Lisbon Fire Department Standard Operating Guidelines and Policies

The following content will be considered the Guideline/Standard of care for

For the patient who sustains major or multiple blunt or penetrating trauma, the following protocols shall be followed:

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  Determine if obvious death before proceeding with resuscitation (se guideline 302)
  
• 
  Patients in ventricular tachycardia or ventricular fibrillation should be defibrillated once at the appropriate setting prior to expedited transport.
  

• 
  Multiple blunt trauma or penetrating trauma to the head or trunk OR
  
• 
  Partial/full thickness burns over at least 80% body surface area in the adult (over age 16) with empirical evidence of inhalation injury
  

• 
  The patient has no signs of life (e.g. respiratory effort, pupil reaction, etc.) AND
  
• 
  The patient has a rhythm of:
  
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  Asystole or
  
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  Agonal PEA at less then 30 per minute with a wide (aberrant) QRS
  

• 
  No resuscitation efforts are indicated
  

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  Give control of the scene/body to the appropriate law enforcement agency.
  
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  Complete a standard EMS report documenting your findings.
  
• 
  Assure the medical examiner has been notified.
  

1. 
   Resuscitation must be started on all patients with narrow (less than0.12 sec-3 small boxes) QRS complexes regardless of the rate.
   
2. 
   Patients in ventricular tachycardia or ventricular fibrillation should be defibrillated once at the appropriate setting prior to expedited transport.
   

1. 
   Administer oxygen
   
2. 
   Control the airway as necessary
   
3. 
   Stabilize the cervical spine
   
4. 
   Begin CPR if patient becomes pulseless
   
5. 
   Control all external hemorrhage
   
   1. 
      Direct pressure
      
   2. 
      Consider hemostatic agents (see guideline # 5014)
      
   3. 
      Consider tourniquet application for massive extremity trauma (see guideline # 5013)
      
6. 
   Protect fracture sites and splint as indicated
   
7. 
   Consider application of pelvic binder or application of and inflation of the pneumatic antishock garment (PASG)(MAST) if appropriate: (see guideline # 5004)
   
   1. 
      Suspected pelvic fracture
      
   2. 
      Significant soft tissue injury in areas covered by the PASG
      
   3. 
      Suspected ruptured abdominal aortic aneurism
      
8. 
   Transport the patient to the ambulance
   
9. 
   Notify the receiving hospital of circumstances and estimated time of arrival.
   
10. 
    Start one (1) IV of Normal Saline in a peripheral site. Do not delay transport if there is difficulty starting the IV. A second IV may be attempted in transit.
    
11. 
    Replace the volume as rapidly as possible if there is evidence of continued hypovolemic shock.
    
    1. 
       Volume replacement in the patient equal to or greater than 16 years is at a “wide open” rate (consider warmed IV fluids)
       
    2. 
       In patients less than 16 years old, volume replacement is given using a wide open bolus of 20cc/kg. Reevaluate the circulatory status and repeat while in route to the hospital if necessary
       
    3. 
       Pressure infusion cuffs can be applied to the IV bag to increase flow rate
       
12. 
    See flow diagram below to assist with transport destination plan
    
13. 
    Transport should be in progress within 10 minutes of the time EMS personnel have full access to the patient
    
14. 
    During the resuscitation attempt and transport of the pulseless non-breathing trauma victim, if the ALS personnel has reason to suspect the presence of a tension pneumothorax as evidenced by increasing difficulty in ventilating the patient and/or a tracheal shift away from the affected side, the ALS personnel may, without base physician contact, decompress the intrathoracic space by inserting a 14 gauge 3.25 inch IV cath in the 2nd intercostal space, midclavicular line on the affected side.
    
15. 
    In the instance of traumatically amputated or avulsed tissue, that tissue should be enclosed in a water-proof plastic bag and cooled. The patient and separated tissues should be conveyed to a medical facility capable of attempting to reattach it.
    
16. 
    ALS personnel should follow the Analgesia guideline (see guideline 112) for pain relief in conscious, non-hypotensive patients with:
    
    1. 
       Thermal burns
       
    2. 
       Isolated extremity injuries
       
    3. 
       Contact medical control for other situations
       

The following guidelines are NOT protocol but should be used as general guidelines:

1. 
   Glasgow Coma Scale of less than 14
   
2. 
   Clinical signs of shock: pale, cold, weak pulses, prolonged capillary refill
   
3. 
   Unstable blood pressure
   

b. Pediatric:

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  Infant less than 6 months: BP less than60 mmHg
  
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  Child 2 months-5 years: less than70 mmHg
  
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  Child 6-12 years: less than80 mmHg
  

4. 
   Respiratory rate (for all ages rate greater than 60)
   

b. Pediatrics under 12 years:

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  Infants less than6 months: less than20 breaths per minute
  
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  6 months-12 years: less than16 breaths per minute
  

5. 
   Penetrating injury to head, neck, torso or proximal extremity
   
6. 
   Flail chest
   
7. 
   Trauma in a patient with burns to face or airway or with burns of 15% or greater of the total body surface area
   
8. 
   Distended, rigid abdomen
   
9. 
   Two or more long-bone fractures (humerus, femur)
   
10. 
    Depressed or open skull fracture
    
11. 
    Major/multiple trauma (cont.)
    
12. 
    Unstable pelvic fracture
    
13. 
    New onset paralysis
    
14. 
    Amputation above the wrist or ankle
    

ALS personnel evaluation and transport should be made to the closest, most appropriate hospital for patients whose mechanism of injury include::

1. 
   Accidents in which the patient was ejected from the vehicle
   
2. 
   Accidents in which another occupant of the vehicle was killed
   
3. 
   Extrication time in excess of 20 minutes
   
4. 
   Falls of 20 feet or greater for adults, 10 feet or greater for children
   
5. 
   Victim of a roll-over motor vehicle crash
   
6. 
   Passenger compartment intrusion greater than 12 inches is present
   
7. 
   Auto vs pedestrian or bicycle
   
8. 
   Accidents involving a pedestrian, motorcyclist or bicyclist struck by a car with significant impact.
   
9. 
   Motorcycle crashes or similar vehicle crash greater then 20 mph
   

1. 
   Whose age is less than 5 or greater than 55
   
2. 
   Who have known cardiac or respiratory disease or
   
3. 
   Who are pregnant
   
4. 
   Who is immunosuppressed
   
5. 
   Who has a with bleeding disorder
   

Field Trauma Triage Decision Tree for Waukesha County

Special needs patients

Yes

Transport per local protocol


GUIDELINE/STANDARD OF CARE

The following content will be considered the Guideline/Standard of care for the patient with a provider impression of:

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
• Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (see guideline # 101,201).
• Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).
• 
  Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate for the condition of the patient.
  
• 
  Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
  
• 
  Consider ALS intercept.
  

• If possible, check core temperature, treat for hypothermia if indicated (see guideline #410)
• 
  Place tourniquet on affected extremities) proximal to and as close to the crushed tissue as possible, tight enough to restrict arterial flow.
  
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  Complete the history and focused physical assessment (see guideline # 103, 1001).
  
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  Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals. Critical patients may need more frequent monitoring. If the patient is hypotensive, see hypotension—shock. (see guideline # 505).
  
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  Document, if known, specific information about the mechanism of injury.
  

For the EMT-Advanced or Intermediate:

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  Initiate 2 large bore IV lines with Normal Saline. Administer fluids in 500 ml increments to achieve and maintain a systolic blood pressure of 90 mmHg (see guidelines #3002-3004)
  

For EMT-Paramedics:

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  Inject 50 mEq sodium bicarbonate into 1000 ml Normal Saline and administer at a wide/open rate.
  
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  Administer additional Normal Saline to maintain a systolic blood pressure of at least 100 mmHg.
  

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  Auscultate breath sounds, check for pulmonary edema.
  
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  Contact medical control for orders as necessary.
  
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  Reassess and document the patient’s respiratory, cardiovascular, nervous and musculoskeletal systems frequently. Expect and monitor for sudden shifts in blood pressure and/or cardiac arrhythmias. Trapped patients can become very unstable when debris is removed and toxins/acidotic blood return to the central circulation.
  
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  Complete a patient care report (see guideline #102) documenting all pertinent information received, procedures ordered/completed, results of interventions and changes in the patient’s condition. Include computation of the Glasgow Coma Scale.
  
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  Transport to the closest, most appropriate hospital. Expedite transport of unstable trauma victims.
  
• 
  Document reasons for any deviation from the preceding Guideline/Standard of care.