Trauma PDF

Acute ABDOMINAL | FLANK PAIN 1. IMC special considerations: Inspect, auscultate, palpate abdomen in all quadrants Compare pulses in upper vs. lower extremities Note/record nature & amount of vomiting/diarrhea, vaginal/urethral/rectal lesions/discha...

Acute ABDOMINAL | FLANK PAIN 1. IMC special considerations: Inspect, auscultate, palpate abdomen in all quadrants Compare pulses in upper vs. lower extremities Note/record nature & amount of vomiting/diarrhea, vaginal/urethral/rectal lesions/discharge; jaundice Vomiting precautions Adjust IV rate to maintain hemodynamic stability Document OPQRST of pain; menstrual history in females of childbearing age; last BM; orthostatic VS; travel history Rx per PAIN Mgt. SOP LOWER ACUITY: NONE to MILD cardiorespiratory compromise Alert, SBP ≥ 90 (MAP ≥ 65), no evidence of tissue hypoperfusion or shock 2. Transport in position of comfort EMERGENT to CRITICAL: Moderate to Severe cardiorespiratory compromise Time Altered sensorium, signs of hypoperfusion. sensitive pt 2. IMC special considerations: Consider need for NS IVF challenges if pt severely dehydrated/hypovolemic: (Ex: appendicitis, cholecystitis, pancreatitis, hepatitis, cirrhosis, upper/lower GI bleed, bowel obstruction, sepsis) 3. If suspected abdominal aortic aneurysm (AAA): Do not give IV fluid challenges unless SBP < 80 (MAP 30 min from a Level I TC: may go to closest Level II TC for stabilization Meets Level I or II criteria & is >30 min from a TC: may go to closest non-TC for stabilization or assess need for helicopter Attempt to keep scene time ≤10 minutes for time-sensitive patients; document reasons for delay Time LEVEL I: HIGH RISK for SEVERE INJURY – Transport to the highest level trauma center sensitive available within the geographical constraints of the regional trauma system* patient Injury patterns Mental status & vital signs Penetrating inj. to head, neck, torso, proximal extremities All patients Age 0-9 years: Skull deformity, suspected skull fracture SBP < 70 + (2 X age) Suspected SCI with new motor or sensory loss - Unable to follow commands Chest wall instability, deformity, or suspected flail chest (Motor GCS < 6) Age 10-64 years: Suspected pelvic fracture - RR < 10 or > 29 SBP < 90 mmHg Suspected fracture of two or more proximal long bones HR > SBP Crushed, degloved, mangled or pulseless extremity - Respiratory distress or need for ventilatory support Amputation proximal to wrist or ankle Age ≥ 65 years: Active bleeding requiring a tourniquet or wound packing - RA SpO2 < 90% SBP < 110 mmHg with continuous pressure HR > SBP CLOSEST TRAUMA CENTER: Patients meeting any one of the YELLOW CRITERIA (below) who DO NOT MEET RED CRITERIA should be preferentially transported to a trauma center as available within the geographic constraints of the regional trauma system (need not be the highest level trauma center) Mechanism of Injury EMS Judgment* High risk auto crash Consider additional risk factors including: - Ejected (partial or complete) Low level FALLS in young children (age ≤5 years) - Significant intrusion (including roof) or older adults (age ≥ 65 years) with significant - > 12 inches occupant site OR > 18” any site head impact - Need for extrication for entrapped patient Anticoagulant use - Death in passenger compartment Suspicion of child (elder) abuse - Child (0-9) unrestrained or in unsecured child safety seat Special, high resource healthcare needs** - Vehicle telemetry data consistent with severe injury Pregnancy >20 wks (fundus level w/ navel or above) Rider separated from transport vehicle with significant Burns in conjunction with trauma*** impact (motorcycle, ATV, horse, etc.) Children should be triaged preferentially to Pedestrian/bicycle rider thrown, run over, or with pediatric capable centers. significant impact If concerned, take to a trauma center Fall from height > 10 feet (all ages) Caveat notes *RED SECTION: Patients in extremis may require an immediate stop at a closer hospital for procedures not available within the EMS System such as complex airway management. Children should be triaged preferentially to pediatric capable centers. *YELLOW SECTION: EMS judgment criteria should be considered in the context of resources available in the regional trauma system. May consult OLMC for further direction. Note: "Low-level" fall refers to less than 10 feet including ground level falls **Examples of special high resource healthcare needs include patients with underlying conditions requiring complex medical care such as patients with tracheostomies, home ventilators, cardiac assist devices, etc. ***Patients with combined burns and trauma should be preferentially transported to a trauma center with burn care capability but if not available then a trauma center takes precedence over a burn center. DHHS & CDC. (2022). National Guideline for the Field Triage of Injured Patients NWC EMSS 2022 SOP 46 Rev. 3-11-24  Penetrating: CARDIAC ARREST due to TRAUMA Time sensitive pt Definition: Trauma patient found unresponsive, apneic or gasping and pulseless who does not meet criteria for Triple Zero or non-initiation of CPR policies ITC special considerations: Co-manage with Cardiac Arrest and Trauma Guidelines If normothermic, and blunt or penetrating trauma found in asystole: Contact OLMC for pronouncement or resuscitation order based on special circumstances Any VS before arrest: Start CPR per Cardiac Arrest SOP | Transport immediately Complete interventions ENROUTE as time and number of EMS personnel permits Assess to find possible reversible cause(s) of arrest, e.g., Hs and Ts: hypoxia, hypoventilation, hypothermia hypovolemia, decreased cardiac output secondary to tension pneumothorax, pericardial tamponade, toxins, or Control visible hemorrhage per ITC SOP/System procedure If decreased/absent lung sounds during PPV and difficulty ventilating pt: suspect pneumothorax (tension): pleural decompress affected side (s) (pause CPR briefly during procedure) If multi-system trauma or trauma to head and neck: Apply spine motion restriction Vascular access per ITC: Do not delay transport attempting to start IV on scene. If volume losses appear significant: Consecutive 200 mL fluid challenges up to 1 L NS Cardiac arrest survival is unlikely if uncorrected severe hypovolemia exists Caveats: Victims of submersion, lightning strike & hypothermia deserve special consideration (See specific SOPs) MPI Incidents: Defer resuscitation for those in traumatic arrest until sufficient responders present to meet the needs of living patients Conducted electrical weapon | Post-TASER Care 1. Scene size up: confer with LEO; determine pt's condition before, during & after Taser discharge 2. ITC special considerations 12 L ECG If pt has S&S that could be cardiac in nature, is elderly, or has Hx of CVD or drug use VS; Assess for hyperthermia; volume depletion; tachycardia (hypersympathetic state); metabolic acidosis IV NS to correct volume depletion if present SAMPLE Hx: Date of last tetanus prophylaxis; cardiac Hx; use of mind-altering stimulants (PCP, meth, cocaine) Secondary assessment: Can have injury/illness that occurs before, during, or after Taser event (fall) 3. Anxiety and SBP ≥ 90 (MAP≥ 65): MIDAZOLAM 2 mg increments slow IVP q. 2 min (0.2 mg/kg IN) up to 10 mg titrated to response. If IV unable/IN contraindicated: IM 5-10 mg (0.1-0.2 mg/kg) max 10 mg single dose All routes: May repeat to a max total dose of 20 mg prn if SBP ≥ 90 (MAP ≥ 65) unless contraindicated If hypovolemic, elderly, debilitated, chronic dx (HF/COPD); and/or on opioids or CNS depressants: ↓ total dose to 0.1 mg/kg 4. Uncooperative patient exhibiting violence/delirium with extreme agitation/great strength; numbness to pain Treat per Psych/BHE SOP: Verbal de-escalation; sedation & monitoring; restraint prn for pt/responder safety KETAMINE SEDATION dose: 2 mg/kg slow IVP (over 1 min) or 4 mg/kg IN / IM (max 300 mg) Contact OLMC if higher doses appear needed | See appendix for dose chart Use w/ caution in patients with active psychosis 5. PROBES: Identify location - If probe becomes disengaged: Handle as a sharp; check with LEO to see if they require probes as evidence If no: Place directly into a designated sharps container - If probe remains attached to pt: Cleanse puncture sites and bandage per System procedure 6. Transport for further evaluation If pt is decisional and refuses Rx / transport: Advise to seek medical attention immediately if they experience any abnormal S or S If patient denies tetanus immunization in the last 10 yrs, advise to acquire it Provide disclosure of risk and execute Refusal per System procedure | Contact OLMC from point of patient contact NWC EMSS 2022 SOP 47 Rev. 3-11-24  Emergent to Critical: BURNS (Adult & Peds) time sensitive pts 1. ITC special considerations: (Scene/responder safety top priority) Stop burning process/remove any burning agent (including chemicals) | Cool per thermal wound care next page Remove clothing, jewelry; belts, suspenders, steel-toed shoes (retain heat) Do not pull away clothing stuck to the skin (cut around) Keep burn as clean as possible; wear gloves/mask until burns covered Airway/breathing – Compromise, hoarseness, wheezing? - Inspect for singed nasal, facial, and eyebrow hairs; burns and edema around the head and neck - Auscultate breath sounds | monitor RR, depth, WOB, chest wall motion, and for dyspnea/stridor - Assess oxygenation (SpO2) | ventilation, perfusion, shock (EtCO2 if available) - Elevate HOB to decrease airway edema - Assess need for ADV Airway: Access may be difficult w/ burns of the face or anterior neck DAI (largest ETT & least airway trauma possible) may be indicated for pts with severe airway impairment/ respiratory distress; secure w/ ties that can be loosened as edema occurs; don’t apply tape to facial burns Circulation: Pulse, capillary refill; ECG Indications for IV/IO: Non-superficial burns TBSA >15-20% (adults) / 15% (peds) | shock; need for IV meds - Avoid if possible, but may start through burned skin if needed; infuse warm fluid - If not in shock: NS IVF 1st hour: ≤ 5 yrs: 125 mL/hr 6-13 yrs: 250 mL/hr ≥ 14 yrs: 500 mL/hr - If in shock: NS 2-4 mL(start with 2) X kg X %TBSA burned | ½ in 1st 8 hrs (OLMC) Titrate to patient response | Document total IVF infused by EMS; report to receiving facility Mental status: If AMS consider hypoxia, shock, head trauma, toxic inhalation, alcohol/drug impairment, or hypoglycemia | Blood glucose: If < 70: Rx per Glucose Emergencies SOP PAIN: Rx per PAIN Mgt. SOP Nausea: ONDANSETRON standard dose / ITC Assess depth: Pain, swelling, skin color, cap refill, moisture, blisters, hair loss, appearance of wound edges, foreign bodies, debris, contaminants, bleeding/soft tissue trauma. Note as superficial, partial, or full thickness Calculate % TBSA: Use Rule of 9s or Rule of Palms (palm + fingers together for small or scattered burns up to 15%). Accurate % may be difficult to determine; include only partial & full thickness in calculation for IVF as superficial burns do not contribute to fluid shifts & do not require IVF resuscitation. Obese pts: Adjust TBSA calculation | Trunk may be up to 50%, each leg up to 20%; Head & arms smaller % Allergies: Sulfa? | Meds: Those w/ implications for wound healing: immunosuppressants/steroids PMH co-morbid factors (preexisting illness, Hx of drug/alcohol use) Events: Type of exposure; burning agent; time of exposure; duration of contact; temp of exposure; LOC; history of enclosed space entrapment/smoke exposure; consider possible abuse VS: Assess on unburned skin if possible; edema may obscure pulse; use alternate sites; ID how quickly condition is changing Assess for multi-system trauma; treat associated injuries. Circumferential burns to torso/limbs dangerous due to potential vascular and ventilatory compromise (compartment syndrome); careful ongoing assessments. Transport per Trauma Triage Guidelines Rule of Nines 4.5% 7% 4.5% 18% 18% 1% 8% NWC EMSS 2022 SOP 48 Rev. 3-11-24  THERMAL 2. WOUND CARE per System protocol COOL PT burns 20% TBSA Open burn sheet on stretcher before placing pt. Cover pt with clean dry sheet and blanket; place in warm environment ASAP. INHALATION Injury: Heat, smoke, or chemical irritants 2. Assess for stridor, wheezing, carbonaceous (black) sputum, cough, hoarseness, singed nasal or facial hair, dyspnea, deep facial or circumferential neck burns, blistering, edema or inflammatory changes in oral pharynx/upper airway; 3. Assess need for advanced airway | O2 15 L/NRM; CPAP (COPD/obesity); or BVM | monitor ECG 4. Consider presence of CO and/or cyanide poisoning and treat per appropriate SOP (SpO2 unreliable) BLAST Injury: Exposed to an explosive force 2. Anticipate: Blunt or penetrating trauma, burns/inhalation injury from positive and negative pressure waves; mass movement of air & debris, and structural collapse. Assess for injuries from shrapnel; barotrauma; burns, crush, or toxic chemical contamination from chemical, biological, radiological, nuclear, and explosive devices/ agents. 3. Safety: Consider possibility of subsequent explosions; assess structural safety, possible toxic chemical contamination; poisonous gasses and other hazards | Remove pt. from scene ASAP 4. Assess for barotrauma: Dyspnea, cough, hemoptysis, or chest pain; ear drum perforation w/ tinnitus or hearing deficit; ecchymosis of chest wall/hemo-pneumothorax; traumatic emphysema S&S air embolism: Can present like AMI, stroke, acute abdomen, blindness, deafness, SCI, and pain with walking 5. Concussion & eye trauma common: Rx trauma per appropriate SOP; optimize O2; don’t overhydrate ELECTRICAL / LIGHTNING: Deep tissue damage may be more extensive than surface burns 2. Scene safety: do not touch pt until certain that electrical source has been disabled/disconnected 3. If unresponsive, apneic and pulseless: Begin CPR and resuscitate per SOP unless contraindicated (Triple Zero) Monitor ECG (12 L if available); Rx dysrhythmias / tonic clonic seizures per SOP Anticipate respiratory muscle paralysis/arrest | If pulse present: Assist ventilations prn 4. Assess for all contact points (entry/exit wounds) | If lightning MOI determine if direct, side splash or ground strike Assess wound appearance/depth (often full thickness) | Lichtenberg figures (reddish, fern-like patterns) from lightning No cooling needed unless an associated thermal burn; apply dry sterile dressings 5. Assess for potential associated trauma: Thrown from contact point / compartment syndrome Note neurovascular function all limbs | Spine motion restriction per SCI SOP 6. Event Hx: Nature of the electrical source (AC vs DC)/lightning; voltage, amperage, duration of exposure if known; position of pt. in relation to electrical source/lightning strike; downtime in cardiac arrest CHEMICAL: PMH: Type of chemical, concentration; time, duration of exposure; how exposure occurred; body parts exposed/affected; first aid measures instituted | Bring in Safety Data Sheets | Early notice to OLMC if decon needed 2. Avoid self-injury; haz-mat precautions | Decon per procedure | Remove contaminated clothing 3. Flush/irrigate burn/eyes ASAP per procedure with the cleanest, readily available water or NS unless contraindicated (sulfuric acid, sodium metals, dry chemicals - especially alkalines) using lg. amounts of fluid | Brush away powders/ dry agent before irrigating | Do not “neutralize” or use antidote except per poison center guidance or clear instructions from industry sources (SDS Sheets) (causes a heat reaction) 4. Hydrofluoric acid skin burn: Apply CALCIUM GLUCONATE 2.5% gel to the burn site (if available) | Monitor ECG BURN CENTER CONSULTATION CRITERIA (Adult & Peds) Tailor Triage/Rx to individual pt characteristics, injury severity, area resources, referring institutions (ABA, 2022) Deep partial-thickness >10% TBSA; Full thickness >5% | Children/older adults w/ dressing and medical needs Burns involving face, hands, feet, genitalia, perineum, or major joints | Electrical; Chemical; Radiation injury Frostbite, Stevens–Johnson syndrome/TENS, and necrotizing soft-tissue infection benefit from burn center Rx Burn Centers within Region 9 transport area): Loyola U Med Center (Maywood), Stroger/Cook County Hospital (Chicago); U of Chicago Hospital (Chicago); OSF St. Anthony Med Center (Rockford) NWC EMSS 2022 SOP 49 Rev. 3-11-24  Time CHEST TRAUMA (Adult & Peds) sensitive pt 1. ITC: high index of suspicion for “deadly dozen”: airway obstruction, tension pneumothorax, open pneumothorax, flail chest, pulmonary contusion, massive hemothorax, cardiac tamponade, blunt cardiac injury, thoracic aortic injury, tracheal or bronchial tree injury, diaphragmatic tears, blast injuries Level I trauma center if transport time 30 minutes or less: (Any 1 of these) All penetrating chest trauma | Chest wall instability, deformity, or suspected flail chest Unable to follow commands (Motor GCS < 6) | RR 29 | Respiratory distress or need for ventilatory support RA SpO2 SBP (shock index) TENSION PNEUMOTHORAX Extreme dyspnea, unilateral absence of lung sounds, SBP < 90 (MAP < 65)/hypotensive for age; JVD, resistance to BVM ventilation, ↑ airway resistance, SUBQ emphysema 2. Needle pleural decompression on affected side per System procedure while on scene (takes priority over airway) Adult: 10 gauge; 3”-3.25” needle or commercial device | Child ≤12 yrs: 14-16 gauge, 1½” needle Frequently reassess catheter patency | May need to repeat procedure with an additional needle 3. Continue ITC enroute; implement other protocols as required 4. Monitor for PEA: Treat per SOP OPEN PNEUMOTHORAX (Sucking chest wound) 2. Convert open pneumothorax to closed by applying an occlusive (vented) dressing Ask patient to maximally exhale or cough if able Cover wound: gloved hand, vented /channeled commercial dressing (preferred); defib pad Monitor VS, ventilatory/circulatory status, jugular veins after occlusive dressing applied If S&S tension pneumothorax: Temporarily lift side of dressing to allow air release; recover wound; assess need for needle pleural decompression if no improvement after dressing removed 3. If impaled object: Do not remove; stabilize object; continue ITC enroute; implement other protocols as required FLAIL CHEST (+/- paradoxical chest movement; anticipate pulmonary contusion – SpO2 < 90%) 2. Adult: If ventilatory distress; adequate ventilatory effort; no S&S pneumothorax: consider early trial of C-PAP PEEP 5-10 cm to achieve SpO2 of at least 94% If SBP falls < 90 (MAP < 65): titrate PEEP downward to 5 cm; D/C CPAP if MAP < 60 3. If ventilatory failure or persistent hypoxia persists: ventilate w/ 15L O2/BVM at 10 BPM [BLS] | ADV Airway [ALS] 4. Monitor for tension pneumothorax: prepare for needle pleural decompression 5. PAIN: Rx per PAIN Mgt. SOP; titrate carefully and support ventilations/MAP Note: Impedance threshold device (RQP) is contraindicated if cardiac arrest occurs PERICARDIAL TAMPONADE SBP < 90 (narrowed pulse pressure) (MAP < 65)/hypotensive for age; JVD; muffled heart tones | Lung sounds usually present bilaterally 2. Permissive hypotension: NS IV WO enroute just to achieve SBP 80 (adult) / 70 (peds) | Additional IVF per OLMC 3. Monitor for PEA: Treat per Traumatic Arrest SOP BLUNT Aortic and CARDIOVASCULAR INJURY Ranges from clinically silent, transient dysrhythmias to deadly injuries that include cardiac wall rupture, cardiac contusion, septal and valvular injury, injury to thoracic aorta, AMI/dysfunction; & lethal dysrhythmias. Aorta: Suspect with rapid deceleration; assess for chest or intrascapular pain, difficulty breathing or swallowing; upper extremity HTN, variation in BP between arms; or bilateral femoral pulse deficits Blunt cardiac injury: Chest wall bruising, sternal, clavicular or rib fx; S&S cardiogenic shock; ECG/12 L abnormal if unexplained ventricular or atrial arrhythmia (multi-formed PACs or new AF/flutter; right BBB, new onset Q waves/St-T wave abnormality) 2. NS titrated just to achieve SBP 90 (MAP 65) (adult) / 70 (peds) | Monitor for pericardial tamponade NWC EMSS 2022 SOP 50 Rev. 3-11-24  EYE Emergencies (Adult & Peds) General approach: 1. ITC special considerations: Quickly assess gross visual acuity in each eye as able: light perception / count fingers / hand motion / read name badge Assess pain | Lids, conjunctiva, sclera, cornea, iris, pupil, lens for S&S of injury, tearing, FB, (lid) spasm Discourage pt from sneezing, coughing, straining, or bending at waist; vomiting precautions (ONDANSETRON) Remove and secure contact lenses for transport with patient 2. PAIN: If Tetracaine ineffective or contraindicated: Rx per PAIN Mgt. SOP CHEMICAL SPLASH | BURN: EMERGENCY – See Chemical burn SOP Time sensitive pt Chemicals may be acid, alkali, irritant, detergent, or radioactive in nature and may be in the form of vapor, dust, particles or liquid. Irritants and detergents may not produce burns, but can damage eyes by inflammation or drawing water into tissues. 3. TETRACAINE 0.5% 1 gtt. each affected eye; repeat prn 4. Irrigate affected eye(s) per procedure using lg. amounts (≥ 500 mL) of NS or any other clean non-toxic liquid immediately available | Do NOT contaminate uninjured eye during irrigation or use antidote or neutralizing agent | Continue enroute to the hospital CORNEAL ABRASIONS: Assess for profuse tearing, severe pain, redness, spasm of eye lid 3. No S&S of penetrating injury: TETRACAINE 0.5% 1 gtt. each affected eye; repeat prn 4. Elevate head of stretcher 45˚ PENETRATING INJURY | OPEN GLOBE S&S: Peaked pupil, excessive edema of conjunctiva (chemosis), subconjunctival hemorrhage, blood in anterior chamber (hyphema), defect on cornea or sclera (vitreous humor prolapse/black defect), foreign body/impaled object 3. DO NOT remove retained FB/impaled object, irrigate eye, instill tetracaine, or apply any pressure to eye 4. Cover affected eye with a protective shield or paper cup per procedure; do not patch eye directly 5. Elevate head of stretcher 45˚ FACIAL Trauma (nose, ears, midface, mandible, dentition) 1. ITC special considerations: Assess for S&S facial injury, inspect nose for rhinorrhea, oral cavity, nose, ears for FB and gross debris | malocclusion, inability to open or close mouth / bite down or clenched jaw, hematoma under tongue; loose, missing or broken teeth | Motor/sensory deficits (CN 5, 7, 8) | Need for SMR | PMH for blood thinners Allow pt to assume position that allows for patent airway (sitting or side-lying unless contraindicated so blood/ secretions drain from nose & mouth) | Avoid aspiration / swallowing blood | Suction prn | No nasal airway adjuncts if midface trauma or above Control epistaxis (squeeze nostrils 10-15 min) | Do not pack nose if rhinorrhea | Collect blood on rolled 4X4 under nose Do not let patient blow their nose Assess need for IVF | Vomiting/aspiration precautions: ONDANSETRON standard dose Control external soft tissue bleeding per procedure | Collect/preserve tissue per Musculoskeletal Trauma SOP Minimize edema: Apply cold packs over injury site | PAIN: Rx per PAIN Mgt. SOP 2. Avulsed tooth: Avoid touching root, pick up by crown; do not wipe off, if dirty rinse under cold water for 10 sec. Place in milk, saline, or commercial tooth preservative solution (not tap water) | Unrecovered teeth may be aspirated If GCS 15, may hold tooth in mouth for transport Mandible fx: No chin lift; aspiration risk Maxillary fx (LeFort I-III): Anticipate nasal bone / anterior basilar skull fx NWC EMSS 2022 SOP 51 Rev. 3-11-24  GCS 13 or less HEAD TRAUMA / Traumatic Brain Injury (TBI) time sensitive Level I TC: Penetrating inj. to head/neck | Skull deformity, suspected skull fx | Unable to follow commands (Motor GCS < 6) RR < 10 or > 29) | Respiratory distress/need for ventilatory support | RA SpO2 < 90% 1. ITC special considerations: SMR if indicated Mod to severe injury: Continuous SpO2 and EtCO2 monitoring; prevent/correct hypoxia and hypoventilation ASAP DO NOT OVERVENTILATE: Assist/ventilate at 10 BPM prn; maintain EtCO2 at 35-40 Consider need for advanced airway if unable to oxygenate, ventilate, or protect airway | Must monitor with EtCO2. Vomiting precautions. ONDANSETRON prn | Limit suction to 10 sec; oxygenate before & after procedure Scalp wounds: No unstable/open fractures: direct pressure, hemostatic dressings 12-L ECG if dysrhythmia present: PACs, SB, SVT, PVCs, VT, Torsades, VF SAH. Pathological Q waves, ST elevation or depression; prolonged QTc, wide, large & deeply inverted (neurogenic or cerebral) T waves; prominent U waves >1 mm common causing incorrect suspicion of myocardial ischemia. Attempt to maintain cerebral perfusion pressure (CPP): Avoid/correct all hypotension ASAP If GCS ≤ 8: Keep head of bed flat; NO permissive hypotension in multi-system trauma w/ TBI NS IVF boluses (200 mL increments up to 1 L); target SBP 110-120 (MAP 85-90) or higher If generalized tonic clonic seizure activity present: MIDAZOLAM standard dose for seizures AMS: Blood glucose | If < 70: Rx per Glucose Emergencies SOP 2. Neuro exam - Establish patient reliability Patient must appear calm, cooperative, alert, and perform cognitive functions appropriately with NO AMS, acute stress reaction, brain injury, chemical impairment causing altered decisional capacity, distracting painful injuries, and language or communication barriers. Rapid neuro exam for evidence suggesting traumatic brain injury Reassess at least q. 15 minutes; more frequently as able: - Mental status [arousal, orientation, memory (amnesia), affect, behavior, cognition, insight]; GCS Early S&S deterioration: Confusion, agitation, drowsiness, vomiting, severe headache - Pupil size (normal: 2 -5 mm, ave. 3.5 mm) | Shape (round, irregular, or oval) | Equality (variation ≤ 1 mm) Reactivity to light (direct & consensual noted as brisk, sluggish, non-reactive) | Gaze palsy Change in visual acuity or fields | Diplopia | Photophobia (light sensitivity) | Hearing deficits - VS: BP (MAP), pulse pressure; HR; RR / pattern / depth / effort; SpO2, EtCO2 - Pain (headache), dizziness | Motor/sensory integrity/deficits | Coordination & balance 3. If nonresponsive to verbal efforts to calm them or uncooperative in remaining still: Sedate and monitor: If SBP ≥ 90 (MAP ≥ 65): MIDAZOLAM standard dose for anxiety Restrain as necessary per System procedure | Document reasons for use ↑ INTRACRANIAL PRESSURE (CRITICAL): Worsening headaches, vomiting (projectile), and altered mental status varying from drowsiness to coma | Visual changes (blurred, double (diplopia), photophobia); gaze palsies; oval pupil w/ hippus (pupils jiggle when light reflex checked); dilated, nonreactive pupils (unilaterally or bilaterally) | Cushing reflex: ↑ SBP (widened PP); bradycardia; respirations vary (RR often decreased/abnormal pattern) | Stiff neck/nuchal rigidity, and/or abnormal motor/ sensory exams ITC special considerations: Maintain supine position with head in axial alignment Assess and trend VS; SpO2; EtCO2, ECG carefully | O2 12-15 L/NRM or BVM at 10 BPM Assess for S&S of brain shift (herniation syndrome) Vary depending on area/structures being compressed: Coma (GCS drops by 2 or more points ≤ 8); dilated, nonreactive pupil(s) (ipsilateral to bilateral); motor deficit (contralateral) | Abnormal flexion or extension; whole body flaccid If present: Seek OLMC order for limited hyperventilation: Adult: 17-20 BPM (must be guided by EtCO2 30-35) Note: NO atropine if bradycardic and SBP ≥ 90 (MAP ≥ 65) NWC EMSS 2022 SOP 52 Rev. 3-11-24  GCS 13 or less HEAD TRAUMA / TBI cont. time sensitive BASILAR SKULL FRACTURE (CRITICAL) Anterior fossa: Telecanthus (wide eyes), periorbital bruising (later), CSF rhinorrhea; lost sense of smell Middle fossa: Hearing deficit, facial droop, CSF otorrhea, or "Battle sign" (later) Do NOT place anything into the nose if possible anterior fracture; do not let patient blow their nose CSF rhinorrhea or otorrhea: Apply 4X4 to collect drainage; do not attempt to stop drainage CONCUSSION: Disturbance in brain function caused by a direct or indirect force to the head resulting in a variety of non-specific S&S and most often does not involve loss of consciousness. Concussion S&S evolve over time. Repeat assessments are needed. History: Hx of previous of previous concussion? How many? Most recent? How long was your recovery from the most recent concussion? Have you ever been hospitalized or had medical imaging done for a head injury? Y/N Have you ever been diagnosed with headaches or migraines? Y/N Do you have a learning disability, dyslexia, ADD / ADHD? Y/N Have you ever been diagnosed with depression, anxiety or other psychiatric disorder? Y/N Medications IMMEDIATE (On-Field) SPORT CONCUSSION ASSESSMENT TOOL 5th EDITION (Scat 5) If any of the “Red Flags” or observable signs are noted after a direct or indirect blow to the head, the athlete should be immediately and safely removed from participation and evaluated by a physician or licensed healthcare professional. If the patient is not fully lucid or conscious, assume a cervical injury until proven otherwise. 1. Red flags: If currently experiencing or occurred following injury; Time sensitive and transport to hospital Neck pain or tenderness Double vision Weakness/tingling or burning in the arms or legs Severe or increasing HA; pressure in head Loss of consciousness; deteriorating consciousness Increasingly restless agitated or combative Seizures | Vomiting 2. Observable signs (witnessed / observed on video): Answered with a yes or no Lying motionless on the playing surface Y/N Balance / gait difficulties / motor incoordination; stumbling, slow/labored movements Y/N (Assess cerebellar function per Stroke assessment) Disorientation / confusion, or an inability to respond appropriately to questions Y/N Blank or vacant look Y/N Facial injury after head trauma Y/N 3. Memory Assessment – MADDOCKS Questions (assess for amnesia) Beware if lacks awareness of event, has difficulty recalling people/places; feels like in a fog; or difficulty concentrating “I am going to ask you a few questions, listen carefully and give your best effort. Tell me, what happened?” What venue are we at today? Which half (sport-specific reference) is it now? Who scored last? What team did you play last game/meet/event? Did your team win? 4. Assess GCS | Cognitive screening: Month, date, year, day of the week; time now within one hour Is there any abnormal behavior (change in personality?) | Sensitivity to light or noise? 5. Cervical Spine Assessment Is the patient’s neck pain-free at rest? If NO neck pain at rest: do they have full range of active pain free movement? Is the limb strength and sensation normal? NWC EMSS 2022 SOP 53 Rev. 3-11-24  MUSCULO-SKELETAL Trauma 1. ITC special considerations: Expose wounds/control bleeding per ITC | Pain mgt if tourniquet applied (do not loosen tourniquet to relieve pain) Assess pain, paralysis/paresis, paresthesias, pulses, pressure & pallor (neurovascular status) before & after splinting Assess for deformity, shortening, rotation, or instability PAIN: Hemodynamically stable, isolated MS trauma, no contraindications: Rx per Pain Mgt SOP (before moving/splinting) Severe muscle spasm/back pain: Analgesia as above and/or MIDAZOLAM (standard sedation dose) Remove jewelry and potentially constricting clothing from injured limb 2. Stabilize/immobilize/splint suspected fx/dislocations per procedure | Minimize edema Gently attempt to align long-bone fx unless open; resistance to movement; extreme pain | Splint joints as found If pulses lost after applying traction splint: Do not release traction | Notify OLMC Apply cold pack over injury | Elevate extremity unless contraindicated | Dress wounds AMPUTATION / DEGLOVING INJURIES: Time sensitive pt Save life over limb | If infield amputation is needed call OLMC Transport amputations above the wrist or ankle to a replantation center if ground transport times are ≤30 minutes 4. Amputation incomplete or uncontrolled bleeding: Hemorrhage control per ITC; splint as necessary 5. Care of amputated parts: Attempt to locate all severed parts | Remove gross debris but NOT tissue; do not irrigate Wrap in saline-moistened (not wet) gauze, towel, or sheet | Do NOT immerse in fluid Place in water-proof container and seal | Surround w/ cold packs or place in second container filled w/ ice/cold water; avoid overcooling or freezing the tissue | Note time cooling of part began CRUSH SYNDROME Time sensitive pt Compression of a muscle mass (w/ distal pulses present) 4 hours or more (2 hours w/ hypothermia) 4. ITC special considerations: Baseline ECG before release (if possible); continue ECG monitoring after release IV NS TKO prior to release; WO up to 1 L/hr after release | Elderly: 200 mL IVF challenges (avoid fluid overload) Assess for HYPERKALEMIA w/ cardiotoxicity (See Chronic Renal Failure SOP): Peaked narrow T waves w/ shortened QT to flattened or absent P waves, prolonged PRI, wide QRS, sine-wave pattern (QRS merges w/ T wave), asystole. If present (OLMC may order one or both: SODIUM BICARBONATE 50 mEq slow IVP over 5 min followed by 20 mL NS IV flush No IV: ALBUTEROL 5 mg continuous neb up 20 mg (throughout transport) [BLS] 5. If HR >100, restless, ↑ RR, wide QRS, long PR interval, or peaked T waves after above: IV NS up to 3 L over 1st 90 min following release unless contraindicated (Ensure clear lung sounds, no SOB) 6. Assess for COMPARTMENT syndrome: Pain more intense than expected from injury especially with passive extension of involved muscle; tingling or burning sensations (paresthesia); muscle may feel tight or full Numbness, paralysis, and absent distal pulses are late signs | If present do not elevate or cool limb IMPALED OBJECTS (EMERGENT to CRITICAL depending on location): 4. Do not remove retained FB unless they pose an airway/ventilatory impairment; would interfere with CPR or transport 5. Stabilize object with bulky dressings; insert small (dental size) gauze roll into mouth to absorb excess blood 6. Elevate extremity with impalement if possible SUSPENSION injury (CRITICAL): "Orthostatic shock while suspended" Person trapped in an upright position within a safety harness with NO movement for prolonged time obstructing venous return from legs to torso. May lose consciousness due to ↓ cerebral blood flow. At risk for Reflow Syndrome: Toxins accumulated in pooled blood return to body after pt lies flat following release 4. Prior to rescue: Lift legs into a sitting position if possible 5. ITC special considerations: ECG monitoring and IVF per Crush Syndrome above 6. Once released: Do not allow pt to stand up or lie flat. If conscious: Position sitting up with legs bent at the hips and knees for at least 30 min. If unconscious, place on side w/ knees drawn up to chest. 7. Treat dysrhythmias per SOP. If significant HYPERKALEMIA suspected: Rx per Crush Syndrome above NWC EMSS 2022 SOP 54 Rev. 3-11-24  SPINE TRAUMA (Adult & Peds) “Spine motion restriction (SMR)” preferred term over “spinal immobilization” (ACS TQP Spine Injury Best Practices Guidelines, 2022) 1. ITC special considerations: Assess in position found Freq. reassess airway / oxygenation (SpO2 target near 100%) / ventilations (EtCO2 target 35-45), ability to talk; muscles used to breathe (beware use of diaphragm only) If airway compromise | RR/depth diminishes | ventilatory failure is imminent/present: Prepare for ADV airway w/ in-line stabilization and/or ventilatory support (CPAP or PPV) | Suction precautions Assess for shock (neurogenic next page): Avoid hypotension for age | IVF NS per ITC | Adult MAP goal: 85-90 Prevent hypothermia: Pt may be unable to maintain a constant core temperature Nausea/vomiting: ONDANSETRON standard dose per IMC PAIN: Rx/ PAIN Mgt SOP | Titrate carefully- judicious use of opioids | Avoid resp. depression; preserve neuro function 2. Consider pt age / comorbidities / assoc. injuries / MOI / exam findings to determine risk of SCI: Older age is a risk factor independent of MOI: osteoporosis; degenerative and age-related changes 3. Establish reliability: Must appear calm, cooperative, alert, and perform cognitive functions appropriately with NO AMS, acute stress reaction, brain injury, chemical impairment, altered decisional capacity, distracting painful injuries, language or communication barriers 4. Rapid exam for evidence suggesting SCI Pain or pressure in neck, head, or back | spine Pain/tenderness/deformity to palpation Paralysis/paresis: Abnormal/asymmetric motor exam in upper and/or lower extremities Abnormal Perception /sensory alterations (sharp/dull or deep pressure): Numb to all touch painful Paresthesias (abnormal sensations): tingling, “pins and needles”, burning, electric shock Priapism | Proprioception (position sense) deficit | Poikilothermia (altered thermoregulation) No sweating below injury | Spinal and/or Neurogenic shock; | Abnormal breathing (diaphragm only) Abnormal Position (Head tilt or arm "Hold-up") | Muscle tone deficit - Loss of bowel or bladder tone 5. Spine motion restriction indications following blunt trauma (also see Elderly SOP: All falls) Acutely altered mental status (GCS