is receiving a consistent source of nutrition

Transition strategy:

Discontinue insulin infusion
Initiate Sliding Scale Insulin per Burn/Trauma order set
Calculate total insulin administered over the past 24 hours
Administer 70% of that total daily dose:
50% as basal insulin (e.g., Glargine)
Continue SSI
Add prandial insulin (Lispro) q4–6h or with meals if needed

8. References

Yendamuri S, et al. Admission hyperglycemia as a prognostic indicator in trauma. J Trauma. 2003; 55:33–38.
Laird A, et al. Relationship of early hyperglycemia to mortality in trauma patients. J Trauma. 2004; 56:1058–1062.
Sung J, et al. Admission hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma. 2005; 59:80–83.
Van den Berghe G, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001; 345:1359–1367.
NICE-SUGAR Study Investigators. Intensive vs. conventional glucose control in critically ill patients. N Engl J Med. 2009; 360:1283–1297.
Jacobi J, et al. Guidelines for the use of insulin infusion in critically ill patients. Crit Care Med. 2012; 40:3251–3276.
Mowery NT, et al. Severe hypoglycemia is not an independent predictor of death after trauma. J Trauma. 2010; 68:342–347.
Mowery NT, et al. Duration of intensive insulin therapy predicts hypoglycemia. World J Surg. 2011; 36:270–277.
Krinsley J, et al. Glycemic variability as a predictor of mortality in critically ill patients. Crit Care Med. 2008; 36:3008–3013.
Kauffmann RM, et al. Balanced nutrition protects against hypoglycemia in surgical ICU patients. JPEN. 2011; 35:686–694.
Bode BW, et al. IV insulin infusion: indications, methods, and transition to subQ insulin. Endocr Pract. 2004; 10(2):71–80.

9. Revision History

January 2020
March 2023

10. Revision Team

Michael Derickson, MD
Jill Streams, MD — Trauma PI Director
Bradley Dennis, MD — Trauma Medical Director
Caroline Banes, DNP, ACNP-BC
Kayla Harding, MSN, AGACNP
Leanne Atchison, PharmD

Pharmacology

Delirium Management Guideline

Division of Acute Care Surgery
Revised: May 2024

1. Monitoring and Initial Assessment

CAM-ICU (Confusion Assessment Method for ICU) should be documented each shift and reviewed during rounds.
Only report as "Unable to Assess" if RASS < -3
If CAM-ICU is positive, evaluate for possible causes:
- Hypoxia
- Sepsis
- Congestive Heart Failure (CHF)
- Over-sedation
- Deliriogenic medications

2. Delirium Classification and Initial Management

A. Hypoactive Delirium

(CAM-ICU positive and RASS 0 to -3)

Prioritize non-pharmacologic management
Minimize or discontinue sedating medications

B. Hyperactive or Mixed Delirium

(CAM-ICU positive and RASS -3 to +4)

See pharmacologic algorithm (Section 4)
Ensure goal RASS is clearly defined for all patients

3. Non-Pharmacologic Interventions

A. Orientation and Stimulation

Provide visual and hearing aids
Reorient frequently
Encourage communication
Maintain sleep hygiene
Provide cognitive stimulation during daytime

B. Environment Optimization

Mobilize early and frequently
Place familiar objects in the room
Minimize overnight noise
Remove unnecessary lines and drains

C. Supportive Measures

Daily Spontaneous Awakening Trials (SATs)
Adequate pain management
Correct dehydration and electrolyte imbalances

4. Deliriogenic Medications to Minimize or Avoid

Benzodiazepines
Anticholinergics:
Diphenhydramine, Glycopyrrolate, Metoclopramide
H2 blockers, TCAs, Cyclobenzaprine
Steroids
Opioids (if not the primary cause of pain)
Taper dose and use multimodal pain control

5. Hyperactive Delirium Management Algorithm

CAM-ICU Positive with RASS +1 to +2

Ensure pain control and sleep hygiene
Initiate:
Quetiapine 25–50 mg q8–12h
OR Olanzapine 2.5 mg q8–12h
Haloperidol 1–10 mg IV q4h PRN for breakthrough agitation

CAM-ICU Positive with RASS +3 to +4

If Extubated:

Ensure adequate pain control
Haloperidol 5–20 mg IV/IM q15min PRN for extreme agitation
If no response at 24 hrs or multiple IV haloperidol doses:
Reassess analgesia
Increase Quetiapine to 50–100 mg q6–8h or Olanzapine to 5–10 mg q6–8h
Continue haloperidol for breakthrough

If Intubated/Trached:

Start sedative infusion (if not already infusing)
Bolus or titrate up current sedative (e.g., propofol)
Ensure pain control
Haloperidol 5–20 mg IV/IM q15min PRN for extreme agitation
Consider Dexmedetomidine

If No Response After 48 Hours

RASS remains ≥ +3 with repeated IV haloperidol:
Reassess pain control
Change atypical antipsychotic
Consider alternate sedative
Adjust to CAM +, RASS +1 to +2 or +3 to +4 pathways as appropriate

6. Special Populations and Considerations

A. Geriatrics (> 65 years)

Reduce initial doses of:
Antipsychotics
Depakote (Valproic acid)
Avoid:
Haloperidol >5 mg
Quetiapine >100 mg
Consider:
Trazodone 25–50 mg qHS before antipsychotics if insomnia-related agitation

B. General

Maximize one agent before switching or adding others
Refractory cases:
Trial Geodon (Max: 40 mg BID)
If still uncontrolled → Psychiatry consult
Monitor QTc:
Modify therapy if QTcF > 500 ms

7. Traumatic Brain Injury (TBI)

Initiate Valproic acid (Depakote) 250–500 mg q8–6h
Titrate up to 60 mg/kg/day as needed
Consider early Propranolol 10–20 mg q8–6h
Max: 360 mg/day
Useful in neurologic storming
Avoid high-dose haloperidol

Valproate Monitoring:

Obtain baseline and weekly LFTs
Discontinue if:
AST or ALT >5× ULN
Alk Phos >2× ULN (on 2 occasions)
T. Bili >2.5 mg/dL with other LFT abnormalities
INR >1.5 with elevated transaminases
Use caution in hepatic disease
Check valproate levels only if toxicity suspected

8. References

Devlin JW, Skrobik Y, Gélinas C, et al. Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Guidelines. Crit Care Med. 2018; 46:825–873.
Girard T, Exline M, Carson S, et al. Haloperidol and Ziprasidone in Delirium. N Engl J Med. 2018; 379(26):2506–2516.
Hughes CG, Mailloux PT, Devlin JW, et al. Dexmedetomidine vs. Propofol in Sepsis. NEJM. 2021; 384:1424–1436.
Marra A, Wesley E, Pandharipande P, et al. The ABCDEF Bundle in Critical Care. Crit Care Clin. 2017; 33(2):225–243.
Plantier D, Luauté J, et al. Drug Therapy for TBI Behavior Disorders. Ann Phys Rehabil Med. 2016; 59(1):42–57.
Williamson D, Frenette A, et al. Agitation in TBI: Systematic Review. BMJ Open. 2019; 9:e029604

9. Authors

Jill Streams, MD
Bradley Dennis, MD
Abby Luffman, MSN, APN, AGACNP-BC
Bethany Evans, RN, MSN, ACNP-BC
Leanne Atchison, PharmD

Stress Ulcer Prophylaxis Protocol

Division of Acute Care Surgery
Updated August 2024

1. Background

Critically ill patients are at increased risk for gastrointestinal (GI) bleeding, primarily due to gastric or duodenal ulceration.
- Overt bleeding risk: ~4.4%
- Clinically significant bleeding: ~1.5%
- Risk increases with Injury Severity Score (ISS) >15 in trauma patients

Definitive Indications for Prophylaxis:

Traumatic Brain Injury (TBI)
Major Burn Injury
Mechanical Ventilation >48 hours
Coagulopathy
INR > 1.5
Platelets < 50,000

Other Risk Factors:

Alcohol use disorder
Acute hepatic failure
Sepsis
Acute renal failure
Trauma
Chronic NSAID use
High-dose steroids

Both H2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) are acceptable agents for prophylaxis.
- No conclusive evidence favoring one class over the other
- Enteral Nutrition (EN) provides mucosal protection and should be initiated early when feasible

2. Indications for Prophylaxis

A. High Risk — Prophylaxis indicated for all patients

Mechanical ventilation >48 hours
Coagulopathy
Traumatic brain injury
Spinal cord injury
Significant burn injury (>20% TBSA)
History of prior GI hemorrhage

B. Moderate Risk — Consider prophylaxis if ≥2 present

Chronic NSAID or aspirin use
High-dose NSAID therapy
Ibuprofen >1200 mg/day
Naproxen >1000 mg/day
Any scheduled ketorolac regimen
Sepsis
Vasopressor or inotrope requirement
Corticosteroids ≥ 250 mg/day hydrocortisone equivalent
New gastroduodenal or gastrojejunal anastomosis

C. Low Risk or Tolerating PO Intake — No prophylaxis needed

Discontinue prophylaxis if previously initiated

3. Prophylaxis Algorithm

A. Trauma Critical Illness

Condition	Duration of Prophylaxis
TBI, SCI, Burn	Continue for entire ICU stay
Intubation >48h or Coagulopathy	Discontinue when EN goal met (unless additional moderate risk factors persist)

4. Medication Management

First-Line Agent:

Famotidine 20 mg PO/PT/IV q12h
If CrCl < 50 mL/min → dose q24h

Suspected or Confirmed Upper GI Bleed:

If enteral access available:
Omeprazole 40 mg PO/PT q12h (oral suspension for DHT)
If no enteral access:
Pantoprazole 40 mg IV q12h

5. Special Situations

Continuation/Initiation for High-Risk NSAID Use:

High-dose NSAIDs plus one or more of the following:
Anticoagulation
Aspirin
Corticosteroids
Peptic ulcer disease
History of H. pylori infection
GI anastomosis
Spinal cord injury
Consider switching to celecoxib 100–200 mg BID if patient can tolerate oral capsules

Home PPI Use:

Resume home PPI if patient was taking one prior to admission

6. References

Cook DJ et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med. 1994; 330(6):377–381.
Cook DJ et al. Sucralfate vs. ranitidine for GI bleeding in ventilated patients. N Engl J Med. 1998; 338(12):791–797.
Hurt RT et al. Stress prophylaxis and enteral nutrition. JPEN. 2012; 36(6):721–731.
Guillamondegui OD et al. EAST Guidelines for Stress Ulcer Prophylaxis. 2008. EAST.org
Marik PE et al. Stress ulcer prophylaxis review. Crit Care Med. 2010; 38:2222–2228.
Lin PC et al. PPI vs. H2RA meta-analysis. Crit Care Med. 2010; 38:1197–1205.
Alhazzani W et al. PPI vs. H2RA in critically ill. Crit Care Med. 2013; 41:693–705.
Liu Y et al. Prophylaxis in non-ICU patients: network meta-analysis. Clin Ther. 2020; 42(3):488–498.
Marker M et al. Pantoprazole in ICU GI bleeding. N Engl J Med. 2018; 379(2):199–208.
Gwee KA et al. Co-prescribing PPIs with NSAIDs. J Pain Res. 2018; 11:361–374.

7. Authors

Bradley Dennis, MD
Jill Streams, MD
Leanne Atchison, PharmD
Jennifer Beavers, PharmD

TICU Analgesia/Sedation Protocol

For Mechanically Ventilated Patients
Division of Trauma and Surgical Critical Care

Use clinical judgment to individualize therapy based on patient comorbidities, goals of care, and evolving clinical condition.

1. Initial Sedation & Analgesia

Initiate:

Fentanyl infusion: 50–200 mcg/hr
AND
Propofol infusion: 5–50 mcg/kg/hr
OR
Dexmedetomidine infusion: 0.1–1.5 mcg/kg/hr

†Do not use dexmedetomidine in patients with: - Neurogenic shock
- Bradycardia
- Need for sedation for ICP control or ventilator synchrony

2. Pain Assessment

Is the patient in pain?

Yes:
Initiate or increase multimodal analgesia:
- Acetaminophen
- Gabapentin
- NSAIDs
- Muscle relaxants
- PRN hydromorphone or oxycodone
Fentanyl bolus: 50–100 mcg IV
Increase fentanyl infusion by 25–50 mcg/hr
No:
Continue monitoring and reassess every 1–2 hours

3. Sedation Assessment

Is the patient at their goal RASS (Richmond Agitation-Sedation Scale)?

A. If Actual RASS < Goal RASS (Over-sedated):

Decrease sedative/analgesic dose to achieve target RASS
If severely over-sedated:
Hold sedative infusion
Restart at 50% of previous dose if clinically indicated

B. If Actual RASS > Goal RASS (Under-sedated or Agitated):

Administer propofol bolus and/or increase infusion rate if appropriate
If patient is agitated or delirious:
Initiate or escalate oral agents per Delirium/Agitation PMG
If propofol intolerance suspected (e.g., CPK ≥ 5000 or triglycerides > 500):
Consider:
- Midazolam infusion: 0.5–10 mg/hr
- Or Dexmedetomidine infusion

Reassess sedation every 1–2 hours

4. Daily Care Measures

Perform Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) daily
Consult Physical Therapy and Occupational Therapy as soon as patient is able to participate

5. References

Devlin JW, Skrobik Y, Gélinas C, et al. Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018; 46:825–873.

6. Last Updated

September 2021

7. Authors

Jill Streams, MD
Diana Hayes, AGACNP
Leanne Atchison, PharmD
Jennifer Beavers, PharmD, BCPS

TICU Atrial Fibrillation Treatment Algorithm

Division of Trauma and Surgical Critical Care
Updated May 2024

1. Initial Evaluation

Confirm atrial fibrillation on more than one ECG lead
Obtain:
CBC, BMP, Magnesium, Calcium, Phosphorus
± Troponin
Chest X-ray (CXR)
Assess volume status and oxygenation

2. Ventricular Response?

A. No Rapid Ventricular Response (RVR)

No acute intervention required
Resume rate or rhythm controlling home medications when able

B. Rapid Ventricular Response Present

Is the patient hemodynamically unstable?

Signs of instability: Hypotension, altered mental status, ischemia, shock

3. Hemodynamically Unstable → Immediate Intervention

Perform synchronized cardioversion
Energy: 100–200 Joules
Pre-medicate with sedative if possible
Administer Magnesium 4 g IV

4. Hemodynamically Stable → Rate Control Pathway

Preferred Agents

Diltiazem (avoid if EF < 40% or hypotensive):
0.25 mg/kg IV push × 1
If inadequate response, repeat 0.35 mg/kg IV push × 1
If still no response, start continuous infusion 5–15 mg/hr
Metoprolol (especially if concern for hypotension or persistent hypotension post diltiazem):
5–10 mg IV every 5 minutes × up to 3 doses
Magnesium sulfate 4 g IV (can be used as adjunctive therapy; especially helpful in COPD/asthma)

5. Alternative or Escalation Options

If rate remains uncontrolled or rhythm persists:

Amiodarone:
150 mg IV bolus
Then start infusion:
- 1 mg/min × 6 hrs
- Then 0.5 mg/min × 18 hrs
May repeat 150 mg boluses or increase rate back to 1 mg/min if AF with RVR persists
Digoxin:
Initial dose: 0.25–0.5 mg IV
May repeat 0.25 mg every 6 hrs
Maximum: 1.5 mg over 24 hours
Use if first- and second-line agents are ineffective or contraindicated

6. Additional Considerations

Identify and address reversible causes:
Fluid overload
Infection/sepsis
Post-operative status
Withdrawal, endocrine, or metabolic causes
Reassess rhythm and rate control efforts after 24 hours
Titrate HR to <110 bpm if hemodynamics allow
Anticoagulation discussion and documentation required if:
New-onset AF persists for >48 hours
Cardiology consult if RVR persists despite escalation

7. Authors

Jill Streams, MD, FACS
Leanne Atchison, PharmD
Diana Williams, AGACNP-BC

VTE Prophylaxis

Division of Acute Care Surgery
Revised: January 2025

I. Purpose

Prevent pulmonary embolism (PE) and deep vein thrombosis (DVT) in trauma patients.

II. Risk Factors

High Risk
- Age > 60
- GCS < 9 > 4 hrs
- PMH of VTE
- Lower extremity fracture
- Multiple spinal fractures
- Pregnancy

Very High Risk
- SCI with paralysis
- ≥2 complex lower extremity fractures
- Major pelvic fracture
- ≥3 long bone fractures (≥1 in LE)
- Age ≥ 75 + any high-risk factor
- Abdominal/LE venous repair/ligation

III. VTE Prophylaxis Protocol

A. All Trauma Patients

Apply bilateral SCDs unless contraindicated

B. Enoxaparin Dosing (q12h)

Weight (kg)	Dose	Anti-Xa Required
< 50	30 mg	Yes
50–89	30 mg	No
90–129	40 mg	Yes
130–179	60 mg	Yes
≥ 180	80 mg	Yes

C. Other Considerations

BMI ≥ 40 → SQ heparin 7500 units q8h if no epidural or block
Do not hold for elevated INR due to liver dysfunction
Hold only for spine/neurosurgical OR or if attending requests

IV. Exceptions

A. TBI – Based on Brain Injury Guidelines (BIG)

BIG Category	Description	Start VTE ppx
BIG 1	Minor bleeds, stable repeat CTH	24 hrs
BIG 2	Moderate bleeds	48 hrs
BIG 3	Severe bleeds, worsening on repeat CTH	72 hrs

MMA embolization → hold morning of procedure
Intraspinal hematoma → start within 48 hrs
Spine surgery → hold AM of surgery, resume 24 hrs post-op
Enoxaparin preferred with ICP monitor/EVD

V. Epidural/Block/Lumbar Drain

Hold enoxaparin 12 hrs pre-placement and 4 hrs post-removal
Use heparin 5000 units q8h + SCDs while catheter is in place

VI. Renal Impairment

CrCl < 30 or significant ↑ in SCr → use SQ heparin
RRT → heparin preferred

VII. Anti-Xa Monitoring

Indications: weight <50 or ≥90 kg; all very high-risk patients
Draw peak 4 hrs after 3rd enoxaparin dose
Goal: 0.2–0.4 IU/mL

Dose adjustment:

Below goal → ↑ to next syringe size
Above goal:
↓ to next size or 30–40 mg q24h
If still high → switch to heparin q8h
Non-standard doses → monitor Anti-Xa weekly
If at goal on weight-based dosing → no further monitoring

VIII. Surveillance

Very high-risk: Duplex LE US 72 hrs post-admission, then weekly × 4 weeks
Then every 2 weeks thereafter

IX. IVC Filter

Refer to IVC Filter PMG

Consider prophylactic filter if:

SCI with paralysis
IVC/iliac/femoral repair or ligation
Severe pelvic + LE long bone fracture
AIS head ≥3 + anticoagulation contraindication
Anticoag failure or complication

X. Post-Discharge VTE Prophylaxis

A. 30 Days:

Very high-risk (e.g. SCI)
Operative LE fracture
Femoral head fracture
Non-ambulatory (>30 ft)

B. 90 Days:

Spinal cord injury

XI. References

Essential literature includes EAST PMG (2002), multiple trauma studies validating weight-based enoxaparin dosing, safety in TBI/spine patients, and recent AAST/ACS protocols for post-discharge prophylaxis.
Full citations available upon request.

XII. Authors

Bradley Dennis, MD
Jill Streams, MD
Jennifer Beavers, PharmD, BCPS
Jennifer Emerson, PharmD
Chelsea Tasaka, PharmD, BCCCP

TRAUMACATS

Thoracic Trauma

Acute Pain Service (APS) Consult Protocol

Definition

The Acute Pain Service (APS) provides multidisciplinary, evidence-based pain management for post-operative and trauma patients. Consults are indicated for patients requiring regional anesthesia, complex multimodal analgesia, or pain refractory to standard regimens.

Typical indications: - RIG (Regional Indication Group) score ≥ 6 - Surgeon discretion for complex pain control or regional block consideration - Early identification at admission preferred

Principles

Goal: Optimize analgesia, minimize opioid use, and facilitate mobilization and recovery.
Timing: Early consult improves outcomes; initiate at admission or preoperatively if possible.
Safety: Coordination with anticoagulation protocols is essential before neuraxial or regional procedures.
Communication: Maintain clear lines between APS, surgical team, and nursing regarding analgesia plan and anticoagulation holds.

Stepwise Evaluation

1. Identify Candidates

RIG score ≥ 6
Significant injury burden (e.g., multiple rib fractures, major abdominal or orthopedic trauma)
Uncontrolled pain despite multimodal regimen
Anticipated high postoperative pain intensity

2. Initiate Discussion with Patient

Explain APS role and adjunct options (e.g., epidural, paravertebral, ESP, serratus anterior blocks).
Document patient understanding and consent.

3. Anticoagulation Status

Hold DVT prophylaxis prior to block placement:
NOACs/antiplatelets: APS will proceed if TEG is normal.
If recently admitted: hold per medication chart.
If inpatient: confirm last dose and follow institutional hold times (see table below).

4. Consult APS

Phone: (520) 449-1468
After 5 PM: text APS and call between 7–8 AM next morning.
Provide:
Patient name and MRN
Indication for consult (injuries/operative site)
ACS team contact and phone number

Management

Anticoagulation Holding Times for Regional Procedures

Catheter Type	Pre-Placement Hold	While Catheter In Situ	Pre-Removal Hold	Restart Prophylaxis After Removal
Epidural	Lovenox: 12 h Heparin 5,000 U BID/TID: 6 h Heparin 7,500–10,000 U BID: 12 h	Hold as above	Lovenox: 12 h Heparin 5,000–10,000 U BID/TID: 6–12 h	Lovenox: 4 h after Heparin: immediately
Paravertebral / ESP	Lovenox: 12 h Heparin 5,000–10,000 U BID/TID: 12 h	Hold as above	Lovenox: 6 h Heparin 5,000–10,000 U BID/TID: 6 h	Lovenox: 4 h after Heparin: immediately
Serratus Anterior	Lovenox: 12 h Heparin 5,000–10,000 U BID/TID: 6–12 h	Hold as above	Lovenox: 12 h Heparin: 6 h	Lovenox: 4 h after Heparin: immediately

Red Flags / Urgent Triggers

Coagulopathy (INR > 1.4, Platelets < 75 K, abnormal TEG) → Hold APS procedure
New neurological deficit while catheter in place → Immediate removal and notification
Active bleeding or hemodynamic instability
Catheter dislodgement or malfunction requiring APS review
Failure of pain control despite regional block

References

American Society of Regional Anesthesia and Pain Medicine (ASRA), 2018. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: 4th Edition Guidelines.
Washington University Department of Surgery, 2024. The Washington Manual of Surgery, 9th Edition.
Cameron JL, Cameron AM. Current Surgical Therapy, 14th Edition, Elsevier, 2023.
*Institutional APS Protocols and Consensus, 2025.

Chest Tube Management Protocol for Traumatic Chest Wall Injury

Definition

Structured management pathway for patients with pneumothorax (PTX), hemopneumothorax (HPTX), or hemothorax (HTX) following traumatic chest wall injury. The goal is to ensure safe, timely chest tube management and minimize retained hemothorax, empyema, or prolonged tube duration.

Principles

All traumatic chest injuries with PTX, HPTX, or HTX require prompt chest tube placement and post-placement imaging confirmation.
All chest tubes should be placed on –20 mmHg suction initially.
Early imaging at 24 hours post-placement guides ongoing management.
Decision-making depends on air leak status, drainage volume, and radiographic findings.

Stepwise Evaluation

1. Initial Management

Chest Tube Placement
Indications: PTX, HPTX, HTX following trauma.
Apply –20 mmHg suction to all chest tubes.
Obtain imaging (CXR) to confirm proper placement and lung re-expansion.

2. 24-Hour Chest X-Ray Evaluation

A. PTX or HPTX

Findings: Resolved PTX, no new or worsening subcutaneous emphysema (subQE)
Pleurovac: No air leak, <300 mL effluent in the last 24 hours
Patient: Not intubated on high ventilatory settings
Action: Transition to water seal (WS)

B. Persistent Opacities or Pleural Effusion

Findings: Persistent pleural effusion or opacity on 24h CXR
Action: Order CT chest for retained hemothorax (RH) evaluation

C. Hemothorax (HTX)

Findings: No persistent pleural effusion or opacity, <300 mL effluent in 24 hours
Action: Remove chest tube
Follow-up: Obtain CXR 4 hours post removal

3. Water Seal Phase

4-Hour CXR after WS
No new or stable PTX
No air leak
<300 mL effluent in last 24 hours
No worsening subQE
Not on high ventilator settings
Action: Remove chest tube and obtain 4-hour post-pull CXR

4. CT Chest Findings (Retained Hemothorax)

If RH volume <300 mL: Continue conservative management, observe.
If RH volume >300 mL:
Assess surgical candidacy:
- Not a surgical candidate: Begin intrapleural fibrinolytic therapy (IPFT)
- Alteplase 10 mg + Dornase alfa 5 mg daily × 3 days
- Repeat CT chest after 3 days
- Surgical candidate: Proceed to VATS or thoracotomy for evacuation

Management Summary (Text-Based Algorithm)

Chest tube placement → suction → confirm on CXR
At 24h:
If resolved PTX/HPTX → water seal
If persistent opacities/effusion → CT chest
If resolved HTX and <300 mL drainage → remove chest tube
After water seal (4h):
If no PTX/air leak → remove chest tube
If CT shows RH >300 mL:
Poor candidate: IPFT
Good candidate: VATS/thoracotomy

Trauma and Acute Care Surgery (ACS) Policy on Chest Tube Placement

The decision and placement of chest tubes in trauma patients are determined by the Trauma Chief or Trauma Resident.
If a patient is evaluated by the Emergency Department (ED) for non-trauma-related effusion (e.g., malignant or parapneumonic effusion), the ED will consult ACS for assistance with chest tube management.
ACS will supervise the procedure, but the ED resident performs the chest tube insertion under ACS supervision.
All chest tube placements require post-procedural imaging and documentation of supervision in the medical record.

Red Flags / Urgent Triggers

Worsening PTX or new air leak
Drainage >300 mL/24h
Increasing subcutaneous emphysema
Persistent or enlarging pleural opacities on CXR or CT
Clinical instability or respiratory compromise

References

Washington University Department of Surgery, 2024. The Washington Manual of Surgery, 9th Edition.
Cameron JL, Cameron AM. Current Surgical Therapy, 14th Edition, Elsevier, 2023.
de Virgilio C, Grigorian A. Surgery: A Case-Based Clinical Review, 2nd Edition, Springer, 2020.
EAST Practice Management Guidelines Committee, 2018. Management of Retained Hemothorax After Trauma.
*Institutional Trauma and ACS Policies, 2025.

Rib Fracture Management Protocol (RIG Scoring)

Definition

The Rib Injury Guideline (RIG) provides a structured framework for evaluating, admitting, and managing patients with rib fractures. The RIG score stratifies patients by risk for respiratory compromise and pain-related morbidity, guiding triage, analgesia, and the need for Advanced Pain Service (APS) involvement.

Principles

The RIG score determines admission level and pain management intensity.
Early multimodal analgesia and respiratory optimization reduce pulmonary complications.
Consider APS consult for RIG ≥ 6, uncontrolled pain, or epidural indication.
ICU admission is warranted for high-risk patients (RIG >10) or those requiring advanced airway or analgesic interventions.

Stepwise Evaluation

1. RIG Scoring Criteria

Criteria	Points
Age > 60 years	4
Incentive spirometer < 750 mL (assessed 1 hr after PO pain meds)	4
Imaging shows severe pulmonary contusions (unilateral or bilateral)	2
>4 rib fractures	2
History of COPD, smoking, or asthma	2
Presence of hemothorax, pneumothorax, or chest tube in situ	2
Pain score >6/10 (1 hr after PO analgesia)	1
Weak or absent cough	1

Total Score Interpretation: - >10 points: ICU admission
- 3–9 points: Floor admission
- <2 points: Eligible for discharge

2. Initial Evaluation and Supportive Care

Assess pain, oxygenation, and work of breathing.
Calculate RIG score.
Determine admission level and notify appropriate service (Trauma, ACS, ICU).
Encourage incentive spirometry and pulmonary toilet on all admitted patients.
Begin multimodal analgesia immediately on admission or at time of extubation.

Management

Multimodal Analgesia Regimen

Scheduled (unless contraindicated): - Acetaminophen 650 mg PO q6h - Gabapentin 200 mg PO q8h - Lidocaine transdermal patch (Lidoderm) - Methocarbamol 750 mg PO TID (Robaxin) - Ketorolac (limit 48 hours; avoid if GFR <30 mL/min, orthopedic injury, or cerebrovascular bleeding)

PRN Options: - Oxycodone PO for breakthrough pain
- IV Dilaudid or IV Morphine for uncontrolled pain

Reassess pain after 8–12 hours. - If pain remains >6/10, consider PCA or Epidural analgesia per attending discretion.

Epidural Analgesia

Indications: - Flail chest
- Escalating narcotic requirements with persistent pain >6/10
- Underlying cardiopulmonary disease (COPD, CHF, etc.)

Contraindications: - Patient refusal or inability to consent
- Platelets <50,000
- INR >1.5
- Infection at insertion site
- Epidural/spinal hematoma
- Prophylactic LMWH within 10 hrs or therapeutic LMWH within 24 hrs
- Major TBI (GCS <9)
- Hemodynamic instability
- Deep sedation (RASS < –3)
- Transverse process fractures near intended insertion level

Consult APS for placement and management.

Pain Escalation Pathway

Start multimodal analgesia.
If pain >6 despite optimized oral/IV therapy, initiate PCA or epidural.
Reassess frequently and titrate therapy based on RIG score and functional pain response.

References

Arizona Trauma Association, 2023. Thoracic: Rib Injury Guidelines (RIG) – Rib Fracture Protocol.
American Society of Regional Anesthesia (ASRA), 2018. Guidelines for Antithrombotic Therapy and Regional Anesthesia.
Washington University Department of Surgery, 2024. The Washington Manual of Surgery, 9th Edition.
Cameron JL, Cameron AM. Current Surgical Therapy, 14th Edition, Elsevier, 2023.
*Institutional Trauma and ACS Policies, 2025.

Emergency general surgery

Acute Appendicitis

I. Purpose

Acute appendicitis is one of the most common reasons for presentation to the Emergency General Surgery service. This document outlines the management considerations for patients presenting with acute appendicitis.

II. Guideline

A. Initial Evaluation

Laboratory tests
- Complete blood count (CBC)
- Basic metabolic panel (BMP)
Imaging
- CT abdomen/pelvis with IV contrast

B. Management

1. Antibiotic Therapy

Recommended durations:

Perforated appendicitis with source control: 4-day postoperative course
Nonoperative management: 10-day course
Appendectomy performed (uncomplicated): Stop antibiotics postoperatively

Regimens:

Without shock
- First-line: Ceftriaxone + Metronidazole
- Severe penicillin allergy: Levofloxacin + Metronidazole
With sepsis or risk for multidrug resistance
- First-line: Piperacillin–Tazobactam
- Severe penicillin allergy: Vancomycin + Cefepime + Metronidazole

2. Additional Management Steps

Place patient NPO pending operative plan
Obtain Emergency General Surgery consultation and admit to service
Proceed with laparoscopic appendectomy if operative management is chosen

3. Considerations for Nonoperative Management

Patient preference for nonoperative approach
Severe inflammation, phlegmon, or perforation on CT requiring ileocecectomy
High operative or perioperative risk
Appendicolith on CT (associated with higher recurrence risk)
Pregnancy: failure of nonoperative management may result in fetal demise
Age >40 with perforation: consider interval appendectomy due to malignancy risk

4. Follow-Up

Operative patients: 7–14 day follow-up (telemedicine or in-person) with pathology review
All patients: Consider colonoscopy referral if colorectal cancer risk factors are present

III. References

de Almeida Leite RM, et al. Nonoperative vs Operative Management of Uncomplicated Acute Appendicitis: A Systematic Review and Meta-analysis. JAMA Surg. 2022;157(9):828–834.
Rushing A, et al. Management of Acute Appendicitis in Adults: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019;87(1):214–224.
Di Saverio S, et al. Diagnosis and Treatment of Acute Appendicitis: 2020 Update of the WSES Jerusalem Guidelines. World J Emerg Surg. 2020;15(1):27. DOI: 10.1186/s13017-020-00306-3

IV. Author

Michael C. Smith, MD
December 18, 2023

Alcohol Withdrawal Management

I. General Considerations

Intubated patients: If receiving a propofol or midazolam infusion, no additional therapy is required while on these infusions.
Excluded patients:
- On essential medications that interact with phenobarbital (e.g., HIV medications)
- Hepatic encephalopathy
- Chronic phenobarbital use
- Pregnant

II. Vitamin Supplementation (All Patients)

Thiamine 100 mg PO/PT/IV daily × 3 days
Folic acid 1 mg PO/PT daily × 3 days
Multivitamin PO/PT daily × 3 days

III. Risk Stratification & Management

A. Low Risk *

Phenobarbital 60 mg PO TID × 6 doses
Then: Phenobarbital 30 mg PO TID × 6 doses

B. High Risk **

Phenobarbital 130 mg PO q1h × 2 doses
If unable to take PO: Phenobarbital 260 mg IV ×1
Then:
- 100 mg PO TID × 6 doses
- 60 mg PO TID × 6 doses
- 30 mg PO TID × 6 doses

C. Active Delirium Tremens (DTs)

Phenobarbital 260 mg IV × 1 dose
Then:
- 100 mg PO TID × 6 doses
- 60 mg PO TID × 6 doses
- 30 mg PO TID × 6 doses
If symptoms uncontrolled → Consider SICU transfer

IV. Additional Information

PO dosing preferred unless:
- Acute symptom management required
- Lack of enteral access
- Patient unable to swallow safely
  PO:IV conversion = 1:1
Breakthrough withdrawal symptoms despite taper:
- Phenobarbital 65 mg IV q1h PRN to goal RASS 0 to -1
- Hold dose if RASS ≤ -2 or RR ≤ 12 → notify provider
Avoid benzodiazepines

Dose Considerations

Soft max cumulative dose: 20 mg/kg (IBW)
Absolute max cumulative dose: 30 mg/kg (IBW)
- Patients with IBW < 70 kg may need adjusted taper
If symptoms persist after 20 mg/kg:
- Consider alternate diagnoses
- Additional phenobarbital dosing should be cautious
- Consult Addiction Psychiatry
If total dose reaches 30 mg/kg → Do not give more phenobarbital

V. Alcohol Withdrawal Presentation

A. Signs and Symptoms

Nausea/vomiting
Tremor
Paroxysmal sweating
Tachycardia (> 100 bpm)
Hypertension
Anxiety/agitation
Visual, tactile, or auditory hallucinations
Clouded sensorium
Seizures

Note: Symptoms may begin within 6–48 hours of alcohol cessation and may progress to DTs if untreated.

B. Delirium Tremens (DTs)

DTs = alcohol withdrawal symptoms plus acute delirium
Occurs in ~5% of patients
Presents typically at 48–72 hours, can occur up to 96 hours after last drink

Symptoms include: - Tachycardia - Hypertension - Fevers - Increased respiratory rate / respiratory alkalosis - Hallucinations (visual/auditory) - Marked agitation

Symptoms may last up to 5 days

Untreated mortality may reach 15%, primarily from aspiration risk

Airway protection should be considered in patients with DTs

VI. Risk Stratification Notes

* Low Risk: - Positive Audit C - No history of DTs or alcohol withdrawal seizures

** High Risk: - History of alcohol withdrawal seizures - History of DTs - BAC > 200 - BAC > 100 plus symptoms of withdrawal

VII. Authors

Jennifer Beavers, PharmD, BCPS
Bradley M. Dennis, MD
February 26, 2024

VIII. References

Tidwell WP, Thomas TL, Pouliot JD, et al. Treatment of alcohol withdrawal syndrome: phenobarbital vs CIWA-AR protocol. Am J Crit Care 2018;27(6):454–460.
Nisavic MD, Nejad SH, Isenberg BM, et al. Use of phenobarbital in alcohol withdrawal management. Psychosomatics. 2019;60(5):458–467.
Oks M, Cleven KL, Healy L, et al. Phenobarbital for severe AWS in the MICU. J Intensive Care Med. 2018.
Ammar MA, et al. Phenobarbital Monotherapy for AWS in Surgical-Trauma Patients. Ann Pharmacother. 2021;55(3):294–302. doi:10.1177/1060028020949137.
Kodadek LM, et al. Alcohol-Related Trauma Reinjury Prevention. J Trauma Acute Care Surg. 2020;88(1):106–112.
Fleenor LM, et al. Phenobarbital vs Benzodiazepine for AWS in trauma patients. J Trauma Acute Care Surg. 2024 Mar;96(3):493–498. PMID: 37599414.

Antimicrobial Therapy

I. Purpose

Many patients who present to the Emergency General Surgery service do so for infectious causes. This serves to provide guidance and consistency in antibiotic prescribing for common EGS presenting diagnoses.

II. Guideline

A. Acute Appendicitis

Without Shock
- First Line: Ceftriaxone + Metronidazole
- Severe PCN allergy: Levofloxacin + Metronidazole
Sepsis / MDR Risk
- First Line: Piperacillin/Tazobactam
- Severe PCN allergy: Cefepime + Metronidazole + Vancomycin
Duration
- Non-perforated: Stop postoperatively
- Perforated: 4 days after source control
- No appendectomy: 10 days

B. Acute Cholecystitis

(If suspected cholangitis, use Sepsis/MDR Risk pathway)

Community-acquired (no shock)
- First Line: Ceftriaxone
  Add Metronidazole only if biliary-enteric anastomosis
- Severe PCN allergy: Levofloxacin
  Add Metronidazole only if biliary-enteric anastomosis
Sepsis / MDR Risk
- First Line: Piperacillin/Tazobactam
- Severe PCN allergy: Cefepime + Metronidazole + Vancomycin
Duration
- Cholecystectomy performed: Stop postoperatively
- Cholecystostomy tube placed: 4 days

C. Secondary Peritonitis

(Perforated gastric/duodenal ulcer, diverticulitis WITH operation/drain, colon perforation)

Community-acquired (no shock)
- First Line: Ceftriaxone + Metronidazole
- Severe PCN allergy: Levofloxacin + Metronidazole
Sepsis / MDR Risk
- First Line: Piperacillin/Tazobactam
- Severe PCN allergy: Cefepime + Metronidazole + Vancomycin
Duration
- 4 days after source control

D. Uncomplicated Diverticulitis

(Without operation/drain AND hemodynamically normal)

First Line: Amoxicillin/Clavulanic Acid or Ampicillin/Sulbactam (if IV needed)
Severe PCN allergy: Ciprofloxacin + Metronidazole
Duration: 7 days

E. Necrotizing Soft Tissue Infection

First Line: Linezolid + Piperacillin/Tazobactam
Severe PCN allergy: Linezolid + Cefepime + Metronidazole
Duration: Stop once source controlled, hemodynamically normal, and no signs of active infection
(typically 5–7 days)

III. References

Sawyer RG, Claridge JA, Nathens AB, Rotstein OD, Duane TM, Evans HL, Cook CH, O'Neill PJ, Mazuski JE, Askari R, Wilson MA, Napolitano LM, Namias N, Miller PR, Dellinger EP, Watson CM, Coimbra R, Dent DL, Lowry SF, Cocanour CS, West MA, Banton KL, Cheadle WG, Lipsett PA, Guidry CA, Popovsky K; STOP-IT Trial Investigators.
Trial of short-course antimicrobial therapy for intraabdominal infection.
N Engl J Med. 2015 May 21;372(21):1996–2005.
Lehman A, Santevecchi BA, Maguigan KL, Laconi N, Loftus TJ, Mohr AM, Shoulders BR.
Impact of Empiric Linezolid for Necrotizing Soft Tissue Infections on Duration of Methicillin-Resistant Staphylococcus aureus-Active Therapy.
Surg Infect (Larchmt). 2022 Apr;23(3):313–317.

IV. Authors

Kelli Rumbaugh, PharmD, BCPS, BCCCP
Jade Flynn, PharmD, BCPS

V. Endorsement

Michael C. Smith, MD
Oliver O. Gunter, MD

August 28, 2023

Biliary Disorders

I. Background

Biliary disorders (cholelithiasis, cholecystitis, choledocholithiasis, pancreatitis, and cholangitis) are some of the more common reasons for Emergency General Surgery consultation and need for operative management.

II. Guideline

A. Initial Evaluation with Concern for Biliary Pathology

Labs
- CBC
- CMP
- Lipase
Imaging
- Right Upper Quadrant Ultrasound is the preferred imaging modality
- CT Abdomen/Pelvis with IV Contrast
  - If diagnostic uncertainty
  - If concern for severe pancreatitis
- HIDA Scan
  - If concern for acalculous cholecystitis
  - If diagnostic uncertainty for cholecystitis and high risk for laparoscopic cholecystectomy
- MRI/MRCP should be considered only:
  - When IOC and/or EUS/ERCP are a prohibitive risk
  - When there is a potential malignancy and MRCP findings will impact management
Emergency General Surgery Consultation
- Patients with gallstone-related disease who will require cholecystectomy should be preferentially admitted to EGS
- Patients with prohibitive operative risk factors should be admitted to a medical team
- Patients referred for bile duct injury should be evaluated by Hepatobiliary Surgery
- Patients with cirrhosis who are listed for liver transplant should be evaluated by Hepatobiliary Surgery
Considerations for Gastroenterology (Advanced Endoscopy) Consultation
- High risk for choledocholithiasis
- Postoperative bile leak (see below)
Considerations for Radiology (Image-Guided Procedures) Consultation
- Prohibitive modifiable surgical risk (e.g. recent MI, multisystem organ failure)

B. Antibiotic Therapy

Without Sepsis
- First Line: Ceftriaxone + Metronidazole
  - Only need Metronidazole if biliary-enteric anastomosis
- Severe PCN allergy: Levofloxacin + Metronidazole
  - Only need Metronidazole if biliary-enteric anastomosis
Sepsis / MDR Risk
- First Line: Piperacillin/Tazobactam
- Severe PCN allergy: Cefepime + Metronidazole + Vancomycin
Duration
- Stop postoperatively if cholecystectomy performed
- 4 days if cholecystostomy tube placed

C. Indications for Laparoscopic Cholecystectomy

Cholelithiasis with intractable pain
Acute cholecystitis
Gallstone pancreatitis
Choledocholithiasis

D. Risk Assessment for Choledocholithiasis

High Risk
- Choledocholithiasis identified on imaging
- Clinical signs of ascending cholangitis
- Total bilirubin > 4 mg/dL with CBD dilation on imaging
Intermediate Risk
- Abnormal liver biochemical tests
- Dilated CBD (> 6 mm) on imaging
Low Risk
- None of the above risk factors
Indication for Intraoperative Cholangiogram
- Intermediate or high risk for choledocholithiasis

E. Management After Subtotal Cholecystectomy

Surgical drain placement in gallbladder fossa
Evaluate drain for bilious output
- If bilious, consult Gastroenterology for ERCP
- If nonbilious, discharge patient. Drain management to be determined by rounding attending

F. Special Considerations

Prior Roux-en-Y Gastric Bypass with possible choledocholithiasis
- Laparoscopic cholecystectomy with intraoperative cholangiogram
- Consider common bile duct exploration vs laparoscopic-assisted ERCP
- Coordinate OR timing with GI
Gallstone Pancreatitis
- Early laparoscopic cholecystectomy if mild or moderate
- Defer cholecystectomy in severe cases
Pregnancy
- Symptomatic cholelithiasis, acute cholecystitis, choledocholithiasis, or cholangitis warrants cholecystectomy during hospital admission

G. Management of Postoperative Bile Leaks

Early presentation, bilious drain output
- If low volume and reliable follow-up, consider discharge and expectant management
- Otherwise consult GI for ERCP
Delayed presentation, no drain in place
- If noninvasive imaging suggests biloma or drainable fluid collection, consult IR for percutaneous drain prior to ERCP
Role of HIDA scan
- Limited to low- or intermediate-suspicion cases where other diagnostics are equivocal
Endoscopic therapy
- Temporary biliary endoprosthesis with or without biliary sphincterotomy
- Plastic stents are appropriate — no strong evidence for metal stents even in subtotal/fenestrated cases
If leak persists despite endoscopic therapy
- Consider source from duct not in continuity (e.g., right posterior sectoral duct)
If common bile duct or hepatic duct injury
- Consult Hepatobiliary Surgery

III. References

Bosley ME, et al. Outcomes following balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration. Surg Endosc. 2023;37(5):3994–3999. doi:10.1007/s00464-022-09571-6
Loozen CS, et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE). BMJ. 2018;363:k3965. doi:10.1136/bmj.k3965
Bosley ME, et al. Antegrade balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration for the acute care surgeon. J Trauma Acute Care Surg. 2022;92(3):e47–e51. doi:10.1097/TA.0000000000003478
Gallaher JR, Charles A. Acute Cholecystitis: A Review. JAMA. 2022;327(10):965–975. doi:10.1001/jama.2022.2350
Okamoto K, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55–72. doi:10.1002/jhbp.516
Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy (ACDC study). Ann Surg. 2013;258(3):385–393. doi:10.1097/SLA.0b013e3182a1599b
Narula VK, et al. Clinical spotlight review for the management of choledocholithiasis. Surg Endosc. 2020;34(4):1482–1491. doi:10.1007/s00464-020-07462-2
Pearl JP, et al. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc. 2017;31(10):3767–3782. doi:10.1007/s00464-017-5637-3
Yachimski P, Orr JK, Gamboa A. Endoscopic plastic stent therapy for bile leaks following total vs subtotal cholecystectomy. Endosc Int Open. 2020;8(12):E1895–E1899. doi:10.1055/a-1300-1319

IV. Authors

Michele N. Fiorentino, MD
Rachel D. Appelbaum, MD
Michael C. Smith, MD
Patrick S. Yachimski, MD

January 22, 2024

Cirrhosis

I. Purpose

Patients with cirrhosis who require emergency general surgery have significantly higher morbidity and mortality rates than patients without cirrhosis[^1]. While data on outcomes and risk prognostication remain limited in this population, this document outlines perioperative management considerations for the cirrhotic patient.

II. Guideline

A. Initial Evaluation of the Cirrhotic Patient with EGS Pathology

Liver disease stratification scores
- MELD 3.0: INR, total bilirubin, creatinine, albumin, sodium, age, sex
- Child-Pugh: INR, total bilirubin, albumin, ascites, hepatic encephalopathy
Imaging review
- Evaluate for sequelae of portal hypertension: abdominal wall varices, splenomegaly, ascites
Postoperative risk scores
- Patients with MELD >20 or Child-Pugh class C have high risk of postoperative decompensation and death
- No absolute cutoff excludes patients from surgery; individualized prognostication recommended
- Risk calculators:
  - POTTER: Apple App Store
  - Mayo Postoperative Mortality Risk Score: Mayo Clinic Tool
  - VOCAL-Penn: vocalpennscore.com

B. Preoperative Correction of Coagulopathy

INR
- Do not reverse unless actively bleeding or on vitamin K antagonist[^3]
Platelets
- No transfusion unless active bleeding or platelets <30,000[^4]
- Hold DVT prophylaxis if platelets <50,000[^5]
Fibrinogen
- Transfuse cryoprecipitate to maintain >100 before surgery or with active bleeding[^2][^3]
TEG (Thromboelastography)
- Use if available to direct transfusions and minimize blood product use[^6]

C. Cholecystitis in the Cirrhotic Patient

Imaging
- RUQ US may show wall thickening or pericholecystic fluid due to portal hypertension
- HIDA scan if ultrasound/CT non-diagnostic[^7]
- MRCP if HIDA is non-diagnostic or biliary obstruction is suspected
Treatment
- MELD ≤13 or Child-Pugh A/B:
  - Antibiotics + laparoscopic cholecystectomy[^8][^9]
- MELD >13 or Child-Pugh C or decompensated:
  - Do not offer cholecystectomy
  - Begin antibiotics
  - If no improvement, consult IR + GI for cholecystostomy vs advanced endoscopy[^8][^10]
    - Avoid percutaneous approach if ascites present
Transplant Surgery Referral
- For patients listed for transplant, with history of HCC, or with a TIPS

D. Postoperative Management

Hepatic Encephalopathy
- Resume home regimen if chronic
- If new:
  - Check ammonia level (no need to trend)
  - Start lactulose 20g or 30mL PO BID–TID to 2–3 BMs/day[^11]
  - Add rifaximin 550mg PO BID if needed
  - If NPO: use lactulose enemas q4–6 hours
  - Hepatology consult if refractory
Ascites
- Diuretics
  - Resume when hemodynamically stable
  - If starting new:
    - Spironolactone 100mg PO daily → up to 400mg
    - Furosemide 40mg PO daily → up to 160mg[^12]
- If surgical drain present:
  - Empty every 4 hours x 72h
  - Remove ASAP after 72h if ascites controlled[^11]
  - Replace albumin: 6g of 25% albumin per liter drained
  - SBP prophylaxis if intra-abdominal sepsis covered:
    - PO: Ciprofloxacin 500mg daily
    - IV: Ceftriaxone 1g daily
- If no drain:
  - Consider large-volume paracentesis (LVP)
    - Indications:
      - Ascites leak from surgical site
      - Suspected peritonitis
      - Diuretics contraindicated
    - Albumin: 6–8g 25% per liter if >5L removed[^11]
- Hepatology consult if unresponsive
Prophylactic Anticoagulation
- Start if platelets >50,000[^5]
- CrCl >30: Enoxaparin 40mg SC daily
- CrCl <30: Heparin 5,000u SC q8h
Fluid Management
- Use balanced crystalloids (e.g., LR, Plasmalyte) to reduce hyperchloremia[^11]
Postop Medications
- Opiates (reduced dose/frequency):
  - Oxycodone 2.5–5mg q6h
  - Hydromorphone 0.125–0.25mg IV q6h
- Acetaminophen safe up to 2g/day[^2]:
  - 500mg q6h or 650mg TID
- Avoid:
  - NSAIDs (renal injury)[^2]
  - Benzodiazepines (hepatic clearance)[^2]
SBP Prophylaxis
- Indications:
  - Resumption of home SBP prophylaxis
  - Intraperitoneal drain in place[^13]
  - High-risk patients[^14]:
    - Prior SBP
    - Ascites protein <1.5g/L
    - Child-Pugh C
    - Renal dysfunction (Cr >1.2, BUN >25, Na <130)
    - Active GI bleed
- Therapy:
  - PO: Ciprofloxacin 500mg q24h
  - IV: Ceftriaxone 1g q24h if NPO[^2]

E. Indications for Perioperative Hepatology Consult

Management of decompensated cirrhosis (e.g., refractory ascites, encephalopathy, GI bleeding)
TIPS evaluation for refractory ascites
Liver transplant evaluation (e.g., acute liver failure)
Long-term management of portal vein thrombosis

III. References

[^1]: Bleszynski MS, et al. World J Emerg Surg. 2018;13:32.
[^2]: Northup PG, et al. Clin Gastroenterol Hepatol. 2019;17(4):595–606.
[^3]: Kaltenbach MG, Mahmud N. Hepatol Commun. 2023;7(4).
[^4]: Northup PG, et al. Hepatology. 2021;73(1):366–413.
[^5]: Simonetto DA, et al. Am J Gastroenterol. 2020;115(1):18–40.
[^6]: De Pietri L, et al. Hepatology. 2016;63(2):566–573.
[^7]: Ziessman HA. Clin Gastroenterol Hepatol. 2010;8(2):111–116.
[^8]: Wang SY, et al. Gut Liver. 2021;15(4):517–527.
[^9]: Delis S, et al. Surg Endosc. 2010;24(2):407–412.
[^10]: Hanna K, et al. Am J Surg. 2023;226(5):668–674.
[^11]: Seshadri A, et al. Trauma Surg Acute Care Open. 2022;7(1):e000936.
[^12]: Aithal GP, et al. Gut. 2021;70(1):9–29.
[^13]: Macken L, et al. Frontline Gastroenterol. 2022;13(e1):e116–e125.
[^14]: Biggins SW, et al. Hepatology. 2021;74(2):1014–1048.

IV. Authors

Stefanie P. Lazow, MD
Michael C. Smith, MD
Michael Derickson, MD
Andrew Medvecz, MD

October 28, 2024

Clostridium difficile Colitis

I. Purpose

Clostridium difficile infection (CDI) is an increasingly common cause of nosocomial morbidity and mortality from the gram-positive, spore-forming anaerobic bacillus. Up to 30% of patients with fulminant CDI require urgent surgery, and there is a >40% mortality rate in those requiring emergency surgery. Prompt recognition and treatment are therefore paramount.

II. Guideline

A. Initial Evaluation

Clinical suspicion for CDI
- Recent healthcare facility exposure
- Recent antibiotic use (especially clindamycin)
- 3 unformed stools in 24 hours without laxatives
- Consider tube feeds as a cause of diarrhea if applicable
Labs
- CBC
- BMP
- C. difficile PCR with Reflex Toxin Panel
  - PCR negative → C. difficile not present
  - PCR positive/Toxin positive → Treat
  - PCR positive/Toxin negative → Likely colonized, treatment based on clinical picture:
    - Does the patient have >3 risk factors?
    - Have alternative causes of diarrhea been ruled out?
    - Are symptoms/WBC/vitals worsening off therapy?
Imaging
- Consider CT Abdomen/Pelvis with IV contrast for suspected severe or fulminant CDI
Evaluation of Severity
- Nonsevere CDI
  - HR < 90 bpm, SBP > 100 mmHg
  - Tmax < 101.5°F
  - WBC < 15,000
  - Normal lactate
  - Oliguria responsive to fluids
  - Mild abdominal tenderness
- Severe CDI
  - HR > 90 bpm without hypotension
  - Fever > 101.5°F
  - WBC > 15,000
  - Creatinine > 1.5 mg/dL
  - Moderate abdominal tenderness
- Fulminant CDI
  - Shock with hypotension
  - Need for vasopressors
  - Ventilator dependence
  - Oliguria unresponsive to fluids
  - Perforation
  - Toxic megacolon (cecal diameter >12 cm or colon diameter >6 cm)

B. Antibiotic Therapy

Nonsevere CDI
- Vancomycin 125 mg PO q6h x 10 days
- OR Fidaxomicin 200 mg PO BID x 10 days (for high-risk patients)
Severe CDI
- Vancomycin 125 mg PO q6h x 10 days
- OR Fidaxomicin 200 mg PO BID x 10 days (for high-risk patients)
Fulminant CDI
- Vancomycin 500 mg PO q6h PLUS Metronidazole 500 mg IV q8h
- If ileus (no megacolon): Add Vancomycin 500 mg PR q6h
Recurrent CDI
- First recurrence: Fidaxomicin 200 mg PO BID x 10 days
- Multiple recurrences:
  - Infectious Disease (ID) consult
  - Fidaxomicin 200 mg PO BID x 10 days
  - Vancomycin taper
  - Vancomycin followed by Rifaximin
High-risk features (≥3 of the following):
- Recent high-risk antibiotics (fluoroquinolones, clindamycin, carbapenems, 3rd/4th gen cephalosporins)
- Healthcare exposure (past 12 weeks)
- Age > 65
- Chronic gastric acid suppression
- Solid organ transplant
- Hematopoietic stem cell transplant
- Chemotherapy
- CKD or ESRD
- Prolonged hospitalization
- Recent GI procedure
Fidaxomicin limitations
- Do not use if PCR+/Toxin-
- Requires ID attending approval (page 317-4376)
- Confirm affordability prior to discharge

C. Indications for Surgical Management

Key principle: Preoperative physiologic status is the strongest predictor of postoperative mortality
Strongly consider TAC with end ileostomy (TAC/EI) if:
- Severe colonic distension
- Clinical deterioration despite maximal medical therapy (within 24–48h)
- Pneumatosis
- Impending perforation

D. Postoperative Management of TAC/EI

Consider pelvic drain (based on rectal stump quality)
ICU admission strongly recommended
Antibiotic therapy post-op
- No clear guidelines exist
- If perforation: consider 4-day course of abdominal sepsis antibiotics
- Continue Vancomycin 500 mg PO q6h or Metronidazole 500 mg IV q8h x 7 days (until bowel function returns)

III. References

McDonald LC, et al. Clin Infect Dis. 2018;66(7):e1–e48. doi:10.1093/cid/cix1085
Johnson S, et al. Clin Infect Dis. 2021
Cornely OA, et al. Lancet Infect Dis. 2012;12(4):281–289. doi:10.1016/S1473-3099(11)70374-7
Van der Wilden G, et al. Surg Infect. 2015
Seltman A. Clin Colon Rectal Surg. 2012
Choron R, Lipsett P. In: Current Surgical Therapy, 13th Ed. 2020
Kelly CR, et al. Am J Gastroenterol. 2021;116(6):1124–1147
Vanderbilt Antimicrobial Stewardship Program. CDI Guidelines

IV. Authors

Michael J. Derickson, MD
Joshua J. Thompson, MD, PhD
Jade Flynn, PharmD, BCPS

July 22, 2024

Enterocutaneous Fistula

I. Background

The major cause of enterocutaneous (EC) or enteroatmospheric (EA) fistulas is surgical intervention, accounting for 80% of cases. Non-surgical etiologies include inflammatory bowel disease, radiation, malignancy, and ischemia. While acute management may follow this PMG, the long-term approach to non-surgical fistulas differs and is not addressed here.

These fistulas have high morbidity and mortality, often requiring months to years of wound care and supplemental nutrition, including parenteral nutrition. Reported mortality rates range from 6% to 33%.

II. Terminology

Fistula: Abnormal connection between two epithelialized surfaces
Enterocutaneous fistula: Abnormal connection between GI tract and skin
Gastrocutaneous fistula: Abnormal connection between stomach and skin (often post-gastrostomy)
Enteroatmospheric fistula: Bowel-to-skin connection without an epithelialized tract

III. Classification

Low output: < 200 cc/day
Moderate output: 200–500 cc/day
High output: > 500 cc/day

IV. Management

A. Resuscitate and Replace Electrolytes

Patients may have large fluid losses and electrolyte disturbances
Admit to stepdown or ICU based on clinical status
Common abnormalities: hyponatremia, hypokalemia, hypomagnesemia

B. Wound and Skin Protection

Control effluent early to prevent skin breakdown and promote successful pouching
Initiate pouching with early WOCN (wound ostomy continence nurse) consultation

C. Control Sepsis

Percutaneous drainage may help divert effluent and improve wound care
Antibiotics:
- Not required unless systemic sepsis or cellulitis is present
- If systemic sepsis:
  - First-line: Piperacillin/Tazobactam
  - Severe PCN allergy: Cefepime + Metronidazole

D. Quantify Output

Document daily volume output to assist with nutrition and fluid planning

E. Nutrition Optimization

Low to moderate output: prioritize enteral nutrition
High output: consider NPO and initiate parenteral nutrition
Involve Gastroenterology and Nutrition early

F. Operative Management

Immediate surgery is rarely helpful in newly presented fistulas
If associated with necrotizing soft tissue infection (NSTI), manage per NSTI guidelines
If the fistula does not resolve with non-operative management and discharge criteria are met, plan elective fistula takedown

G. Nonsurgical Options

Consider endoscopic or percutaneous management if anatomically feasible

V. Flowchart

VI. References

Cowan KB, Cassaro S. Enterocutaneous Fistula. StatPearls, 2023.
Gribovskaja-Rupp I, Melton GB. Enterocutaneous Fistula: Proven Strategies and Updates. Clin Colon Rectal Surg. 2016;29(2):130–137.
Edmunds LH Jr, et al. External Fistulas of the GI Tract. Ann Surg. 1960;152(3):445–471.
Ballard DH, et al. Percutaneous Management of EC Fistulae. Dig Dis Interv. 2018;2(2):131–140.
Metcalf C. Management of Enterocutaneous Fistula. Br J Nurs. 2019;28(5):S24–S31.
Gross DJ, et al. Challenge of Uncontrolled Enteroatmospheric Fistulas. Trauma Surg Acute Care Open. 2019;4(1):e000381.
Schecter WP, et al. Principles of Enteric Fistula Management. J Am Coll Surg. 2009;209(4):484–491.

VII. Authors

Mina F. Nordness, MD, MPH
H. Andrew Hopper, MD
Michael C. Smith, MD

Glycemic Control

I. Considerations

For insulin-naive patients, basal insulin (glargine) should be ordered to begin on hospital day 2 after glucose checks
If BG remains <180, consider continuing only sliding scale insulin (SSI)
Basal insulin should not be held if the patient is NPO
All patients with insulin orders should also have the Adult Hypoglycemia Management order set
Use caution in:
Renal dysfunction
Elderly patients
Patients on glucocorticoids
Large volume fluid shifts
Discontinue sliding scale and glucose monitoring if:
Glucose remains <150 mg/dL for 24 hours
Patient is on goal diet

II. Choice of Sliding Scale

Patients without DM: (BG - 100) / 50
DM on 1–2 oral meds or GLP-1 agonists: (BG - 100) / 30
DM on >2 oral meds or insulin at home: (BG - 100) / 20
DM on insulin and A1c >9%: (BG - 100) / 15

III. Insulin Infusion

If glucose >250 mg/dL despite maximal sliding scale administration:
Consider transfer to SICU for intensive glucose management
Refer to SICU Glycemic Control Guideline

IV. Indications for Endocrinology Consultation

Type I Diabetes Mellitus
Use of concentrated insulin U-500 at home
Use of insulin pump at home
Discharge recommendations/follow-up in patients with:
New DM diagnosis and A1c > 6.5%
Known DM with A1c > 9%

V. References

Yendamuri S, et al. J Trauma. 2003;55:33–38
Laird A, et al. J Trauma. 2004;56:1058–1062
Sung J, et al. J Trauma. 2005;59:80–83
Van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367
NICE-SUGAR Investigators. N Engl J Med. 2009;360:1283–1297
Jacobi J, et al. Crit Care Med. 2012;40:3251–3276
Mowery NT, et al. J Trauma. 2010;68:342–347
Mowery NT, et al. World J Surg. 2011;36:270–277
Krinsley J, et al. Crit Care Med. 2008;36:3008–3013
Kauffmann RM, et al. JPEN. 2011;35:686–694
Bode BW, et al. Endocr Pract. 2004;10(2):71–80

VI. Authors

Michael J. Derickson, MD
Kelli Rumbaugh, PharmD, BCPS, BCCCP
Jade Flynn, PharmD, BCPS

High Ostomy Output

I. Background

High ostomy output (>1 liter/day) can result in dehydration, malnutrition, and prolonged hospitalization. A standardized approach improves outcomes and reduces length of stay.

II. Guideline

A. Patient on Oral Diet or Bolus Tube Feeds

Applies regardless of remaining bowel length
Discontinue all oral bowel regimens
Avoid high-sugar and sugar alcohol drinks
- Examples: electrolyte sports drinks, sweet tea, colas
Ensure strict I/Os are documented (all PO/enteral intake)
Switch to carbohydrate-restricted diet
Convert liquid medications to tablet/capsule form if possible
Order IV fluid replacement
- 1:1 IVF q4h PRN for UOP < 0.5 mL/kg/hr or signs of dehydration
Assess for parenteral nutrition (PN) if:
- High output >1 week
- Protein-calorie malnutrition confirmed by dietitian

Output Thresholds:

Colostomy >700 mL/day
Ileostomy >1000 mL/day

Stepwise Management:

Step	Medications
1	Metamucil BID (stop if decreased appetite) + Loperamide 2 mg AC/HS
2	Loperamide 4 mg AC/HS + Pantoprazole 40 mg IV BID
3	Diphenoxylate/Atropine 5 mg AC/HS
4	Diphenoxylate/Atropine 10 mg AC/HS
5	Tincture of Opium 0.5 mL AC/HS

Reassess output after 48 hours; advance to next step if not improved
Dietitian should re-evaluate diet with each escalation

B. Patient on Continuous Tube Feeds

Applies regardless of remaining bowel length
Discontinue all bowel regimens
Use a standard polymeric formula (e.g. Replete, Isosource, Nutren)
- Consider bolus feeding if patient can tolerate
Convert liquid meds to tablet/capsule form
Replace fluids as needed
- 1:1 IVF q4h PRN for UOP < 0.5 mL/kg/hr or dehydration symptoms
Consider PN if:
- High output >1 week
- Malnutrition confirmed by dietitian

Output Thresholds:

Colostomy >700 mL/day
Ileostomy >1000 mL/day

Stepwise Management:

Step	Medications
1	Loperamide 2 mg q6h
2	Loperamide 4 mg q6h + Pantoprazole 40 mg IV BID
3	Diphenoxylate/Atropine 5 mg q6h
4	Diphenoxylate/Atropine 10 mg q6h
5	Tincture of Opium 0.5 mL q6h

Reassess output after 48 hours; advance to next step if needed
Dietitian should re-evaluate formula/diet during escalation
If maximum therapy fails after 48 hours, discuss escalation with attending

III. References

Parrish CR, Copland A. Enteral Nutrition in the Adult Short Bowel Patient. Pract Gastroenterol. 2021: 36–51.
Kumpf VJ. Pharmacologic Management of Diarrhea in Patients with Short Bowel Syndrome. JPEN. 2014;38(Suppl 1):38S–44S.
Bridges M, et al. High Output Ileostomies: The Stakes Are Higher Than the Output. Pract Gastroenterol. 2019: 20–33.

IV. Authors

Joshua P. Smith, DO
Jennifer Beavers, PharmD
Leanne Atchison, PharmD
Diana Mulherin, PharmD

Date: January 22, 2024

Necrotizing Soft Tissue Infection

I. Background

Necrotizing soft tissue infection (NSTI) is a rapidly progressing, life-threatening infection with significant morbidity and mortality. Prompt recognition, initiation of antibiotics, and surgical debridement are essential for effective management.

II. Guideline

A. Initial Evaluation

Labs
- CBC
- BMP
- Lactate
- CRP
- Blood cultures
Imaging
- Diagnosis is primarily clinical and confirmed in the operating room
- CT with IV contrast can support diagnosis in equivocal cases
- Presence of soft tissue gas is highly specific
- Absence of gas does not rule out NSTI
Initial Antibiotic Therapy
- First-line: Linezolid + Piperacillin/Tazobactam
- Severe PCN allergy: Linezolid + Cefepime + Metronidazole

Consultations
- STAT Emergency General Surgery consultation for trunk NSTI
- Additional specialty consults as indicated:
  - Urology (perineal/scrotal NSTI)
  - Gynecology (vulvar NSTI)
  - Orthopedics / Hand (extremity NSTI)
  - Plastic Surgery (for reconstruction after infection control)
- Strongly consider SICU admission postoperatively

B. Surgical Management

Early, aggressive debridement within 6 hours
Expedite Level 2 OR activation
Send intraoperative specimens for gram stain and culture
Use skin-sparing technique when feasible; elevate full-thickness and subcutaneous flaps to access necrotic tissue
Debride skin only if necrotic
Avoid incisions near bony prominences, major vessels, and nerves
Plan for second look operation within 24 hours or sooner if patient deteriorates
For perineal/perianal involvement: consider diverting colostomy once hemodynamically stable
For large wounds:
- Apply negative pressure wound therapy (VAC)
- Cleanse with dilute Dakin’s solution between VAC changes
Once stable and debridement complete:
- Close with interrupted sutures, split-thickness skin grafts, or flaps (Plastic Surgery)

C. Ongoing Management

Antibiotic Duration
- Continue systemic antibiotics until ALL of the following:
  - Adequate source control
  - Hemodynamic normalization
  - Afebrile for 48 hours
  - WBC improvement
Infectious Disease Consultation
- Indications:
  - Multidrug-resistant organisms
  - Osteoarticular involvement
  - Per VUMC policy (e.g., S. aureus or Enterococcus bacteremia)
Physical & Occupational Therapy
- Early involvement recommended

III. References

Stevens DL, Bryant AE. N Engl J Med. 2017;377(23):2253–2265.
Stevens DL, et al. Clin Infect Dis. 2014;59(2):147–159.
Hua C, et al. Lancet Infect Dis. 2023;23(3):e81–e94.
Hadeed GJ, et al. J Emerg Trauma Shock. 2016;9(1):22–27.
Zacharias N, et al. Arch Surg. 2010;145(5):452–455.
Duane TM, et al. Surg Infect (Larchmt). 2021;22(4):383–399.
Dorazio J, et al. Open Forum Infect Dis. 2023;10(6):ofad258.
Tom LK, et al. J Am Coll Surg. 2016;222(5):e47–60.

IV. Authors

Michael J. Derickson, MD
Eddie Blay, MD
Kelli Rumbaugh, PharmD, BCPS, BCCCP
Jade Flynn, PharmD, BCPS

Date: February 26, 2024

V. Appendix

Refer to institutional documents for visual guides and operative illustrations related to skin-sparing debridement techniques.

Ostomy Reversal Pathway

Outpatient Management: Colostomy

Postoperative Follow-Up
- First visit: 7–14 days post-op OR 2 weeks post-discharge if hospitalized on POD #14
- Second visit: 2 months post-op (telehealth if eligible)
Pre-Reversal Workup
- If age >44 and no recent colonoscopy:
  - Order colonoscopy
  - Barium enema if indicated on discharge checklist
- If age <44 or recent colonoscopy:
  - Barium enema if indicated on discharge checklist
- If family history of colon cancer → consider screening colonoscopy
- If known or suspected sphincter injury:
  - In-person visit with rectal exam
  - Anal manometry at discretion of attending
  - If abnormal → refer to Colorectal Surgery
- Schedule reversal surgery
Preoperative Orders
- Antibiotic Bowel Prep
  - Neomycin 1g TID the day before surgery (2 PM, 4 PM, 10 PM)
  - Metronidazole 500 mg TID same schedule
  - If neomycin unavailable → use erythromycin 1g TID
- Mechanical Bowel Prep
  - Magnesium citrate (1–2 bottles) OR
  - Miralax (256 g polyethylene glycol)
- Chlorhexidine wipes: use the day before surgery
- NPO 6 hrs prior to procedure
- Clear electrolyte/sports drink immediately before NPO
- Anesthesia: Perioperative Consultation Service referral for adjunctive analgesia

Outpatient Management: Ileostomy

Postoperative Follow-Up
- First visit: 7–14 days post-op OR 2 weeks post-discharge if hospitalized on POD #14
- Second visit: 2 months post-op (telehealth if eligible)
Pre-Reversal Workup
- If age >44 and no recent colonoscopy:
  - Order colonoscopy
  - Barium enema if indicated on discharge checklist
- If age <44 or recent colonoscopy:
  - Barium enema if indicated on discharge checklist
- If family history of colon cancer → consider screening colonoscopy
- If known or suspected sphincter injury:
  - In-person visit with rectal exam
  - Anal manometry at discretion of attending
  - If abnormal → refer to Colorectal Surgery
- Schedule reversal surgery
Preoperative Orders
- No bowel prep needed
- Chlorhexidine wipes: use the day before surgery
- NPO 6 hrs prior to procedure
- Clear electrolyte/sports drink immediately before NPO
- Anesthesia: Perioperative Consultation Service referral for adjunctive analgesia

Preoperative Risk Optimization

Glycemic Control
- If diabetic → check HgbA1c
- Consider delaying elective surgery if HgbA1c > 7%
- Refer to PMD or Endocrinology for long-term management
Smoking/Nicotine Cessation
- Consider referral to Tobacco Quit Line
Anesthesia Referral
- VPEC (phone/in-person) → for low periop risk
- Hi-Rise → for elevated periop risk

Discharge Checklist (To Be Completed by Operating Surgeon)

Estimated Time to Reversal (default: 4 months post-colostomy unless specified)
- If not a candidate, surgeon must discuss with patient/family
Time to First Post-Op Visit (default: 7–14 days)
Time to Second Post-Op Visit (default: 60 days)
Pre-Second Visit Workup
- Patients <44 yrs: No colonoscopy unless strong personal/family history of colon cancer
- Colonoscopy 10 years prior to youngest family member’s diagnosis if family history present
- Avoid routine barium enema for Hartmann’s procedures at VUMC
- All DLI patients require anastomosis evaluation prior to reversal (preferred: barium enema)
Hi-RISE or VPEC Referral Needed (YES / NO)
Barriers to Reversal
- Smoking
- Obesity
- Diabetes
- Wound healing issues

Percutaneous Endoscopic Gastrostomy (PEG) Tube

I. Background

Percutaneous endoscopic gastrostomy (PEG) is a commonly performed procedure that provides durable enteral access for feeding and medications. This document outlines patient selection and perioperative considerations for PEG tube placement.

II. Guideline

A. Patient Selection / Preoperative Care

Contraindications to PEG Placement
- Anatomic inability to place PEG (e.g., Roux-en-Y anatomy, mesh overlying site, esophageal stricture)
- Uncontrolled agitation (requiring restraints/sitter in prior 48 hrs)
- Ascites
- Severe dementia
- Anorexia nervosa
Special Situations
- Esophageal cancer: Discuss with Thoracic Surgery if esophagectomy planned
- Failure to thrive: Proceed only if medically reversible
- Palliative decompression: OK in unresectable malignancy
- Peritoneal dialysis: Must be on HD x6 weeks before PEG; wait ≥4 weeks to resume PD
- VP shunt: Separate PEG and VP shunt placement by ≥7 days
- ALS (without trach): Prefer IR-placed gastrostomy due to anesthesia risk
- Active chemotherapy:
  - Delay PEG during severe leukopenia (WBC <2.5 or ANC <0.5) or platelets <50k
  - Risk/benefit discussion required
- Immunosuppressants / Corticosteroids:
  - Delay PEG during induction therapy
  - If planning to stop, wait until discontinued
  - If long-term use, wait until on stable maintenance dose
Anticoagulation Management
- Heparin drip: Hold 4 hours pre- and post-procedure
- Prophylactic heparin/enoxaparin: Do not hold
- Therapeutic enoxaparin: Hold AM dose; resume PM if no bleeding
- DOACs: Hold 24 hrs prior; resume PM if no bleeding
- Aspirin: Continue
- Clopidogrel/Ticagrelor/Effient (alone): Continue
- Dual antiplatelet therapy (DAPT):
  - Preferred: Continue aspirin, hold second agent 5 days before procedure
  - If unable: Risk/benefit discussion on delaying PEG vs. performing while on DAPT
Preoperative Tube Feeds & Diet
- Bedside PEG (ICU)
  - Protected airway: Hold feeds for ≥1 hour
  - Unprotected airway: Hold solids/tube feeds ≥6 hrs, clear liquids ≥2 hrs
- OR PEG
  - NPO after midnight
  - High-risk nutrition: solids/tube feeds ≥6 hrs, clear liquids ≥2 hrs

B. Procedural Care

Follow bedside surgery protocol: sterile prep, timeout, sedation, consent
Antibiotic prophylaxis: Weight-based Cefazolin within 1 hr of incision
T-fastener Indications:
- Corticosteroids
- Chemotherapy
- Immunosuppressants
- At attending discretion
Equipment: See Appendix A

C. Postoperative Care

Immediate PEG Care
- PEG to gravity drainage (foley bag) x 4 hrs
- Start tube feeds and meds ≥4 hrs post-procedure
- Document PEG depth post-op and POD1
- Continue postop checks for high-risk or complicated patients
- Remove T-fasteners at 2–3 weeks unless causing necrosis
- Schedule follow-up at 4 weeks
- If PEG becomes dislodged → Urgent EGS evaluation
Dislodged PEG Tube
- If <30 days from placement → emergent EGS consult
- Concerning findings: peritonitis, free air/fluid, infection → consider exploration
- If stable, attempt balloon gastrostomy tube placement with imaging confirmation (X-ray or CT with IV + per-tube contrast)
- Consider repeat PEG in stable patients
PEG Removal
- Minimum of 4 weeks post-placement
- Criteria to remove:
  - Resolved indication (e.g., cleared by SLP)
  - 2 weeks of full PO intake
  - Weight stability
  - Tolerance of food textures
  - No planned surgery or radiation
- Consider high-dose PPI to support tract closure

III. References

Abraham NS, et al. J Can Assoc Gastroenterol. 2022;5(2):100–101.
Bischoff SC, et al. Clin Nutr. 2022;41(2):468–488.
Boullata JI, et al. JPEN J Parenter Enteral Nutr. 2017;41(1):15–103.
ASGE Standards of Practice Committee, et al. Gastrointest Endosc. 2016;83(1):3–16.
ASGE Standards of Practice Committee, et al. Gastrointest Endosc. 2015;81(1):81–89.
Davies N, et al. Cochrane Database Syst Rev. 2021;8(8):CD013503.
de Sousa Magalhaes R, et al. Scand J Gastroenterol. 2020;55(4):485–491.
Gangwani MK, et al. Dig Dis Sci. 2023;68(5):1966–1974.
Keung EZ, et al. J Am Coll Surg. 2012;215(6):777–786.
Lipp A, Lusardi G. Cochrane Database Syst Rev. 2013;2013(11):CD005571.
Lucendo AJ, et al. Rev Esp Enferm Dig. 2015;107(3):128–136.
Meenaghan N, et al. J Gastrointest Surg. 2009;13(2):236–238.
Oterdoom LH, et al. J Neurosurg. 2017;127(4):899–904.
Rosenberger LH, et al. Surg Endosc. 2011;25(10):3307–3311.

IV. Authors

Elizabeth D. Krebs, MD
Nina E. Collins, APRN
Christian J. Carpenter, RN
Michael C. Smith, MD

Appendix A: Procedural Equipment

Trauma procedure cart
Sterile towels
Bite block
Sterile gown and gloves
Eye protection
Endoscopy scope
- Pediatric colonoscope for PEG-J
- Pediatric XP scope for esophageal narrowing
1-liter bottle normal saline
Endoscopy connector set
Suction tubing and canister
Chlorhexidine skin prep
PEG or PEG-J kit
- If PEG-J: T-fasteners are required

Appendix B: Bedside Gastrostomy Care

Tube site monitoring
- Record external length every shift
- Clean site each shift with NS-moistened gauze
  - If skin breakdown: Triple Care EPC + dry gauze
  - If intact skin: Triple Care Ointment or Ilex Cream + dry gauze
- Change gauze PRN
Tube care
- Flush with 30 mL water every 8 hrs and PRN
- Secure tube to prevent pulling or dislodgement
- Use abdominal binder or appropriate tape
Feeding Instructions
- Follow attending or nutrition orders
- If tube is dislodged or depth changes → stop feeds and notify EGS

Percutaneous Tracheostomy

I. Overview

Patients with prolonged mechanical ventilation and endotracheal intubation are at risk for complications such as pneumonia, tracheomalacia, and subglottic stenosis. Tracheostomy offers a safer and more comfortable long-term airway option. Bedside percutaneous tracheostomy is a safe alternative to open surgical tracheostomy and reduces the need for patient transport and OR resources.

II. Purpose

To define indications and contraindications for tracheostomy
To describe the accepted protocol for bedside percutaneous tracheostomy

III. Patient Selection

A. Indications

Prolonged mechanical ventilation >7 days
Inability to protect airway (e.g., AMS, stroke, deconditioning)
Structural issues (e.g., severe facial fractures, unresolving airway edema)
Consider early tracheostomy (<7 days) for:
- Severe TBI
- Cervical spinal cord injury
- TBI + submaxillary fractures
- Laryngotracheal injury

B. Contraindications

<7 days post-op from anterior cervical fusion
High ventilator requirements:
- FiO₂ > 60%
- PEEP > 10
- Incompatible with volume control ventilation
Elevated ICP
Hemodynamic instability

C. Special Situations

High-risk patients:
- Morbid obesity
- Airway edema
- Cervical trauma
- Halo brace/MMF
- Extremes of age
- High ventilator dependence, mucous plugging
- Frequent desaturation
- → Consider bronchoscopy guidance, ENT/OR backup, second proceduralist
COVID-19 patients (must meet all):
- Cleared from isolation
- PEEP <12
- FiO₂ <80%
- Must be performed by attending
BMI ≥ 35 → use Proximal XLT tracheostomy

D. Anticoagulation and Tube Feeds

Anticoagulation
- Heparin drip: Hold 4 hrs pre- and post-procedure
- Prophylactic heparin/enoxaparin: do not hold
- Therapeutic enoxaparin: Hold AM dose, resume PM if no bleeding
- DOACs: Hold 24 hrs pre-, resume PM if no bleeding
- Aspirin: Do not hold
- Clopidogrel/Ticagrelor/Effient: Do not hold
- DAPT: Risk/benefit discussion required
Feeds
- Hold ≥1 hour prior to procedure
- May be held longer at ICU/intensivist discretion

IV. Procedure

A. Supplies

Portex percutaneous tracheostomy kit (Blue Rhino for XLT)
Mayo scissors (1)
Curved hemostats (3)
Needle holders (2)
Army-Navy retractors (2)
Tracheostomy tubes (#8 Portex + backups)
Sterile towels, gowns, gloves
Chlorhexidine skin prep
2-0 silk or monofilament sutures (2)
Difficult airway cart/intubation set
CO₂ detector
Towel clamps (2)

B. Procedure Steps

Sedation
- Follow bedside sedation protocol
- Recommend chemical paralysis + analgesia
Setup & Timeout
- Surgical prep per protocol
- Preoperative timeout
Tracheostomy Technique
- Infiltrate skin with lidocaine + epinephrine
- Make vertical incision 1–2 fingerbreadths above sternal notch
- Blunt dissection to trachea in midline
- Cut ET tube tape, retract ET tube under direct palpation to cricoid level
- Complete tracheostomy via needle access and Seldinger technique
Confirmation
- Connect CO₂ monitor and confirm position by color change and exhaled volumes
- Withdraw ET tube completely
- Secure tracheostomy with sutures and neck strap
- Obtain post-procedure chest X-ray

V. Downsize and Decannulation

A. Downsize

Criteria
- POD 5
- Tolerating ≥10 min trach collar trials
- No further OR or bronch needs
- Off vent & cuff deflation tolerated >48 hrs
  → Downsize to #6 non-cuffed XLT or #7 Portex
Supplies
- Airway box and McGrath
- Ambu bag, suction
- Two new trachs
- ETCO₂ detector, 10cc syringe, trach tie, lubricant
- Suction catheter
Techniques
1. Obturator/fish hook:
  - Remove trach → insert obturator with trach → advance at 90° angle → remove obturator → insert inner cannula
2. Seldinger with suction catheter:
  - Insert suction catheter through current trach → remove old trach → guide new trach over catheter → confirm ETCO₂ and suction pass
Document general procedure note

B. Decannulation

Criteria
- Off vent >72 hrs
- Tolerating PMV or capping
- No pending surgery or need for positive pressure
- Managing secretions independently
Post-removal Care
- Cover stoma with tightly taped dry dressing
- Change dressing twice daily

VI. References

Anand T, et al. J Trauma Acute Care Surg. 2020;89(2):358–364
Brass P, et al. Cochrane Database Syst Rev. 2016;7:CD008045
de Franca SA, et al. Crit Care Med. 2020;48(4):e325–331
Dennis BM, et al. J Am Coll Surg. 2013;216(4):858–865
Jackson LS, et al. J Trauma. 2011;71(6):1553–1556

VII. Authors

Christian Carpenter, RN
Elizabeth Krebs, MD
Michael C. Smith, MD
Brad Dennis, MD

Revised: February 2019, October 2021, February 2024, June 2024

Small Bowel Obstruction

I. Background

Small bowel obstruction remains one of the more common reasons for Emergency General Surgery consultation. Protocolized management has been shown to shorten length of hospital stay and time to operative management.

II. Guideline

A. Initial Evaluation with Concern for Bowel Obstruction

Labs
- CBC
- BMP
- Lactate
Imaging
- CT Abdomen/Pelvis with IV Contrast
Surgical Evaluation
- Emergency General Surgery Consultation
- If due to gastrointestinal malignancy (known or suspected), consult Surgical Oncology
- If Inflammatory Bowel Disease (Crohn’s or Ulcerative Colitis), consult Colorectal Surgery
- If due to gynecologic malignancy, consult Gynecologic Oncology
Admission
- Patients with bowel obstruction should preferably be admitted to a surgical service

B. Indications for Urgent Exploration

Suspected Ischemia
- Peritonitis on physical examination
- Concerning laboratory values
  - Leukocytosis
  - Lactic Acidosis
- Concerning CT findings
  - Closed-loop obstruction
  - Internal hernia
  - Pneumatosis intestinalis
  - Mesenteric edema
Incarcerated Hernia
No Prior Abdominal Surgery
- Strongly consider exploration

C. Nonoperative Management – Small Bowel Follow Through

Initial Steps
- Nasogastric decompression for 2 hours
- Abdominal X-ray to confirm gastric tube placement
Orders
- Xray Small Bowel Nonfluoro
- iohexol (OMNIPAQUE) 300 mg/mL, 300 mL
- X-rays at 0, 2, 8, 24 hours
Interpretation
- If contrast in the colon OR bowel movement within 24 hours → passed small bowel follow through
- If no contrast in the colon AND no bowel movement within 24 hours → consider exploration

D. Criteria for Discharge

Tolerating diet without nausea or vomiting
Bowel function
Resolution of pain

E. Criteria for Discharge

III. References

Choi HK, Chu KW, Law WL. Therapeutic value of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment: a prospective randomized trial. Ann Surg. 2002 Jul;236(1):1–6.
Goussous N, Eiken PW, Bannon MP, Zielinski MD. Enhancement of a small bowel obstruction model using the gastrografin(R) challenge test. J Gastrointest Surg. 2013 Jan;17(1):110–6.
Loftus T, Moore F, VanZant E, et al. A protocol for the management of adhesive small bowel obstruction. J Trauma Acute Care Surg. 2015 Jan;78(1):13–9.
Maung AA, Johnson DC, Piper GL, et al. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S362–9.
Medvecz AJ, Dennis BM, Wang L, et al. Impact of operative management on recurrence of adhesive small bowel obstruction: A longitudinal analysis of a statewide database. J Am Coll Surg. 2020 Apr;230(4):544–551.e1.
Moskowitz EE, McIntyre RC, Burlew CC, et al. Evaluation of a water-soluble contrast protocol for small bowel obstruction: A Southwestern Surgical Congress multicenter trial. Am J Surg. 2019 Dec;218(6):1046–1051.
Zielinski MD, Haddad NN, Cullinane DC, et al. Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction. J Trauma Acute Care Surg. 2017 Jul;83(1):47–54.

IV. Authors

Elizabeth D. Krebs, MD
Andrew J. Medvecz, MD, MPH
Michael C. Smith, MD

December 18, 2023

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Appendices

In-House Directory

Patient & Family Services

Admissions & Registration

Emergency & Critical Care

Clinical Departments

Surgical & Perioperative Services

Imaging & Radiology

Pharmacy Services

Rehabilitation & Therapies

Operations & Support

Emergency (In-House Only)

Pharmacy

Inpatient Pharmacy

Unit-Based Clinical Pharmacy Coverage

Medication History Team

Outpatient & Specialty Pharmacies

Emergency & Security Contacts

Medical Imaging – Useful Numbers

Reading Rooms

Technologists

Post-Operative Check — Workflow

Step 1. Chart Check (before entering the room)

Step 2. Patient Examination + Nursing Check

Step 3. Post-Op Orders and Documentation

Step 4. Red Flags — Call Senior Immediately

Common Post Operative Issues

Post-Operative Pain Management

Definition

I. Principles

II. Stepwise Framework

Step 1: Scheduled Non-Opioids (baseline for all unless contraindicated)

Step 2: PRN Oral Opioids (breakthrough pain)

Step 3: IV Opioids (if NPO, severe pain, or unable to tolerate PO)

Step 4: Escalation / Severe or Refractory Pain

III. Monitoring & Safety

IV. Pediatric Considerations

V. Red Flags / Urgent Triggers

VI. Intern Pearls

VII. Summary Tables

Non-Opioids

Opioids

VIII. References

Post-Operative Bradycardia

Definition

I. Principles

II. Etiologies

Reversible / Transient

Pathologic

III. AV Block Classification

IV. Evaluation

V. Management

A. Stable, Asymptomatic

B. Symptomatic or High-Grade Block (Mobitz II, Complete HB)

C. Unstable (hypotension, AMS, ischemia, shock)

VI. ACLS Algorithm (ASCII Flowchart)

VII. Quick Reference: Drugs & Doses

VIII. Red Flags – Call Senior Immediately

IX. Intern Pearls

X. References

Key Takeaways

Post-Operative Fever

I. Principles

II. Timeline-Based Differential

III. Stepwise Evaluation

Step 1 – Confirm Fever

Step 2 – Assess Stability

Step 3 – History and Exam

Step 4 – Initial Workup

IV. Management

V. Red Flags – Call Senior Immediately

VI. Intern Pearls

VII. Quick Reference Table

Initial Workup

VIII. References