A. Begin oxygen therapy as early as possible in all traumatic emergencies.
B. Insert oral or nasal airway in all unconscious patients. Do not insert EOA in apneic patients with bleeding from facial, mouth, or throat trauma. May ET intubate, if authorized, or use Combitube or LMA in patients with severe respiratory distress and/or ineffective ventilation or Glasgow Coma Score <8.
C. Spinal Precautions /Immobilization
1. Full spinal immobilization should be considered for all non-ambulatory trauma patients who sustain a mechanism of injury with the potential for causing spinal injury and have one of these clinical findings:
a. Spinal pain or tenderness
b. Altered mental status
c. Evidence of intoxication
d. Significantly distracting painful injuries (ex. long bone fracture)
e. Neurological deficits
f. Extremes of age (young-old)
2. Patients who are or who have been ambulatory and meet the criteria above should be considered for the following spinal precautions:
a. Hard cervical collar: if complaining of neck pain or any other from C.1. above.
b. Secure to stretcher: if complaining of neck, thoracic or lumbar pain or any other from C.1. above.
3. Backboards may be used at any time if the attending ambulance personnel feel it is useful. If the patient is on a backboard prior to the ambulance arrival they should remain on the backboard
D. The pneumatic compression trousers(PCT) may be used for the splinting of lower extremity fractures only when it is indicated for other injuries; otherwise, extremity splints (especially traction splints) are more appropriate.
E. Consider pain management per protocol. See "Pain Management" page 1-11.
F. All intravenous lines, whether started on standing orders or physician's verbal orders, should be started in transit to the hospital. (The only exception is when there is an unavoidable delay moving the patient from the scene, i.e., trapped in auto, etc.) IV fluids should be hung whenever IV access is established for trauma.
G. Under no circumstances should transport of critical trauma patients be delayed for detailed physical examination and/or treatment of non-life-threatening injuries. Set priorities and expedite transport.
H.
Attempt to notify the receiving
hospital as soon as possible when transporting a critical trauma patient. See
"Patient Disposition" page 1-4.
Standing Orders
1. Begin oxygen therapy.
2. Spinal immobilization as appropriate.
3. If patient is intubated and begins to develop strong evidence of tension pneumothorax (i.e. increased airway resistance; hypotension; jugular vein distention) consider needle thoracostomy.Perform needle thoracostomy at 2nd intercostal space, midclavicular line of affected side.
· May be done without verbal orders if patient is already intubated. If patient is not intubated consult a medical control physician immediately if tension pneumothorax suspected (see #7 below).
4. Apply pneumatic compression trousers(PCT) on any patient with significant trauma:
a. Do not inflate without verbal orders if patient has chest injury or penetrating injury of neck.
b. Inflate if evidence of intra-abdominal and/or pelvic hemorrhage.
c. Inflate for external hemorrhage that can be controlled if systolic BP less than 90.
d. Inflate if attempting resuscitation of a traumatic arrest.
5. Transport.
6. Start IV Normal Saline while en route on any patient with severe trauma. If SBP <90, run wide open until BP reaches 90, then TKO.
After Obtaining Verbal Orders
7. Consider needle thoracostomy if strong evidence of tension pneumothorax.
Standing Orders
1. Spinal precautions/immobilization as appropriate.
2. Monitor spine injury patients closely for neurogenic shockand/or respiratory problems.
3. If clinical evidence of herniation, consider mild hyperventilation.
4. If patient unconscious, start IV Normal Saline and run TKO if BP > 90. If BP < 90, treat per Traumatic Shock protocol.
5. If time permits, determine blood glucosend treat hypoglycemiaper protocol.
Standing Orders
1. Patient:
a. Control hemorrhage and cover stump with sterile dressing saturated with saline;
b. Treat as per protocol for General Trauma/Traumatic Shock;
c. Do not spend excessive time looking for amputated part if patient unstable.
2. Amputated Part:
a. Wrap part in sterile gauze;
b. Moisten with saline;
c. Place in plastic bag;
d. Place on ice, if available, or cold packs (do not freeze).
Standing Orders
1. Confirm prolonged entrapment(> 1 hour) of one or more full extremities by a crushing object (vehicle, building rubble, hanging in harness, self).
2. Complete trauma assessment to evaluate patient for other injuries and treatments.
3. If extremity is accessible, check for decreased sensation, motor function, skin color and distil pulses.
4. For entrapments with extended scene times, contact the on-duty ER physician for further orders.
5. Pre-Extrication:
a. Apply oxygen via mask
b. Start large bore IV with Normal Saline x 2. Give 2 liter NS bolus, followed by 500 cc/hr.
c. Control pain per protocol.
d. Monitor cardiac rhythm.
e. Immediately prior to extrication consider Sodium Bicarbonate, 2 mEq/Kg IV up to 100 mEq.
f. Extricate.
6. Post-Extrication:
a. Suspect hyperkalemiaif T waves become peaked, QRS becomes prolonged (>0.12 sec) or hypotension develops.
b. Consider Calcium Chloride 1Gm IV over 5 minutes for dysrhythmias.
c. Consider additional Sodium Bicarbonate
d. Contact medical control physician for persistent hyperkalemiaor dysrhythmias.