Monterey County EMS System Policy

Protocol Number: T-4 Effective Date: 1/1/2020 Review Date: 6/30/2024

MAJOR TRAUMA PATIENT

BLS CARE

Routine Medical Care – be prepared to support ventilation with appropriate airway adjuncts. Control bleeding. Apply direct pressure/pressure bandage. Use hemostatic dressing if still not controlled. Apply tourniquet for uncontrolled extremity bleeding: Apply 2-3 inches proximal to wound Tighten until bleeding controlled Document time tourniquet is placed and presence/absence of distal pulses

Maintain high index of suspicion for if significant mechanism of injury is present or physical examination is remarkable for findings. DO NOT REMOVE IMPALED OBJECTS unless causing airway obstruction or if it interferes with CPR.

Stabilize any impaled object manually or with bulky dressings For bleeding to head, neck, pelvis or for to extremities, refer to protocol T-6: Hemorrhage Control.

Spinal Motion Restriction (SMR) if indicated

Oxygen to maintain Sp02 >94%. EXCEPTION: Head require 100% 02 by Non- Rebreather mask. Keep patient warm. Hypothermia is to be avoided whenever possible.

Attempt to have patient packaged prior to the ALS transport unit arrival, if possible. Primary goal is immediate stabilization and transport to a . Time on scene should not exceed 10 minutes unless extrication is required. Conditions requiring extended scene times shall be documented.

If injury may have resulted from abuse, neglect, assault, attempted suicide/homicide and/or other crimes, report to appropriate agency and document on PCR.

ALS CARE

Routine Medical Care IV/IO access with large bore catheter with extension tubing (saline lock). Normal Saline up to 500 mL bolus. Goal of is to maintain SBP of > 90 mmHg. If SBP > 90 mmHg, then maintain IV/IO at TKO rate.

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Injury-Specific Trauma Care Guidelines (ALS and BLS based on Scope of Practice)

Head injuries Elevate head of bed 30°. If on a backboard, elevate the head of backboard 30° unless contraindicated by hypotension. Systolic blood pressure must be maintained at greater than 90mmHg. Do not hyperventilate. Ventilate at no more than 10 breaths/minute. Use a timing device if available. Utilize capnography to maintain EtCO2 between 35-45. Provide oxygen to ensure an oxygen saturation greater than 90%. Do not attempt to intubate head injured patients unless unable to manage with BLS airway measures.

Facial injuries Assess airway and suction as needed. Remove loose teeth or dentures if present

Eye injuries Remove contact lenses Irrigate eye thoroughly with sterile Normal Saline for suspected acid/alkali Avoid direct pressure Cover both eyes Neck Injuries Penetrating Do not remove impaled objects. If there is bubbling/gurgling or , cover the neck wound with an occlusive dressing.

Assess airway and lung sounds frequently. Perform needle thoracotomy as indicated for signs/symptoms of tension . Blunt Spinal motion restriction-See policy #4509 Spinal Motion Restriction.

Spine Injuries In the presence of penetrating injuries, if no neurologic deficit is present upon physical examination withhold SMR. Neck injuries Monitor airway Control bleeding if present

Thoracic Trauma Keep patients sitting high fowlers unless contraindicated by hypotension or altered level of consciousness. If in spinal precautions, elevate head of backboard 30° unless contraindicated by hypotension In the presence of isolated penetrating injuries, if no neurologic deficit is present upon physical examination, withhold SMR. /Rib injuries Immobilize with padding and bulky dressings to the affected area. Pneumothorax/ Keep patients sitting high fowlers unless contraindicated by hypotension. Suspected tension pneumothorax Needle Thoracostomy – Monterey County EMS Policy #4507 (Pleural Decompression) Open (Sucking) Chest Wound Place an occlusive dressing to the wound site. Use a chest seal or secure on 3 sides only. – if suspected, expedite transport Beck’s Triad: Muffled heart tones Jugular venous distention (JVD) Hypotension, especially if clear lung sounds bilaterally Trauma Aortic Disruption – if suspected, expedite transport Assess for quality of radial and femoral pulses

Auscultate blood pressures on both arms, if time permits.

Abdominal Trauma Blunt injuries Place patient in supine position if hypotension is present. Eviscerations DO NOT REPLACE ABDOMINAL CONTENTS Cover wound with sterile saline-soaked dressings Pregnancy Place patient in left lateral position. If in SMR, place padding under backboard to tilt to the left Pelvic Trauma Physical findings which may indicate the presence of a pelvic ring fracture include, but are not limited to: Signs and/or symptoms of shock in the presence of to the pelvis Crepitus and/or pain when applying compression to the iliac crests Perineal or genital swelling Testicular/groin pain Blood at the urethral meatus Rectal, vagina, or perineal lacerations/bleeding If pelvic ring fracture is suspected, use either a commercial pelvic binder or wrap a bed sheet tightly around the pelvis and tie it together for use as a binder to help control . When stabilizing a suspected pelvic ring fracture, care must be taken not to over-reduce the fracture. Over-reduction can be assessed by examining the position of the legs, greater trochanters and knees with the patient supine. The goal is to achieve normal anatomic position of the pelvis, so the lower legs should be symmetrical after stabilization. When clinically indicated and logistically feasible, the pelvic binder should be placed prior to extrication/movement. Assessment of pelvis should be only performed ONCE to limit additional injury. If possible, avoid log rolling patient

Extremity Trauma General treatments Evaluate CSM distal to injury

If decrease or absence in CSM is present: Manually reposition extremity into anatomical position. Re-evaluate CSM If no change in CSM after repositioning, splint in anatomical position and expedite transport Cover open wounds with sterile dressings Place ice pack on injury area (if closed wound) Splint/elevate extremity with appropriate equipment Dislocations Splint in position found with appropriate equipment Femur fractures Utilize traction splint only if isolated mid-shaft femur fracture is suspected. Assess CSM before and after traction splint application Amputations Clean the amputated extremity with sterile NS Wrap in moist sterile gauze Place in plastic bag Place bag with amputated extremity into a separate bag containing ice packs Prevent direct tissue contact with the ice packs.

Crush Injuries Patients with are identified by the following (all must be present): • Prolonged entrapment (greater than 60 minutes) • Traumatic injury to muscle mass proximal to the wrist or ankle • Compromised circulation to the injured area Treatment: • If chest is accessible, obtain 12-lead ECG (monitor for signs of hyperkalemia (high, peaked T-waves, flattening P-waves, broad QRS complexes) • Pain management as appropriate (Monterey County EMS Protocol M-2) • IV/IO Fluid Challenge Normal Saline up to 2000 ml o Lactated Ringers is to be avoided because it contains potassium Medications. All medications are to be given PRIOR to releasing the patient from the crush environment: • Calcium Chloride 1 gm IV/IO

• Albuterol 5 mg in 6 ml NS via nebulizer • Sodium Bicarbonate 1 mEq/kg IV/IO, delivered over sixty (60) seconds