Procedure Manual

Trauma Procedures

Combat Application Tourniquet

C-A-T Instructions

Emergency Bandage (formerly known as the "Israeli Bandage")

Instructions for Use

QuikClot® Hemostatic Dressing

Instructions for Use

Patella Dislocation - Relocation Procedure

Dislocation of the patella is a frequently occurring, painful injury. Lateral dislocation is the most common and may be caused by flexion and external rotation of the knee with simultaneous contraction of the quadriceps tendon. The quadriceps contraction pulls the patella laterally. Common mechanisms are rotational motion of the knee with a planted foot, often seen in volleyball, tennis, basketball, football, gymnastics, and dancers.

Clinically, patients will present with obvious deformity of the knee and a displaced patella. Swelling may be present. This injury is extremely painful and significant relief of pain will occur once the patella is relocated.

Fractures accompanying patellar dislocation occur in 30%-50% of patients and typically involve a direct blow to the patella. Medial patellar dislocations are almost always associated with direct trauma to the patella. When a fracture is suspected field relocation should not be attempted.

Field relocation of patellar dislocations should only be attempted for lateral dislocations and when there was no direct blow or trauma to the patella.


  • Palpate and inspect the patella for obvious signs of fracture or open wounds
  • If fracture suspected or medial dislocation do not attempt relocation and splint the injury as found
  • If possible, place the patient supine with the injured extremity elevated and flexed at 60-90 degrees
  • Smoothly straighten the extremity by lifting under the ankle, while simultaneously applying firm medial pressure to the lateral aspect of the patella
    • If the patient experiences significant pain with relocation attempt discontinue and apply splint

  • The patella should “pop” easily back into place as the knee approaches full extension
  • Once reduced, apply ice or cold packs, splint in the extended position and transport for further evaluation


  • Pain with attempted reduction technique
  • Fractures related to the relocation procedure are rare
  • Most complications are related to the injury itself

Pleural Decompression for Suspected Tension Pneumothorax


  1. Suspected Tension Pneumothorax in patients exhibiting at least 3 of the following criteria:
    • Severe respiratory distress with hypoxia
    • Unilateral decreased or absent lung sounds
    • Evidence of hemodynamic compromise (Shock, hypotension, tachycardia, altered mental status)
    • Tracheal deviation away from the collapsed lung field (less reliable than the above)
  2. Cardiac Arrest after blunt or penetrating trauma involving the chest or abdomen
    • Unless the injury in clearly unilateral, consider bilateral pleural decompression in patients who suffer cardiac arrest is this scenario


  • 14 gauge 2 - 2.5 inch catheter over the needle
  • Tape
  • Sterile gauze pads
  • Antiseptic swabs
  • Occlusive dressing


  • Locate decompression site
  • Identify the 2nd intercostal space in the mid-clavicular line on the same side as the suspected tension pneumothorax
  • Prepare the site with an antiseptic swab
  • Firmly introduce catheter immediately above 3rd rib in the mid-clavicular line
  • Insert the catheter into the thorax until air exits
  • Advance catheter and remove needle
  • Secure the catheter taking care not to allow it to kink
  • Reassess lung sounds and patient condition
  • Assess breath sounds and respiratory status

Pleural Decompression Diagram

Spinal Immobilization for Football Players

EMS providers must use extreme caution when evaluating and treating an injured football player, especially when the extent of the injury remains unknown. Suspect spinal injury in any football player who has altered mental status or any other neurologic complaint. If the football player isn't breathing work quickly and effectively with the athletic trainer staff to remove the face mask and administer care. In most situations, the helmet and shoulder pads should not be removed in the field. Manage of head and neck injuries with the helmet and shoulder pads in place, removing only the face mask from the helmet.

Football Face Mask Removal:

  • The face mask should be removed prior to transportation, regardless of current respiratory status
  • Those involved in the prehospital care of injured football players must have the tools for face mask removal readily available

    Indications for Football Helmet Removal:

    • The athletic helmet and chin strap should only be removed if:
      • The helmet and chin strap do not hold the head securely, such that immobilization of the helmet does not also immobilize the head
      • The design of the helmet and chin strap is such that even after removal of the face mask the airway can not be controlled, or ventilation be provided
      • The face mask can not be removed after a reasonable period of time
      • The helmet prevents immobilization for transportation in an appropriate position

    Helmet Removal Technique:

    • If it becomes absolutely necessary, spinal immobilization must be maintained while removing the helmet
    • Due to the varying types of helmets encountered, the helmet should be removed with close oversight by the team athletic trainers and/or sports medicine staff
    • In most circumstances, it may be helpful to remove cheek padding and/or deflate air padding prior to helmet removal
    • Appropriate spinal alignment must be maintained during care and transport using backboard, straps, tape, head-blocks or other necessary equipment.
      • Be aware that the helmet and shoulder pads elevate an athlete's trunk when in the supine position.
    • The front of the shoulder pads can be opened to allow access for CPR and defibrillation