Trauma

  • Initial Trauma Care
  • Major Trauma Criteria
  • Trauma Alert Criteria
  • Out-of-Hospital Spinal Clearing/Immobilization
  • Spinal Immobilization for the Pregnant Trauma Patient
  • Eye Injuries
  • Chest Injuries
  • Abdominal Injuries
  • Musculoskeletal Injuries
  • Crush Injury
  • Burns
  • Rule of Nines
  • Burn Severity
  • Conducted Energy Weapson
  • Traumatic Brain Injuries
  • Traumatic Cardiac Arrest

Initial Trauma Care

    To be performed on all patients following a traumatic or suspected traumatic event.

     

    As scene evaluation, initial assessment, rapid trauma assessment, focused assessment, on-going assessment, and detailed physical exam are part of the training of EMTs and paramedic, the details of those steps will not be provided in this protocol. It is expected that EMS personnel will perform in accordance to their training.

 

BLS

 

  1. Begin Initial Medical Care.

    2.  

  2. Control all significant external bleeding. If direct pressure does not rapidly stop the bleeding in an extremity, apply a tourniquet.

    3.  

  3. If bleeding continues despite tourniquet use or wound is not amenable to tourniquet placement (e.g. groin or armpit), pack the wound cavity with a sterile gauze roll and apply direct pressure with a pressure bandage.

    4.  

    1. Providers may also utilize a TCCC-approved gauze based hemostatic dressing (e.g., Combat Gauze, Chito Gauze, Celox Gauze) if available.

      2.  

    2. The number of dressings packed into the wound must be documented in the patient care record.

     

  4. Follow Airway Management protocol.

    5.  

  5. Follow Oxygen Administration protocol.

    6.  

  6. Record LOC using AVPU method. Obtain an initial GCS as early as possible.

    7.  

  7. Expose patient to perform a detailed physical exam.

    8.  

  8. Cover and keep patient warm between assessments in order to conserve body heat.

    9.  

  9. If patient’s presentation, or the mechanism of injury, meets “Trauma Alert” criteria:

    10.  

    1. Call for a paramedic unit. See “ALS and BLS Team Approach”.

      2.  

    2. Rapidly extricate with cervical spine immobilization if indicated.

      3.  

    3. Try to keep scene time to 10 minutes or less. If scene time exceeds 10 minutes, document the reason for the delay.

     

  10. Patients with major multiple system trauma or penetrating trauma to the head, neck, chest or abdomen should be transported to a Trauma Center. If there are multiple patients with penetrating trauma at an incident, providers must consider trauma center capacity to avoid overwhelming a single facility. During a declared MCI, transportation destination will be made by the Transportation Officer.

    11.  

  11. Patients with serious burns should be transported to a Burn Center.

    12.  

  12. If the patient can be transported by BLS to a Trauma or Burn Center in less time than it would take for ALS to arrive, then transport by BLS.

    13.  

 

ALS

 

  1. During transport – Establish 2 large bore IV’s of 0.9% NaCl or LR. Titrate fluids to an SBP of 90 mmHg. (LR should not be used if blood products are being administered in the same line.)

    2.  

  2. Apply cardiac monitor.

    3.  

  3. Intubation with C-spine control may be necessary to maintain a patent airway and/or to prevent aspiration of vomitus.

    4.  

  4. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.

Major Trauma Criteria

Physiologic

 

    Systolic BP < 90 mm Hg for adults or vital signs outside of physiologic ranges for pediatrics
    Glasgow Coma Scale (GCS) ≤ 13
    Respiratory rate < 10 or > 29
    Patient receiving blood to maintain vital signs
    Airway or respiratory compromise as defined by:
      BVM, Intubation, adjunct airway, or cricothyroidotomy in the field
      Needle chest decompression

 

Anatomic

 

    Penetrating trauma to the head, neck, chest, abdomen, or extremities proximal to the knees and elbows
    Traumatic amputation proximal to the wrist or ankle
    Burns > 15% or high voltage (>1000 volts) electrical injury
    Any crushed, degloved, pulseless, or mangled extremity
    Pelvic fracture
    Two or more long bone fractures (tibia/fibula or radius/ulna count as only 1 bone)
    Flail chest
    Extremity paralysis suggestive of spinal cord injury
    Open or depressed skull fracture
    Victim of hanging who meet above criteria

 

Healthcare provider discretion

Trauma Alert Criteria

Mechanism of Injury

 

    Ejection from vehicle
    Vehicle roll-over
    Prolonged extrication from vehicle
    Pedestrian struck by vehicle at speed > 20 MPH
    Falls > 20 feet (adults) or > 3x the child’s height

 

Healthcare provider discretion

Out-of-Hospital Spinal Clearing/Immobilization

  1. Spinal immobilization is to be provided to blunt trauma patients only if significant evidence of spinal injury exists, see below.

    2.  

  2. Penetrating trauma patients do NOT require full spinal immobilization on backboard for transport.

    3.  

  3. Patients that are ambulatory upon arrival do NOT require full spinal immobilization on backboard for transport.

    4.  

    BLS
    ALS

     

    If cervical collar cannot be fitted due to improper size or lack of cooperation, consider using rolled towels.

     

    1. Cervical collar immobilization should be used for trauma patients meeting any of the following:

      2.  

      1. Presence of midline bony tenderness of c-spine to palpation or with movement
      2. Focal neurologic deficit present or reported
      3. Age < 8 or > 65
      4. Intoxication
      5. Distracting injury present
      6. High risk injury/mechanism of injury or provider discretion

       

    2. Cervical collar immobilization should be used for any pediatric trauma patient meeting any of the following:

      3.  

      1. Age < 8
      2. Presence of midline tenderness to palpation or with movement
      3. Distracting injury present
      4. Complaint of any neck pain
      5. Torticollis
      6. Focal neurologic deficit present or reported
      7. AMS including GCS < 15, intoxication, and other signs (agitation, apnea, hypopnea, somnolence, etc.)
      8. Involvement in a high-risk motor vehicle, high impact diving injury, or has substantial torso injury.

       

    3. Cervical collar and long spine board immobilization should be provided to patients meeting Trauma Alert Criteria and any of the following

      4.  

      1. Unconscious or altered mental status on exam
      2. Neurologic deficit present or reported
      3. Midline spinal tenderness or deformity
      4. Intoxication

       

      Penetrating head, neck or torso trauma with no evidence of spinal injury does not require backboard immobilization.

       

      If a long spine board is used for extrication purposes only, and the patient does not meet the above criteria, the patient does NOT need full spinal immobilization for transport unless necessary for patient safety. The patient can be moved onto the stretcher.

       

      Patients who are ambulatory upon arrival do NOT require full spinal immobilization on a backboard for transport.

Spinal Immobilization for the Pregnant Trauma Patient

  1. During the third trimester, transport the patient in the left lateral recumbent position (tilted 20-30 degrees to the left by securing the patient to the backboard and tilting the backboard with pillow or blankets).

    2.  

  2. If the patient is hypotensive, transport the patient in the left lateral recumbent position (tilted 20-30 degrees to the left) and re-check the vital signs.

Eye Injuries

  1. Assess for the following:

    2.  

    1. Intact globe (do not touch the globe).
    2. Hemorrhage, lacerations, contusions.
    3. Ability of both eyes to move together.
    4. Fluid from the globe.
    5. Decreased visual acuity (unable to see light, hand motion, or count fingers)
    6. Visible foreign bodies.

     

  2. Cover both eyes when bandaging, but avoid pressure on the eyes.

    3.  

  3. Do not remove impaled objects – stabilize.

    4.  

  4. Cover avulsed eye with paper cup if available.

    5.  

  5. For chemical burns, irrigate the eye with normal saline or water for 20 minutes and then bandage both eyes. If initiating transport will not interrupt eye irrigation, continue irrigation en route to the hospital.

Chest Injuries

BLS

 

  1. Assess for flail segments or rib fractures. Do not use sandbags.

    2.  

  2. Cover open chest wounds with an occlusive dressing. If a commercial seal is used, a vented seal is preferred. Apply on exhalation. Watch for signs of increased respiratory distress and decreasing blood pressure. If this occurs lift one edge of the dressing long enough to allow air to escape.

    3.  

  3. Stabilize impaled objects. Secure occlusive (e.g., Vaseline®) gauze at base of impaled objects.

    4.  

  4. Assess breath sounds every 5 minutes.

    5.  

  5. If level of consciousness is decreased or vital signs abnormal; transportation by advanced life support is preferred.

 

ALS

 

  1. If tension pneumothorax is suspected perform needle decompression (see Needle Chest Decompression).

Abdominal Injuries

 

  1. If an evisceration is present, keep it covered with moist sterile, non-adherent dressings. Use normal saline. Do not attempt to replace organs. Do not use Vaseline dressing.

    2.  

  2. Transportation by ALS is preferred.

Musculoskeletal Injuries

  1. Assess distal circulation, movement, and sensation before moving the injured extremity.

    2.  

  2. Cover open wounds with a sterile dressing. If bone is exposed, use a moist, sterile saline dressing.

    3.  

  3. Splint the injured extremity.

    4.  

  4. Do not attempt to straighten the extremity unless pulses are absent. Never attempt to straighten an injury involving a joint. If resistance is met while straightening a limb, splint the injury as it is.

    5.  

  5. Reassess distal circulation, movement and sensation.

    6.  

  6. Elevate the extremity in a supported position and apply cold packs.

    7.  

  7. When in doubt, splint.

    8.  

  8. If the patient is in more pain after splinting of the injured part, reassess and re-splint.

    9.  

  9. Care of amputated parts:

    10.  

    1. Rinse away gross contamination with sterile saline.

      2.  

    2. Cover the injured site on the amputated part with a moist, sterile saline dressing and bulky bandage.

      3.  

    3. Place the amputated part in a plastic bag. If ice is immediately available, place the plastic bag on ice. Do not delay transport to obtain ice.

      4.  

    4. Do not clamp bleeders. Apply a compression dressing.

Crush Injury

 

  1. Prior to the release of an extremity or large muscle group from an entrapped position longer than 20 minutes, initiate normal saline or LR infusion “wide open” to encourage diuresis.

    2.  

  2. Consider applying a commercial tourniquet proximal to the entrapped extremity prior to release.

    3.  

  3. Apply EKG prior to release if possible. For patients who exhibit a wide QRS (> 0.12 sec), peaked T-waves, experiences cardiac arrythmias or goes into cardiac arrest, refer to Hyperkalemia protocol.

Burns

 

  1. Protect yourself!

    2.  

  2. Remove the patient from the source, put out fire on the patient and remove burned clothing.

    3.  

  3. Address the more life threatening injuries first, and then treat burns.

    4.  

  4. Maintain sterility when treating burns.

    5.  

  5. Estimate the percentage and degree of burns using the rule of nines, or as an alternative for burns less than 10 percent, the palm of the patient’s hand is equivalent to ~1% BSA

    6.  

  6. Categorize type of burn and provide appropriate treatment:

    7.  

    Thermal Burns

     

    1. Suspect inhalation injury in any patient with facial burns or involvement in any fire in an enclosed space.

      2.  

    2. For first and second degree thermal burns involving < 10% body surface, soak area with sterile water for 10-15 minutes until temperature is the same as the normal skin, then cover. Do not apply cold packs to burned areas.

      3.  

    3. For all other thermal burns, cover with dry, sterile dressings or burn sheets (If in doubt whether to soak burns, leave dry.)

      4.  

    4. Leave unbroken blisters intact.

     

    Chemical Burns

     

    1. Brush off excess dry agent
    2. Copious irrigation with saline or water for at least 20-30 minutes.
    3. Transport in dry sterile sheets.
    4. Keep warm – protect from hypothermia associated with wet skin.

     

    Electrical Burns

     

    1. Turn off the source.
    2. Be aware of musculoskeletal injuries and an irregular pulse.
    3. Look for entrance and exit wounds.

      4.  

  7. Place the patient on high flow oxygen with a non-rebreather at 10 – 15 LPM.

    8.  

  8. ALS is preferred for:

    9.  

    1. Any burns complicated by fractures
    2. All electrical burns
    3. Any burns complicated by smoke inhalation, damage to the airway or confinement in an enclosed space.
    4. Pediatric patients
    5. Partial or full-thickness burns of > 10% BSA.
    6. Burns involving hands, feet, face, genitalia or joints
    7. Patients meeting medical alert criteria
    8. Patients meeting trauma criteria

     

    ALS

     

    1. Intubate the patient if indicated. Strongly consider oral intubation if LOC is decreasing and one or more of the following signs are present:

      2.  

      1. Obvious oral inhalation injury (e.g., increasing hoarseness, stridor)
      2. Soot in the airway or nasal hair burned

       

    2. Apply the cardiac monitor to non-burned skin.

      3.  

    3. Initiate an IV with normal saline for partial or full thickness burns > 20% BSA, other associated trauma, significant dysrhythmias, or need for intubation.

      4.  

      1. Insert IV catheter preferentially through non-burned skin.

        2.  

      2. Run wide open until arrival at hospital or 1000 mL infused.

        3.  

      3. Document total IV fluids given in the field and advise receiving facility upon arrival.

       

    4. Administer fentanyl as appropriate (See Pain Management Protocol)

      5.  

        Burn injuries that should be referred to a burn center include:

          Partial thickness burns greater than 10% total body surface area (TBSA).

          Burns that involve the face, hands, feet, genitalia, perineum, or major joints.

          Third degree burns in any age group.

          Electrical burns, including lightning injury.

          Chemical burns.

          Inhalation injury.

          Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.

          Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.

          Burned children in hospitals without qualified personnel or equipment for the care of children.

          Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

Rule of Nines

Burn Severity

BSA
Superficial
Partial Thickness
Full Thickness
100%
Moderate
> 50%
Critical
> 30%
Critical
> 30%
90%
80%
70%
60%
50%
40%
Minor
< 50%
30%
20%
Moderate
< 30%
15%
10%
Minor
< 15%
2%
Moderate
< 10%
0%
Minor
< 2%
 
Critical
Any partial or full thickness burn involving hands, feet, face, genitalia, or joints.

Conducted Energy Weapons

This protocol is intended to provide guidelines for care of patients following the use of electromuscular disruption (EMD) weapons (e.g., the X26 TASER®). For situations involving altered level of consciousness, significant secondary trauma or other medical problems, follow the applicable protocol(s).

  1. Assure the scene is secure. Use of this type of weapon to subdue a violent person implies he/she was a risk to him/herself or others.

    2.  

  2. Evaluate and treat for secondary injuries/altered level of consciousness as indicated.

    3.  

  3. Stabilize dart(s) in place and transport patient to ED if the dart(s) is/are embedded in the eyelid/globe of eye, genitalia, or face/neck.

    4.  

  4. Darts in other locations may be carefully removed by gently pulling backwards in the same plane as they entered the body. Assure the dart is intact and no portion of the dart remains inside the patient’s skin.

    5.  

  5. Provide the darts to law enforcement officers.

    6.  

  6. Control minor bleeding and clean the wound area(s) with alcohol and/or povidone-iodine solution. Cover with an adhesive bandage.

    7.  

  7. If all darts are out, any minor bleeding is controlled, and no other injuries or symptoms exist, EMS transport is not indicated and an SOR may be obtained.

Traumatic Brain Injuries

AVOID THE 3 “H-BOMBS” IN TRAUMATIC BRAIN INJURY:
HYPOXIA, HYPOTENSION AND HYPERVENTILATION

 

  1. Identify patients with physical trauma and a mechanism consistent with the potential to have induced brain injury and:

    2.  

    1. GCS of 12 or less
    2. GCS  < 15 with decreasing mental status
    3. Multisystem trauma requiring intubation (whether the primary need for intubation was from TBI or from other potential injuries)
    4. Post‐traumatic seizures (whether status or not).

     

  2. Elevate head of gurney 30o if possible.

    3.  

  3. Start 15 L/min O2 via NRB and obtain IV access when applicable.

    4.  

  4. Monitor O2, BP, HR, and neurologic status every 3-5 minutes.

    5.  

  5. AVOID HYPOXIA: Maintain oxygen saturation > 90%.

    6.  

    1. If oxygen saturation falls below 90% despite NRB, reposition airway and start BVM ventilation with airway adjuncts (eg, OP or NP airway when appropriate). Do not hyperventilate.

       

    2. If airway compromise or hypoxia persists after these interventions, a non-visualized airway or ETI should be considered (see Airway Management Protocol).

     

  6. AVOID HYPERVENTILATION: Maintain Normo-Ventilation.

    7.  

    1. If there is evidence of hypoventilation (ineffective respiratory rate, shallow or irregular respirations or periods of apnea) despite high-flow O2, assist ventilation with BVM and if ineffective, consider non-visualized airway or ETI (see Airway Management Protocol).

      2.  

    2. When assisting ventilation with BVM, maintain respiratory rate according to the following:

      3.  

        25 breaths per minute in infants (0-24 mo)
        20 bpm in children (2 yo-14 yo)
        10 bpm in children aged 15 or older
        10 breaths per minute in adults

       

    3. In intubated patients, use BVM to maintain ETCO2 between 35 and 45 mmHg.

      4.  

  7. AVOID HYPOTENSTION: Maintain blood pressure according to the following:

    8.  

    > 70 mmHg for infants 0-24 mo
    > 80 mmHg for children 2 yo-7 yo
    > 90 mmHg for children 8 yo and older and all adults

    Prevent even a single isolated episode of hypotension by IV fluid resuscitation withinitial bolus of 1 L NS, followed by repeat boluses of 500 ml NS to keep SBP > 90 mmHg in adults. 20 ml/kg for pediatric patients, followed by repeat boluses of 10 ml/kg NS or at sufficient rate to keep SBP as above. Do not treat hypertension, but restrict IVF TKO in adults with SBP > 140 mm Hg, infants with SBP > 100 mmHg and older children/adolescents with SBP > 130 mm Hg.

     

  8. Check for hypoglycemia.

    9.  

    If hypoglycemic, follow hypoglycemia protocol in Altered Level of Consciousness

Traumatic Cardiac Arrest Resuscitation

Definitions:

Signs of Life is defined as: pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure or extremity movement.

 

Blunt Trauma – Adult

 

  1. Initiate resuscitation using traumatic cardiac arrest protocol only if the adult patient had initial Signs of Life when first encountered by public safety [Police, Fire, EMS] after injury prior to cardiac arrest (i.e. a witnessed traumatic cardiac arrest due to blunt trauma)

  2. Withhold traumatic cardiac arrest resuscitation if unwitnessed with blunt mechanism. Fully document absent signs of life in patient care report.

    3.  

      If a first responder prior to EMS arrival has already started resuscitation on an unwitnessed arrest with blunt trauma, EMS providers are to ask about to surrounding circumstances to verify if there was signs of life before resuscitation was started. Resuscitation does not need to be continued if there were no signs of life before first responder arrival.

 

Penetrating Trauma – Adult

 

  1. Initiate resuscitation using traumatic cardiac arrest protocol if the adult patient had initial Signs of Life when first encountered by public safety [Police, Fire, EMS] after injury prior to cardiac arrest (i.e. a witnessed traumatic cardiac arrest due to penetrating trauma) or if the arrest was unwitnessed with suspected downtime less than 10 minutes from first medical contact

  2. Withhold traumatic cardiac arrest resuscitation if unwitnessed with a suspected downtime of > 10 minutes with penetrating mechanism. Fully document absent signs of life in patient care report.

 

Exceptions

 

     Pregnancy > 24 weeks or palpable fundus at/above the level of umbilicus (transport immediately).

     If in doubt of circumstances, initiate resuscitation and transport.

     Pediatric patients who are in traumatic cardiac arrest should be transported to the nearest pediatric trauma center if the arrest was witnessed or unwitnessed.

 

If resuscitation started, begin CPR, then:

 

  1. Control obvious external hemorrhage by application of tourniquets and/or direct pressure/wound packing
  2. Provide oxygenation and ventilation by BVM or advanced airway
  3. If mechanism of injury was blunt or penetrating trauma to chest, perform bilateral needle thoracostomy.
  4. Evaluate cardiac rhythm and defibrillate if required
  5. Initiate fluid resuscitation by IV/IO access
  6. Transport to the nearest trauma center

 

Adult Traumatic Cardiac Arrest – Blunt Mechanism
Did the patient have any signs of life for Public Safety
(Police, Fire, EMS?)
YES or Unsure ↙ ↘ NO
Initiate Resuscitation
Transport to Trauma Center as
soon as possible
     Do not initiate resuscitation unless
pregnant > 24 weeks or palpable
fundus at/above the level of umbilicus

 

Adult Traumatic Cardiac Arrest – Penetrating Mechanism
Did the patient have any signs of life for Public Safety
(Police, Fire, EMS?) or has suspected downtime of less than
10 minutes before first medical contact?
YES or Unsure ↙ ↘ NO
Initiate Resuscitation
Transport to Trauma Center as
soon as possible
  Do not initiate resuscitation unless
pregnant > 24 weeks or palpable
fundus at/above the level of umbilicus