General Approach to All Patients

Trauma

Trauma Transportation

Dispatch / Joint Response / Mutual Aid Procedures:

Each agency has individual Standard Operating Guidelines (SOG’s) pertaining to dispatch, joint response and mutual aid. The filing of these procedures with the State is the responsibility of each agency at the time of licensure renewal.

Adult & Pediatric Trauma Alert Procedure:

  • Assess the trauma patient and determine the need for transportation to the State Approved Trauma Center (SATC) using the adult or pediatric trauma criteria:
    • A "Trauma Alert" is to be initiated immediately when an adult or pediatric trauma patient is determined to meet the adult or pediatric trauma alert criteria
    • Patients meeting Trauma Alert criteria will be transported to the nearest available SATC
    • All Trauma Alert patients ≤ 15 years of age will be transported to the Level I Pediatric Trauma Center at Arnold Palmer Children’s Hospital
  • Once a Trauma Alert has been initiated, contact the receiving facility and provide initial notification that a Trauma Alert patient will be transported, or is en route:
    • Give agency name and unit number, paramedic/EMT number, incident location, brief description of injury and estimated time of arrival
      • Be specific as to the actual Trauma Alert criteria when possible
    • Use the term "Trauma Alert" to avoid any confusion
  • When en route, the transporting crew will re-contact the SATC and provide a full radio report, as outlined in the Radio Report Format section
  • The transporting agency will provide a completed Patient Care Report to the hospital staff upon delivery of patient to the SATC, or other appropriate facility
  • All medical care will be provided in accordance with condition specific protocols or Medical Control orders
  • Trauma Alert patients may also be transported to the nearest emergency department (other than a State Approved Trauma Center) when the following conditions exist:
    • Cardiac arrest on initial patient assessment following trauma
    • Unmanageable airway emergencies
    • Logistical failures that make transport to SATC impossible

Transport Mode

  • The route (air or ground) that enables the patient to arrive at the trauma center in the shortest time shall be used
  • Traumatic cardiac arrest is a contraindication to initiating helicopter transport
    • An exception to this principle is when the arrest occurs during the transition of the patient to the helicopter (this may include transport in a ground unit to the landing zone)
Central Florida State Approved Trauma Centers
Orlando Regional Medical Center Level I Orlando
Arnold Palmer Children's Hospital Level I Pediatric Orlando
Shand's Health Care Level I Gainesville
Tampa General Hospital Level I Tampa
Central Florida Regional Hospital Level II Sanford
Osceola Regional Hospital Level II Kissimmee
Lakeland Regional Medical Center Level II Lakeland
Holmes Regional Medical Center Level II Melbourne
Halifax Medical Center Level II Daytona

List of alternative facilities in Central Florida:

  • Dr. P. Phillips Hospital
  • Florida Hospital Altamonte
  • Florida Hospital Apopka
  • Florida Hospital East Orlando
  • Florida Hospital Kissimmee
  • Florida Hospital Orlando
  • Florida Hospital Waterman
  • Florida Hospital Celebration Health
  • Florida Hospital Winter Park
  • Health Central Hospital
  • Hunter's Creek ER
  • Nemours Children's Hospital
  • Oviedo ER
  • South Lake Hospital
  • South Seminole Hospital
  • St. Cloud Hospital

Emergency Interfacility Transfer of Trauma Victims

Patients may occasionally require emergency interfacility transfer from an outlying hospital to a State Approved Trauma Center (SATC). The decision to initiate this level of interfacility transfer is made by the treating physician at the outlying hospital, in coordination with the accepting physician at the SATC.

When this scenario arises, adhere to the following:

  • Assess the patient upon arrival, but avoid unnecessary delays in transport
  • Transport to the facility at which a physician has accepted the patient; it is the transferring hospitals responsibility to assure the receiving center has accepted the patient
  • If EMS crew members have not received training on, and/or are not capable of managing, devices or medications that must be continued during transport, an adequately trained care provider from the transferring facility must accompany the patient during transport

Adult Trauma Alert Criteria

General Approach to All Trauma Patients

Immediately assess all trauma patients for Trauma Alert Criteria. If criteria are met, begin transport to state approved trauma center within 10 minutes of arrival on scene whenever possible.

Basic Life Support

  • Secure airway/Spinal immobilization if indicated
  • Supplemental 100% oxygen if any respiratory symptoms
  • Examine patient for obvious bleeding
  • Control active bleeding with direct pressure
  • Assess Disability – neurologic status/record Glasgow coma score
  • Head to toe examination to assess for injuries
  • Apply physical restraints if needed to ensure patient/crew safety
  • Prevent loss of body heat

Advanced Life Support

  • When condition warrants (specified as “Full ALS Assessment and Treatment” in individual protocols):
    • Advanced airway/ventilatory management as needed
    • Perform cardiac monitoring
    • Record & monitor continuous 02 saturation and microstream capnography
    • IV 0.9% NaCl KVO or IV lock
    • If BP < 90 mm Hg systolic, administer boluses of 0.9% NaCl at 250 ml until systolic BP > 90 mm Hg
    • Assess for Tension Pneumothorax
      • Tension pneumothorax should be suspected in patients who exhibit:
        • Severe respiratory distress with hypoxia
        • Unilateral decreased or absent lung sounds (may see tracheal deviation away from collapsed lung field)
        • Evidence of hemodynamic compromise (shock, hypotension, tachycardia, altered mental status)
      • Pleural decompression for tension pneumothorax should only be preformed when all 3 of the above criteria are present; If indicated perform pleural decompression at 2nd intercostal space, mid-clavicular line
      • In the setting of traumatic cardiac arrest with suspected chest trauma, consider bilateral pleural decompressions as part of the resuscitation efforts
  • Do not delay transport to perform procedures on scene unless immediately needed to stabilize patient (e.g. airway management, hemorrhage control)

Burns-Thermal

Basic Life Support

  • Remove or cool heat source if present (tar, clothing)
  • Cool compress dressings on minor burns with sterile saline (do not use ice packs)
  • Dry, sterile burn sheet on:
    • 2° burns greater than 15% of Body Surface Area
    • 3° burns
    • Electrical and chemical burns
  • Spinal immobilization if high voltage electrical injuries (>1000 Volts, excluding Taser)

Advanced Life Support

  • If moderate, severe pain:
    • Fentanyl (Sublimaze) 1 mcg/kg (maximum 50 mcg) slow IV; repeat once after 5 minutes as needed (maximum 100 mcg total dose) OR 100 mcg intranasal via MAD (divide dose equally between nostrils)
      • Preferentially use intranasal delivery via MAD for those where IV access may be difficult to obtain in a timely fashion
    • Initiate only after BP stabilized
    • Use with caution in inhalation injuries

Chest Injuries

Basic Life Support

  • Assess breath sounds frequently
  • Assess for ventilatory compromise and assist with BVM as needed
  • For Open/Sucking Chest wounds, apply occlusive dressing sealed on three sides
    • Remove temporarily to vent air if respiratory status worsens

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Total amount of IVF should not exceed 1000 ml
  • Assess for flail segment and tension pneumothorax
  • Observe for signs of impending respiratory failure; Refer to the Airway Management Protocol if needed:
    • Hypoxia (O2 Sat <90) not improved by 100% Oxygen
    • Poor ventilatory effort
    • Altered mental status/ decreased level of consciousness
    • Inability to maintain patent airway

Extremity Trauma

Basic Life Support

  • Remove or cut away clothing to expose area of injury
  • Control active bleeding
  • Check distal pulses, capillary refill, sensation/movement prior to splinting
    • If pulse present, splint in position found if possible
    • If pulse absent, attempt to place the injury into anatomical position
  • Open wounds/fractures should be covered with sterile dressings and immobilized in the presenting position
  • Dislocations should be immobilized to prevent any further movement of the joint
  • Check distal pulses, capillary refill, and sensation after splinting
  • Isolated lateral patellar dislocations may be reduced according to Orange County EMS Procedural Manual
    • If unable to reduce patellar dislocation after one attempt provide pain management and transport to nearest facility
    • If patellar dislocation successfully reduced, patient MUST be transported to an appropriate destination (may not accept patient refusal after successful dislocation reduction)

Advanced Life Support

  • For isolated extremity trauma:
    • Fentanyl (Sublimaze) 1 mcg/kg (maximum 50 mcg) slow IV; repeat once after 5 minutes as needed (maximum 100 mcg total dose) OR 100 mcg intranasal via MAD (divide dose equally between nostrils)
    • Consider pain control only after BP stabilized
  • For uncontrollable hemorrhage despite aggressive direct pressure with standard gauze:
    • Refer to Hemorrhage - Life Threatening protocol
  • For limbs that remain entrapped despite all other extrication attempts contact ORMC via radio and Med Com to arrange for on-scene medical direction.

Eye Trauma

Basic Life Support

  • Stabilize any penetrating objects
  • Do not remove any impaled object
  • Protective metal shield unless impaled object precludes
  • Prevent patient from bending or straining
  • If blood observed in anterior chamber, transport with head elevated 60°

Head Injuries

Airway interventions can be detrimental in patients with head injury by raising intracranial pressure, worsening hypoxia (and secondary brain injury) and increasing risk of aspiration. Whenever possible, these patients should be managed in the least invasive manner to maintain O2 saturation > 90% (i.e. NRBM or BVM, with 100% O2).

Basic Life Support

  • Supplemental oxygen
  • Restrain as needed
  • If Normotensive or Hypertensive elevate head of backboard 15°-30°

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Advanced airway/ventilatory management as needed
    • Observe for signs of impending respiratory failure; Refer to the Airway Management Protocol if needed
      • Hypoxia (O2 Sat <90) not improved by 100% Oxygen
      • Poor ventilatory effort (increasing ETCO2)
      • Altered mental status/ decreased level of consciousness
      • Inability to maintain patent airway
    • For patients with assisted ventilation administer eucapneic (normal rate 12-15/minute) ventilations with a goal of ETCO2 between 35-40 mmHg
    • Acute herniation should be suspected when the following signs are present:
      • Acute unilateral dilated and nonreactive pupil
      • Abrupt deterioration in mental status
      • Abrupt onset of motor posturing
      • Hyperventilation (ventilatory rate of 20) is a temporizing measure which is only indicated in the event of acute herniation
        • If signs of acute herniation develop, increase ventilatory rate to 20/minute with a goal of ETCO2 between 30-35 mmHg
  • For awake patients experiencing nausea or vomiting administer Ondansetron (Zofran), 4 mg slow IV or 4 mg Oral Disintegrating Tablet (ODT) by mouth
  • For combative patients secondary to head trauma
    • Ensure hypoxia and hypotension are addressed
    • Apply physical restraints if needed to ensure patient/crew safety
    • If severely agitated despite all other efforts: Ziprasidone (Geodon) 10 mg IM if < 60 kg and 20 mg IM if > 60 kg
      • Avoid if history of long QT-syndrome or dementia-related psychosis
      • Inform receiving facility the patient was given sedating medication
      • DO NOT use Midazolam (Versed) or any other benzodiazepine

Hemorrhage - Life Threatening

The most effective method to control serious bleeding is direct pressure. If aggressive direct pressure fails to control life threatening hemorrhage proceed as below, in addition to all other applicable advanced life support measures.

Basic Life Support

  • Supplemental oxygen
  • Direct pressure to bleeding source with standard gauze

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Advanced airway/ventilatory management as needed
  • For uncontrollable hemorrhage despite aggressive direct pressure with standard gauze:
    • Apply a Hemostatic Agent Impregnated Gauze dressing if available (must be approved by the medical director)

Extremity Trauma Only:

  • If uncontrollable, life threatening hemorrhage continues after applying Hemostatic Agent Impregnated Gauze, apply one of the following based on availability:
    • A pressure bandage over the hemostatic dressing in accordance with manufacturer's recommendations
    • A tourniquet device 4-6 inches proximal to bleeding site
      • Tourniquet must be at least 2 inches wide or an approved commercially available product
      • Do not apply over a joint
      • Tighten tourniquet until bright red bleeding has stopped
  • Secure in place and expedite transport to Level I Trauma Center
  • Notify receiving center of presence and location of the Emergency Bandage or tourniquet

Sexual Assault

  • For victims of sexual assault who meet Trauma Red or Trauma Alert criteria, transport to Orlando Regional Medical Center (ORMC)
  • For all other cases, transport to nearest emergency department
  • Provide supportive care as indicated by patient’s condition

Traumatic Amputations

Basic Life Support

  • If amputation incomplete:
    • Attempt to stabilize with bulky pressure dressing
    • Splint inline
  • If amputation complete:
    • Cleanse amputated part with sterile saline
    • Wrap in sterile dressing soaked in sterile saline
    • Place in plastic bag if possible
    • Attempt to cool with cool pack during transport

Advanced Life Support

  • For isolated extremity trauma:
    • Fentanyl (Sublimaze) 1 mcg/kg (maximum 50 mcg) slow IV; repeat once after 5 minutes as needed (maximum 100 mcg total dose) OR 100 mcg intranasal via MAD (divide dose equally between nostrils)
      • Initiate only after BP stabilized
  • For uncontrollable hemorrhage despite aggressive direct pressure with standard gauze:
    • Apply a Hemostatic Agent Impregnated Gauze dressing if available (must be approved by the medical director)
  • If uncontrollable, life threatening hemorrhage continues after applying Hemostatic Agent Impregnated Gauze, apply one of the following based on availability:
    • A pressure bandage over the hemostatic dressing in accordance with manufacturer's recommendations
    • A tourniquet device 4-6 inches proximal to bleeding site
      • Tourniquet must be at least 2 inches wide or an approved commercially available product
      • Do not apply over a joint
      • Tighten tourniquet until bright red bleeding has stopped
  • Secure in place and expedite transport to Level I Trauma Center
  • Notify receiving center of presence and location of the Emergency Bandage or tourniquet