Protocol 21

Trauma Management

Hypovolemic Shock

Suspected Head/Spinal Injury

Soft Tissue Injuries

Suspected Fractures

Trauma in pregnancy

Burn Injuries

Eye Injuries

Patient Entrapment

Reperfusion (Crush) Injury

Field Amputations




This protocol is designed to focus on patient care not covered in the Initial Assessment/Care (Protocol  1) and specific injuries such as burns, amputations, etc. that require specialized care.  Patients meeting Trauma Alert Criteria should be transported immediately, with scene times as minimal as possible. 

General Care

BLS        1.      Initial Assessment/Care

2.      The mode of transportation to a Trauma Center will be decided as soon as possible if the patient meets the Trauma Alert Criteria (Appendix 3 or 4).  In these cases, emphasis in pre-hospital care will be on rapid packaging and initiating transport to a Trauma Center.  Therefore, on-scene delays should be minimal.

3.      Control active hemorrhage with appropriate sterile pressure dressings.  Note exact nature and location of blood/fluid loss
(e.g., ear canals, nostrils, face or scalp wounds).

A.  Hypovolemic Shock

Adult Care

ALS        1.      Attempt to establish at least two large-bore IV's.

a)   Do not delay transport to obtain intravenous access in the Trauma Alert patient.

2.      Upon IV (s) access, run wide open to deliver a fluid challenge of
one-two liters or until a minimum systolic BP of 90 mmHg is obtained.

3.      After the fluid challenge, reassess the patient and if still exhibiting signs of shock, contact MCP.

MCP      4.      Additional fluid boluses above two liters.

Pediatric Care

ALS        1.      In cases of suspected hypovolemic shock, attempt IV access with           the largest applicable catheter.

2.      If signs or symptoms suggest shock, infuse a 20 ml/kg rapid IV fluid bolus and reassess the patient.  If there is no improvement in the cardiovascular status, additional boluses may be repeated in
20 ml/kg increments up to a total bolus of 60 ml/kg.

MCP      3.      Additional fluid boluses above 60 ml/kg.

B.  Suspected Head/Spinal Injury

General Care

BLS        1.      If history, symptoms, or signs of head or neck injuries are            present, manually immobilize the head and neck while assuring      airway maintenance per Airway Management (Protocol 7).

2.      Immobilization of the entire spine is necessary to prevent potentially life-threatening or further disabling injuries during the movement and transportation of the trauma victim (Procedure 26).  Indications for immobilization include:

a)   Physical findings:

1)   Pain to, or pain on movement of the neck or back.
2)   Point tenderness, deformity, and/or guarding of the spine area.
3)   Paralysis, paresis, numbness, or tingling in the arms or legs at any time post-insult.
4)   Signs or symptoms of neurogenic shock.
5)   Unconsciousness with unknown cause.
6)   Possible injury to the spine when evaluation is difficult due to altered mental status.
7)   Significant injuries above the clavicles.

b)   Mechanism of injury:

1)   Any mechanism that impacts violently on the head, neck, torso, or pelvis, associated with sudden violent movement of the spine.
2)   Incidents producing sudden acceleration, deceleration, or lateral bending (commonly occurring in motor vehicle collisions).
3)   Falls from a significant height.
4)   Any unrestrained victims in a vehicular rollover or persons ejected from a moving vehicle.
5)   Penetrating wounds to the head, neck, chest, back, or pelvis.
6)   Other significant injuries and/or significant mechanisms of injury (i.e.-electrocution, explosion, lighting, shallow water dive).

3.      In the absence of hypotension, consider elevating the head of the backboard 30 degrees (12-18").

4.      Hyperventilation (assisted ventilation’s at a rate of 20/ minute with an ETCO2 of 30-34) should only be used with signs of brainstem herniation (pupillary dilatation, asymmetric pupillary reactivity, or motor posturing).

Pediatric ventilation rate 10 greater than normal

ALS        5.      Endotracheal intubation, if indicated, will be accomplished while          maintaining in-line stabilization with no hyperextension of the   head and neck.

C.  Soft Tissue Injuries

General Care

BLS        1.      Do not remove penetrating objects.  Such objects may be cut        down to six inches from the point of entry to minimize          movement.

2.      Any apparent penetrating injuries to the chest, upper back, neck and/or upper abdomen will be covered immediately with an occlusive-type dressing, such as foil or Vaseline gauze
(Procedure 6).

3.      Open wounds of the cranial vault will be dressed carefully with a sterile dressing, without the use of Betadine.

4.      Penetrating, open injuries of the abdominal cavity will be dressed rapidly and carefully with a sterile gauze dressing; use care not to injure any exposed intra-abdominal organs.  Exposed bowel (evisceration) will be dressed with a dressing previously moistened with sterile saline.  This, in turn, will be covered by a dry, occlusive dressing, such as Abd. or foil.  Do not put organs back in.

5.      Amputations and open fractures will be dressed with a sterile dressing (Procedure 28).

D.  Suspected Fractures

General Care

BLS        1.      Any fracture or suspected fracture will be immobilized to reduce          the possibility of further injury.

2.      Severe angulated fractures may be aligned if there is an absence of distal pulse or neurological function.  Distal pulses, skin color, and temperature will be documented prior to and after splinting the angulated fracture.

3.      Proximal and distal manual traction may be applied to the injured extremity, as necessary, when applying a splint.  The splint should extend, if possible, one joint above and one joint below the fracture site.

4.      The use of cold packs is recommended to help reduce swelling.  Avoid direct application to exposed skin.

5.      Primary care of open fractures involves removal of gross contamination.  If protruding contaminated bone ends have been pulled back into the wound, it will be noted in the report.  Dress open bone fractures with moist dressing using normal saline.

6.      Because of the severe muscle spasm associated with femoral fractures, traction leg splints are to be used to adequately stabilize isolated fractures of the femur.  Do not use the traction splint if a pelvic fracture is suspected.

7.      Patients >55 years old are at high risk for muscular skeletal injuries.

E.   Trauma in pregnancy

BLS        1.      Adequate maternal oxygenation is essential to assure fetal well being.  Oxygen should be administered via high-flow face mask.

2.      Avoid placing the mother in a supine position.  After immobilizing the mother on a spineboard, slightly elevate the right side of the board.

ALS        3.      If signs of shock are present, aggressive fluid resuscitation is      indicated.

4.      It is important to consider that post-mortem C-section has a high success rate for fetal survival if accomplished as early as possible.  Therefore, rapid transport to the appropriate facility is essential.

F.   Burn Injuries

General Care

BLS        1.      Assess the burn:

a)   Determine the extent with the Rule of Nines (Appendix 7).
b)   Determine the type of burn (thermal, chemical, etc.).
c)   Determine if the patient was in an enclosed space.

2.      Cover burned areas with Water JelÒ dressings.  If not available, cover the burned areas with sterile sheets.  For pain control, tepid water lavage or soaks may be used; use for only 15 minutes for pain relief of second degree burns of 10% or less of body surface area.

ALS        3.      Establish IV access on all victims with second or third degree     burns of 15% or greater body surface area or greater than 10% in    pediatric patients.

4.      Provide Pain Management (Protocol 18).

G.  Eye Injuries

General Care

BLS        1.      Obtain a brief injury history including the mechanism of injury,             possible chemical exposure, and allergies.

2.      Examine the eye(s) for signs of penetrating injury, foreign body, irritation, hemorrhage, prosthesis, or contact lenses.

3.      Remove or ask the patient to remove contact lenses if still in the affected eye(s).

4.      Determine gross visual acuity in both eyes.  Have the patient read the largest letters on the patient report at arms length.

5.      If penetrating injury is known or suspected:

a)   Stabilize obvious penetrating objects.
b)   Avoid direct pressure on eye or any maneuvers that might increase intraocular pressure.
c)   Apply ocular shield or similar rigid device over affected eye.  Cover both eyes to minimize eye movement.

6.      If enucleation has occurred (eyeball has been forced out of the socket) cover the entire eye area with a rigid container, such as a disposable drinking cup.  Avoid direct contact with the exposed globe.  If bleeding, control by direct pressure with a sterile dry dressing.

7.      If there are signs/symptoms or suspicion of ocular exposure to chemicals or foreign body without obvious or suspected penetrating injury or laceration of cornea or globe, irrigate with Normal Saline IV solution.

ALS        8.      Irrigation with Morgan Lens® (Procedure 31).

H.  Patient Entrapment

General Care

As stated before, in general trauma care the emphasis is on rapid packaging and transport of the patient to achieve definitive care.  If transportation of the patient is delayed due to entrapment (motor vehicle collision, structural collapse, confined space environments, or trench collapse), the patient must be treated appropriately while technical rescue operations are under way to free the patient.

BLS        1.      Don the appropriate protective gear for the environment.

2.      Stabilize the scene.

3.      Gain access to the patient.

4.      Protect the patient from further harm.

5.      In cases where spinal injury is suspected provide immobilization by manual means initially.  The environment may require special patient packaging equipment (Stokes Basket, KED, SKED, LSP-Halfback, or a Miller Board).  Patient packaging and extrication should be coordinated with the Extrication Sector.

ALS        6.      Obtain vascular access (Procedure 13).

MCP      7.      Consider a field blood transfusion for extended extrications
(Protocol 22)

I.    Reperfusion (Crush) Injury

If the patient’s extremity or extremities have been trapped for 60 minutes or more by a heavy object occluding peripheral perfusion, the patient must be treated to prevent reperfusion injury.  Crush injury is to be distinguished from a simple entrapment.  This treatment must be administered prior to the object being lifted from the patient.

Adult Care

ALS        1.      Infuse a 1000ml bolus of Normal Saline.  Simultaneously ,           administer 50 mEq of Sodium Bicarbonate IV

Pediatric Care

ALS        1.      Infuse 40 ml/kg bolus (Maximum bolus of 1000 ml) of Normal   Saline.  Simultaneously administer 1 mEq/kg (Maximum
50 mEq) of Sodium Bicarbonate IV.

J.    Field Amputations (Refer to Protocol 31)


© 2009 Greg Rubin
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