COOKE COUNTY EMERGENCY MEDICAL SERVICES

Transcription

1 COOKE COUNTY EMERGENCY MEDICAL SERVICES Patient Treatment Protocols For use by Cooke County Emergency Medical Services Douglas T. Lewis, M.D. Medical Director Effective Date: June 1, 2012

2 Table of Contents Geographical and Status Personnel... 5 Protocol Definitions... 6 Trauma Section 5 37 Introduction... 8 Initial Scene Survey... 9 Decision to Attempt Resuscitation Initial Trauma Assessment and Treatment Traumatic Arrest Traumatic Shock Penetrating Injuries: Truncal Wounds Neck wounds Head/Face Wounds Isolated Extremity Wounds Impaled Objects Sucking Chest Wound Traumatic Brain Injury Eye Injuries: Corneal Burns and Abrasions Blunt or Penetrating Eye Injuries Burn Injuries: Chemical Injuries to Eye Thermal Burns Chemical Burns Electrical Burns / Electrocutions Amputation Pregnant Trauma Patient Pediatric Trauma Isolated Musculo-Skeletal Injury Acute Blunt Spinal Cord Injury Domestic Violence These protocols are unique to Cooke County EMS per Medical Director Page 1

3 Medical Section Abdominal Pain Allergic Reaction Mild Allergic Reaction Moderate Allergic Reaction Severe - Anaphylaxis Cardiac Arrest Asystole Pulseless Electrical Activity (PEA) VF / Pulseless VT Post Resuscitation Bradycardia PSVT: Stable PSVT: Unstable VT: Stable VT: Unstable Acute Coronary Syndrome (Chest Pain - Suspect MI) STEMI Induced Hypothermia Cardiogenic Shock Hypotension / Shock unexplained Hypertensive Crisis Stroke Asthma CHF and Pulmonary Edema COPD Pneumonia / Bronchitis Seizures Dehydration Diabetic Emergencies Altered Mental Status Overdose / Poisoning Behavioral/ Emotionally Disturbed Chemical Restraint Carbon Monoxide Poisoning Heat Cramps / Exhaustion Heat Stroke Hypothermia Radiation Exposure Snakebite Sexual Assault These protocols are unique to Cooke County EMS per Medical Director Page 2

4 OB / GYN Section Vaginal Bleeding Pre-Eclampsia / Eclampsia Labor Delivery Breech Presentation Cord Presentation Limb Presentation Pediatric Section Post Delivery Neonatal Resuscitation Meconium Staining Asystole PEA VF / Pulseless VT Post Resuscitation Unstable Narrow Complex Tachycardia Bradycardia Abdominal Pain Allergic Reaction Mild Allergic Reaction Moderate Allergic Reaction Severe- Anaphylaxis Altered Mental Status Hypoglycemia Hyperthermia Hypothermia Near Drowning Overdose / Poisoning Asthma Bronchiolitis Croup Epiglottitis Obstructed Airway / Foreign Body Seizures These protocols are unique to Cooke County EMS per Medical Director Page 3

5 Appendix: Procedure Protocols Pain Management Medication Assisted Intubation (MAI) Rapid Sequence Induction for Intubation (RSI) Continued Sedation / Paralysis Airway Management for the Burn Victim Air Evacuation Protocol Pacing Protocol DNR Protocol Transtracheal Jet Ventilation Surgical Cricothyroidotomy Nasotracheal Intubation Orotracheal Intubation King Airway Needle Chest Decompression Mucosal Atomization device (MAD) Portable Ventilator Tidal Volumes (Pedi & Adult) Blood Administration Continuous Positive Pressure EZ IO Intraosseous Infusion Rule of Nine s Adult Burn Chart Rule of Nine s Child Burn Chart Lund & Browder Burn Chart Classification of Burn Severity Reference Pediatric Drug Chart Drug Calculations Dopamine Drip Chart Levophed Drip Chart Nitroglycerin Drip Dosage Chart Dobutamine Drip Chart Nasogastric Tube Lead Placement Reference Termination of Pre-hospital Resuscitation Spinal Immobilization Clearance Orthostatic BP Measurement Start Triage Guide System Drug Guide Section Pregnancy Category for Drugs Drugs A Z These protocols are unique to Cooke County EMS per Medical Director Page 4

6 Geographical and Status of Personnel Geographical Responsibility and Status of Personnel Cooke County Emergency Medical Services covers 874 Sq. Miles of Cooke County. We are a rural EMS provider with pockets of dense population. This protocol is to clarify when an EMT, EMT-P, Licensed Paramedic or Critical Care Paramedic may perform his or hers protocols and in what areas they may utilize these protocols. It is intended that these protocols are for on duty personnel. It is understood that there are times the off duty personnel respond to major incidents, and in this case, the off duty personnel may utilize their skills. It is further understood that off duty personnel may come across incidents that may require for them to utilize their skills. Within the operating area of Cooke County, the personnel may utilize their skills, but all must be documented on the Patient Care Report. Off Duty personnel that are traveling outside of Cooke County, that come across an incident, may utilize all their skills within the guidelines of these protocols. An incident report must be completed and turned into the Administrator, and a copy must go to the Medical Director for review. On Duty personnel that are out of Cooke County EMS operating area and come across and incident, may utilize their skills to the certified level. All appropriate patient care documentation must be completed. These protocols are unique to Cooke County EMS per Medical Director Page 5

7 Protocol Definitions Definitions 1. Vital signs For the purposes of these protocols, vital signs will be defined as follows: a. Pulse b. Respirations c. Blood Pressure d. Pulse Oximetry e. Temperature f. Blood Glucose (as Indicated) g. End Tidal Co2 numbers and Charted waveforms on the following types of patients: 1) All intubated patients 2. Multi-Casualty Incident: Any incident that overwhelms local response capabilities 3. Verified intubation tube placement A successful endotracheal intubation will be verified and documented by at least 4 of the following criteria: 4. Pediatric Limits a. Direct Visualization of tube passing through the cords b. Auscultation of six lung fields with positive air return c. Auscultation of an absence of air in the epigastrium d. Fogging of the tube e. Positive initial ETCO2 return f. Continuous ETCO2 return g. Charting of ETCO2 waveform h. Proper use of Bougie Stylet device a. Any patient < 18 years of age and < 40 kg or b. Any patient < 12 years of age. These protocols are unique to Cooke County EMS per Medical Director Page 6

8 Trauma Protocols These protocols are unique to Cooke County EMS per Medical Director Page 7

9 Trauma Introduction The initial assessment and treatment of a trauma patient must be performed in a rapid, systematic, and thorough fashion. Evaluation of the patient according to established priorities will help one to identify serious life-threatening situations quickly, so that intervention can take place, possibly preventing further deterioration in the patient s status. The systematic evaluation of the trauma patient should be performed on all injured patients, even those with minor trauma. The most important priorities in the evaluation and treatment of the trauma patient are found in the primary survey of the patient. Frequently, patient assessment must occur simultaneously with patient treatment during this phase of the patient s evaluation. At times, invasive procedures (e.g., intubation with in-line cervical stabilization) or initiation of rapid transport may be required before the complete, overall patient assessment is achieved. The primary survey in a trauma patient includes assessment and treatment of the following: 1. Airway Evaluation, establishment, and maintenance of an airway using C-spine precautions; determination of the patient s level of consciousness in order to provide additional information concerning the patient s airway status. 2. Breathing Determination of whether or not a trauma patient is adequately breathing and oxygenating. Serious chest injuries may rapidly progress to cardio-respiratory arrest, and certain chest injuries that may require immediate intervention (sucking chest wounds, tension pneumothorax). 3. Circulation Determination if a pulse is present, controlling external bleeding, and identification of injuries that may use significant blood loss. Initiation of rapid transport and intravenous fluids play a role in the treatment of the patient at this stage. 4. Disability Performance of a rapid neurological evaluation to establish a patient s level of consciousness, and pupillary size and reaction. 5. Exposure The clothing is removed to identify all injured areas with special care to avoid hypothermia. These protocols are unique to Cooke County EMS per Medical Director Page 8

10 Trauma - Initial Scene Survey This guideline should be used in the initial assessment of the scene where a trauma patient is located. 1. Survey the scene for possible hazards and resurvey periodically. 2. Protect yourself first, then victims from hazards. 3. Identify mechanism of injury. 4. Identify all potential patients. Notify Medical Control of victim count. 5. Prioritize patients, if more than one, using the same ABC system. 6. If MCI, triage using START. 7. Secure the scene. These protocols are unique to Cooke County EMS per Medical Director Page 9

11 Trauma Decision to Attempt Resuscitation The following are guidelines regarding the decision to attempt resuscitation in the field. Good judgment and common sense shall be used in the application of these guidelines. 1. In all situations where there is any possibility that life exists, every effort should be made to resuscitate the patient and transport to the hospital. 2. The paramedic should be aware of the following facts: a. Those persons in VF, PEA, and Asystole can potentially be resuscitated. b. That time down is an inaccurate parameter of resuscitation, as the patient could have been in bradycardia or simply unconscious for all of that time, yet still perfusing blood to the brain. Additionally, information received from bystanders in regard to time is often inaccurate. c. That pupil size and response to light can be inaccurate as medications taken orally or intraocular can affect them. Additionally, children and hypothermic patients may have fixed and dilated pupils from anoxia and yet be resuscitated without neurological deficit. 3. Resuscitation need not be attempted in the field in cases of: a. Decapitation b. Decomposition c. Rigor mortis d. Dependent lividity e. Visual massive trauma to the brain or heart conclusively incompatible with life f. Blunt mechanism of injury in cardiac arrest 4. Mass Casualty Incidents - In these situations, the acceptable triage protocol will apply. 5. Living Wills - The paramedic s actions should not be changed by a Living Will described or produced by the family or bystanders. 6. NO TRANSPORT Decisions to not transport must be approved through MEDICAL CONTROL. Note: Since it is usually not possible to predict no recoverability of a brain acutely insulted by cardiac arrest and attempts to do so increase anoxia time with the likelihood of further permanent brain damage, the responsible paramedic is usually obligated to start CPR. Paramedics should keep in mind that they may be held liable if they elect not to do so, on an arbitrary basis. These protocols are unique to Cooke County EMS per Medical Director Page 10

12 Trauma - Initial Assessment and Treatment Clinical Definition: This guideline establishes priorities in the initial assessment and treatment of trauma patients. The trauma patient must be evaluated and treated in a rapid and orderly fashion in order to achieve the best patient outcome. When a treatable problem is identified, treatment is initiated for that problem before proceeding with the next step in the guideline. Using this approach, life-threatening injuries are identified and treated in a stepwise manner. NOTE: Assume the following in ALL severely injured patients: a. The patient has a spinal injury until proven otherwise b. The patient has an immediate threat to life that has not yet been found. c. The patient is going to decompensate at any moment. The only aspects of patient care that, in most cases, would be performed prior to the initiation of patient transport include: a. Establish and maintain an adequate and appropriate airway with oxygenation and ventilation as required. b. Immobilize and protect the spine as indicated and required c. Initial attempts to control significant external hemorrhage AIRWAY: Basic Life Support: 1. Assess level of consciousness 2. Assess, establish, and/or maintain an adequate airway, while also observing C-spine precautions. Apply cervical collar if indicated and while doing so, note: a. Is trachea midline? b. Any bruising, swelling, or crepitus in the neck? c. Is carotid pulse present? If no pulse present, begin CPR and immediately refer to Traumatic Arrest Protocol. (pg. 15) 3. Insert oral or nasopharyngeal airway as indicated. 4. Administer high flow oxygen (100% by face mask or BVM) and assist patient s ventilation as needed. If the patient has a decreased level of consciousness, ventilate: a. 13 y/o breaths/mi b y/o breaths/min c. 0 4 y/o breaths/min If the patient has a decreased LOC or other signs of a traumatic brain injury: refer to Traumatic Brain Injury Protocol (pg. 23), after completion of the Initial Trauma Assessment and Treatment Protocol. (pg ) 5. Reassess patient frequently including adequacy of ventilations. Intermediate and Paramedic: 6. Establish need for in-line endotracheal intubation. Observe C-spine precautions. 7. If intubation is necessary, it should be performed using the two-man technique with one person stabilizing the cervical spine while the other person performs the intubation. Extreme care must be taken to avoid flexion or extension of the neck. These protocols are unique to Cooke County EMS per Medical Director Page 11

13 8. If intubation is performed, endotracheal tube placement should be assessed and documented using three or more of the following techniques: a. Visualization of endotracheal tube passing through vocal cords. b. Equal breath sounds. c. Absence of ventilated air in the epigastrium d. Rise and fall of chest wall. e. Use of a Bougie f. Fogging of the Endotracheal Tube g. Positive Initial Co2 return with EtCo2 (if available) h. Charting of ETCO2 waveform 9. End-tidal CO2 monitor. If the patient has a decreased level of consciousness, ventilate to maintain an EtCo2 of mmhg, otherwise ventilate at a rate of breaths/minute for adults and children at a rate of breaths/min for children less than 4 years of age. If the tube cannot be confirmed in the proper position, it should be removed and the patient re-intubated. When proper placement is confirmed, the tube should be properly secured with tube holder and c-collar and CID to minimize the chances of dislodgment. (If unable to fit patient with c-collar, secure head with CID). 10. Reassess patient s airway/ventilation frequently. NOTE: Failure to provide and maintain an adequate airway is the most common cause of preventable pre-hospital morbidity and mortality. The airway should be carefully assessed initially and frequently reassessed to assure a competent airway is maintained during the pre-hospital phase of treatment. BREATHING: Basic Life Support: 1. Observe chest wall movement for symmetry and auscultate breath sounds on both sides of the chest. Rate, depth, and pattern of breathing as well as the integrity of the chest wall should be assessed. 2. Assist or deliver ventilations as required. All patients with a decreased level of consciousness ventilate: a. 13 y/o breaths/min b breaths/min c. 0 4 y/o breaths/min 3. All patients with more than minor injuries (e.g., isolated extremity fractures, minor lacerations, etc.) should receive supplemental 100% oxygen by non-rebreather mask or BVM. 4. If sucking chest wound has been identified, apply dressing as described in Sucking Chest Wound Protocol. (pg. 22) Intermediate: 5. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask or endotracheal tube to maintain a EtCo2 of mmhg. Paramedic: 6. If signs of tension pneumothorax are present, refer to the Needle Chest Decompression Protocol (pg. 132) and contact MEDICAL CONTROL These protocols are unique to Cooke County EMS per Medical Director Page 12

14 CIRCULATION/ BLEEDING: Basic Life Support: 1. Control serious external bleeding by direct pressure or pressure dressings. 2. If not already done, palpate for a pulse. If not present, initiate CPR and proceed to the Traumatic Arrest Protocol (pg. 15) 3. If pulse is present, then obtain pulse rate and BP. If systolic BP < 90, Heart Rate > 120, and/or clinical evidence of shock is present, refer to Traumatic Shock Protocol. (pg. 16) 4. Palpate abdomen for rigidity or tenderness and pelvis for pain or crepitus (identifying potential sources for significant blood loss). 5. Examine the patient s back, if possible, for gross deformities or penetrating injuries prior to placing the patient on the backboard. 6. For penetrating injuries, also see Penetrating Injuries Protocol. (pg. 17) Intermediate and Paramedic: 7. If there is evidence of a significant mechanism of injury, external blood loss, or evidence of possible pelvic or femur fracture or other significant injuries, attempt to establish 2 large bore IVs with NS and run wide open if the patient s SBP is less than 90 mmhg systolic. Run IV at TKO rates or at the direction of MEDICAL CONTROL. Attempts to establish IV access are usually made en route but may be made at the scene if long transports are anticipated after consulting MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If the patient has a SBP < 90 or heart rate > 120, see the Traumatic Shock Protocol. (pg. 16) DISABILITY (Neurological Exam): All Levels: 1. Evaluate neurological status by noting the following: a. Mental status/level of consciousness. b. Presence/absence of movement in extremities, either spontaneously or in response to pain c. Pupillary size and reactivity. d. Evidence of trauma to the head or neck. 2. If evidence of head trauma, have suction ready and observe for any seizure activity. 3. If altered level of consciousness, assist or ventilate patient (if patient will allow). a. 13 y/o breaths/min b y/o breaths/min c. 0 4 y/o breaths/min End-tidal CO2 monitor, ventilate to maintain an EtCo2 of mmhg. 4. If evidence of closed head injury, see Traumatic Brain Injury Protocol. (pg ) NOTE: The patient s status must be reassessed at frequent intervals to detect changes and these changes should be immediately reported to Medical Control. The ABC s including vital signs should be repeated every 15 minutes in potentially stable patients and every 5 minutes in unstable patients. These protocols are unique to Cooke County EMS per Medical Director Page 13

15 EXPOSE AND EXAMINE: All Levels: 1. Examine for specific injuries burns, chemicals, drowning, eye, etc. If present, see specific protocol. 2. Assess extremities by inspection and palpation for present of tenderness, gross deformity, soft tissue swelling, lacerations, or abrasions. Also, note motor, sensory, and vascular integrity in each extremity. Appropriately dress and splint extremity injuries as required and as time will allow. Elevate injured extremities when possible. 3. If possible, when patient is log rolled onto backboard, palpate and inspect back for evidence of trauma. 4. Calculate Glasgow Coma Score and Revised Trauma Score. GLASGOW COMA SCORE REVISED TRAUMA SCORE Eye Opening Spontaneously To verbal Command To Pain No Response Score: Score Respiratory Rate = > 29 = 6 9 = 1 5 = 0 = Score: Score Best Verbal Response Oriented Confused Inappropriate words Incomprehensible sounds No Response Score: Systolic Blood Pressure > 89 = = = 1 49 = 0 = Score: Best Motor Response Obeys Localized Pain Withdraws to pain Abnormal Flexion to pain Extension to pain No Response Glasgow Coma Score = 9 12 = 6 8 = 4 5 = 3 = Score: Score: Total Total These protocols are unique to Cooke County EMS per Medical Director Page 14

16 Traumatic Arrest Clinical Definition: This protocol should be used for the treatment of a patient who has suffered a traumatic cardiac arrest. Patients with a blunt mechanism of injury and who have a cardiac arrest have minimal, if any, chance of survival, and many pre-hospital providers do not attempt resuscitation. For those providers who attempt resuscitation, the following protocol should be used. Resuscitation should be attempted in all patients with a penetrating mechanism of injury. Basic Life Support: 1. If not already done, evaluate/treat ABC s according to Trauma assessment and Treatment Protocol. (pg ) 2. Initiate CPR and prepare for rapid transport. Immobilize spine, if appropriate. Intermediate: 3. Intubate using in-line cervical spine stabilization, if appropriate. 4. Identify correctable causes of hypoxia and initiate treatment: a. Administer 100% oxygen. b. For sucking chest wounds, treat according to Sucking Chest Wound Protocol. (pg. 22) 5. End-tidal CO2 monitor. If the patient has a decreased level of consciousness, ventilate to maintain an EtCo2 of mmhg, otherwise ventilate at breaths/minute for adults and children at breaths/min for children less than 4 years of age. 6. Attempt to establish 2 large bore IVs with Normal Saline and run wide open. Attempts at IV access should be made en-route, but can be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If unable to obtain IV, IO may be used. Paramedic: 7. Apply ECG electrodes and determine cardiac rhythm. 8. If rhythm other than PEA, treat cardiac arrhythmia per protocol during transport. 9. Continue evaluation as per Initial Trauma Assessment and Treatment Protocol. (pg ) 10. Evaluate for tension pneumothorax, Contact Medical Control and refer to the Needle Chest Decompression Protocol. (pg. 132) Note: PEA in a trauma patient is most likely due to hypovolemia from blood loss. Definitive therapy is usually required to stop the source of hemorrhage and blood transfusions are needed usually ASAP. Hence rapid extrication and transport is essential. Remember that Normal Saline helps expand the circulating blood volume BUT DOES NOT CARRY OXYGEN. These protocols are unique to Cooke County EMS per Medical Director Page 15

17 Trauma - Traumatic Shock Clinical Definition: This protocol should be used for the treatment of patients with traumatic shock SBP < 90 & HR > 120, but with a palpable pulse. If no pulse is palpable, proceed to (Traumatic Arrest Protocol) (pg. 15). Frequently, shock in a trauma patient is due to internal or external bleeding. Hemorrhagic shock can be recognized by hypotension, tachycardia, diaphoresis, pallor, cyanosis, tachypnea, and other clinical signs of shock. Fluid resuscitation should be aimed at maintaining a SBP mm/hg and no higher. Basic Life Support: 1. If not already done, evaluate/treat ABC s according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11) 2. Prepare for rapid transport. Intermediate: 3. If indicated, intubate the patient using C-spine precautions. If intubation is used, End-tidal CO2 monitor ventilate to maintain an EtCo2 of mmhg, otherwise ventilate at breaths/minute for adults and larger children and at breaths/min for children less than 4 years of age. 4. Attempt to establish 2 large bore IVs with Normal Saline and run wide open. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If unable to obtain IV, IO may be used. 5. Continue evaluation as per Initial Trauma Assessment and Treatment Protocol. (pg ) Paramedic: 6. Evaluate as to need for Blood Therapy. (Blood Administration Protocol (pg. 136) 7. Apply ECG electrodes and determine cardiac rhythm. Note: Fluid resuscitation in children is performed according to weight. Definitive therapy is usually required to stop the source of hemorrhage and blood transfusions are needed usually ASAP. Rapid extrication and transport is essential. Remember that Normal Saline helps expand the circulating blood volume; BUT DOES NOT CARRY OXYGEN. MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 16

18 Trauma Penetrating Injuries (Truncal Wounds) Clinical Definition: Any injury in which there is evidence for penetration of the skin by an object that could result in injury to underlying structures. Examples include gunshot wounds, stab wounds, ice pick wounds, impaled objects, sucking chest wounds, etc. Other protocols may apply in cases of penetrating injuries, such as traumatic shock and traumatic arrest. Refer to all of the appropriate protocols that apply. General Guidelines: Truncal Wounds Chest / Abdomen / Back / Proximal Extremities Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Treat open chest wounds according to guidelines for sucking chest wounds; refer to Sucking Chest Wounds Protocol (pg. 22) 5. Treat evisceration of abdominal contents by covering tissue with saline-moistened gauze sponges or sterile towels. DO NOT attempt to replace abdominal contents through the wound. Intermediate: 6. Attempt to establish 2 large bore IV s with Normal Saline and run at appropriate rate to be aimed at maintaining a SBP between mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 7. Apply ECG electrodes and determine cardiac rhythm. MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 17

19 Trauma Penetrating Injuries (Neck Wounds) General Guidelines: Head / Neck / Face Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Maintain high index of suspicion for C-spine injury, tracheal injury, blood vessel injury, and lung injury. 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Monitor closely for signs of soft tissue swelling in the neck that could lead to airway obstruction. 5. Have suction set up and ready to clear airway of blood or secretions. 6. Observe closely for signs of a tension pneumothorax. Intermediate: 7. Attempt to establish 2 large bore IV s and Normal Saline and run at appropriate rate to be aimed at maintaining a SBP mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 8. Apply ECG electrodes and determine cardiac rhythm. Contact Medical Control: Prophylactic intubation (MAI or RSI) may be required if airway compromise from neck swelling occurs. Consult MEDICAL CONTROL. MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 18

20 Trauma Penetrating Injuries (Head & Face Wounds) General Guidelines: Head / Face Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Maintain high index of suspicion for C-spine injury, tracheal injury, and/or blood vessel injury. 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Have suction set up and ready to clear airway of blood or secretions. 5. Elevate head of backboard 15 to 30 degrees - DO NOT elevate head by flexing neck! Intermediate: 6. If patient is unconscious or has a decreased LOC without a gag reflex and or rising ICP is suspected, endotracheal intubation should be performed to decrease intracranial pressure. If intubated then use, End-tidal CO2 monitor. Ventilate to maintain an EtCo2 of mmhg, otherwise ventilate at breaths/minute for adults and larger children and at breaths/min for children less than 4 years of age. 7. Attempt to establish 2 large bore IVS with Normal Saline and run at rate to be aimed at maintaining a SBP mm/hg and no higher. 8. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 9. Apply ECG electrodes and determine cardiac rhythm. Contact Medical Control: Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs. MINMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 19

21 Trauma Penetrating Injuries (Isolated Extremity Wounds) General Guidelines: Isolated Extremity Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Check neurovascular status distal to wound (presence of pulse, feeling, and movement). 2. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 3. Control external bleeding with direct pressure first, then pressure dressings. 4. Splint affected extremity. 5. Elevate affected extremity 15 to 30 degrees. 6. Prepare for rapid transport, even if vital signs are stable. Intermediate: 7. If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or wound close to trunk or thigh area, attempt to establish 2 large bore IV with Normal Saline and run at appropriate rate to be aimed at maintaining a systolic blood pressure between mm/hg and no higher. 8. Attempts at IV access should be made en-route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 9. Apply ECG electrodes and determine cardiac rhythm. 10. Refer to Pain Management Protocol. (pg. 117) MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 20

22 Trauma Impaled Objects Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) 2. In general, do not remove impaled object. If impaled object is causing airway compromise resulting in respiratory distress, and this distress cannot be corrected without removal of the foreign body, contact MEDICAL CONTROL immediately for further orders. 3. When possible, stabilize the impaled object on the body so that it does not move around and cause more internal injury. 4. Any impaled object to the torso (chest, abdomen, back, lower neck, or proximal extremities) should be considered a potentially life-threatening injury and treated as such. Transportation should be initiated as soon as possible, even if the patient appears stable. 5. If manpower is available and time exists during transport, continue further evaluation and treatment of patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Intermediate: 6. If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or wound close to trunk or thigh area, attempt to establish 2 large bore IV S of Normal Saline and run at appropriate rate to be aimed at maintaining a SBP between mm/hg and no higher. 7. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 8. Apply ECG electrodes and determine cardiac rhythm. 9. Refer to Pain Management Protocol (pg. 117) MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 21

23 Trauma Sucking Chest Wound Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg ) 2. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask 3. Seal the wounds as rapidly as possible, preferably with Vaseline-coated gauze or asherman chest seal, to prevent further collapse of the lung. * In general, the dressing should be sealed on two or three sides only. This allows it to act as a one-way valve allowing air in the pleural space (chest cavity) to get out when the lung expands, but preventing air on the outside from entering the chest cavity through the wound.* 4. Watch closely for signs and symptoms of a tension pneumothorax. If these signs develop, usually lifting one corner of the occlusive dressing will relieve the tension pneumothorax. 5. Prepare for rapid transport. 6. As time allows and manpower permits, continue evaluation and treatment of the patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Intermediate: 7. Attempt to establish 2 large bore IVS and Normal Saline and run at rate to maintaining a SBP between mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. *Note: If patient is awake and cooperative, have him/her cough (this removes as much air as possible from the chest cavity), and then apply the Vaseline gauze or Asherman Chest Seal System immediately afterwards. 8. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask or endotracheal tube. If intubation is used, End-tidal CO2 monitor, ventilate to maintain an EtCo2 of mmhg. Paramedic: 9. Apply ECG electrodes and determine cardiac rhythm. Contact Medical Control: Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs MINIMIZE ON SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 22

24 Trauma Traumatic Brain Injury Clinical Definition: Any traumatic injury to the face or head which results in an injury to the brain, as manifested by some degree of impairment in mental function. Typically, these patients rage from being comatose to wild and combative. Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Maintain high index of suspicion for C-spine injury. Provide supplemental oxygen. 2. If patient is hypoventilating, assist or provide ventilations (with supplemental oxygen) at a rate of Have suction hooked up and readily available. Be prepared to roll patient, if necessary, should vomiting occur. 4. Monitor Oxygen Saturation 5. Take seizure precautions. 6. Prepare for rapid transport. 7. Elevate head of backboard 15 to 30 degrees. DO NOT elevate the head by flexing the neck! Intermediate: 8. Appropriate airway management may require endotracheal intubation while observing C-spine precautions. If patient is unconscious or has decreased LOC without a gag reflex, endotracheal intubation with in-line cervical spine stabilization and hyperventilation should be performed to decrease increased intracranial pressure. If intubated, use, End-tidal CO2 monitor and ventilate to maintain an EtCo2 between mmhg, otherwise ventilate at breaths/minute for adults and larger children and at breaths/min for children less than 4 years of age. 9. Attempt to establish 2 large bore IV s of Normal Saline and run at appropriate rate to maintaining a SBP mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene only if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 10. Apply ECG electrodes and determine cardiac rhythm. 11. If seizures occur and are prolonged (greater than seconds), administer Valium slow IV push in 2 mg increments, (10mg maximum for adult) until seizure stops. If intubation not performed prior to seizure, it should be performed after Valium has been administered so that hyperventilation may be more effectively performed and the airway is better protected. These protocols are unique to Cooke County EMS per Medical Director Page 23

25 12. If nausea / vomiting: Ondansetron (Zofran): 4 mg IVP, IM or Oral ODT; (Max 8 mg Q 4 hours); may repeat in 15 minutes if no improvement Pediatric Dosages of Ondansetron (Zofran): Ages 2 7: 1 mg IVP / IM or Oral ODT; (Max 2 mg Q 4 Hours); may repeat in 15 minutes if no improvement Ages 7 12: 2 mg IVP, IM or Oral ODT; (Max 4mg Q 4 Hours); may repeat in 15 minutes if no improvement Under 2 years of age.15 mg/kg IVP or Oral ODT; may repeat in 15 minutes if no improvement Contact Medical Control: Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs. These protocols are unique to Cooke County EMS per Medical Director Page 24

26 Trauma Eye Injuries (Corneal Burns & Abrasions) Clinical Definition: These injuries usually occur when the eye is exposed to sources of high intensity light or ultraviolet radiation such as associated with tanning booths, or sun lamps, also corneal injuries may be produced by prolonged wearing of contact lenses. Basic and Intermediate: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Lie patient down and have them close both eyes. 3. Bandage as necessary. Paramedic: 4. If available, and no contraindication exists, have patient open eyes and add 2 drops of a topical anesthetic for the eyes (such as Alcaine / Tetracaine) to the affected eye(s). Instruct patient not to rub their eyes once the medication has been administered. 5. Transport patient. These protocols are unique to Cooke County EMS per Medical Director Page 25

27 Trauma Eye Injuries (Blunt or Penetrating Eye) All Levels: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Have the patient lie flat or with the head slightly elevated. 3. DO NOT attempt to open the injured eye(s). 4. Instruct the patient to close both eyes. 5. Bandage as necessary. 6. DO NOT place any type of compressive dressing over the injured eye(s), and be careful not to apply pressure to the eye. 7. DO NOT REMOVE any penetrating object from the eye (unless ordered by medical control) 8. Transport the patient. These protocols are unique to Cooke County EMS per Medical Director Page 26

28 Trauma Eye Injuries(Chemical Injuries to Eye) Basic and Intermediate: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Flush the affected eye(s) with copious amounts of water or Normal Saline, using a minimum of 2 liters or more for each eye continued throughout transport. If the substance is alkaline in nature, perform continuous irrigation during transport. Contact lenses should be removed if present. Paramedic: 3. If available, and no contraindication exists, have patient open eyes and add two drops of a topical anesthetic for the eyes (such as Alcaine / Tetracaine) to the affected eye(s). Instruct patient not to rub their eyes once medication has been administered. 4. Transport patient. These protocols are unique to Cooke County EMS per Medical Director Page 27

29 Trauma- Burns (Thermal) Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Look closely for any evidence of inhalation injury (hoarseness, stridor, sooty sputum, facial burns, and signed facial hair). If present, provide supplemental oxygen, preferably humidified. 2. Prepare for rapid transport, if significant burn or inhalation injury. 3. Remove any jewelry, belts, shoes, etc. from areas of burns as these objects may retain heat and increase the burn; also swelling of burned areas may make subsequent removal difficult. In addition, remove any burned or singed clothing that is not stuck to the underlying skin of the patient. 4. Assess depth of burn (first, second, third) as well as the total area of the burn using Lund & Brower burn chart / rule of nines (pg ) or fact that palmar surface of the patient s hand usually represents 1% of body surface area. 5. Perform local burn care as follows: a. Do not apply ice to burned area. b. Do not apply ointments or solutions to burns. c. Do not attempt to open blisters. d. Small burns (<10 of BSA): 1) If burn occurred less than 15 minutes prior to your arrival, cover burn with sterile towels or gauze sponges soaked with cool saline, water or non-menthol shaving cream otherwise apply dry dressing. e. Larger burns: a. Wear sterile gloves and mask until large burns are covered. b. Cover large burns with dry, sterile or clean sheets. Do not use wet dressings since they may cause hypothermia on large burns. c. Cover patients who have large burns with additional sterile or clean sheets or blankets to prevent loss of body heat. 6. Treat any associated injuries (bandage and splint). 7. If eyes are affected, refer to Eye Injury Protocol. (pg ) Intermediate: 8. IV therapy with Normal Saline should be initiated in patients with the following: a. Evidence of inhalation injury. b. Elderly or underlying chronic illnesses or other associated injuries that require an IV. c. Burn exceeds 10% BSA. d. Electrical burns. 9. Run IV (ml/h) at rate equal to ( 1 /4) X (Weight in kg) X (% BSA). These protocols are unique to Cooke County EMS per Medical Director Page 28

30 Paramedic: 10. Apply ECG electrodes and determine cardiac rhythm. 11. Monitor EtCo2 12. For patients with less than 10% BSA burn and no evidence of inhalation injury: 13. Consider Pain management: Morphine 10 mg SIVP (Max Dose 40 mg) AND Valium 10 mg SIVP (Max Dose 20 mg) May be repeated only if SBP is maintained <90 mmhg Contact Medical Control: If evidence of inhalation injury present with progressive airway compromise, monitor ETCO2. Medically Assisted Intubation (MAI) or Prophylactic intubation (RSI) may be required. Refer to the Airway Management for the Burn Victim. (pg. 122) Consult MEDICAL CONTROL These protocols are unique to Cooke County EMS per Medical Director Page 29

31 Trauma Burns (Chemical) Ensure Crew Safety! Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Remove contaminated clothing and wash all exposed skin unless Lyme exposure is suspected. DO NOT USE WATER ON LYME. Contact Poison Control and Medical Control for instructions on specific chemicals. 2. Splint any fractures or deformities as required. Intermediate: 3. Start IV with Normal Saline and run TKO unless hypotension or clinical evidence of shock exists. 4. Run IV (ml/h) at rate equal to ( 1 /4) X (Weight in kg) X (% BSA). Paramedic Life Support: 5. Apply ECG electrodes and determine cardiac rhythm. Refer to appropriate arrhythmia protocol as required. 6. Consider Pain Management: Morphine 10 mg SIVP (Max Dose 40 mg) AND Valium 10 mg SIVP (Max Dose 20 mg) May be repeated only if SBP is maintained <90 mmhg Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 30

32 Trauma Burns (Electrical & Electrocution) Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Cover entrance and/or exit wounds with dry sterile dressings. 3. Splint any fractures or deformities as required. Intermediate: 4. Start IV with Normal Saline and run TKO unless hypotension or clinical evidence of shock exists 5. Run IV (ml/h) at rate equal to ( 1 /4) X (Weight in kg) X (% BSA). Advanced Life Support: 6. Apply cardiac monitor and determine rhythm. Refer to appropriate arrhythmia protocol as required. 7. Consider Pain Management: Morphine 10 mg SIVP (Max Dose 40 mg) AND Valium 10 mg SIVP (Max Dose 20 mg) May be repeated only if SBP is maintained <90 mmhg Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 31

33 Trauma - Amputation Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg.11-14) 2. Control bleeding with direct pressure or pressure points. Tourniquet is used only as a last resort. 3. Remove gross contaminants on part by rinsing with saline solution. No other attempt should be made to debride the part. 4. Wrap amputated part in moistened saline gauze and place in plastic bag or container. Seal the plastic tightly, so fluid cannot come in contact with the amputated part. Place sealed container in iced solution of water or saline. Intermediate: 5. Initiate IV Normal Saline if indicated. Run TKO unless hypotensive or clinical evidence of shock exists. Paramedic: 6. Apply ECG electrodes and determine cardiac rhythm. 7. Consider Pain Management; refer to the Pain Management Protocol. (pg. 117) Contact Medical Control: These protocols are unique to Cooke County EMS per Medical Director Page 32

34 Trauma - Pregnant Trauma Patient In order to adequately care for the mother and unborn child that have been traumatized, one MUST be aware of the following facts: 1. The average maternal heartbeat will increase by 10 to 15 beats per minute when compared to the non-pregnant patient. 2. The systolic and diastolic blood pressure of the pregnant patient will often decrease by 10 to 15 mmhg in the second trimester of pregnancy and then return to normal by term. 3. The pregnant patient undergoes a significant increase in circulating blood volume - about 40 to 50%. This represents as increase in both plasma and red blood cells. However, there is usually a greater increase in plasma compared to the increase in red blood cells, thereby resulting in a relative anemia for many pregnant patients. 4. The pregnant patient may lose 30 to 45% of her circulating blood volume before hypotension develops. 5. When the pregnant patient is lying flat on her back, the enlarged uterus can cause significant compression of the inferior vena cava, thereby reducing venous return to the heart by up to 25 or 30%. This can then result in hypotension. Therefore when possible, pregnant patients should be transported in the left lateral decubitus position. If it is necessary to immobilize the patient supine, then the backboard should be tilted upward 20 to 30 degrees towards the patient s left. This will help to roll the pregnant uterus away from the inferior vena cava. 6. Gastric emptying and motility are decreased during pregnancy. This, combined with the compressive effects of the enlarging uterus on the stomach, increases the risk of aspiration in patients with a decreased level of consciousness. 7. Trauma to the pregnant patient can result in very significant amounts of OCCULT bleeding - either intrauterine or retroperitoneal. 8. Abruptio placenta is the leading cause of traumatic fetal death. Vaginal bleeding is seen in about 75% of cases. Maternal hemorrhage that does not result in decreased blood pressure can still reduce fetal blood flow by 90-95%. Trauma significant enough to cause shock in the mother is associated with Fetal Death. Contact Medical Control: Consider: An NG tube These protocols are unique to Cooke County EMS per Medical Director Page 33

35 Trauma - Pediatric Trauma Patient Clinical Definition: This protocol applies to pediatrics < 18 y/o & <40 kg or any patient < 12 y/o. Individual protocols apply to all injured patients and should be applied to the pediatric patient with reference to this protocol. When the protocols differ, a special reference is noted in the general protocol. Pediatric Differences: Normal Pediatric Vital Signs: 1. Blood pressure: systolic 80 + two times age Diastolic 2 /3 systolic pressure 2. Pulse: Newborns Infants Preschool School age Respirations: Newborns Infants Preschool School age Blood Volume: The normal total blood volume of a child is about ml/kg. Estimated Pediatric Endotracheal Tube Sizes: Age Size Newborn months year years years years years > 14 years These protocols are unique to Cooke County EMS per Medical Director Page 34

36 Shock: 1. Shock in a child is demonstrated by a faster than normal heart rate; cool and pale extremities; evidence of poor perfusion; and a systolic blood pressure less than 70 mmhg. Children have excellent compensatory systems and the appearance of a fall in blood pressure represents severe shock. 2. A child in traumatic shock has lost at least 25% of their total blood volume. 3. Treatment of shock: Basic: 4. High flow 100% oxygen. Intermediate: 5. At least one large bore IV with Normal Saline. As with adults, attempts to establish IV access are usually made enroute but may be made at the scene, if long transport are anticipated after consulting MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL 6. When replacing volume loss in a child suffering from hemorrhagic shock, give an initial fluid bolus of 20 cc/kg. If the vital signs then stabilize and the child no longer appears to be in shock, run the IV at a TKO rate while continuing to transport. If the first fluid bolus of 20 cc/kg does not stabilize the child s vital signs, then give a second fluid bolus of 20 cc/kg. This means that the child has probably lost at least one half of his/her total blood volume and will need blood transfusions upon arrival at a health care facility. Paramedic: 7. Apply ECG electrodes and determine cardiac rhythm. These protocols are unique to Cooke County EMS per Medical Director Page 35