Does Patient Meet LERN Criteria?

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Jasmine Collins
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1 ROUTINE TRAUMA CARE Ensure scene safety & BSI precautions Assess the MECHANISM OF INJURY (MOI) / Scene Size Up / Need for Additional Resources 1 / MCI? Assess for and begin treating LIFE THREATENING injuries and appropriate spinal precautions as needed 2 Use Airway Management protocol as indicated 3 Determine if pt(s) meets LERN criteria Does Patient Meet LERN Criteria? CALL LERN FOR APPROPRIATE DESTINATION 4 Limit on scene to 10 minutes or less. Utilize Spinal Motion Restrictions (SMR) as needed All non-life Threatening treatments other than SMR and tracheal intubation 5 will be initiated during transport UNLESS circumstances dictate or allow for earlier interventions Perform focused history & physical exam Stabilize and treat patient as needed Vital signs 6 q 5 min Transport to appropriate facility Establish 2 large bore IV s. If peripheral IV access is unobtainable or for unstable pts, IO access can replace one large bore IV. Monitor EKG Assess for and treat non-life threatening injuries ¹ IF NEEDED, call for additional resources early (i.e. personnel, Med Units, Air Transport, etc.) ² According to SMR protocol 3 Airway Management Protocols are in the Adult Medical Section 2 4 Refer to LERN Protocol & MCI Protocol (if needed) for necessary patient information required for reporting purposes 5 Only one intubation attempt is allowed on scene. 6 Vital signs include: blood pressure, heart rate, respiratory rate, pain scale, SpO2, temperature & GCS (Quantitative ETCO2 for management of suspected Head Injury / Intracranial Pressure). IV fluids should be titrated to a radial pulse or SBP > 80 mm/hg Fluid boluses are controlled in 250cc increments with continous patient monitoring If the pt is or becomes pulseless, proceed to the appropriate pulseless protocol. Standard of Care is an on scene time T > 10 min. Make every effort possible to not take the entire 10 minutes. Tension Pneumothorax air escapes into pleural spaces and cannot reenter the lung which is the reason affected structures shift away from the affected lung. The shift displaces the trachea, heart, aorta, inferior and superior vena cava decreasing venous return which causes PEA. A simple pneumothroax is accompanied with decreased or absent breath sounds and is not an indication for chest decompression. The following are common signs and symptoms of Tension Pneumothorax: deviation of trachea, tachycardia, tachypneic, JVD, absent breath sounds on the affected side, progressively increasing respiratory distress (harder to ventilate pt) and hypotension. Should clinical presentation dictate a tension pneumothorax and Medical Control is unable to be reached, proceed with the treatment. ROUTINE TRAUMA CARE 1

of respiratory distress, then follow Pain Management Protocol Medication below: Fentanyl 25 50 mcg IV/IM/IN to Max of 200 mcg OR Morphine Sulfate 1-2mg IV/IO OR Dilaudid 1 2 mg IV/IO OR Ketamine 0.

2 BURNS Routine Trauma Care Provided the pt is no longer in contact with the burn source, treatment of life threatening injuries takes priority. Determine the burn source and remove any clothing or jewelry that is a potential hazard Using The Rule of Nines, determine % of BSA burned For critical burns¹ IV/IO NS² IF SBP > 100mm/Hg & no signs of respiratory distress, then follow Pain Management Protocol Medication below: Fentanyl mcg IV/IM/IN to Max of 200 mcg OR Morphine Sulfate 1-2mg IV/IO OR Dilaudid 1 2 mg IV/IO OR Ketamine mg/kg IV/IM/IN WITH MEDICAL CONTROL ORDERS For minor soft tissue burns involving < 20% BSA, apply moist sterile dressing. All moist or wet dressings must be covered with at least a burn sheet. For thermal burns > 20% BSA, use dry sterile dressings. Chemical burns are uncommon but do still occur especially in the industrial settings of our region. If safety permits, remove any clothing & brush off any residue that may still be present. REGARDLESS OF THE EXTENT OF INJURY flush the patient with copious amounts of water for no less than 20 minutes. This will make certain the burning has stopped and aid in decontaminating the patient. Flushing should not be done in the ambulance. If patient care can be SAFELY DELIVERED, it may be done so during this time. The SAFETY OF THE EMT S AND HOSPITAL STAFF TAKE PRIORITY. Serious injury or death to the EMS crew could result from transporting improperly decontaminated patients in the confines of their ambulance. Furthermore, ED staff could become exposed if pts are not decontaminated prior to transport. 1 Critical Burns > 20% Body Surface Area (BSA) having any 2 and/or 3 burns; any burns to the perineum, face and/or circumferential burns. Patients with non-critical burns complaining of pain 5 may receive IV analgesia without an order. ² Fluid given in burns is done according to Parkland Formula: 4 x patient's weight (kg) X % BSA burned. 50% of that answer should be infused in the first 8 hours. When both arms are burned and IV access is needed, use the veins of the feet or one external jugular. If the incident occurs at an industrial site obtain an MSDS sheet when possible. BURNS 2

3 Crush Injury / Syndrome (>2 hours 1 ) Crush Injury compression of extremities or other major muscle groups causing muscle swelling and/or neurological impairment Crush Syndrome systemic manifestations of crush injury due to traumatic rhabdomyolysis & the release of potentially toxic cell components & electrolytes. This may lead to lethal dysrhymias, hyperkalemia, hypocalcemia, renal failure, local tissue injury or death. More likely with multiple crushed limbs. Crush syndrome may also lead to AMS and hypotension. Compartment Syndrome, signs & symptoms: pain parasthesias pallor paralysis pulselessness Routine Trauma Care Control external hemorrhage, per protocol Remove any rings, bracelets or constricting items Monitor EKG Establish 2 large bore IV s 2 Bolus 2 liters NS with one amp (50 meq) of Sodium Bicarb added per liter of NS Following bolus, infuse 500ml NS / hour Pain control, per protocol Monitor for hyperkalemia: (peaked T-waves, widened QRS, sine wave) Contact Medical Control if hyperkalemia is suspected: 50 meq Sodium Bicarb added per liter of NS CaCl 500mg IV over 2 minutes Bolus 100mEq Sodium Bicarb IV Albuterol 5mg nebulized (Consider up to 20mg if available) Contact Medical Control if further orders are needed. 1 Crush Injury Syndrome can begin within shorter time frames depending on body area and entrapment capacities 2 IV access should be established and infusions started prior to disentrapping the patient Monitor the air quality for confined space rescue Monitor the patient closely during extrication Large volume fluid resuscitation is required to avoid renal failure and death. Do not overlook other potential injuries 3 Crush Injury Syndrome

4 Drowning Drowning When treating drowning victims, addressing submersion induced hypoxia remains an immediate focus in the American Heart Association s 2010 updates. Attention should be on oxygenation and ventilation; therefore, CPR for drowning victims should follow the traditional A-B-C approach to cardiac arrest care opposed to the newer C-A-B approach. Routine Medical / Trauma Care If mechanism exists, evaluate the need for Spinal Immobilization Once the patient is out of the water, or in shallow water, open airway and evaluate respiratory function Respiratory Distress Respiratory / Cardiac Arrest Support respiratory function as needed per Airway Management Protocol If fluid is auscultated in lungs: Albuterol 5mg CPAP up to 10 cmh20 PEEP, if available Deliver two rescue breaths if the patient is not breathing, can be done while in the water. Once pt is out of the water, begin chest compression and apply defib pads to the patient s dry chest. Follow appropriate pulseless arrest protocol Contact Medical Control if further orders are needed Contact Medical Control if further orders are needed Paramedics should use sound clinical judgment when deciding if resuscitation efforts should be initiated, including but not limited to water temperature, length of submersion and any associated trauma. If there is any doubt or if the events leading to the submersion are unclear, it is recommended that resuscitation be initiated and the victim be transported to an ED unless there is obvious death (eg, rigor mortis, decomposition, hemisection, decapitation, or lividity). Initiate CPR in patients who have been submerged for < 60 minutes Unnecessary cervical spine immobilization can impede adequate opening of the airway and delay delivery of rescue breaths. Routine stabilization of the cervical spine in the absence of circumstances that suggest a spinal injury is not recommended. Drowning 4

5 HEMORRHAGE CONTROL Routine Trauma / Medical Care Apply direct hand pressure or immediately apply a Tourniquet if the situation dictates, exposing area as needed. Apply Pressure Bandage (unless a Tourniquet stopped the bleeding) Bleeding Controlled? Transport 3 Torso or Junctional Location 4 Extremity Wound Packing / Hemostatic Agents 1 Transport 3 Tourniquet 2 Establish 2 large bore IV s. If peripheral IV access is unobtainable or for unstable pts, IO access can replace one large bore IV. (See Routine Trauma Care for Permissive Hypotension criteria) 1 Use Wound Packing / Hemostatic agent per manufacturer s guideline. Presure Bandages should be placed on top of wound packing. 2 Tourniquets should be used in potentially life threatening hemorrhage to control bleeding. Utilize 2nd Tourniquet or Wound Packing as needed. Apply to most proximal wound location as per manufacturer s guideline. Cut away clothing prior to application so that the tourniquet is visible. Mark TK and time of application on a piece of tape, then secure to the tourniquet. Notify receiving emergency department staff of tourniquet placement upon arrival at ED. 3 Amputation: Gently wash severed part with sterile saline to remove debris. Wrap severed part in sterile gauze moistened in sterile saline and place in transport container. Place transport container on ice (if available) for transport to receiving ED (amputated part should not come in direct contact with ice). 4 Junctional Injuries are defined as locations where the extremities meet the torso HEMORRHAGE CONTROL 5

6 OPEN WOUND / FRACTURE / DISLOCATION Routine Trauma Care Evaluate MOI and the need for spinal immobilization using the Spinal Motion Restriction (SMR) protocol Locate, expose and provide manual stabilization of injury Control any bleeding and assess distal circulation¹ Clean, bandage and dress any open wound using an aseptic technique IV NS, consider Pain Management² prior to manipulation of fracture Immobilize fx or dislocated joints securing the bones above and below the injured joint. Immobilize fx or dislocated bones securing the joints above and below the injured bone. Reassess distal circulation before and after immobilization. Apply cold packs to fx locations with evidence of swelling ¹ If distal circulation is present (no distal pulse, no capillary refill, cyanosis) make ONE attempt to reposition the fx or dislocation in hopes of restoring distal circulation. ² Pain Medications should be administered as indicated in the Pain Management Protocol This protocol is developed for use on stable patients with complaints of an isolated fracture or dislocation. Patients suspected of pelvis & femur fractures should be monitored closely for signs and symptoms related to shock. Never reintroduce an exposed bone (open fx) back into the skin unless vascular compromise is present. For suspected hip fractures / dislocations, immobilize in the position found. Consider using the sheet wrap method of immobilization. OPEN WOUND / FRACTURE / DISLOCATION 6

7 PAIN MANAGEMENT (N-CARDIAC) PAIN rated > level 5 is considered a distracting condition prudent Spinal Motion Restrictions (SMR) should be considered. Routine Medical / Trauma Care (including pain scale) Use clinical judgment along with S/S to verify level of discomfort Administer ONE of the following: Fentanyl mcg IV/IN/IM q 2min PRN to MAX of 200mcg OR Morphine Sulfate 2 4 mg IV q 2min PRN to MAX of 10 mg OR Dilaudid 0.5 mg PRN to max of 2 mg OR Ketamine 0.5-1mg/kg IV/IN/IM (Requires orders from Med Control) For N/V related to analgesia, consider Zofran 4mg IV; may repeat an additional 4 mg in 15 min PRN All administrations of Controlled Substances, whether by Standing Orders or by Medical Control must include the Physicians name or the receiving Physicians name recorded in the Patient s Care Report These patients must be transported to the ED. This standing order is to address pain in the following situations: - isolated extremity fracture with deformity - burns *** see Burn protocol - obvious dislocations with severe pain - cancer patients and patients with other co-morbid illnesses who manage pain at home Pain control cannot be given for complaints of head or abdominal pain unless ordered by Medical Control. PAIN MANAGEMENT (N-CARDIAC) 7

8 SPINAL MOTION RESTRICTION Spinal Motion Restrictions (SMR) describes the procedure used to care for patients with possible unstable spinal injuries. SMR includes: Reduction of gross movement by the patient; prevention of additional damage to the spine 1 ; and regular reassessment of motor/sensory function Assess Mechanism of Injury and/or Special Circumstances SMR Procedures Not Required ANY One of the Following MOI: Falls -- Adults: >20 feet (one story is equal to 10 feet) -- Children: >10 feet or two or three times the height of the child High-risk auto crash -- Intrusion, including roof: > 12 inches occupant site; > 18 inches any site -- Ejection (partial or complete) from automobile or rollover MVC -- Death in the same passenger compartment -- Vehicle telemetry data consistent with a high risk of injury Auto vs. pedestrian/bicyclist/atv thrown, run over, or with significant (>20 mph) impact Motorcycle crash >20mph Axial Load (i.e., diving injury, spearing tackle, etc.) Special Circumstances: PMHx of Osteoporosis, bone or vertebral Disease Age > 65 or < 5 years old Physical Findings and/or Patient Complaints ANY ONE OF THE FOLLOWING: Altered Mental Status (AVPU) (GCS < 15) Any evidence of Intoxication (staggered gait / ataxia / slurred speech, etc.) Any focal neurologic deficits or complaints (Motor / Sensory assessment) Distracting injury or Mental distress Inability to communicate Pain or Point Tenderness on over any spinous process or with unassisted 4 ROM ANY Loss of Consciousness PTA 1 Follow SMR Procedures IF IN DOUBT SMR 1. SMR Procedures : (least to most invasive) Utilizing a cervical collar in fowler s, semi-fowler s or supine on the stretcher and adequately and appropriately securing the patient in order to limit the excessive motion of the spinal column, utilizing vacuum mattresses, scoops, skeds, short-boards, keds, backboard and head blocks with straps. 2. Long spine boards (LSB) have both risks and benefits for patients and have not been shown to improve outcomes. The best use of the LSB may be for extrication, patient movement, or providing a firm surface for compressions during cardiac arrest. However, several other devices may be appropriate for patient extrication and movement. (See Appendices for "BEMS Spinal Memo" & "American College of Surgeons LSB" for info 3. Patients with penetrating trauma, i.e. GSW or stabbing, should T be considered for spinal motion restriction unless there is a focal neurological deficit or complaint. 4. Range of motion should T be assessed if patient has midline spinal tenderness. SPINAL MOTION RESTRICTION 8

9 SIMPLE TRIAGE AND RAPID TREATMENT (START) Minor Ambulatory at Scene? 1 Spontaneous Respirations? Position Airway Immediate < 1 year old Breathing? Adult: RR > 29 or RR < 10 Child: RR > 45 or RR < 15 Control Bleeding 2 Radial Pulse Present Children Only: 5 rescue breaths & Reassess Breathing? Follows Simple Commands Not Breathing Deceased Delayed 1. Ambulatory Patients should be directed to move to a secondary triage / treatment location. Allow those ambulatory patients / victims who are providing Basic Life Support / 1 st Aid medical care to the injured to continue when resources are limited. 2. Control major bleeding immediately (see Hemorrhage Control Protocol) Call for resources early if needed. Initiate the Incident Command System. Utilize the A-RPM method (Ambulatory, Respirations, Pulses, Mental Status) for the initial triage. Realize the ambulatory patients (walking wounded) may quickly deteriorate & need reassessment as soon as resources allow. Triage tags: GREEN = Minor YELLOW = Delayed Transport RED = Immediate Transport BLACK = Deceased SIMPLE TRIAGE AND RAPID TREATMENT (START) 9

Call LERN Communication Center at 1-866-320-8293 for patients meeting the following criteria: Unmanageable airway Traumatic cardiac arrest Burn patient > 40 % BSA without IV Tension pneumothorax Burn

10 Call LERN Communication Center at for patients meeting the following criteria: Unmanageable airway Traumatic cardiac arrest Burn patient > 40 % BSA without IV Tension pneumothorax Burn patient without patent airway Closest ED/Trauma Center Measure vital signs and level of consciousness GCS 13 SBP <90mmHg RR <10 or >29 breaths per minute, or need for ventilator Support (<20 in infant aged <1 year) Assess anatomy of injury All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee Chest wall instability or deformity (e.g. flail chest) Two or more proximal long-bone fractures Crushed, degloved, mangled, or pulseless extremity Amputation proximal to wrist or ankle Pelvic fractures Open or depressed skull fracture Paralysis Fractures with neurovascular compromise (decreased peripheral pulses or prolonged capillary refill, motor or sensory deficits distal to fracture) Transport to Trauma Center/Trauma Program These patients should be transported to the highest level of care within the defined trauma system. This is a Level 1 or a Level 2 Trauma Center or Trauma Program. * If distance or patient condition impedes transport to trauma facility, consider transport to most appropriate resourced hospital. Falls -- Adults: >20 feet (one story is equal to 10 feet) -- Children: >10 feet or two or three times the height of the child High-risk auto crash -- Intrusion, including roof: > 12 inches occupant site; > 18 inches any site -- Ejection (partial or complete) from automobile -- Death in the same passenger compartment -- Vehicle telemetry data consistent with a high risk of injury Auto vs. pedestrian/bicyclist/atv thrown, run over, or with significant (>20 mph) impact Motorcycle crash >20mph Older Adults -- Risk of injury/death increases after age 55 years -- SBP <110 may represent shock after age Low impact mechanisms (e.g. ground level falls) may result in severe injury Children -- Should be triaged preferentially to pediatric capable trauma centers Anticoagulants and bleeding disorders -- Patients with head injury are at high risk for rapid deterioration Burns -- With trauma mechanism: triage to trauma center Pregnancy >20 weeks Hip Fractures (hip tenderness, deformity, lateral deviation of foot) excluding isolated hip fractures from same level falls Major joint dislocations (hip, knee, ankle, elbow) Open Fractures EMS provider judgment Assess mechanism of injury and evidence of high-energy impact Assess special patient or system considerations Destination Protocol TRAUMA Transport to Trauma Center/Trauma Program which, depending upon the defined trauma system, need not be the highest level trauma center/program. If no Trauma Center/Trauma Program in the region, LCC may route to the most appropriate resourced hospital. Multi / Mass Casualty Incident When in doubt, transport to a trauma center. Transport according to local protocol 10 Rev Eff

11 ADULT TRAUMATIC PRE-HOSPITAL TERMINATION OF RESUSCITATION Adult Traumatic Pre-hospital Termination of Resuscitation The patient must meet all of the following criteria Age 18 Victim of blunt or penetrating trauma Apneic and pulseless with EKG that shows asystole or PEA < 40 If all the above are met, contact Medical Control with your patient report; Document "Time of Death" if Termination of Resuscitation is granted & the physician's name. The Medical Control Physician will determine whether to continue resuscitative efforts beyond this point. IF T, PACKAGE THE PATIENT FOR TRANSPORT TO THE NEAREST MOST APPROPRIATE EMERGENCY DEPARTMENT ADULT TRAUMATIC PRE-HOSPITAL TERMINATION OF RESUSCITATION 11

PRE-HOSPITAL PATIENT CARE PROTOCOLS BASIC LIFE SUPPORT/ADVANCED LIFE SUPPORT

PRE-HOSPITAL PATIENT CARE PROTOCOLS BASIC LIFE SUPPORT/ADVANCED LIFE SUPPORT Board Approved June 2007 Revised December 2009 Revised July 2011 Revised June 2015 435 Hunter Street Fredericksburg, VA 22401