Specialty Services and Other Injuries

Original Date: 06/2008 | Last Review Date: 05/2024
Purpose: To clarify service assignment, admission criteria, and rotation schedules of specialty services and certain injuries.

The following specialty consultations are detailed below:

Contents

  • Traumatic Brain Injury Admissions
  • Admission or Transfer of Patients with Isolated Extremity and/or Pelvic Injuries
  • Facial Trauma Consults
  • Hand and Microsurgery Consults
  • Spine and Spinal Cord Injury Consults
  • Admission Following Drowning / Near Drowning / Hanging

Traumatic Brain Injury Admissions

In patients with moderate (GCS 9-12) to severe (GCS ≤8) traumatic brain injury (TBI) for whom ICU admission is appropriate should be admitted to the NTICU if the injury is isolated TBI or TBI with facial fracture or scalp laceration but no other injuries.

Patients who do NOT require ICU level of admission and who have isolated TBI (or TBI with facial fracture or scalp laceration but no other injuries) shall be admitted at the discretion of the Neurosurgery Trauma service.

ICU Overflow:  NTICU patients in the STICU & STICU patients in the NTICU

If the NTICU is full, patients meeting above criteria for NTICU admission will be admitted to the STICU as overflow:

  • The patient will be assigned to the Neurosurgery service attending and admitted to the STICU.
  • The STICU team will provide all primary critical care services.
  • The patient will be transferred to the Neurosurgery service when a clinically appropriate bed becomes available (ICU, IMU, or Floor as necessitated by the patient’s condition) and will include a direct checkout from the STICU team to the Neurosurgery team.
  • The Neurosurgical team will coordinate with the STICU team for neurosurgical specific care and will respond to all emergencies. Any acute neurosurgical decompensation or acute escalation of care will be immediately communicated to the Neurosurgical team.
  • Please refer to “Management of Severe Traumatic Brain Injury” for further management details.

If the STICU is full, patients with TBI and multi-system trauma will be admitted to the NTICU as overflow.

  • The patient will be assigned to the Trauma service attending and admitted to the NTICU.
  • The Neuro Critical Care team will provide all primary critical care services.
  • The trauma team will evaluate the patient daily, and communicate and document any concerns to the NTICU team, until the patient transfers back to the trauma service or has resolution of multi-system trauma injuries and care.
  • The patient will be transferred to the Trauma service when a clinically appropriate bed becomes available (ICU, IMU or Floor as necessitated by patient’s condition).
  • NTICU team will consult the trauma team for any surgical procedures (tracheostomy, PEG tubes).

After admission, if the STICU is full and the hospital is on trauma diversion, patients may need to be transferred to other ICU’s.  Please follow the guidelines for “STICU Bed Overflow“.

Exceptions to the above guidelines AND transfers between ICU should always be discussed and approved by attending physicians and careful report given between teams upon transfer.

Admission or Transfer of Patients with Isolated Orthopedic Extremity and/or Pelvic Injuries

Patients with orthopedic injuries NOT meeting the criteria for trauma team activation or consultation may be directly admitted to the Orthopedic or Hospitalist service. The trauma service may still be asked to evaluate the patient at the discretion of the admitting service, and these requests will be monitored.

After evaluation of patients with isolated orthopedic injuries requiring joint replacement, hemodynamically stable patients may be transferred to a Memorial Hermann Joint center after clearance by orthopedic surgery and the ED physician or trauma surgeon.

If any further trauma related issues or questions arise on the patient, the trauma service is always available and happy to see the patient.  The trauma chief resident can be reached at 713-704-7055.

Facial Trauma Consults

Facial trauma call is taken by three services: oral maxillofacial surgery (OMFS), plastic & reconstructive surgery (PRS), and Otolaryngology (ENT).  The on-call day starts at 7:00 am and concludes at 6:59 am the following morning.

Patients will be assigned to the on-call service based upon the time the consult is initiated, not based on time of patient arrival to the ER, regardless of location in the emergency department or if already admitted to the hospital.

Delayed or deferred diagnosis of facial injuries requiring facial trauma service evaluation that were not identified or consult was not called at initial presentation will be directed to the service on call at the time the consultation is made, regardless of location (intra-operative or in a unit) or upon return to the Emergency Department of a patient previously unassigned to a face consult service.

Facial Trauma with Vascular Injury

Patients with facial injuries and a suspected extra-cranial vascular injury (e.g. branch of external carotid artery) will be initially evaluated by Endovascular Neurosurgical Radiology (ENR) through the UTH Neurosurgery Department call schedule.  They will decide on and perform arteriography and intervention as appropriate.

Hand and Microsurgery Consults

Hand trauma call is taken by two services:  Orthopedic surgery (ORS) and Plastic & Reconstructive Surgery (PRS)

The on-call day starts at 7:00am and concludes at 6:59am the following morning.

Patients will be assigned to the on-call service based upon the time the consult is initiated, not based on time of patient arrival to the ER, regardless of location in the emergency department or if already admitted to the hospital.

Patients transferred from outside facilities will be assigned to the on-call service that is on duty at the time the patient is physically present in the Emergency Department and the consult is initiated, even if the patient was accepted by the prior service on call.

  • Example: If a patient with an isolated hand injury is accepted in transfer by the on-call service at 0300, but is not physically present in the Emergency Department and contact with the Hand service is not made until 0715, then the service beginning at 0700 will provide the attending and resident for that patient.

Delayed or deferred diagnosis of hand injuries requiring hand service evaluation that were not identified or consult was not called at initial presentation will be directed to the service on call at the time the consultation is made, regardless of location (intra-operative or in a unit) or upon return to the Emergency Department of a patient previously unassigned to a hand consult service.

Spine and Spinal Cord Injury Consults

Spine call is taken by two services:  Orthopedic Spine Surgery (ORS) and Neurosurgical Spine Surgery (NSG).

All confirmed or suspected spinal cord injury patients will also be assessed by the Trauma Service per Urgent Consult criteria.

The on-call day starts at 7:00am and concludes at 6:59am the following morning.  Patients will be assigned to the on-call service based upon the time the consult is initiated, not based on time of patient arrival to the ER, regardless of location in the emergency department or already admitted to the hospital.  Spine injuries requiring spine service evaluation that were not identified or consult called at initial presentation will be directed to the service on-call at the time the consultation is made, regardless of location.

If an isolated injury, the patient may be admitted by the appropriate spine service.  If the patient requires ICU admission, patients admitted to or followed by orthopedic spine will go to the STICU and patients admitted to the neurosurgery spine service will go to the NTICU, unless they are multi-trauma, in which case they will be admitted to STICU.

Admission Following Drowning / Near Drowning / Hanging

Initial evaluation will be per usual Emergency Medicine (EM) standard of care.  A trauma activation is needed only if mechanism criteria are met for a trauma activation. Intubation alone DOES NOT necessitate trauma activation.

Patients with a level 2 trauma activation who require intubation (for drowning/hanging related issues or otherwise) should be upgraded to a level 1 per our standard process for level 2 trauma activations.  Radiographic evaluation of an intubated patient with suspicion of trauma will routinely include a CT scan of the head and cervical spine in addition to other imaging studies at the discretion of the EM faculty.  Routine imaging following suspected hanging should include Neck CT Angiography to evaluate for potential cerebrovascular injury.  If cerebrovascular injury is identified, the Neurosurgical Vascular team should be consulted.

Patients without traumatic injuries can be admitted to the appropriate medical services (18 and over to the adult services, 17 and younger to the pediatric services).

If traumatic injuries are identified, then appropriate consultation with trauma service (age 16 and over) or pediatric trauma service (age 15 and younger) will be required and patient should be admitted to appropriate service per usual standard of care.