Pre-hospital management of the trauma patient is best performed by an integrated team focused on minimizing the time from injury to definitive care at an appropriate trauma center. Dispatchers, first responders, law enforcement officials, and ambulance personnel must all take an active role to eliminate unnecessary delays in the delivery of care and transport to definitive care. Priorities Chief Complaint LOPQRST AS/PN AMPL Initial Exam Rapid Trauma Assessment Detailed Focused Exam Data Goals of Therapy Monitoring Assessment Findings Various depending on incident. Identify specific cause of traumatic injury Significant mechanism, loss or altered level of consciousness. Evidence of intoxicant use. Identify medical conditions that may have led to the event (e.g. Alzheimer s, CVA, Diabetes, Seizures,) Check ABC s and correct any immediate life threats. Manual C-spine stabilization. Perform rapid trauma assessment as appropriate including Glascow Coma Score (GCS) (Reference 002). Vitals: BP, HR, RR, Temp, SpO 2 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? Blood Glucose (EMT only), SpO 2, ECGas authorized Maintain ABC s. Restore adequate respiratory and circulatory conditions. Reduce pain SpO 2, Cardiac monitoring, repeat vitals 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. Victims of multiple trauma have decreased mortality and morbidity when transported to verified trauma centers. Appropriate triage criteria aid in the identification of multiple trauma and therefore will improve the ability of pre-hospital providers to determine the appropriate destination of multiple trauma victims. ALL LEVELS 1. While en route to scene contact hospital(s) to relate nature of call as necessary. 2. Request additional resources as anticipated such as additional ambulances, air-medical services, fire suppression, hazmat, MCI, extrication, etc. Request additional resources prior to initiating care on scene if situation was not anticipated en route. 2. Survey Scene. Do not approach patient until scene is safe. 3. Perform primary/initial trauma assessment along with GCS. a. Evaluate airway, provide C-spine immobilization as authorized, and assess initial LOC. b. Evaluate breathing c. Evaluate circulation Revised: Page 1 of 5
d. Briefly evaluate abdomen, pelvis, and extremities if time allows (Do not interrupt primary assessment except for airway obstruction or cardiac arrest) e. Determine LOAD and GO status. 4. Perform critical interventions while packaging patient if ambulance and EMTs on scene. a. Remove airway obstructions. Secure airway with use of jaw thrust and nasal/oral airway. Provide 10 to 15 liters oxygen via non-rebreather or via BVM. b. Stop major bleeding. c. See trauma protocols for management of specific injuries. EMT 5. If patient condition is LOAD and GO, initiate immediate transport delaying secondary/focused trauma assessment and non-critical interventions until enroute. a. Maintain spinal immobilization while quickly securing patient to long back board. Maintain manual immobilization of cervical spine until patient is fully immobilized in appropriate adjunct. Transport immediately. b. Do not delay rapid extrication and patient packaging for the arrival of ALS c. Continually monitor LOC and ABCs paying close attention to changes in status. d. Notify medical control of patient status as soon as possible. e. Perform secondary/focused trauma assessment and non-critical treatments as time permits. Revised: Page 2 of 5
Definition of Major Trauma Major Trauma includes the following categories: 1. Physiologic Status Patients with multi-system blunt or penetrating trauma and unstable vital signs. 2. Anatomical Injuries Patients with known or suspected anatomical injuries and stable or normal vital signs. 3. Mechanism of Injury Patients who are involved in a high energy event with a risk for severe injury despite stable or normal vital signs. Once these patients are identified, an appropriate systems response should be activated. Triage occurs at both the pre-hospital and hospital level. ****************************************************************************************** Activate Local Trauma Plan Major Trauma Adult Inadequate Airway, grunting, or stridor Multi-system Blunt or Penetrating Trauma with Unstable Vital Signs (Systolic BP<90, HR>120, Resp < 10 or > 30, GCS < 14, RTS < 11) Penetrating injury of head, neck, torso, groin Burns 15% TBSA (2 nd or 3 rd degree) or involving face, airway, hands, feet, or genitalia Amputation proximal to wrist or ankle Paralysis or other signs of spinal cord injury Flail chest Open or suspected depressed skull fracture Unstable pelvis or suspected pelvis fracture Two or more proximal long bone fractures suspected Distended, rigid abdomen with signs of shock Major Trauma Pediatric Inadequate Airway, grunting, or stridor Multi-system Blunt or Penetrating Trauma with Unstable Vital Signs (Systolic BP Neonate <60 Infant (<2 yrs) <65 Child (2-5 yrs) <70 Child (6-12 yrs) <80 Respirations (all ages) <10 or >60 GCS <14 PTS <9 Penetrating injury of head, neck, torso, groin Burns 15% TBSA (2 nd or 3 rd degree) or involving face, airway, hands, feet, or genitalia Amputation proximal to wrist or ankle Paralysis or other sign s of spinal cord injury Flail chest Open or suspected depressed skull fracture Unstable pelvis or suspected pelvis fracture Two or more proximal long bone fractures suspected Distended, rigid abdomen with signs of shock Consider Trauma Plan Activation High Risk Factors for Major Trauma Ejection from vehicle Vehicle rollover Bent steering wheel (driver) Major auto deformity (damage into passenger area) Auto-Pedestrian or Auto-Bicycle impact High speed vehicle crash (>40MPH adult and >20MPH child) Motorcycle or ATV crash Fatality in same vehicle Prolonged extrication (>20 minutes) Fall >20 feet adult and >10 feet child Pregnancy Age <5 or >55 Significant underlying medical conditions (lung, heart, diabetes, bleeding disorder, anticoagulants, immunosuppressed) Significant assault Revised: Page 3 of 5
Air Medical & ALS Intercept Guidelines If patient meets major trauma criteria, dispatch helicopter and/or ground ALS. Major Trauma Patient No Manage per established protocols Transport to nearest appropriate facility Adequate Airway No Manage per established protocols ALS Intercept Transport to nearest appropriate facility Is level I or II Trauma No Manage per established protocols Center >30 minutes away? Transport to Level I or II Trauma Center (scene + transport time) Dispatch Helicopter and/or ALS Intercept (depending on time = scene + transport time) Can Helicopter Fly? No Consider ALS Intercept Transport to nearest appropriate facility Helicopter Intercept or Meet at Closest Facility Transport to Level I or II Trauma Center Air ALS Transport is indicated, if time and weather permits, when critical care is needed during transport, the distance is long, prolonged scene time (eg. prolonged extrication, multiple trauma patients, difficult topography), and it will reduce the time to a crucial intervention while en route or at tertiary care. Critical Care Ground Intercept may be requested by BLS / ALS when air transport is not available and/or critical care is needed during transport. Ground ALS Intercept is indicated when time is crucial to patient outcome and either air transport is not available or would not result in time savings. This option should be encouraged if the needed level of care cannot be maintained by the provider bringing the patient to an intercept. Revised: Page 4 of 5
Ground Transport is indicated when BLS / ALS meets the needs of the patient, other transport is not available, air transport would not result in time savings, or time is not crucial to patient outcome. Prehospital Triage & Transport Guidelines Transportation time from injury to definitive care will meet the Golden Hour. This is the goal of the Lake Superior RTAC. For the patient that sustains major trauma, the following guidelines will be observed: Scene Safety - All responders will assess scene safety and follow universal precautions. If the scene is determined to be unsafe, do not put yourself or others in danger of injury or exposure. The Incident Commander will contact law enforcement or other agencies to further secure the scene and determine safety precautions to be used in order to proceed. Major Trauma Definition - Adult and Pediatric Major Trauma Definition and Transport Algorithm may be found on the following two pages. Patients meeting the criteria for major trauma should be transported to the nearest Level I or Level II Trauma Center in the most expeditious manner. Any recognized emergency services agency may request ALS ground and/or helicopter. Communications - Dispatch should consider activating the helicopter for incidents involving High Risk Factors for Major Trauma (see Definition of Major Trauma document). Trauma Alert The receiving facility needs to be notified to activate their Trauma Alert system. The Incident Commander is responsible for early notification of the receiving facility for patients meeting the definition of major trauma. Transport - It is the goal of Lake Superior RTAC that transport time should be less than 30 minutes to the nearest appropriate facility. The decision for transport destination should be made by the first recognized emergency services agency person to arrive and assess the patient. This may require a BLS unit to request an ALS ground unit for intercept or to request a helicopter directly to the scene. For delayed extrication, a helicopter should be requested. In a trauma situation, transport destination may be made without immediate Medical Control contact. Medical Control may be consulted or notified of the situation if necessary. Providers should remember that while trauma centers provide definitive care and life-saving surgery, local hospitals can provide life-saving interventions before transfer if needed. Uncontrollable airway and CPR patients should be transported to the nearest hospital. Depending on location, bad weather, mechanical failure, or communication breakdown, patients should be transported to the nearest appropriate hospital for stabilization. This may also include helicopter intercept, critical care ground transport, or ALS ground intercept. Revised: Page 5 of 5
[The preceding Definition of Trauma, Intercept Guidelines and Triage and Transport Guidelines were developed by the Lake Superior Regional Trauma Advisory Council with input from medical directors throughout the region.] Revised: Page 6 of 5