Bedside Clinical Trauma Workflow

Extremity Trauma Scoring & VTE Protocol Guide

Standalone Bedside Guide

Step 1: Primary Survey Step 2: MESS Score Step 3: GHOISS Open Fractures Step 4: sPESI Screen Step 5: Full PESI Score Step 6: ESC Thrombolysis Step 7: VTE Prophylaxis

Step 1 Immediate / Arrival

Primary Survey & Resuscitation

Focus on life-saving stabilization prior to orthopedic scoring

Trigger: Major trauma (fall, crush, blast, high-velocity injury)

Actions Required

• Perform ATLS primary survey (Airway, Breathing, Circulation, Disability, Exposure).
• Address immediate life threats (tension pneumothorax, severe hemorrhage, airway obstruction).
• Resuscitate with IV fluids and blood products if hemodynamically unstable.

Scoring Applied

None Required At This Stage

Life-saving interventions take total priority over clinical scoring. Do not delay resuscitation for scoring calculations.

Progression Criteria: Patient is hemodynamically stable (or temporarily stabilized) & ready for secondary survey.

Step 2 Secondary Survey

Secondary Survey & Orthopedic Assessment

Assessment of limb viability and decision on salvage vs. amputation

Trigger: Patient stabilized. Systematically assess musculoskeletal injuries.

Physical Examination

• Inspect limbs for deformities, open wounds, swelling, discoloration.

• Palpate for focal bone/joint tenderness.

• Perform detailed neurovascular exam: distal pulses, cap refill, sensation, motor function.

• Order trauma X-ray series (Pelvis, bilateral femurs, tibiae, spine as indicated).

MESS Score (Mangled Extremity Severity)

Evaluates Skeletal/Soft-tissue injury, Limb Ischemia, Shock, and Age.

Score < 7 Limb Salvage Likely

Apply splints, prepare for definitive surgical fixation.

Score ≥ 7 Amputation Strongly Indicated

Urgent vascular and plastic surgery consultation for shared decision-making.

Progression Criteria: Move to Step 3 during intraoperative wound exploration or pre-op planning.

Step 3 Wound Assessment

Open Wound Assessment (If Applicable)

Stratification for open limb fractures requiring complex reconstruction

Trigger: Presence of an open fracture over the injured extremity.

Clinical Evaluation

• • Inspect wound dimensions and degree of skin loss.
• • Assess muscle viability and nerve integrity.
• • Check level of environmental contamination.
• • Grade using Gustilo-Anderson Classification.

GHOISS Application

Grade III Open Fracture: Calculate GHOISS (Ganga Hospital Open Injury Severity Score) to predict salvage viability.

Closed or Grade I/II Open: GHOISS is NOT applicable. Skip to monitoring steps.

Progression Criteria: Move to Step 4 if patient develops new cardiorespiratory symptoms at any point in admission.

Step 4 Symptom Onset / Screen

New Cardiorespiratory Symptoms (sPESI Screen)

Immediate bedside screening for suspected Pulmonary Embolism

Trigger: Inward onset of dyspnea, pleuritic chest pain, sudden tachycardia, hypotension, or SpO₂ drop.

Immediate Bedside Workup

• 1. Check Vitals (HR, BP, RR, SpO₂, Temp).
• 2. Assess mental status / orientation.
• 3. Order CT Pulmonary Angiogram (CTPA) if stable to transport.
• 4. Bedside Echocardiogram if unstable.

sPESI (Simplified PESI) Score

Assign 1 point for each positive variable:

• Age > 80 yrs

• HR ≥ 110 bpm

• History of Cancer

• Systolic BP < 100 mmHg

• Chronic Cardiopulm Dis.

• SpO₂ < 90%

Score = 0: Low Risk (<1% 30-day mortality)

Score ≥ 1: High Risk (Mandatory Monitored Bed/ICU)

Progression Criteria: PE confirmed on imaging or strongly suspected with need for granular prognosis → Proceed to Step 5.

Step 5 Prognostic Risk Class

Precise 30-Day Mortality Prediction (Original PESI)

Determine specific 30-day risk class for level-of-care disposition

Trigger: PE confirmed on CTPA / Echo; fine-tuning care level (Ward vs. Step-down vs. ICU).

Original PESI Risk Classes & Action Plan

Class I (≤ 65)

0.3% Mortality

Ward Care

Class II (66–85)

1.0% Mortality

Ward Care

Class III (86–105)

3.4% Mortality

Close Monitor / Stepdown

Class IV (106–125)

10.5% Mortality

Stepdown / High Care

Class V (> 125)

24.5% Mortality

ICU Admission

Progression Criteria: Patient exhibits hemodynamic instability (SBP < 90 or arrest) → Proceed to Step 6 immediately.

Step 6 Critical Care / Reperfusion

Hemodynamic Instability & Reperfusion (ESC Criteria)

Managing massive vs. sub-massive PE with potential thrombolytic therapy

Trigger: SBP < 90 mmHg for > 15 mins, vasopressor requirement, or cardiac arrest.

High-Risk (Massive PE)

Unstable (SBP < 90, vasopressors, or arrest)

ACTION: Immediate reperfusion: Systemic Thrombolysis (e.g., Alteplase) or Surgical Embolectomy.

Intermediate-Risk (Sub-massive)

Stable BP, but RV Dysfunction (Echo/CT) + Elevated Troponin

ACTION: ICU admission, full anticoagulation, monitor closely. Prepare for rescue thrombolysis if deteriorating.

Low-Risk PE

Stable BP, Normal RV function, Normal Cardiac Biomarkers

ACTION: Standard therapeutic anticoagulation, general ward admission.

Step 7 Universal Prevention

Preventive Protocol (VTE Prophylaxis)

Critical baseline protection to avoid progression to Steps 4–6

Timing: Initiate within 12–24 hours of admission for ALL major trauma patients.

Contraindication Screen

Check for active bleeding, PLT < 50k, INR > 2.0, expanding TBI, spinal hematoma, or severe renal impairment before chemical dosing.

High-Risk Trauma Indications

Pelvic fractures, Long-bone fractures (femur/tibia), Spinal Cord Injury, or Major Trauma (ISS > 15).

Dosing Guidelines

Standard Chemical: Enoxaparin 40mg SC once daily (30mg SC BID for obese/high risk).

Renal Impairment (CrCl < 30): Unfractionated Heparin (UFH) 5000 units SC TID.

High Bleed Risk: Intermittent Pneumatic Compression (IPC) devices; reassess daily for chemical conversion.

Complete Workflow Summary Table

Quick bedside reference across all clinical steps

Step	Trigger / Timing	Score / Protocol	Key Clinical Action
1	Arrival, major trauma	None	ATLS primary survey, immediate life-saving resuscitation.
2	Patient stabilized, secondary survey	MESS Score	< 7: Limb salvage. ≥ 7: Amputation consult & shared decision.
3	Wound exploration (open fracture)	GHOISS	Only for Grade III open fractures. Closed/Grade I/II skip.
4	New chest symptoms / dyspnea	sPESI Score	≥ 1: High risk, admit to monitored bed/ICU. Urgent CTPA.
5	PE confirmed, prognostic need	Original PESI	Class I-II (Ward), Class III-IV (Stepdown), Class V (ICU).
6	Hemodynamic instability (SBP < 90)	ESC Criteria	High-risk PE → Immediate thrombolysis or embolectomy.
7	Within 12–24h of admission	VTE Prophylaxis	Enoxaparin 40mg SC daily if no contraindications. Prevents Steps 4–6.

Mangled Extremity Severity Score (MESS)

Score: 1

1. Skeletal / Soft Tissue Energy Low energy (stab, simple fracture, civilian gunshot) [+1] Medium energy (open/multiple fractures, dislocation) [+2] High energy (high velocity gunshot, crush) [+3] Very high energy (gross contamination, tissue loss) [+4]

2. Limb Ischemia None / Reduced pulse with normal perfusion [+0] Pulseless with paresthesia, diminished cap refill [+1] Cold, numb, paralyzed, non-reactive [+2]

Ischemia duration > 6 hours (+2 points)

3. Shock / Hemodynamics SBP > 90 mmHg consistently [+0] Transient hypotension [+1] Persistent hypotension (SBP < 90 mmHg > 1 hr) [+2]

4. Patient Age < 30 years [+0] 30 – 50 years [+1] > 50 years [+2]

Simplified PESI (sPESI)

0 Points

Age > 80 years History of Cancer Chronic Cardiopulmonary Disease Heart Rate ≥ 110 bpm Systolic BP < 100 mmHg SpO₂ < 90%

Low Risk (30-day mortality < 1%). Consider ward care or outpatient management if stable.

Original PESI Score

0 Points

Age (Years)

Male (+10) Cancer (+30)

Heart Failure (+10) Chronic Lung Disease (+10) Pulse ≥ 110 bpm (+20) Systolic BP < 100 mmHg (+30) Resp Rate ≥ 30/min (+20) Temp < 36°C or ≥ 38°C (+20) Altered Mental Status (+60) SpO₂ < 90% (+20)

Class I (≤65 points) - Very Low Risk (0.3% mortality). Ward care.

Clinical Trauma & VTE Decision Support Tool — For Bedside Professional Use

Scores: MESS | GHOISS | sPESI | PESI | ESC Reperfusion Criteria | VTE Prophylaxis Guidelines