Note:
• This protocol may be used as a general guide for trauma in both Adults and Pediatrics. Follow appropriate protocol and/or procedure for specific trauma care
Priorities Assessment Findings
Chief Complaint Various depending on incident.
OPQRST Identify specific cause of traumatic injury Associated Symptoms/
Pertinent Negatives
Significant mechanism, loss or altered level of consciousness. Evidence of intoxicant use.
SAMPLE Identify medical conditions that may have lead to the event (e.g. Alzheimer’s, CVA, Diabetes, Seizures,)
Initial Exam – Rapid Trauma Assessment
Check ABC’s and correct any immediate life threats. Manual C-spine stabilization. Perform rapid trauma assessment as appropriate.
Detailed Focused Exam Vitals: BP, HR, RR, Temp, SpO2
General Appearance: Unresponsive, pale, diaphoretic? Signs of trauma?
HEENT: PERRL? Pupils constricted or dilated? Discharge from ears or nose?
Lungs: Signs of respiratory distress, hypoventilation, diminished or absent lung sounds?
Heart: Rate and rhythm? Signs of hypoperfusion?
Neuro: Loss of movement and/or sensation in extremities, Unresponsive?
Focal deficits?
Data Blood Glucose, SpO2, EKG, EtCO2
Goals of Therapy Maintain ABC’s, restore adequate respiratory and circulatory conditions, reduce pain
Monitoring SpO2, Cardiac monitoring, EtCO2, repeat vitals
EMERGENCY MEDICAL RESPONDER
• Ensure “Scene Safety” and Body Substance Isolation (BSI)
• Determine need for additional resources (e.g. helicopters, additional ambulances, heavy rescue)
• Airway: Relieve airway obstruction, if present
o Open the airway with a jaw-thrust (No head tilt – Chin lift in trauma patients) o Remove foreign material, emesis and blood
• Oxygen
o 2-4 LPM per nasal cannula or
o High-flow oxygen 10-15 LPM by non-rebreather mask to maintain SpO2 > 90% or
• Breathing:
o Assist ventilations with bag-valve-mask and high-flow oxygen, as needed
• Circulation:
o Control major external hemorrhage with direct pressure, if it is penetrating trauma use a tourniquet to quickly control life threatening arterial bleeding
o If the patient arrests,
Re-assess the airway and oxygen delivery
Consider initiating the Cardiac Arrest Guidelines
Prolonged efforts to restore spontaneous circulation in a traumatic arrest should not be made, unless
• It is due to a penetrating injury
• The nearest hospital is < 5 minutes away
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CPR should not be attempted if:
• Blunt trauma caused the arrest
• There are other injured survivors with urgent needs for help
• C-Spine: Manual stabilization
• Refer to Pain Management Guidelines
• Suction the airway
• Consider oropharyngeal airway or nasopharyngeal airway (use caution in facial trauma)
• Cover sucking chest wounds with a three-sided flap valve
• Splint obvious extremity fractures
• If there is ALOC
o Check Blood Glucose
o Follow Hypoglycemia Guidelines if < 60
• Spinal Immobilization, as indicated.
AEMT
• IV (18ga or larger) 0.9% Normal Saline @ KVO or an appropriate rate
• Consider 2nd IV where hypovolemia is suspected (Adult only)
• If SBP < 100 mmHg, initiate a fluid bolus of Normal Saline: 250 ml (Adult) or 20 ml/kg (Peds)
• Selective Spinal Immobilization – In the presence of a mechanism of injury for spinal trauma:
o Cervical collar application is optional if there is no:
complaint of neck pain or tenderness on exam
numbness, tingling or weakness in any extremity
distracting injury
evidence of alcohol or drug intoxication
major trauma to the head or face
history of loss of consciousness
altered level of consciousness on exam o Long board application is optional if there is no:
complaint of back pain or tenderness on exam
indication for c-spine immobilization
o Do not remove a C-collar or long board already applied. You may open the C-collar briefly to examine the neck
Contact Medical Control for the following:
• Additional fluid orders
INTERMEDIATE
• Consider endotracheal intubation:
o Respiratory arrest or apnea o GCS is <8
• If tension pneumothorax is suspected perform needle decompression
• Consider external jugular (EJ) IV if one cannot be established in the extremities
• Consider intraosseous (EZ-IO) access if an EJ cannot be established Contact Medical Control for the following:
• Additional pain orders
PARAMEDIC
Give a status report to the ambulance crew by radio ASAP.
EMT
• Consider RSI in trauma patients with the following indications:
o Respiratory failure with hypoventilation or persistent hypoxia on high-flow oxygen o Severe head injury:
Glasgow Coma Scale < 8
Agitation/combativeness that jeopardizes the well being of the patient or the safety of the crew
o Inability to protect the upper airway due to loss of gag reflex or ALOC o Flail chest
o Sucking chest wound
Leave the wound open or covered with a flap valve o Threat of imminent airway compromise:
Massive facial injuries
Hemorrhaging into or around the airway
Expanding neck hematoma
Penetrating injuries of the neck o See Respiratory Distress Guidelines Contact Medical Control for the following:
• Surgical or needle cricothyroidotomy
• Additional orders
FOOTNOTES:
Approved by: Michael J. Kellum, MD, FACEP Date of Origin: November 2008
Date of This Revision:
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Mercy Walworth EMS
Suggested Medical Guidelines
Seizure
Note:
• Seizures usually last from 1-3 minutes and involve a loss of consciousness and convulsions. Not uncommonly, the patient is incontinent and may bite his tongue or is injured in other ways because of the convulsions.
• When the seizure is over, the patient enters a postictal state, characterized by a gradual return to full consciousness over about 20 – 30 minutes, with initial confusion eventually giving way to normal alertness and orientation.
• Whenever seizures occur, look for an underlying cause and treat it. This is especially important if there is no previous history of epilepsy.
• Febrile Seizure is defined as a seizure with a fever >100.6 °F rectal.
• If the patient is more than 20 weeks pregnant, refer to the Eclampsia Guidelines.
• Status epilepticus is defined as a seizure lasting longer than 30 minutes or frequently recurring seizures without clearing the postictal state or return to baseline neurological status. This is a life-threatening emergency!
• Pseudoseizures look like seizures, but are actually a behavioral disturbance characterized by intermittent spells of non-epileptic convulsions that are usually involuntary. They are frequently misdiagnosed as epilepsy and often treated with anti-epilepsy drugs for a long time, before the true nature of the attacks is revealed. Careful assessment may reveal telltale clues [2].
Priorities Assessment Findings
Chief Complaint “Seizure” “Unresponsive” “Convulsions”
OPQRST How long did it last? History of seizures? Fever? Possible contributing factors [1]
Associated Symptoms/
Pertinent Negatives
Unresponsive, Postictal, Incontinent SAMPLE History of seizures, Seizure medications?
Initial Exam ABC’s and correct any immediate life threats
Detailed Focused Exam Scene size-up: Is there a significant mechanism of injury?
General Appearance: Pt. currently seizing? Unresponsive? Postictal?
Vitals: BP, HR, RR, Temp, SpO2 Skin: Flushed, warm
Neuro: ALOC?, Focal deficits (CVA) Data Blood Glucose, SpO2, Temperature Goals of Therapy Stop the seizure
Treat the underline cause Monitor and maintain airway.
Monitoring Vitals, Cardiac monitoring, SpO2
EMERGENCY MEDICAL RESPONDER
• Routine medical care
• Protect the patient with ongoing seizures from harming themselves by clearing away potential hazards and placing a pillow or padding under the head
• Oxygen 2-4 LPM per nasal cannula, to keep SpO2 > 90%
•
Consider Non-rebreather mask if necessary 10-15 LPM Give a status report to the ambulance crew by radio ASAP.AEMT
• IV 0.9% NS @ KVO
Contact Medical Control for the following:
• Additional fluid orders
INTERMEDIATE
• If the patient is still seizing, give Lorazepam (Ativan) 1mg IV/IO or Diazepam (Valium) 5mg IV/IO
Contact Medical Control for the following:
• If Pseudoseizures or Febrile Seizures are suspected, withhold Ativan and Valium until you speak with Medical Control.
• If IV access unavailable consider IO administration of Ativan or Valium at the same doses.
• If seizures persist, repeat doses of Ativan or Valium every 5 min until seizures stop. Maximum doses: Ativan 6mg (3mg peds), Valium 10mg (6mg peds)
PARAMEDIC
• If the patient is still seizing, give Lorazepam (Ativan) 1mg IV/IO (peds 0.05mg/kg) or Diazepam (Valium) 5mg IV/IO (peds 0.3mg/kg). May repeat every 5 min until seizures stop
• Maximum doses: Ativan 6mg (3mg peds), Valium 10mg (6mg peds)
• If IV/IO access unavailable Midazolam (Versed) 5mg Intranasal
• For pediatric patients Diazepam (Valium) 0.5mg/kg can be administered rectally Contact Medical Control for the following:
• Persistent seizures
• There appears to be a need for RSI. Note: Once the patient is paralyzed, muscular convulsions will cease, but occult CNS seizure activity may persist. Therefore, you must repeat doses of Valium or Ativan every 5 minutes under the assumption of ongoing seizure activity
FOOTNOTES:
[1] The causes of seizures include: fever in children up to about 6 yrs, epilepsy, eclampsia, hypoglycemia, hypoxia, drug or alcohol withdrawal, drug overdose, stroke and head trauma
[2] Characteristics of pseudoseizures are listed below:
• Identifiable trigger (emotional stress, crisis or grief)
• The patient usually has an audience
• Asynchronous or asymmetric motion during the seizure (“bicycling” or head turning)
• Mid-range and reactive pupils during the convulsion (they’re widely dilated in a real seizure)
• Lack of tongue biting or incontinence
• Apparent purposeful movements
• Remaining consciousness, or even speaking, during the convulsion