Tox and Trauma PDF

Toxicology Responsoft EMS Protocols Toxicology Page 57 Toxicology 10/13/2020 Carbon Monoxide Poisoning Toxicology Crews are to assure that ALL firefighters are assessed for elevated levels of CO after structural firefighting activities. Universal Patient Assessment Remove from exposure en...

Toxicology Responsoft EMS Protocols Toxicology Page 57 Toxicology 10/13/2020 Carbon Monoxide Poisoning Toxicology Crews are to assure that ALL firefighters are assessed for elevated levels of CO after structural firefighting activities. Universal Patient Assessment Remove from exposure environment and remove contaminated clothing Adult Adult Airway Airway Protocol Toxicology Patients suffering from exposure to byproducts of combustion should, when feasible, have a carboxyhemoglobin recorded. These situations include fire victims of smoke inhalation, exposure to CO, firefighters during rehab activities, patients or families with complaints of general illness or headaches. Determine Carbon Monoxide Level IV/IO If necessary NS Fluid Bolus 20 20 ml/kg ml/kg Cardiac Monitor For patients with significant smoke inhalation or who display signs of altered mental status following exposure. (See Toxic Exposure Cyanide Poisoning) Remember that pulse oximetry should not be used as a determination of oxygenation in the patient with elevated carboxyhemoglobin. Symptomatic patients should be treated accordingly regardless of carbon monoxide levels. Smokers may have baseline CO levels as high as 9% COHb Level % Signs & Symptoms Treatment 0 – 4% None - Normal None Necessary (smoker 3-5% higher) 5 – 9% Minor Headache 100% O2 via NRB Mask Reassess after 10-15 min. 10 – 19% Headache / SOB 100% O2 via NRB Mask And transport to closest hospital 3 Adult 20 – 29% Headache, Nausea, Dizziness, Fatigue ABC’s, 100% Oxygen, Transport HBO 30 – 39% Severe Headache, Vomiting, Vertigo, ALOC ABC’s, 100% Oxygen, Transport HBO 40 – 49% Confusion, Syncope, Tachycardia ABC’s, 100% Oxygen, Transport HBO 50 – 59% Seizures, Shock, Apnea ABC’s, 100% Oxygen, Transport HBO 60% - up Cardiac Arrhythmias, Coma, Death ABC’s, 100% Oxygen, Transport HBO Transportation to OSU-Main for Hyperbaric Oxygen Therapy if Carboxyhemoglobin 20% or higher. Transport all pregnant and pediatric patients with concern for carbon monoxide poisoning as these patients are more sensitive to the effects of CO and may be treated at lower thresholds. Responsoft EMS Protocols Page 58 10/13/2020 Overdose Toxicology Obtain History a) Medications - type, dose, bring bottles with patient. b) Time and duration of exposure and via what route. c) Notify receiving facility as soon as possible. Poison Control 1-800-222-1222 Universal Patient Assessment Toxicology Consider physical or chemical restraint for uncontrollable patients IV/IO Cardiac Monitor Calcium Channel Blocker OD Contact Poison Control 1-800-222-1222 or 228-1323 or Calcium Chloride 0.5 gm IVP, IO Encode #101 or Every 3 – 5 minutes as needed for significant bradycardia 9 Poison for information If necessary Hypoglycemia Protocol Spinal Injury Assessment < 60 mg/dl Blood Glucose Yes Lethargic or unconscious ? 60 or > 60 mg/dl Consider Naloxone if signs or symptoms of opiate overdose (pinpoint pupils, decreased or absent respirations). Naloxone 0.4 - 2 mg IVP, IO, IN Specific ingestions Tricyclic ingestion? Aspirin Overdose NS Fluid Bolus 250 ml/hr May repeat every 5 minutes as needed Administer in lowest dose as needed to maintain adequate respirations Tricyclic Antidepressants: Elavil, Sinequan, Vivactyl, Endep, Norpramin, Pamelor, Surmontil, Tofranil, Amitriptyline, Doxepin, Imipramine, Nortriptyline, Desipramine Responsoft EMS Protocols Sodium Bicarbonate 8.4% mEq/kg IVP, IO 11mEq/kg Hypotension NS Fluid Bolus 300 - 500 ml May repeat bolus if no response. Seizures? Seizure Protocol Ventricular Dysrhythmia Amiodarone Mix 150 mg in 100 ml of 0.9 NS over 10 minutes, 15 mg/min. Page 59 10/13/2020 Toxic Exposure Toxicology Toxicology Universal Patient Assessment The amount and route of exposure to the nerve agent or OP pesticide, the type of nerve agent or pesticide, and the premorbid condition of the person exposed person will contribute to the time of onset and the severity of illness. IV/IO IV/IO Cardiac Monitor Contact Chemtrec 1-800-424-9300 Poison Control Phone: 1-800-222-1222 or 228-1323 Radio: Encode #101 or 9 POISON Skin Exposure Respiratory Exposure 1. Remove clothing and wash skin with copious amounts of water (brush off dry chemicals but don't delay applying water). 2. Wear gloves and masks (appropriate mask for contaminant) while handling the patient 3. Cover the patient with sheet (cloth or plastic) to prevent the spread of the contaminant. Adult Airway Airway Protocol Adult Organophosphate Exposure Development of coma, ataxia, psychosis, dyspnea, convulsions, bradycardia, or cyanosis. Smoke Inhalation / CO Poisoning Adult Airway Protocol Determine CO levels per 2-PAM 2 PAM 600 mg IVP, IO, IM Suspected Cyanide Poisoning All Yes Wheezing Transport immediately to nearest facility. Encode facility as soon as possible that you have a possible cyanide poisoning case. Transport to a facility with hyperbaric capabilities should be considered. If significant burns are involved, transport should be to a trauma center. Albuterol 2.5 mg/ 3 ml saline Mixed together 0.5 mg/ 2.5 ml saline (May repeat) Atrovent Responsoft EMS Protocols 2 - 5 mg IVP, IO, IM May be repeated every 15 minutes until signs of flushing, dry mouth, and dilated pupils appear. Carbon Monoxide Protocol 2 Indications: 1. Firefighter down at fire scene & in cardiac arrest, or 2. Victim (FF or civilian) meeting all 3 criteria Confined space smoke exposure Altered Level of Consciousness Nasal/Oral Soot or burns Atropine Page 60 10/13/2020 Trauma Responsoft EMS Protocols Trauma Page 61 Trauma 10/13/2020 Abdominal Trauma Trauma Organs of the abdomen involve: Liver, kidney’s, gall bladder, duodenum, pancreas, stomach, spleen, aorta, colon, appendix, small and large intestine. Trauma Universal Patient Assessment Multiple Trauma Protocol AdultAirway Airway Protocol Adult IV/IO IV/IO large bore IV 20 ml/kg ml/kg NS Fluid Bolus 20 (If necessary) If systolic BP < 90 mmHg, Absence of radial pulse, or decreased mental status secondary to hypoperfusion (not head trauma). Infuse fluid until return of radial pulse or maximum of 2 liters. Cardiac Monitor If eviscerated bowel present, cover with saline soaked sterile dressings. Responsoft EMS Protocols Page 62 Do not remove any impaled foreign object. Stabilize object for transport. 10/13/2020 Burns Trauma Universal Patient Assessment Remove rings, bracelets, and any other constricting items Spinal Injury Assessment If necessary Trauma Burns can be thermal, or chemical. Types of burns are First degree (red and painful), Second degree (Skin blisters) and Third degree (Necrosis). Use the Lund-Browder to estimate body surface percentage affected. Take extra caution to use aseptic / sterile technique in all procedures.  Providers should be careful to use gloves and other barrier precautions as needed to protect themselves from becoming injured from a chemical burn while rendering care. IV/IO Adult Airway Protocol Thermal Cover wounds with dry sterile dressings, maintain body warmth. May immerse body part in cool water if burn is limited to less than 10% BSA. Powder Remove clothing or expose area. Brush powder off Evaluate patient for other injuries (consider nature of accident). Assess the depth and extent of burns. Chemical Eye involvement? Continuous Normal Saline flush Remove clothing or expose area Flush with copious amounts of water, but be cautious.. some chemicals should not be mixed with water. Cardiac Monitor For all electrical & lightning Injuries Smoke inhalation Toxic Exposure Protocol “If cyanide poisoning is suspected” Pain relief Pain Control Protocol Responsoft EMS Protocols Transport patient. Page 63 NOTE: Evaluate for associated injuries, and treat per appropriate protocol. Do not attempt IV unless reasonably certain one can be obtained. You cannot afford to ruin potential IV sites on burn victim with multiple attempts. You may "stick" a patient through a burn if that is all you can get for an IV/IO site. Acute hypotension in burn victim is probably not from the burn itself. Think about other trauma with blood loss. 10/13/2020 Chest Trauma Trauma The thorax is a large, relatively common target for low and high velocity projectiles. Universal Patient Assessment Spinal Injury Assessment Wound Care Trauma Blunt or penetrating injuries to the chest with shock that are not immediately responsive, should be transported without delay. Do not remove any impaled foreign object. Stabilize object for transport. Adult Airway Protocol Cardiac Monitor Assess for and treat other life-threatening injuries Multiple Trauma Protocol IV/IO IV/IO NS Fluid Bolus 2020 ml/kg ml/kg Open Chest Wounds Tension Pneumothorax Cover sucking wound with non-porous dressing (Vaseline™ gauze, jelled defibrillator pad, cellophane, aluminum foil) taped over 3 sides, or Asherman Dressing. Chest Decompression Reassess adequacy of ventilations and perfusion. “Load and Go” with continued treatments. Massive Hemothorax Monitor and reassess Do not decompress. Treat for hypovolemic shock. Support ventilations If systolic BP < 90 mmHg, Absence of radial pulse, or decreased mental status secondary to hypoperfusion (not head trauma). Infuse fluid until return of radial pulse or maximum of 2 liters. Flail Chest A. Reassess adequacy of ventilation. B. If ventilation is inadequate consider positive pressure ventilation via bag-mask device Other Injuries Simple Pneumothorax a. Treatment is supportive. b. Administer 100% Oxygen should be administered to maintain SpO2 >94% c. Monitor for development of tension pneumothorax Pericardial Tamponade a. Rapid transport b. Initiate IV at wide open Responsoft EMS Protocols Page 64 10/13/2020 Crush Syndrome Trauma Three mechanisms are responsible for the death of muscles cells. Immediate cell disruption, Direct pressure on muscle cells, Vascular compromise. Reference: Mediccom.org James R. Dickson MD Universal Patient Assessment If patient has been trapped/pinned for longer than 20 - 30 minutes, and exhibits signs/symptoms of relevant mechanism of injury to suspect crushing injury. Spinal Injury Assessment SERT Guideline See: SERT Trauma Crush injury causes a toxic mixture of fluids, electrolytes, and acids from lack of cellular respiration to pool in the area that is crushed. Upon release of the mechanism of crush, that mixture starts to flow with normal circulation and mixes with oxygenated blood which makes the mixture even more toxic. When this mixture of toxins gets to the heart, the patient experiences sudden cardiac death. Adult Airway Protocol Pre-Extrication IV/IO Minimum of 2 IV’s (one for resuscitation/cardiac and one for administration of Sodium Bicarbonate) Post-Extrication Continue aggressive fluid resuscitation with NS Fluid Bolus 2020ml/kg ml/kg If systolic BP < 90 mmHg, Absence of radial pulse, or decreased mental status secondary to hypoperfusion (not head trauma). Infuse fluid until return of radial pulse Coordinate time of release with rescue personnel Monitor ECG closely, watch for: Widen QRS complexes – 0.12 seconds or greater. Sodium Bicarbonate Begin infusion: 2 liters over 1 hour Presence of PVC’s, V-Fib / V-Tach, 50 mEq/liter Cardiac Monitoring Obtain monitor tracing prior to and sequentially during further treatment. Treat appropriately Yes NOTE: If patient is in cardiac arrest, treat as TRAUMA ARREST Advise the receiving ED early of the patient’s “Crushing Injury”. Anticipate Crushing Syndrome and possible cardiac arrest upon extrication of patient. Responsoft EMS Protocols Page 65 10/13/2020 Spinal Injury Assessment Trauma Negative Mechanism of Injury Uncertain Positive Positive Mechanisms:  High-Speed MVC  Falls > Three Times Patient’s    Apply Manual Stabilization Until Exam Complete SPINAL PAIN OR TENDERNESS Trauma   Height Axial Load Diving Accidents Penetrating Wound In or Near Spinal Column Sports Injuries to Head or Neck Unconscious Trauma Patient YES Reliable Patient Has:      Calm Cooperative Sober Alert Without Distracting Injuries NO MOTOR AND SENSORY EXAM ABNORMAL NORMAL YES RELIABLE PATIENT? NO Unreliable Patient Has: Negative Spinal Injury: SMR NOT INDICATED      Acute Stress Reaction Head/Brain Injury Altered Mental Status Intoxication with Drugs/Alcohol Other Distracting Injuries Note: If any doubt exists... Positive Spinal Injury Spinal Motion Restriction SMR includes taking steps to minimize head movement including the use of a cervical collar, padding, coaching and positioning. Long backboards, scoop stretchers, and other devices may be used for extrication purposes only. They are not necessary for spinal motion restriction and should be removed as soon as safe for the patient and crew prior to transport. Patients presented to the crew already immobilized should be reassessed using the clinical criteria provided. The crew may remove any previously applied spinal motion restriction devices that are not indicated, and should additionally remove any rigid immobilization device prior to transport. Responsoft EMS Protocols Page 66 10/13/2020 Trauma Most causes of broken and avulsed teeth are: falls, assaults, sports, multiple trauma. Dental Injuries Universal Patient Assessment Trauma Protect the airway. Make every attempt to salvage any lost teeth. Reassure patient. Inspect surrounding area of soft tissue. Check for other fractured, chipped, or deformities of teeth. Control bleeding with pressure Tooth avulsion? No Yes Save all avulsed teeth in 0.9 NS moistened gauze or a jar of 0.9 NS Assess for pain Reassess and monitor Responsoft EMS Protocols Page 67 10/13/2020 Extremity Trauma Trauma History Mechanism of injury Environmental exposure Findings at the scene Pre-hospital care Universal Patient Assessment Wound Care SERT Guideline See: SERT For tactical medic use only Trauma with “moderate to severe” or “suspected “hemorrhage or hemorrhagic shock. Tranexamic Acid (TXA) 1 gram/100 ml over 10 minutes, IV Infusion (16 years and older) Severe Bleeding Control Bleeding by: 1. Direct Pressure Wound Care with QuickClot Combat Gauze Trauma Life Threatening Hemorrhage Major Crush Injury Syndrome Severe Open Fracture Proximal Amputations Multiple Fractures Limb Threatening Vascular Emergency Compartment Syndrome Open Fracture Crush Injury Major Dislocation Unstable or Multiple Trauma Patient, transport to closest trauma facility. 3. If not successful; Tourniquet IV/IO IV/IO large bore IV 20 ml/kg NS Fluid Bolus 20 ml/kg (If necessary) If systolic BP < 90 mmHg, Absence of radial pulse, or decreased mental status secondary to hypoperfusion (not head trauma). Infuse fluid until return of radial pulse or maximum of 2 liters. Pain Control Protocol Complex Injuries Remember with all injuries… Stabilize patient before transport and transport all amputated parts, regardless of condition. Severed tendons and nerves 1. Control bleeding with pressure Complex forearm fracture 1. Splint and apply pressure dressing Ring Avulsion Complete Amputation 1. Rinse with saline or water, place on moist gauze 2. Place in plastic bag. Place on Ice (no dry ice). 3. Apply pressure dressing 1. Wrap with moist gauze and surround with ice. Incomplete Amputation 1. Splint 2. Apply pressure dressing 3. Surround with ice. Bleeding easily controlled Monitor vital signs and treat for shock. Adult amputations are to be transported to Riverside Methodist or OSU Wexner Medical Center Hospitals if they are stable. Responsoft EMS Protocols Page 68 Distal Injuries: Finger & Toes Aspirin 324 mg PO (4 baby aspirin) 10/13/2020 Trauma Multiple trauma is injury of two or more parts of the body. Obtain Glasgow Coma Score prior to calling trauma center. Multiple Trauma Pregnant trauma patients are more susceptible to life threatening injury than non pregnant patients. Shock may not always be obvious due to increase in circulating blood volume. Aggressively treat hypovolemia and transport all pregnant patents to the hospital for evaluation. Patient Assessment-Trauma Patient Assessment-Trauma Rapid transport to closest most appropriate facility. Do not delay on scene for noncritical procedures that can be performed en route. Assume cervical spine injuries on all unconscious patients with known or suspected trauma and on all patients with multiple trauma. Splinting Splinting Immobilize, splint and restrain as appropriate and as time allows. Adult Airway Airway Protocol Adult Trauma with suspected or verified “moderate to severe” or “suspected” hemorrhage or hemorrhagic shock. Spinal Injury Assessment IV/IO (large bore) Wound Care (control active bleeding) Do not delay transport if unable to initiate an IV. If systolic BP < 90 mmHg, Absence of radial pulse, or decreased mental status secondary to hypoperfusion (not head trauma). Infuse fluid until return of radial pulse or maximum of 2 liters. See Fluid Therapy above 1 gram/100 ml over 10 minutes IV Infusion (16 years and older) For patients that are 4 months pregnant or more: Tilt patient on the left side or elevate right buttock and push uterus to the left. Vital Signs / perfusion? Abnormal 20 ml/kg NS Fluid Bolus 20 ml/kg Tranexamic Tranexamic Acid Acid (TXA) (TXA) Cardiac Monitor Fluid Therapy Normal Suspected internal injuries and long bone fractures require 2 IV's. This Should not delay transport Ongoing assessment Appropriate Protocol based on patient symptoms Reassess Adult Airway Protocol Pain Control Protocol for acute pain due to fractures, burns, or other types of trauma. Trauma Transport as quickly as possible. Provide continuous monitoring and re-evaluation. If Respiratory Compromise, See: Rapid Sequence Intubation (RSI) Pelvic Injury: Procedure SAM Pelvic Sling Responsoft EMS Protocols Page 69 10/13/2020 Trauma Neurological Trauma (Head) Types of Head Trauma: Concussion, Skull fracture (Linear, Depressed & Basilar), Intracranial (Subdural, Epidural, Subarachnoid). Universal Patient Assessment Isolated head trauma? No Yes Trauma If confirmed head injury with impaired level of consciousness, assist patient with positive pressure ventilation using a bagvalve-mask. Intubate as needed. In the head injured patient with signs of shock, look for the other sources of bleeding (i.e. chest, abdomen, pelvis, and femurs) Multiple Trauma Protocol Spinal Injury Assessment Trauma with “moderate to severe” or “suspected” hemorrhage or hemorrhagic shock. Control Severe bleeding Wound Care Tranexamic Acid (TXA) 1 gram IV/IO Fluid Therapy Observe spine injured patients for neurogenic shock, i.e. hypotension with bradycardia. If signs of inadequate perfusion: 20 ml/kg NS Fluid Bolus 20 ml/kg Anticoagulants increase the risk of intracranial bleeding, even with minor head injury. Patients on anticoagulants with head injury should be offered transport to the ED. Commonly used anticoagulants include: ORAL Coumadin (warfarin), Eliquis (apixaban), Xarelto (revaroxaban), Pradaxa (dabigatran), Savasa (edoxaban) INJECTABLE Lovenox (enoxaparin), Arixtra (fondaparinux) ORAL ANTIPLATELET Plavix (clopidogrel), Effient (prasugrel), Brilinta (ticagrelor) Responsoft EMS Protocols If systolic BP < 90 mmHg, Absence of radial pulse, or decreased mental status secondary to hypoperfusion (not head trauma). Infuse fluid until return of radial pulse or Maximum of 2 liters. Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes For combative patients with head injuries, refer to the: Rapid Sequence Intubation (RSI) Procedure Load and Go in patients with either: A. Unilaterally dilated pupil B. Deteriorating mental status Page 70 10/13/2020 Trauma The eye is well protected by a series of facial bones. Patient’s sight may be threatened if their is loss of aqueous or vitreous humor fluid, usually caused by penetrating trauma. Blunt trauma can cause a hemorrhage which can also cause a loss of vision. Penetrating Injuries Ocular Trauma Trauma Embedded or impaled objects should not be removed, but should be stabilized securely for transport. Universal Patient Assessment Spinal Injury Assessment Chemical Injuries If needed: 1. Stabilize impaled objects, cover both eyes and transport. 2. If the object has pierced the globe, transport in supine position. 3. Use metal eye shield if possible. 4. Cover BOTH eyes using folded 4x4's. 5. Transport in position of comfort. Responsoft EMS Protocols Tetracaine 1 - 2 drops, may be instilled into the eye(s) prior to the Morgan Eye Lens. If available Insert Morgan Eye Lens connect to the I.V. tubing and immediately flush with one liter of 0.9NS per eye. Page 71 10/13/2020 Trauma Pregnant patients suffering from major trauma are more susceptible to life-threatening injury than non-pregnant patients. Any pregnant patient who has suffered trauma should be transported to the hospital for evaluation. Trauma in Pregnancy Universal Patient Assessment Spinal Injury Assessment For patients that are 4 months pregnant or more: Tilt patient on the left side or elevate right buttock and push uterus to the left. Trauma Note: Shock is not always obvious in the pregnant patient because of an increase in circulating blood volume. The pregnant female will show signs of hypovolemia later in the course of the trauma event. Treat hypovolemia aggressively Pregnant trauma patients are more susceptible to life threatening injury than non pregnant patients. Shock may not always be obvious due to increase in circulating blood volume. Aggressively treat hypovolemia and transport all pregnant patents to the hospital for evaluation. IV/IO IV/IO If hypovolemic, treat aggressively. Initiate two large bore IV's Responsoft EMS Protocols Page 72 10/13/2020