Trauma

2-10-a. Trauma: General Guidelines

Penetrating injuries and blunt trauma are time sensitive conditions which may require rapid hospital surgical intervention. EMS must expedite transport of these patients to hospitals and trauma centers. For patients with hemorrhagic shock a lower BP may be acceptable, as excessive fluid administration can lead to increased hemorrhage. Early communication with the receiving hospital is imperative so that Trauma Activation is facilitated. Provide condition updates to the receiving hospital for unstable patients. The paramedic shall:

1) Rapidly extricate and immobilize the patient if indicated

2) Initiate transport

3) If patient airway and effort is unstable, support ventilation. If indicated, administer supplemental oxygen

4) Patients with head injury and/or shock who are breathing spontaneously and can maintain O2 saturation > 90% should be transported without delay for definitive establishment of the airway at the hospital

5) Establish IV/ IO access with NS and administer fluid: in 250 mL boluses until systolic BP reaches 90mm if no head injury, or 110mm Hg in patients with suspected head injury

6) Once BP target is reached, then drop the infusion rate to TKO

7) Caution: Be aware of possible hypothermia in patients with large blood loss, large open wounds, or in elderly patients. If necessary cover patients with blankets and possibly turn off the air conditioning in the ambulance patient compartment

8) Physical exam should not repeatedly search for crepitus / manipulate the pelvis or other broken bones, since this increases pain and bleeding

9) Dislodged teeth may be transported in a container with NS or milk, with care to not clean the tooth off, as this reduces the chances of successful re-implantation

2-10 Trauma 2-10-b. Fractures, Extremity Injuries and Amputations

1) Control all major bleeding. Consider tourniquet use when direct pressure fails to control life threatening hemorrhage rapidly

2) Appropriate wound care: Cover open wound with sterile dressings

3) Splinting:

a) Immobilize stable fractures by placing a padded splint across the fracture, and the adjacent joints above and below

b) If an injured extremity is noted to be pulseless distal to an angulated fracture, a single attempt at realignment may be performed prior to splinting

c) Document distal vascular and neurological findings

d) For suspected isolated mid-shaft femur fractures without evidence of pelvic fracture, use a traction splint as indicated

4) Amputations: Cover amputated anatomy with saline moistened gauze, then covered by a dry dressing. Amputated body parts should be transported with cool, damp saline moistened gauze, in a sealed bag, and kept cool, but not packed directly on ice

5) Pain management

2-10-c. Head Injuries

1) Perform a careful exam of the entire head and spine, and a brief neurological exam including GCS

2) Find out if the patient is on any blood thinner medications

3) Start an IV and give O2, evaluate airway, control vomiting, and if possible, elevate the head of the bed 20 - 30 degrees

4) Try to avoid any hypoxic or hypotensive episodes. Keep POX 94- 98% and BP ≥ 110 systolic

5) Repeat the GCS scoring for any apparent worsening on repeat neurological exams and notify the receiving hospital of possible brain herniation for unilateral pupil dilation or abnormal posturing

2-10-d. Ocular Trauma

Eye injuries or periorbital injuries with possible injuries to the globe should be protected with a rigid eye shield, taped in place. Avoid any pressure on the globe.

2-10-e. Shock: Hypovolemia

For systolic BP < 90 mmHg which is considered to be secondary to hypovolemia [see 1-7. Shock/Hypovolemia]

2-10-f. Death Pronouncement Traumatic Cardiac Arrest

[see 1-10. Termination of Resuscitation].

1) Blunt Trauma: If patients are in asystole after significant blunt trauma, strongly consider field pronouncement

2) Penetrating Trauma: If patients are in asystole after significant penetrating trauma, strongly consider field pronouncement

3) Consider transporting patients in cardiac arrest, who are in asystole, when there are concerns such as scene safety, provider safety, and cardiac arrest in a very public place