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Management
Patients with differentiated abdominal pain require
treatment that is often individualized and directed
at the underlying disease. This makes treatment of
these patients in the OU somewhat more complicated. As mentioned earlier, it is important to
define clear goals of care prior to placing these
patients in the OU. Often it is necessary to consult
subspecialty services prior to placing the patient in
the OU. For example, a patient with a flare of
Cohn’s disease with no clear need for admission
may be treated with antibiotics, steroids, and pain
control. Alternatively, a patient with gastroparesis
who presents with abdominal pain may be treated
with IV fluids, pain control, and bowel rest. Postprocedural patients often present to the ED with
abdominal pain and fall into this category. Postendoscopy patients with abdominal pain and
bloating can be treated with IV fluids, pain control,
and bowel rest. In general, treatment of differentiated abdominal pain focuses on the following principles: treatment of underlying disease process,
pain control, and managing diet.
Disease-specific care
Inflammator y Bowel Diseas e
Patients with inflammatory bowel disease often present with abdominal pain flares. This is frequently
accompanied by diarrhea and nausea. Many of
these patients will have severe symptoms that
require inpatient treatment. Patients with known
or suspected abscess, concern for obstruction or
perforation, surgical abdomen or signs of severe
infection require treatment as an inpatient. Patients
with moderate disease with good outpatient followup are good candidates for observation treatment. It
may be necessary to obtain a CT scan or MRI of the
abdomen and pelvis in the ED to determine the
extent of disease prior to disposition.
1,2
Treatment
of these patients may include the following: steroids,
pain control, antibiotics, and antiemetics.
1,2
The
primary endpoint in this patient population is pain
control and ability to tolerate PO. It is often helpful
to discuss the case with the patient’soutpatient
physician at some point prior to discharge, as these
patients often require close follow-up.
Postprocedural Abdominal Pain
Postprocedural patients will often develop abdominal pain. This can occur after upper and lower
endoscopy and minor surgery.
3
There are multiple
sources of pain in these patients including
bloating from endoscopy, anesthesia, constipation
related to opioid medications, and the underlying
process. Treatment for this patient population
often includes bowel rest, IV fluids, and pain
control. It is often necessary to obtain an abdominal plain film to rule out free air. Diet should be
slowly advanced. Care should be coordinated with
the procedural provider. The patient can be discharged when they are tolerating PO and their
pain is controlled.
Gastroparesis
Patients with gastroparesis frequently have
exacerbations or flares of their symptoms. These
flares have many triggers including hyperglycemia, infection, diet, and medication noncompliance. These patients often complain of severe
abdominal pain, nausea, and vomiting.
4
They
often present with signs of dehydration. Some
of these p atients can be safely managed in
an OU. Treatmen t of this group of patients
usually involve s pain control, antiemetics, and
IV fluids. Prokinetic medications such as metoclopramide may improve symptoms.
5
Their
diet should be slowly advanced. This group
can be discharged when their pain is controlled
and they are tolerating PO intake. Patients
with cyclic vomiting syndrome and chronic
abdominal pain can often be treated in a similar
manner.
Outcome
The primary goal in this patient population is
improvement in symptoms. It is unlikely that
the abdominal pain will completely resolve, but
rather the goal is that the pain is manageable. In
addition, patients should be able to tolerate PO
intake and should have an outpatient follow-up
plan. Patient’s whose pain is not controlled, are
unable to tolerate PO, or who require further
testing despite treatment in the OU should be
made inpatient status.
Conclusion
Patients with differentiated abdominal pain can
often be appropriately treated in an OU. This
population is diverse and often requires an individualized care plan. It is often necessary to consult
Abdominal Pain
060
21:22:15
or discuss with subspecialty services to ensure that
an appropriate plan is established. The primary
goals and outcomes in this population include
the following: pain management, nausea control,
diet management, and establishing outpatient
follow-up.
References
1. Carter M, Lobo A, Travis S.
Guidelines for the management
of inflammatory bowel disease
in adults. Gut. 2004. 53: v1–v16.
2. Lichtenstein G, Hanauer S,
Sandborn W. Management of
Crohn’sdiseaseinadults.ACG
practice guidelines. American
Journal of Gastroenterology. 2004.
3. Ko C, Riffle S. Incidence of
minor complications and time
lost of time from minor
complications after screening
colonoscopy. Gastrointestinal
Endoscopy. 2007. Apr(4):
648–656.
4. Cherian D, Sachcheva P, Fisher
RS, et al. Abdominal pain is a
frequent symptom of
gastroparesis. Clinical
Gastroenterology and
Hepatology. 2010. Aug(8):
678–681.
5. Parkham H, Hasler W, Fisher
R. Diagnosis and treatment of
gastroparesis. AGA medical
position statement.
Gastroenterology. 2004.
Nov(127), issue 5: 1589–1591.
Mark G. Moseley and Miles P. Hawley
060
21:22:15
Subpart IVM
Chapter
57
Clinical – Pain Management and Musculoskeletal
Pain Management, Including
Musculoskeletal and Low Back Pain
Nathaniel L. Scott, MD, FACEP
James R. Miner, MD, FACEP
Introduction
Pain management is often an important part of
treatment in an observation unit (OU). This chapter will discuss general principles of the treatment
of pain in the OU, as well as the management of
specific painful conditions. Criteria for referral to
observation services relevant to acute musculoskeletal pain will be reviewed. Other pain-related complaints that require specific evaluation and
treatment, such as chest pain, abdominal pain,
and sickle-cell pain, are discussed elsewhere in
this text.
Epidemiology
Painful complaints are frequently treated in the
observation setting.
1
In one study, back pain was
the sixth most common condition treated in an
OU, accounting for 4.7% of patients.
2
Nephrolithiasis, abdominal pain, pyelonephritis, cellulitis,
traumatic injuries, and headache are also painful
conditions routinely treated in OUs.
Principles of Pain Management
The treatment of pain is frequently the reason that
patients seek medical care, and satisfaction with
care has been correlated with effective analgesia.
3
In addition to the relief of suffering, evidence
supports the importance of adequate pain management in the treatment of disease. Unrelieved
acute pain has been associated with increased sympathetic nervous system activation, decreased
immune function, the development of chronic
pain, greater need for subsequent pain treatment,
and psychosocial dysfunction.
4–6
From a regulatory standpoint, the Joint Commission mandates
documentation of the evaluation and treatment of
pain. Clearly, a priority must be placed on the
effective treatment of pain in the OU.
Assessment
Accurate assessment of pain is critical to effective
management. Inadequate treatment is often due
to inaccurate assessment.
7
A patient’s experience
of pain is dependent on the interaction between
the patient’s physical stimulus, physiology, prior
experience and expectation of pain, and their current emotional and cognitive states. It is known
that patients presenting with the same injury
will often report widely varying levels of pain.
8
Currently, there are no reliable tests or physiologic measurements to objectively assess a patient’s
level of pain.
9–11
The assessment of pain therefore
remains subjective and unique to each individual’s experience. To accurately assess pain, it is
necessary to consider both verbal and nonverbal
communication from the patient, in add ition to
objective observations. Accordingly, patients who
are unable to communicate effectively are at risk
for undertreatment. These groups include children, patients with a cultural background different from their provider, patients with mental
illness, or patients with emotional or cognitive
impairment.
8,12–15
OUs should have a well-defined method for
assessing pain. The Joint Commission has mandated that pain must be assessed using a pain scale
as part of routine vital signs. For various developmental reasons, numeric pain scales are difficult to
use with children <7 years old. Nonnumeric scales
can be utilized, such as the FACES pain scale
or color-based pain scales, but it is unclear if children <7 years old, and particularly children
<5 years old, can rate pain on a scale. For preverbal children, provider-based scales such as
Modified Pre-Verbal, Early Verbal Pediatric Pain
Scale (M-PEPPS) and the Children’s Hospital of
Eastern Ontario Pain Scale (CHEOPS) can be used,
but they largely represent a provider’sjudgmentof
how much pain the child is observed to have.
061
21:22:29
Medications
Opioid analgesics are the first-line agents for the
management of acute severe pain. Opioids activate endorphin system receptors throughout
the peripheral and central nervous system to provide analgesia. Potential side effects can include
respiratory depression, constipation, nausea and
vomiting, urinary retention, and histaminemediated urticaria and pruritis. However, most
patients tolerate opioids well.
A variety of opioid medications are available.
Morphine remains commonly used in clinical
practice. Hydromorphone is a semisynthetic
derivative of morphine that has been associated
with less pruritis and nausea than morphine. Elderly patients and those with liver disease often
tolerate hydromorphone better than morphine
because its metabolites are less active and accumulate slower than the metabolites of morphine.
Fentanyl has a short onset and short duration of
action and does not produce active metabolites,
but requires frequent monitoring because its associated incidence of respiratory depression is
higher than other opioids, limiting its use in
the observation setting. Oxycodone is an efficiently absorbed oral agent with a bioavailability
approaching 80%, and its effectiveness is comparable to parenteral therapy.
16
Hydrocodone is a
weaker opioid than oxycodone, and is commonly
used in combination preparations with acetaminophen or nonsteroidal anti-inflammatory
drugs (NSAIDs). Codeine is a weak opioid that
is associated with a high rate of side effects and
has little role in the treatment of pain. Tramadol
is a weak mu agonist and has some opioid-like
properties, but frequently causes nausea and
vomiting with increasing doses, limiting its use
as a single agent. Table 57.1 lists opioids that are
commonly used and provides an equianalgesic
factor using morphine 10 mg as a reference value.
Patients who have been referred to an OU for a
painful complaint often have pain that has been
refractory to initial treatment, or has required frequent dosing that is not amenable to outpatient
treatment, therefore, IV administration is often indicated. Once pain has been effectively treated and a
patient’s symptoms have stabilized, efforts should be
made to transition to oral medications so that an
effective regimen can be continued as an outpatient.
Multiple non-opioid medications exist and are
appropriate for either first-line or adjunctive treatment of pain in combination with opioids. Acetaminophen is a safe and well-tolerated medication
in both children and adults. It can cause hepatic
toxicity in the setting of underlying liver disease or
concomitant alcohol abuse. Patients with pain who
do not have a contraindication should receive acetaminophen as part of any pain treatment strategy.
NSAIDs such as ibuprofen inhibit cyclooxygenase, and therefore decrease prostaglandin,
resulting in analgesic effects in patients with
inflammation. They have a synergistic effect when
administered with opioids and acetaminophen and
can reduce the amount of opioid needed to treat a
painful complaint. Notably, NSAIDs are the cause
of more serious drug-related side effects than any
other class of analgesic.
18
Side effects include renal
failure, gastrointestinal bleeding, platelet dysfunction, and anaphylaxis. NSAIDS should be used
cautiously, or not at all, in patients with preexisting
renal disease, cardiovascular disease, gastrointestinal disease, or in pregnant or elderly patients.
Pain Specialists and Pain Clinics
A growing number of physicians are specializing in
the practice of pain management, which has been
Table 57.1 Commonly Used Opioid Medications and Their Pharmacokinetic Properties
17
Name Initial Parenteral
Dose
Initial Oral
Dose
Duration
of Action
Equipotent
IV Dose
Equipotent
Oral Dose
Morphine 0.1 mg/kg 0.5 mg/kg 3–4 hrs 10 mg 50 mg
Hydromorphone 0.015 mg/kg 0.075 mg/kg 2–4 hrs 1.5 mg 7.5 mg
Fentanyl 1.5 μg/kg 3 μg/kg 30–90 min 100 μg n/a
Oxycodone 0.1 mg/kg 0.15 mg/kg 3–4 hrs 10 mg 15 mg
Hydrocodone n/a 5–15 mg 3–4 hrs n/a 30 mg
Codeine 1.3 mg/kg 2.5 mg/kg 2–4 hrs 130 mg 200 mg
Nathaniel L. Scott and James R. Miner
061
21:22:29
accompanied by a growth in pain clinics that specialize in the treatment of pain. Pain specialists often
have advanced training in the medical management
of acute and chronic pain. Some are trained to perform procedures such as nerve blocks, steroid injections, or radiofrequency procedures. Depending on
local resources, the potential exists for patients being
cared for in an OU to engage with these providers.
Pain specialists may be available to consult on
patients in the OU, or patients can be referred
to a pain clinic after discharge. Patients thought
to potentiall y benefit from the services of a pain
specialist include those with refractory chronic
pain, those who have required a large quantity or
theprolongeduseofopioids,thosewithanacute
exacerbation of chronic pain, patients with
chronic pain of malignancy, and people with a
chronic or recurrent painful c ondition who may
benefit from a specific procedure or treatment
regimen from a pain specialist.
19
Special Populations
In general, the principles of pain management for
adults are also appropriate to use in a pediatric
patient. One of the key differences in the management of pain in children is that assessment is
more difficult, increasing the risk of under appreciation and inadequate treatment. It is important
for the medical provider to notice both verbal and
nonverbal cues in children. Pharmacokinetics of
analgesic medications are similar in children,
except in neonates and infants, for whom opioid
clearance is delayed and plasma levels can be high
for a given dose of medication.
The treatment of painful complaints in elderly
patientsis complicated by more difficult assessment
due to underlying medical conditions, the increased
accumulation of breakdown products of medications, and increased sensitivity to side effects. Doses
of opioids should be reduced to avoid side effects
such as confusion, which occurs much more readily
in the elderly. Lastly, NSAID medications are best
avoided or used in decreased doses due to their
potential to cause renal dysfunction or adverse cardiac events in this age group.
Specific Conditions
While much of the discussion in this chapter can
be applied to a variety of painful conditions that
are treated in the OU, there are several conditions
and scenarios that deserve special mention.
Acute Low Back P ain
Back pain is a common symptom that represents a
considerable source of lost productivity for
workers and a large amount of health care expenditures.
20
Though the vast majority of patients presenting for an evaluation of acute back pain will be
ultimately diagnosed with mechanical or nonspecific back pain, several emergent diagnoses must be
excluded during the evaluation of this complaint.
While the majority of patients with acute low
back pain can be managed as an outpatient, observation may be considered in certain circumstances.
For example, if physicians are not able to achieve
adequate pain control for a patient with back pain
in the emergency department, administration of
analgesics can be continued in the observation
setting until the pain is controlled sufficiently to
permit discharge home. If a neurologic deficit is
present and raises concern for serious underlying
pathology, a patient could be observed for serial
neurologic assessments to assess the progression of
the disease and determine the need for additional
diagnostic evaluation.
For most patients referred to the OU with low
back pain, a careful history and physical examination is sufficient to evaluate their disease state.
Plain radiographs have not been found to be
useful in the evaluation of uncomplicated back
pain of 1–2 months duration.
21
Special attention
should be paid to the neurologic and musculoskeletal examination.
Emergent diagnoses that should be considered
include abdominal aortic aneurysm, aortic dissection, cauda equina syndrome, epidural abscess
or hematoma,spine fracturewith cord or nerve root
compression, meningitis, osteomyelitis, and tumor.
If any of these diagnoses are considered, they should
be evaluated for appropriately. Patients who have
been determined to have a serious and progressive
cause of their back pain should typically be treated
in an inpatient setting rather than observation. For
patients with a significant or progressive neurologic
deficit, advanced imaging is often indicated, while
noting that advanced imaging for patients with
radicular pain and only sensory deficits does not
typically change outcome and an initial course of
conservative treatment is recommended.
21,22
Medical treatment of acute low back pain
should include analgesic medications. Either acetaminophen or NSAIDs should be prescribed for all
patients, unless a contraindication exists. For moderate to severe pain, opioids can be considered in
Pain Management, Including Musculoskeletal and Low Back Pain
061
21:22:29
addition. Muscle relaxants such as benzodiazepines
and cyclobenzaprine may benefit some patients
demonstrating muscle spasm on examination, but
also can cause serious side effects and should be
used with caution.
23
Patients should be encouraged
to be as active as their level of pain permits, and
should be discouraged from sitting or lying down
for prolonged periods of time.
Chronic Pain
The evaluation and treatment of patients with
chronic pain is challenging. Patients with chronic
pain are considered to be those with a pain complaint that has persisted beyond the normal
healing of the underlying condition or is not
expected to improve with further treatment
of the underlying condition. Patients with chronic
pain can present with an acute exacerbation of
chronic pain, or with untreated/refractory chronic
pain. In general, an acute exacerbation of chronic
pain can be managed in an OU. There, the
patient’s pain can be stabilized and their previous
treatment plan can be resumed. However, inadequately treated chronic pain should be referred to
a primary care provider to develop an outpatient
care plan. Because patients with chronic pain can
exhibit complex maladaptive behaviors associated
with their pain, it can be difficult to develop an
effective approach to their pain. For OUs with
protocol-based treatment plans, this level of decision making is often too complex for what can be
effectively accomplished. Making changes in
patients’ chronic pain treatment strategies during
an acute exacerbation of pain and over the relatively short period of observation is unlikely to
provide an effective long-term solution.
Chronic Pain of Malignancy
Chronic pain of malignancy differs from other
causes of chronic pain in that it is managed with
an approach similar to that used for acute pain.
Opioid pain medications are often indicated and
associated with improved outcomes and quality of
life, in contrast to their use in nonmalignantchronic
pain. Patients are commonly prescribed a longacting opioid medication in addition to a shortacting medication for breakthrough pain.
24
In the
OU, opioid medications may be titrated to the
desired effect prior to discharge. For a patient with
chronic pain of malignancy who is experiencing an
acute exacerbation of pain, care must be taken to
evaluate appropriately for a new medical condition
causing the pain, and to not assume that the pain is
secondary to the underlying oncologic process.
Criteria for Observation
Careful consideration must be given to which
patients with painful complaints are appropriate
for observation. Generally, patients with musculoskeletal pain that may be appropriate for observation are those with 1) an underlying cause of the
pain for which inpatient care is not appropriate,
and 2) who require multiple doses of IV analgesics
without adequate pain relief. Conditions that may
require surgery such as a fracture and patients with
pain secondary to significant medical illness such
as cancer are likely to be most appropriate in an
inpatient setting rather than an OU. On the other
hand, patients with acute musculoskeletal pain
responding to oral analgesics are not likely to be
considered appropriate for observation services
and could be treated as outpatients. Patients with
painful complaints who are unable to ambulate or
adequately care for themselves secondary to pain
may also be good candidates for observation, as
they cannot be safely discharged home.
InterQual® criteria are a commonly used set of
criteria to determine the appropriateness of a specific level of care. Though InterQual® or another
resource can provide a common foundation for
institutions to determine which patients should
be referred to observation services, local capabilities, expertise, and resources ultimately require
individual OUs to formulate their own criteria.
One of the first steps in determining the appropriate level of care for a patient is to consider
whether a specific subset of criteria should be
applied. For patients with chest pain of a suspected
cardiac etiology, for example, the cardiac criteria
should be reviewed. If no other set of criteria seems
appropriate, then the following criteria under the
“Pain, severe” section may be useful.
To meet InterQual® Severity of Illness criteria
for referral to observation services for severe pain,
at least one of the following Severity of Illness (SI)
criteria should be met.
25
Intractable and unresponsive to 2 doses of
parenteral analgesics within the last 6 hours
Renal calculus or pyelonephritis, suspected
Migraine, intractable and failed outpatient
treatment
Nathaniel L. Scott and James R. Miner
061
21:22:29
Abdominal pain, unknown etiology
Sickle cell crisis
For discussion of abdominal pain, headache, renal
disease, and sickle cell crisis, please see the appropriate sections elsewhere in this text. (See Chapters 35, 42, 48, 56.) Patients must also meet at least
one criteria from the Intensity of Service (IS)
section to satisfy InterQual® criteria for observation services. Listed next are common criteria by
which patients admitted with painful complaints
meet criteria for observation services.
IV fluids 100 ml/hr or IV fluids 75 ml/hr
and age 65 or history of chronic heart failure
or renal failure
At least two doses of IV analgesics or IV
antiemetics or IV anxiolytics
Monitoring of neurologic examination at least
six times over 24 hours
Monitoring of vital signs every 4 hours
Consideration should also be given as to whether
patients are most appropriate for an inpatient
level of care, as opposed to observation. The
CMS Two-Midnight Rule was implemented in
2014 and has provided some guidance in this
area. In brief, if it is expected at the time of
admission that the patient’ slengthofstaywill
be at least two midnights or they have another
qualifying condition, they should be admitted as
aninpatientinmostcircumstances.Insummary,
most patients with acute musculoskeletal pain
will be deemed appropriate for observation services based on the frequency and route of analgesic medication administration. It is important
to note that hospitals are not strictly bound to
these criteria, and that by physician review, a
patient can be deemed appropriate for observation services even if these criteria are not precisely met. An example of this could be a patient
with severe back pain, who is not able to ambulate due to pain, but is not requiring multiple
doses o f IV analgesic pain medication.
Recommendations for Observation
Unit Protocols
While protocols used in OUs must take in to
consideration local resources and practice patterns,
we have several recommendations regarding the
evaluation and treatment of pain in OUs.
All OU protocols or standing orders should
include a mechanism to assess pain at regular
intervals. The assessment of pain should be
performed at least every 4 hours, and often
more frequent assessment is indicated.
Assessment of pain should be performed
using age and developmentally appropriate
tools. This can be addressed by having
different protocols for the treatment of pain
for different age groups.
The determination of severity of pain should
not rely solely on a numeric rating, and should
instead take in to account verbal
communication with the patient, nonverbal
cues, and objective signs as deemed appropriate.
Orders for appropriate pain medications to be
given as needed (prn) should be placed. Only
one type of opioid per route of administration
should be ordered as a prn medication.
Patients receiving opioid medications should
also receive acetaminophen and NSAIDS if
they are not contraindicated.
The choice of pain medications should be
individualized for each patient, therefore,
protocols should require medical providers to
actively choose which analgesic medications to
use in the OU. Contraindications to certain
medications, dosing adjustments, the
underlying disease process, and multiple other
factors must be considered.
Pulse oximetry monitoring should be
considered in patients receiving IV opioids.
A complete history and physical examination
should be performed for all patients referred
for observation services, focusing on
evaluating for emergent and life-threatening
causes of pain.
Plain radiography and advanced imaging
should not be routinely ordered for patients in
OUs with uncomplicated back pain, as this
information rarely changes care.
Conclusions
The treatment of pain and painful complaints in
the OU is dependent on appropriate assessment,
frequent reassessment, recognition of any underlying medical conditions, and individualized
treatment. Care should be taken that patients
referred for observation meet criteria, which are
often dependent on the frequency at which intravenous analgesic medi cations are administered.
OU protocols should include provisions for the
regular assessment of pain.
Pain Management, Including Musculoskeletal and Low Back Pain
061
21:22:29
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2011th ed. Newton, MA:
McKesson Health Solutions,
LLC.
Nathaniel L. Scott and James R. Miner
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Subpart IVN
Chapter
58
Clinical – Trauma
Trauma
Mark G. Moseley, MD, MHA, FACEP
Miles P. Hawley, MD, MBA
Background
Given the high volume of patients with traumatic
complaints that present to most emergenc y
departments (EDs), this patient population is an
excellent potential source of observation unit
(OU) patient volume. ED-based OUs have been
found to be useful and cost efficient in the management of trauma patients.
1
One of the primary
reasons for this fact is that it can be difficult to
diagnose all injuries on initial presentation to the
ED, and as such, many trauma patients require
additional diagnostic tests, repeat examinations,
and clinical monitoring. Historically, this has
often lead to trauma patients being hospitalized
to accomplish these patient management goals
and to ensure safe disposition s.
2
With this noted,
recent studies have demonstrated the feasibility of
managing trauma patients including trauma team
activation patients at Level 1 trauma centers
(clearly a sicker cohort of trauma patients) in
the OU setting with favorable outcomes.
3,4
Trauma patients in the OU can be considered
for both diagn ostic and therapeutic end points on
an observation protocol. Diagnostically, many
blunt trauma patients require extensive imaging
evaluation and a period of serial examinations.
For penetrating or blunt trauma patients, the
observation period can afford an environment
closely linked to intensive resources available to
reevaluate the patient and quickly intervene if
clinical deterioration is observed. Therapeutically,
some patients arrive in the OU with a clear diagnosis (such as rib fractures) and the goal of the
observation period is merely to determine whether
the patients are able to manage their symptoms
in the outpatient setting sufficient to facilitate
discharge.
To this end, it is important to define the goals of
the observation period. Is it to diagnose a potential
occult injury? Is it to monitor for a complication
like vascular compromise or compartment syndrome? These goals will help define the resources
necessary to successfully evaluate and disposition a
given patient. This is extremely important in the
trauma patient population, as local resources and
the trauma status of the hospital the clinician works
at may lead to distinctly different patient populations managed. At a high-volume, high-acuity
trauma center, the majority of trauma patients in
theOUwillhavealreadybeen“cleared” by the
trauma team of life-threatening injury. Further,
extensive resources would be available to reevaluate
and resuscitate the patients should they deteriorate.
At a nontrauma hospital without trauma team
backup, the goals, management resources, and the
ability to disposition specific patient populations
may differ greatly and should be considered in
trauma protocol design.
Patient Selection – Inclusions
Inclusion criteria will vary based on local
resources and the capabilities of the OU and its
provider team. As noted earlier, there will be
variation in the capabilities based on the facility
where the clinician works (trauma center or not).
While a general observation protocol for trauma
can be a catchall for multiple conditions, specific
protocols for specific conditions may be considered separately and have distinct criteria. For
higher-volume protocols of this subset such as
closed head injury, this is prudent since the needs
of these patients will differ from patients with
more extensive blunt or penetrating trauma.
Whether to include pediatric patients, and the
age that defines a pediatric patient, will also be
an important consideration based on institution
and provider preferences. One other important
consideration for patient placement is the comfort level of the providers with managing trauma
patients. Physicians that are routinely managing
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trauma patients should be board certified in emergency medicine, trauma surgery, or other appropriate surgical specialty with trauma experience or
well versed in Advanced Trauma Life Support
(ATLS) or its equivalent. Nurses routinely caring
for trauma patients should be certified emergency
nurses or well versed in a nursing equivalent
of ATLS. This should ensure appropriate knowledge, aptitude, and skill sets in managing trauma
patients.
Patient Selection – Exclusions
In the trauma patient population, intoxication
and altered mental status are clearly a challenge
for appropriate patient selection.
5
Some units and
protocols have specific blood alcohol cutoffs,
while others prefer to select based upon the perception of clinical sobriety or patients who are
directable and compliant with therapy rather than
a specific number on the patient’s blood alcohol
level (BAL). Care should be taken to ensure that
violent, belligerent, and nonparticipatory patients
with intoxicants on board are not placed in
the OU. Setting a Glasgow Coma Scale (GCS) of
<14 as an exclusion criteria can assist to this
end and also appropriately risk stratify for mild
head injury patients. Other exclusion criteria
would include hemodynamically unstable patients,
patients receiving blood products or aggressive
fluid resuscitation, major burn patients, or patients
who inevitably need surgical management. Any
patient that meets criteria for a transfer to a
higher-level trauma center based on ATLS should
be excluded at a nontrauma facility.
Pathophysiology
Numerous traumatic conditions are amenable to
observation protocols in the OU. As noted earlier,
local resources will dictate which protocol populations can be targeted and created based on the
demographics and capabilities of the facility where
the OU is located. What follows is a listing of some
commonly managed traumatic conditions.
Motor Vehicle Collisions
Blunt trauma can be challenging both diagnostically
and therapeutically. Occult injuries can be difficult
to uncover after initial ED evaluation. As such,
patients with blunt trauma from motor vehicle collisions (MVC) are an excellent population to target
for an OU protocol. Benefits of the observation
period include the ability to do serial examinations,
obtain final readings on imaging studies (which can
be significant in this population), monitor the
patient’s ability to control his or her symptoms,
and discharge the patient with a lower risk for
significant injury misses.
6,7
Issues in management for this patient population can include dealing with cervical spine
clearance, such as a protocol for who clears the
patient’s c-spine, when it is important or necessary to establish c-spine clearance, and the criteria for c-spine clearance in significantly injured
MVC patients. The occurrence of closed head
injury (or concerns sufficient to warrant observation for same) in the MVC population provides adequate justification in most instances to
observe a patient and obtain frequent neurologic
checks (particularly if imaging is withheld in
favor of clinical monitoring).
Patients experiencing more significant blunt
trauma from MVC often benefit from serial
examinations even if imaging is negative. Repeat
Focused Assessment by Sonography for Trauma
(FAST) examinations are also recommended.
6,7
Pain and symptom control, intravenous (IV)
fluids, and the ability to ambulate and tolerate
oral intake are important for disposition considerations in this patient population.
Rib Fractures
Patients with isolated or in some cases even multiple rib fractures are candidates for a trauma
protocol with therapeutic end points. Safety, efficacy, and cost-effectiveness of managing these
patients has been previously studied.
6,7,8
The goals
of the observation period are primarily to determine if the patient can tolerate his or her pain and
symptoms assuming life-threatening traumatic
injury has been excluded. The focus of the observation period can be therapeutic in terms of providing analgesia and relief from pain as well as a
focus on pulmonary toilet. A subset of patients
with thoracic trauma has a concern for cardiac or
myocardial contusion. In this patient population,
cardiac monitoring, serial cardiac enzymes, and
even echocardiography are sometimes considered
in patient management and disposition decisions
and can clearly be accomplished in the OU setting
(although the precise workup diagnostically for
these patients is still controversial).
Mark G. Moseley and Miles P. Hawley
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