Updated Fluid Bolus Protocols 25JUL13

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Updated Fluid Bolus
Protocols
25JUL13
Hespan Removed
from all Protocols
Initial Trauma Care
Class I Trauma
Transport to trauma center
Glasgow Coma Scale…….< 13 (at time of
report)
Systolic blood pressure…..<90
Respiratory rate…………..<10 or >29
Airway compromise, flail chest, hemo or
pneumothorax
Active hemorrhage
Penetrating injuries to head, neck, torso
Extremity trauma with loss of distal pulse
Amputation proximal to wrist or ankle
Paralysis or signs of spinal cord injury
Major burns of >20% BSA or any signs of
inhalation injury
200 volt or higher electrical injury
Two or more long-bone fractures
(humerus/femur)
Paramedic discretion
Ensure Scene Safety
GOAL: On scene < 10 minutes
Assess ABC's and life threatening conditions
Immediate
action
required?
Yes
Correct conditions and
reassess
No
MOI for
spinal injury
present?
Class II Trauma
Spinal exam
requires
immobilization?
(See spinal
assessment protocol)
Yes
Yes
Transport to trauma center
No
Initial speed >40 mph
Major auto deformity >20 inches
Intrusion into passenger compartment
>12 inches
Death in same passenger compartment
Extrication time >20 minutes
Ejection from automobile or auto rollover
Auto-pedestrian/auto-bicycle injury with (>5
mph) impact
MCC or ATV crash >20 mph or separation of
rider from bike
Assault with LOC
Falls >12 feet
Pelvic fractures
All open fractures
All degloving/Crush injuries
Penetrating injuries to extremities proximal to
elbow or knee
Amputation distal to wrist or ankle of two or
more digits
Pregnancy with acute abdominal pain
Auto crash
No
Complete applicable diagnostics:
Physical Exam: Primary and secondary
Vital signs: 2 sets; BP (including diastolic, pulse, respirations
Establish IV if indicated: LR or Normal Saline; 250 – 500 cc
bolus(es) wide open,
Titrate to patient’s hemodynamic status. BP 80-90
Oxygen: Metered to patient condition and medical history
Pulse Oximetry: if available
Cardiac Monitor: 3 lead, 12 lead if available and applicable
Remove all Clothing
Patient
complaining of
pain?
Yes
Full spinal
immobilization
Assess with 'Patient Pain Scale' and
reassess after each treatment
No
Class III Trauma
Preferential transport to closest
hospital
MVC <40 MPH or UNK speed
Assault without LOC
Burns <20%
Auto-pedestrian and auto-bicycle <5 mph
impact
MCC/ATV crash <20 mph
All falls of >5 ft/5 steps
Penetrating injury distal to elbow or knee
Pregnant patients involved in traumatic event
Place patient in position of comfort if possible
Information given to receiving facility includes
Glasgow coma scale, revised trauma score,
and trauma classification. (Class 1,2, or 3)
Reviewed 12/12
Go to condition specific
protocol
Patient Pain Scale
Assessment
Assessed by asking the
patient to rate the severity
of their pain based on a 110 scale; 10 rated as the
worst pain they have ever
experienced and 1 rated as
the least.
Multi-System Trauma
Initial Trauma Care or Follow TCCC depending on scenario
Correct all immediate life
threatening conditions
Go to condition
specific protocol
IV LR or Normal Saline: 500 cc bolus repeat in 30 minutes if needed
titrate to patient's hemodynamic status Sys BP 80-90 mm Hg
And improvement of mental status
Consider pain management
Antibiotics: Per TCCC (recommended for all open combat wounds)
a. If able to take PO:
- Moxifloxacin, 400 mg PO qd.
b. If unable to take PO (shock, unconsciousness):
- Ertapenem/Invanz 1 g IV/IM q24h or
- Cefotetan 2 g IV/IM
OPTIONS
Reviewed 12/12
Specific procedures as indicated:
Chest decompression, surgical airway, etc.
Patient Trauma Status:
Information given to receiving facility includes Glasgow coma scale, revised
trauma score and trauma classification (Class 1, 2, or 3)
-------------------------------------------------------------------------------------------------------Initiate transport as soon as possible
Abdominal / Pelvic Trauma
Initial Trauma Care
IV LR or Normal Saline:
500cc bolus if indicated
Titrate to patient's hemodynamic status; repeat in
30 minutes if needed
If intra-abdominal bleeding suspected, then by
definition this is a Class I Trauma; notify Medical
Control; and titrate systolic BP to 80-90
Yes
Pelvis
unstable?
No
OPTIONS
Reviewed 12/12
Per TCCC protocol
Titrate to patient's hemodynamic status up to 1L
Patient Trauma Status:
Information given to receiving facility includes Glasgow coma scale, revised trauma score and
trauma classification ( Class 1,2 or 3)
------------------------------------------------------------------------------------------------------------------Initiate transport as soon as possible
Apply splint for
abdominal/pelvic
stabilization.
Musculoskeletal Injuries
Initial Trauma Care
Ice and splint as applicable
Maintain BP systolic 80-90:
IV LR or Normal Saline:
500 cc bolus(es) if indicated by
hypotension;
Titrate to patient's hemodynamic status
Yes
Patient
complaining of
severe pain ?
No
OPTIONS
Titrate to patient's hemodynamic status
Patient Trauma Status:
Information given to receiving facility includes Glasgow coma scale, revised
trauma score and trauma classification (Class 1, 2, or 3)
-------------------------------------------------------------------------------------------------Reviewed 12/12
Go to Pain Protocol
Spinal Column / Cord Injuries
Initial Trauma Care
Yes
GCS <13
Significant neurological
signs and symptoms may
include:
Go To Head Trauma Protocol
No
Motor function
Sensory function
Reflex responses
Visual inspection of spinal
column
Bradycardia
Priapism
Hypotension
(possible spinal shock)
Hypertension
(possible herniationCushing syndrome)
Loss of sweating or shivering
Loss of bowel or bladder
control
Determine presence or absence of
significant neurological signs and
symptoms
Ensure ventilations are adequate
Cardiac Monitor:
Manage dysrhythmia(s) per protocol
Bradydysrhythmias are commonly seen
in high level spinal injuries
Patient
hypotensive?
Yes
IV of NS, LR or :
250-500 cc bolus and titrate to patient's
hemodynamic status
Caution: Persistent hypotension
unresponsive to titration may reflect
neurogenic (spinal) shock
No
CONSIDER VASOPRESSORS
Significant signs and
symptoms of spinal cord
injury may include:
Partial or complete loss of
sensation
Partial or complete loss of
muscle function
Partial or complete loss of
sympathetic tone
Signs and symptoms will
present at or below the
level of the suspected
injury site
OPTIONS
Additional IV Normal Saline or LR :
250-500 cc bolus(es); titrate to patient's hemodynamic status
Dopamine:
2-20 mcg/kg/minute for suspected neurogenic shock without hypovolemia;
Titrate to patient's hemodynamic status
Levophed:
0.5-30mcg/min
Reviewed 12/12
------------------------------------------------------Initiate transport as soon as possible
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