PROTOCOLS: TRAUMA RESUSCITATION, PROTOCOLS: Trauma, PROTOCOLS: additional Trauma

The goal of the START program is to provide the

"greatest good for the greatest number of patients."

Jump Start Triage AGES?

(1-8)

4. LTOWB-STANDS FOR

(Low titer Group O Whole Blood)

EPCR Documentation

Document administration in the flow chart section, currently the only option is blood, please indicate the type and volume. In the narrative please describe the reason for blood, what products where used, Patients Temperature Before, During and After administration, response to blood products, Qin Flow warmer was used, any adverse reactions, patient or family consulted about blood products and if medical director contact was made.

8. Scene Delays- In the event the storage window is getting close and the supervisor can not make it back to the office to exchange blood products, contact the EMS Chief to arrange the swap. In the event the Chief is not available request an

EMS crew to do the exchange

(PED)Circulation-Carotid or femoral pulse is palpable, but the radial or pedal pulses are not palpable or the systolic blood pressure is less than 100 mmHg. RED/BLUE?

BLUE

(PED)Consciousness-Exhibits symptoms of amnesia, or there is loss of consciousness. RED/BLUE?

BLUE

(PED)Fracture-Reveals signs or symptoms of a single closed long bone fracture. Long bone fractures do not include isolated wrist or ankle fractures. RED/BLUE?

BLUE

(PED)Size-Pediatric trauma patients weighing 11 kilograms or less, or the body length is equivalent to this weight on a pediatric length and weight emergency tape (the equivalent of 33 inches in measurement or less). RED/BLUE?

BLUE

• BLOOD TRANSFUSION

BSO Air Rescue Only

*Temperature Controls-Check and log freezer Temp BLANK. *Temperature Controls -Each BLANK, change the temp graph in the blood refrigerator and scan and send a copy to the blood Bank along with fridge and freezer logs *Temperature Controls-Monthly copy all logs and send to BLANK Assistant chiefs office for filing

DAILY THURSDAY EMS

START TRIAGE (ADULT) No respirations after head tilt SEVERITY?

DEAD

Jump Start Triage NOT BREATHING-POSITION AIRWAY-STILL APNEIC-CHECK PULSE-IF HAS PULSE-GIVE 5 BREATHS-STILL APNEIC-THEN (SEVERITY)?

DECEASED

Jump Start Triage NOT BREATHING-POSITION AIRWAY-STILL APNEIC-CHECK PULSE-IF NO-THEN (SEVERITY)?

DECEASED

Jump Start Triage Respiratory Rate 15-45-PULSE-YES-AVPU "A,V OR P" APPROPRIATE(SEVERITY)?

DELAYED

SIGNS & SYMPTOMS OF DECOMPENSATED SHOCK

Decreased LOC, hypotension, peripheral cyanosis, delayed capillary refill, inequality of central/distal pulses, and tachycardia (later progressing to bradycardia)

TRANSFUSION PROTOCOL-Scope

Describes the storage and maintenance of blood products for use in the field

A minimum of 1 paramedic and 1 EMT must accompany a LEVEL BLANK TRAUMA patient in the back of the rescue, provided it does not cause a significant delay in transport.

ONE

ANTIPLATELET (NOT ASPIRIN) 3 MEDCATIONS

PLAVIX, BRILINTA, EFFIENT

Unless otherwise noted, IV fluids should be given for a SBP less than 100 mmHg and should be given at a rate (boluses) necessary to maintain BLANK pulses (which is typically a SBP of 80-90 mmHg).

Peripheral

7. EPCR Documentation- Document administration in the flow chart section, currently the only option is blood, please indicate the type, titer and volume.. In the narrative please describe the reason for

blood, what products where used, Patients Temperature Before, During and After administration, response to blood products, Qin Flow warmer was used, any adverse reactions, patient or family consulted about blood products and if medical director contact was made.

TRANSFUSION PROTOCOL HISTORY

• What was the mechanism of injury - blunt (MVC, fall, blow to body) vs. penetrating (stabbing, GSW, foreign body)? • Did a medical condition contribute to the mechanism of injury? Other medical conditions? • Medications - Coumadin? Plavix? Aspirin? Pradaxa? Xarelto? Eliquis? (any blood thinners or anticoagulants) • Beta Blockers and Calcium Channel Blockers may not allow HR to increase appropriately

• Hemorrhagic Shock-ADULT Rapid transport, keep on-scene times less than BLANK minutes.

10

Any patient that is in cardiac arrest as a result of electrocution or lightning injury should receive

immediate defibrillation, if applicable.

• Hemorrhagic Shock-ADULT Cervical Spinal Motion Restriction if

indicated.

6. Usage-When the blood products are used, maintain the proper paperwork as per EMS Guideline. Be sure the usage card

is filled out, sticker both copies, white top copy stays with the patient, yellow copy goes back to the blood bank and a copy should be scanned into the run record. Contact ********* for replacement units.

On-scene times for LEVEL ONE TRAUMA patients should be blank or less. On-scene times greater than 10 minutes shall have the reason for the delay documented in the ePCR report.

10 minutes

Level IV-

101-1000 patients

Level II -

11-20 patients

5. Rotation-LTOWB has a 21 day shelf life At 72 hours out, be sure to contact ONE BLOOD to re-order. In the event we have Plasma and/or PRBCs they can be exchanged as stated below A. Liquid Plasma BLANK days, 24hour turn around on ordering B. PRBC BLANK days, 24hour turn around on ordering

14 14

(Pediatric patients are those age BLANK or younger) Pediatric Trauma Alert patients will be transported to the nearest appropriate Pediatric Trauma Center).

15

HOW MANY BLUE=TRAMA ALERT?

2

Level III -

21-100 patients

Level I -

5-10 patients

TRANSFUSION PROTOCOL-If more than 500 mL of Whole Blood is available on scene the following general guidelines apply FOR 6-10 y/o 11-13 y/o ≥13 y/o (are eligible for HOW MANY ML OF WHOLE BLOOD?)

6-10 are eligible for 500 mL of Whole Blood 11-13 are eligible for 1000 mL of Whole Blood > THAN OR EQUAL TO 13 are eligible for >1000 mL of Whole Blood

Hemorrhagic Shock -Minimum Pediatric Systolic Blood Pressure Values • Neonates *Infants • Children 1-10 years old • Children greater than 10years old

60mmHg 70mmHg 70+(age in years x 2) mmHg 90mmHg

3. In the event none of the above criteria is identified in the assessment of the pediatric patient, the paramedic can call a Trauma Alert if, in his or her judgment, the trauma patient's condition warrants such action. Where paramedic judgment is used as the basis for calling a trauma alert, it shall be documented as required in the

64J-1.014 F.A.C., on the patient care report and County Unified Trauma Telemetry Report (CUTT) (see 1.10.1).

Hemorrhagic Shock-ADULT (FLUID RESUSCITATION) Internal hemorrhage -Give only enough normal saline to maintain a blood pressure high enough for adequate peripheral perfusion (radial pulse). The presence of a radial pulse equates to a SBP of BLANK mmHg, which is the goal of fluid resuscitation for a patient with suspected internal hemorrhage. Bolus of Normal Saline BLANK mL, reassess blood pressure and lung sounds prior to each bolus. Maximum1L.- Permissive Hypotension in trauma

90 500

• Hemorrhagic Shock-ADULT Maintain an SpO2of BLANK% and EtCO2 levels between 35-45mmHg.

95

LEVEL ONE TRAUMA patients shall be transported to closest appropriate

Trauma Center

ADULT AND PEDIATRIC Non-trauma alert patients that present with a mechanism of injury suggestive of a significant injury or in the paramedic's judgment present with a non-significant injury and/or taking an anti-coagulant (i.e., Coumadin) or anti-platelet (i.e., Plavix), the EMS unit will be required to triage and transport this patient to the nearest appropriate

Trauma Center.

The only things that can cause the treating paramedic to interrupt the primary survey are an unsafe scene or BLANK. Respiratory arrest, dyspnea, or bleeding control should be delegated to a crew member so that the treating paramedic does not have to interrupt the primary survey.

airway obstruction

BSO AIR RESCUE ONLY-TRANSFUSION PROTOCOL Universal Patient Guideline

*Assure Scene safety. Primary Survey / Control Severe Traumatic Bleeding *18 or 20-gauge catheter x (2) or IO Humeral (preferably)

HOW MANY RED=TRAMA ALERT?

1

(HIGH INDEX Trauma criteria are as follows)-SIGNIFICANT INJURY PLUS ONE OF THE FOLLOWING

1. Falls > 12 feet (adults) falls > 6 feet (pediatrics) 2. Extrication time > 15 minutes 3. Rollover 4. Death of occupant in the same passenger compartment 5. Major intrusion into passenger compartment 6. SEPARATION from a bicycle 7. FALL FROM ANY HEIGHT IF ANTICOAGULATED OR ANTIPLATELET (ADULT OVER 55) 8. Paramedic judgment.

. 2. Blood Cooler

Approved cooler used to store blood outside of the blood refrigerator, and deliver products to the field.

1. Blood Refrigerator

Approved refrigeration device to store blood products long term

BLANK is often the most common rhythm following an electrical insult. Perform CPR on all electrocution/lightning strike victims in cardiac arrest.

Asystole

4. Cooler Usage

At shift change the insert should be removed from the freezer, and allow to thaw for 20 minutes. The insert should be loaded in the cooler and the blood products container from the blood refrigerator placed in it, assuring temperature controls are in place. The routine time for products in this cooler is to be 12 hours, with a maximum time of 24 hours. The products from the previous shift should be rotated back to the blood refrigerator. Be sure the temp probe is maintained in the cooler and monitored throughout the shift.

1. Procurement

Blood products are distributed to the Broward County Air Rescue Station 85, through ONE BLOOD, via regular or PRN delivery * O -/+ Whole Blood * LTOWB , titer should be < 256

• Hemorrhagic Shock-ADULT Control external severe extremity hemorrhage (direct pressure, Combat Application Tourniquet (C.A.T.), apply CAT at the most proximal anatomical location of extremity until the bleeding stops). Never apply BLANK directly over injury site or joint.

C.A.T.

ANTICOAGULATION 4 MEDICATIONS

COUMADIN ,PRADAXA ,XARELTO, ELIQUIS

Hemorrhagic Shock-ADULT (FLUID RESUSCITATION) Isolated external hemorrhage controlled with direct pressure or BLANK. Give only enough normal saline to maintain a blood pressure high enough for adequate BLANK. The presence of a radial pulse equates to a SBP of 80-90 mmHg. Bolus of Normal Saline 500ml, reassess blood pressure and lung sounds prior to each bolus. Maximum BLANK L.

Combat Application Tourniquet (C.A.T.). peripheral perfusion (radial pulse) 1

(TRANSFUSION PROTOCOL-Administration) 1. Place flat thermometer on patient's BLANK 2. Whole Blood 1 unit IV/IO via blood Y-tubing. Flow through blood warmer to completion and / or hemodynamic stability. Repeat PRN x 1. Utilize low titer BLANK for most patients, utilize low titer O - for female patients < 40. 3. In the event Whole Blood is not available Low BLANK Liquid Plasma may be given to reach permissive hypotension with hemodynamic stability. Repeat PRN x 1.

FOREHEAD O+ Titer A

Level V -

Greater than 1000 patients

Jump Start Triage NOT BREATHING-POSITION AIRWAY-IF NOW BREATHING (SEVERITY)?

IMMEDIATE

Jump Start Triage NOT BREATHING-POSITION AIRWAY-STILL APNEIC-CHECK PULSE-IF HAS PULSE-GIVE 5 BREATHS-IF BREATHING (SEVERITY)?

IMMEDIATE

Jump Start Triage Respiratory Rate 15-45-PULSE-NO (SEVERITY)?

IMMEDIATE

Jump Start Triage Respiratory Rate 15-45-PULSE-YES-AVPU-"P"(INNAPPROPRIATE) POSTURING OR "U"- (SEVERITY)?

IMMEDIATE

Jump Start Triage Respiratory Rate <15 OR >45 (SEVERITY)?

IMMEDIATE

START TRIAGE (ADULT) Perfusion -No radial pulse Cap refill > 2 sec (Control Bleeding) SEVERITY?

IMMEDIATE

START TRIAGE (ADULT) Respirations > 30/min SEVERITY?

IMMEDIATE

START TRIAGE (ADULT) Mental Status -Unable to follow simple commands SEVERITY?

IMMEDIATE *Otherwise DELAYED

• Hemorrhagic Shock-ADULT If clotting agent is available, severe junctional hemorrhage (e.g., neck, axillary, thoracic, abdominal, pelvis and groin) and any other severe external hemorrhage that is not able to be easily controlled using C.A.T). shall be controlled using clotting agent or XSTAT. Pack wound with clotting agent and maintain pressure for a minimum of one minute. USE BLANK BANDAGE WHEN APPROPRIATE.

ISRAELI

11. Out of Temperature

If any product is discovered out of temperature, range notify the EMS Chief and generate and incident report. Take the blood out of service in the fridge, the blood bank will be contacted and an incident investigation will be done to prevent reoccurrence.

9. Adverse Reaction

Immediately STOP, maintain alternate fluids and follow appropriate protocol. Any transfusion reaction, will need to be reported to the receiving facility. The blood products should also be packaged up in appropriate material and returned with all tubing to the blood bank.

TRANSFUSION PROTOCOL-In general one unit 500mL (1 unit) of

Low Titer O+ Whole Blood (LTO+WB) will be available per patient.

START TRIAGE (ADULT) Move the walking wounded SEVERITY?

MINOR

Jump Start Triage IF Able to walk (SEVERITY)?

MINOR(SECONDARY TRIAGE)

NEUROGENIC SHOCK-IF PATIENT IS HYPOTENSIVE (SBP LESS THAN 100mmHg)TX

NORMAL SALINE-1L. Assess lung sounds and blood pressure every 500mL.

NEUROGENIC SHOCK-IF PATIENT REMAINS HYPOTENSIVE AFTER FLUID ADMINISTRATION Apply

Push Dose Epinephrine

• (PED)Airway-Active ventilation assistance required due to injury(ies) causing ineffective or labored breathing beyond the administration of oxygen. RED/BLUE?

RED

•(PED) Cutaneous-Major soft tissue disruption, including major de-gloving injury, or major flap avulsions, or 2nd or 3rd degree burns to 10 percent or more of the total body surface area, electrical burns (high voltage/direct lightning) regardless of surface area calculations, or amputation proximal to the wrist or ankle, or any penetrating injury to the head, neck or torso (excluding superficial wounds where the depth of the wound can be determined). RED/BLUE?

RED

•(PED) Fracture-Evidence of an open long bone (humerus, radius/ulna, femur, or tibia/fibula) fracture or there are multiple fracture sites or multiple dislocations (except for isolated wrist or ankle fractures or dislocations). RED/BLUE?

RED

•(PED)Circulation-Faint or non-palpable carotid or femoral pulse or the patient has a systolic blood pressure of less than 50 mmHg. RED/BLUE?

RED

•(PED)Consciousness-Patient exhibits an altered mental status that includes drowsiness, lethargy, inability to follow commands, unresponsiveness to voice or painful stimuli or suspicion of a spinal cord injury with/without the presence of paralysis or loss of sensation. RED/BLUE?

RED

TRANSFUSION PROTOCOL -CONTRAINDICATION

Religious objection to receiving blood products—consult On Call Medical Director

3. Freezer

Separately maintained freezer to hold the cooler inserts

10. Religious Observations

Some religions will refuse to accept blood products. In this instance follow EMS protocol, and document the refusal in the EPCR.

IV attempts shall not delay transport. A minimum of BLANK large bore IV's should be initiated for all LEVEL ONE TRAUMA patients. BLANK are not recommended for trauma patients requiring aggressive fluid resuscitation however, if unable to establish an IV, an IO (preferably Proximal Humerus) should be placed.

TWO, IO'S

3. Temperature Controls

The blood product refrigerator will be temperature checked daily at 7am and 7pm and recorded in the log. If at anytime the temperature is below or above normal range, remove the units and place in the cooler, contact EMS Chief for storage options

TRANSFUSION PROTOCOL-Purpose

To maintain blood products for EMS delivery

2. Maintenance

Upon receipt the blood products will be logged in, triage tag added and placed in the refrigerator at station 85 in the EMS supervisors office.

. In the event the product is out past 24 hours maximum time, monitor temp, if at anytime the temp is out of range, alert the blood bank and request immediate

exchange of blood products

(TRANSFUSION PROTOCOL Confirmation Procedure) 1. Confirm patent administration site if any question exists utilize a BLANK 2. Identify the patient meets BLANK 3. Record BLANK vitals 4. (2) EMS personnel must confirm the tag and the blood product match including BLANK, BLANK, BLANK, BLANK and BLANK amount 5. Both confirming personnel must sign the accompanying BLANK tag

new site criteria above baseline number, blood type, Rh factor, expiration date and fluid blood component

• Hemorrhagic Shock-ADULT Maintain body temperature with blankets and consider increasing the temperature in the BLANK compartment.

patient

*Hemorrhagic Shock-ADULT (FLUID RESUSCITATION) Establish two large bore IVs while enroute. NEVER delay BLANK to start IVs on scene.

transport

START or JumpSTART (ages 1-8) Triage System to

triage patients.

Of Note-At this time the LTO+WB does not have

volume markings on the bag.

(TRANSFUSION PROTOCOL-For Patients in HEMORRHAGIC SHOCK) Blunt or Penetrating Trauma-1 of the following Administer Whole Blood with signs of acute hemorrhagic shock as evidenced by

• Systolic Blood Pressure < 70 mmHg OR • Systolic Blood Pressure < 90 mmHg with- Heart Rate ≥ 110 beats per min OR • ETCO2 < 25 OR • Witnessed traumatic arrest < 5 min prior to provider arrival and continuous CPR throughout downtime OR • Age ≥ 65 y/o and SBP ≤ 100 AND HR ≥ 100 beats per minute

SIGNS & SYMPTOMS OF COMPENSATED SHOCK

• Anxiety, agitation, restlessness, normotensive, capillary refill normal to delayed • Tachycardia (a weak rapid pulse greater than 130 beats/min is usually a sign of shock in children of all ages except neonates)

ADULT & PEDIATRIC RESUSCITATION SHOULD NOT BE ATTEMPTED FOR TRAUMA PATIENTS THAT HAVE ALL THREE OF THE FOLLOWING PRESUMPTIVE SIGNS OF DEATH PRESENT

• Apneic • Pulseless (Asystole confirmed in two leads) • Fixed and dilated pupils • INJURY INCAPATIBILE WITH LIFE

TRAUMACRITERIA GRAY CRITERIA Informational only Patients who do not meet "Trauma Alert" criteria, but meet one (1) or more of the following criteria may be at risk of serious injury and special consideration should be given to them, including bypass of a local hospital and transport to the nearest Trauma Center WHICH ARE

• Blunt head, chest or abdominal trauma on blood thinners with high risk of bleeding or history of a bleeding disorder • 65 years or older sustaining blunt trauma exhibiting minimal symptoms or borderline criteria • 65 years or older with SBP <110 mmHg • MVC > 20 mph, with seatbelt marks on the torso • MVC with partial ejection from an automobile • End stage renal disease on dialysis

Hemorrhagic Shock PED-FLUID RESUSCITATION

• Establish two large bore IV's or an IO if unable to obtain IV access. Do not delay transport!

SCENE MANAGEMENT-TRAUMA, THE FOLLOWING CONDITIONS SHOULD BE MANAGED AS SOON AS THEY ARE DISCOVERED. THESE INTERVENTIONS SHOULD BE COMPLETED BY ANOTHER TEAM MEMBER SO THAT THE PRIMARY SURVEY IS NOT DISRUPTED

• Maintain airway (positioning, suctioning, ETT/IGEL, cricothyrotomy) • Assist respirations for a respiratory rate less than 10 or EtCO2 greater than 45 • Apply Spinal Motion Restriction for neck tenderness or an AMS with MOI present • Control major bleeding (direct pressure or a C-A-T) • Tension Pneumothorax (needle decompression)

TRANSFUSION PROTOCOL-MARCHES PROTOCOL

• Massive bleeding control • Airway - NPA/OPA/Advanced Airway • Respiratory - decompress chest if tension pneumothorax, occlusive dressing for open pneumothorax • Circulation- IV/IO, tourniquet, pelvic binder, wound packing • Hypothermia care • Eye injuries - cover with rigid shield and no pressure on the eye • Spinal motion restriction if indicated

Hemorrhagic Shock PEDS-FLUID RESUSCITATION FOR SUSPECTED INTRATHORACIC, INTRA-ABDOMINAL OR RETROPERITONEAL HEMORRHAGE OR ISOLATED EXTERNAL HEMORRHAGE

• NORMAL SALINE-20mL/kg bolus, titrated to maintain a SBP as listed below. May repeat 2x prn for hypotension. • Assess lung sounds and blood pressure often.

TRANSFUSION PROTOCOL -CRITERIA HEMORRHAGIC SHOCK- in medical or trauma Adult and Pediatric (≥ 6 y/o) patients Relative Contraindications

• Patient < 6 years old Consult Medical Direction if patient is in hemorrhagic shock and < 6 y/o Medical Director may elect to give blood in patients < 6 y/o

Hemorrhagic Shock-PEDIATRIC MANAGEMENT

• Rapid transport, keep on-scene times less than 10 minutes. • Maintain anSpO2 at 95% and EtCO2 levels between 35-45 mmHg. • Control external severe extremity hemorrhage (direct pressure, Combat Application Tourniquet (C.A.T.), apply at the most proximal anatomical location of extremity until the bleeding stops). Never apply C.A.T. directly over injury site or joint. • If clotting agent is available, severe junctional hemorrhage (e.g., neck, axillary, thoracic, abdominal, pelvis and groin) and any other severe external hemorrhage that is not able to be easily controlled using • C.A.T. shall be controlled using clotting agent. Pack wound with clotting agent and maintain pressure for a minimum of one minute. • Spinal Motion Restriction if indicated. • Maintain body temperature with blankets.

ADULT-SIGNS, SYMPTOMS & TREATMENT OF NEUROGENIC SHOCK

• Skin - Warm/Dry • Hypotension with bradycardia • Paralysis- Injury present above the T6 spinal cord level • (Neurogenic Shock vs. Spinal Shock)