Multi-System Trauma
Capital Area Trauma Regional Advisory Council
Capital
Area
Trauma
Regional
Advisory
Council
Capital Area Trauma Regional Advisory Council
4100 Ed Bluestein Blvd.
Suite 207
Austin, TX 78721
These protocols are valid from Oct. 26, 2006, through Oct. 31, 2008 .
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Capital Area Trauma Regional Advisory Council
CATEGORY II(EMERGENT TRAUMA PATIENTS) ------------------------------------------------------ 8
CATEGORY III(DELAYED TRAUMA PATIENTS) ---------------------------------------------------------- 8
CATEGORY III(DELAYED TRAUMA PATIENTS) ---------------------------------------------------------- 9
AERO-MEDICAL CARE AND DISPATCH GUIDELINES ------------------------------------------------- 10
P URPOSE : --------------------------------------------------------------------------------------10
: --------------------------------------------------------------------------- 11
ACTIVATION AND PRE-HOSPITAL TRAUMA TRIAGE --------------------------------------------------- 12
BURN TRIAGE AND TRANSPORT PROTOCOL ------------------------------------------------------------ 14
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Capital Area Trauma Regional Advisory Council
Introduction
Recognition, rapid assessment and rapid transport for the patient suffering from a major traumatic event or an emergent medical condition have been shown to decrease the mortality and morbidity for such patients. It is the intent of the Capital Area Trauma Regional Advisory Council (CATRAC) to establish regional minimum patient care protocols for those pre-hospital providers responding to patients suffering from these conditions. These protocols establish a minimum standard of care for TSA-O. Individual departments shall establish procedures that meet or exceed this standard.
Authority
The Capital Area Trauma Regional Advisory Council, under the authority established by the Department of State Health Services Office of Emergency
Medical Services and Trauma Systems Division publishes this standard. The
TSA-O Pre-hospital Care and Transportation Committee manage this document.
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Definitions
BLS: The level of care provided by those individuals who are certified by the Texas
Department of State Health Services at the Emergency Care Attendant (ECA) and
Emergency Medical Technician – Basic (EMT-B) levels.
ILS: The level of care provided by those individuals who are certified by the Texas
Department of State Health Services at the Emergency Medical Technician-Intermediate
(EMT-I) level.
ALS: The level of care provided by those individuals who are certified or licensed by the Texas
Department of Health at the Emergency Medical Technician-Paramedic (EMT-P, LP) level.
Bypass: Pre-determined triage criteria; pass the nearest hospital for transport to the most appropriate hospital/trauma facility.
1. A patient with an inadequate airway or traumatic arrest should be taken to the closest appropriate facility for intermediate stabilization.
2. If expected transport time is greater than 30 minutes or if prolonged extrication (>20 minutes) is expected consider activating aero-medical resources.
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Capital Area Trauma Regional Advisory Council
Capital Area Trauma Regional
Advisory Council
TSA-O
Hospital
Status Change and Definition
Policy
Approved 12-22-05
I. INTRODUCTION :
The TSA-O healthcare community agrees that a mechanism to communicate the
current capacity and capability of each area hospital is necessary to provide optimal
patient care.
II. PURPOSE:
To establish a mechanism to communicate current hospital capacity and capability
status to transporting Pre-hospital Provider units and other regional hospitals;
enabling informed transport and transfer determinations based upon patient care
needs.
III. SCOPE:
This policy affects all TSA-O hospitals and licensed Pre-hospital Providers.
IV. PROCEDURE:
A.
Hospital-
Hospital Administration and/or Emergency Department Charge Nurse, or his/her designee, shall update the current status of their site as needed or upon request.
B. Pre-hospital Provider-
Upon notification that a hospital is reporting a BLACK status (see V.
Definitions), medics will not transport patients to Hospitals on BLACK status as defined below.
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V. DEFINITIONS:
Black – Internal Disaster
The hospital site officially closes to all EMS traffic as a result of a loss of critical services or a threat to patient safety (examples include loss of medicinal gasses, flooding, power outage, etc).
Black – Trauma Priority
The Designated Trauma Center officially closes to all Critical Medicine
EMS traffic as defined by the EMS agency.
Red
–
This hospital is experiencing overcrowded conditions.*
YELLOW – Hospital is approaching overcrowded conditions.*
GREEN
–
Normal operating conditions.*
AutoGREEN will occur at two (2) hours when a physical
status update is not performed by the hospital.
* Red, Yellow, and Green status are for information purposes only.
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Trauma Category Designations
To assist in establishing appropriate transport decisions, level of response and care, “Trauma Category Designations” have been defined. All trauma patients shall be transported to the closest appropriate hospital.
Category I- (Critical Trauma Patients)*
This category includes those patients who require immediate life-saving interventions. This category is equivalent to Priority 0 and Priority I Patient
Severity Categories as outlined in the American College of Surgeons’
“Resources for Optimal Care of the Injured Patient: 1999”, page 14. This category applies to patients who present with any of the following:
1. Glasgow Coma Score less than 13 associated with trauma.
2. Physiologic Criteria:
Adult
Systolic Blood Pressure: less than 90 mmHg
Respiratory Rate: less than 10 or greater than 29 breaths per
minute
Children less than 5 years
Systolic Blood Pressure: less than 70 + 2 times age in years
Heart Rate: greater than 180 or less than 60 bpm
Respiratory Rate: less than 10 breaths per minute
Children Greater Than 5 Years
Systolic Blood Pressure: less than 70 + 2 times age in years
Heart Rate: greater than 160 bpm
Respiratory Rate: less than 10 breaths per minute
3. Depressed or open skull fracture.
4. Flail Chest.
5. Paralysis.
6. Amputation proximal to wrist or ankle.
7. Two (2) or more long bone fractures.
8. Gunshot wound to the head or torso.
9. Burns: a. Inhalation injuries.
b. 2 nd or 3 rd degree burns greater than 20% total body surface area.
* BLS EMS agencies responding to a scene requiring ALS patient care shall perform early activation of the closest appropriate ALS provider to obtain the appropriate level of care indicated for patient transport. Consider rendezvous with ALS provider where appropriate.
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CATEGORY II- (EMERGENT TRAUMA PATIENTS)*
These patients require urgent assessment (within 30 minutes of arrival) by a trauma surgeon to evaluate both potential and actual injuries. This category is equivalent to Priority II Patient Severity Category as outlined in the American College of Surgeons’ “Resources for Optimal Care of the
Injured Patient: 1999”, page 14. This category applies to patients who present with any of the following:
1. Motor vehicle collisions with any of the below: a. Ejection from a moving vehicle. b. Death in the same passenger compartment. a. Auto rollover. b. Steering wheel damage. c. Auto-pedestrian incident. d. Auto-bicycle collisions.
2. Venomous snake bites.
3. Burns: 2 nd or 3 rd degree burns less than or equal to 20% TBSA.
4. Blunt trauma patients with concomitant medical disease or process including: a. Immunosuppression (i.e. HIV, TB, chemotherapy treatment for cancer, etc.). b.
Coagulapathy (i.e., Hemophilia, Von Willebrand’s disease, factor IX deficiency). c. Pregnancy.
5. Pelvic Fracture
6. Stab wounds with hemodynamic abnormality (SBP <100 or HR >100.)
7. Extrication time greater than 20 minutes.
8. Motorcycle crashes greater than 20 mph.
9. Gun shot wound to extremities proximal to the elbow or knee.
10. Stab wounds to the head, neck or torso with hemodynamic normality
(SBP >100 or HR < 100).
11. Any significant traumatic incident in patients < than 5 yrs. or > than 55 yrs.
10. Fall: a. Greater than 10 ft. in patients < 10 yrs. or > 55 yrs. of age. b. Greater than 20 ft. in other patients
*BLS EMS agencies responding to a scene requiring ALS patient care shall
perform early activation of the closest appropriate ALS provider to obtain
the appropriate level of care indicated for patient transport. Consider
rendezvous with ALS provider where appropriate.
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Capital Area Trauma Regional Advisory Council
CATEGORY III- (DELAYED TRAUMA PATIENTS)*
Patients with injuries requiring intervention but whose care can be delayed without deterioration in condition. These conditions may or may not require in-house admission. This category is equivalent to Priority III
Patient Severity Category as outlined in the American College of Surgeons’
“Resources for Optimal Care of the Injured Patient: 1999”, page 14.This category applies to patients who present with any of the following:
1. Single bone fractures, isolated extremity trauma.
2. Abrasions, lacerations, sprains, strains, simple puncture wounds.
3. Isolated C-spine pain (no neurological deficit present).
4. Snake bite without envenomation.
* BLS EMS agencies responding to a scene requiring ALS patient care shall
perform early activation of the closest appropriate ALS provider to obtain
the appropriate level of care indicated for patient transport. Consider
rendezvous with ALS where appropriate.
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Capital Area Trauma Regional Advisory Council
Aero-medical Care and Dispatch Guidelines
Purpose : to provide a standardized method for ground emergency medical service providers to request a scene response by an aero-medical provider, to reduce delays in providing optimal care for severely injured patients, and to decrease mortality and morbidity.
Decision Criteria : Helicopter activation/scene response should be considered when it could reduce transportation time for trauma patients meeting dispatch criteria.
Guidelines for Activation :
1. The ground emergency medical service provider may, when one or more of the elements of the activation criteria exist, request a scene response by an Aeromedical provider to assist with transportation to an appropriate trauma facility.
2. Once an air ambulance is en route to the scene, only the highest qualified medical personnel in attendance may make the determination to cancel the air medical response.
3. The CATRAC Performance Improvement Committee may review aero-medical response requests and aero-medical responses, for appropriate utilization of aeromedical providers.
4. Ground emergency medical service providers should not remain on scene awaiting aero-medical arrival if an appropriate trauma facility is nearby.
5. Ground emergency medical service providers should dispatch the Aero-medical provider as early as possible, including prior to their arrival at the scene if the mechanism of injury or dispatch report meets criteria.
6. The medical Incident Commander or ambulance crew chief will utilize the triage criteria to activate helicopter transport. The following factors should be considered: a. Location of incident b. Number of patients c. Age of patients d. Response time of Aero-medical provider e. Weight of patients
7. In all instances the helicopter service that best meets the needs of the patient will be utilized when available.
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Capital Area Trauma Regional Advisory Council
Aero-medical Activation Criteria :
1. Severely injured or ill patients located in a remote or off-road area not readily accessible to ground ambulance.
2. Ground resources exhausted or exceeded in the region.
3. BLS agencies responding to ALS calls when requesting ALS mutual aid via ground would delay transport time to the appropriate facility.
4. Reduction in transport time to a trauma center compared to ground transport for the seriously injured trauma patient.
5. Any patient presenting with one (1) Category I Trauma Designation
Criteria.
6. Any patient presenting with two (2) or more Category II Trauma
Designation criteria.
Other considerations : Patients meeting criteria for helicopter dispatch should be transported to a Level I or Level II Trauma Center.
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Capital Area Trauma Regional Advisory Council
Activation and Pre-hospital Trauma Triage
Aero-medical Decision Scheme
Measure vital signs and level of consciousness
Glasgow Coma Scale
Systolic Blood Pressure
Respiratory Compromise or requiring intubation
<13
<90 with signs of shock
Or
All penetrating injuries to head, neck, torso and extremities proximal to elbow and knee
Flail chest
Major burns
Inhalation injuries
2 nd or 3 rd degree burns > 20% BSA
Combination trauma with burns
Two or more proximal long-bone fractures
Pelvic fractures
Traumatic paralysis
Amputation proximal to wrist and ankle
Or
Ejection from automobile
Death in same passenger compartment
Extrication time > 20 minutes
Falls > 20 feet
Roll over
Evidence of high impact
Auto-pedestrian injury with significant (> 20 mph) impact
ACTIVATE AEROMEDICAL PROVIDER
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Capital Area Trauma Regional Advisory Council
General Trauma Care
BLS*
1. Insure scene safety.
2. Complete an initial assessment (maintain spinal motion restriction if indicated); provide oxygen as indicated, assist ventilations with BVM if indicated.
3. Obtain vital signs.
4. Perform a focused assessment (do not delay transport of Category I or II patients).
5. Place patient in position of comfort unless contraindicated.
6. Maintain patient warmth as indicated.
ILS
As above
All ILS treatment shall be rendered per local protocols.
ALS
As above
All ALS treatments shall be rendered per local protocols.
Note: Category I and II patients require rapid transport to the closest appropriate level designated trauma facility via an ALS transporting agency. Skills such as IV therapy and fracture immobilization (excluding spinal motion restriction) can be accomplished while enroute to the facility. Consider early activation of air transport if ground time exceeds 30 minutes to a Level I or II Trauma Facility.
Remember the Golden Hour concept. All efforts should be utilized to keep scene times to the Platinum Ten (minutes) for optimum patient outcome; Load and Go.
*BLS EMS agencies responding to a scene requiring ALS patient care shall
perform early activation of the closest appropriate ALS provider to obtain
the appropriate level of care indicated for patient transport. Consider
rendezvous with ALS where appropriate.
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Capital Area Trauma Regional Advisory Council
Burns
BLS
1. Insure scene safety.
2. Provide high flow oxygen.
3. Cool and dress burns.
4. Flush chemical burns.
5. Apply moist sterile dressings if < 10% TBSA.
6. Apply dry sterile dressings if > 10% TBSA.
7. Consider transport to nearest appropriate Burn Center.
ILS/ALS
1. As above.
2. Additional ILS/ALS care shall be rendered per local protocols.
Burn Triage and Transport Protocol*
Purpose : To ensure that critically injured burn patients are transported to the most appropriate facility
Procedure :
1) EMS should assess the severity of the burn and triage the patient appropriately according to established trauma classifications
Patient may be candidate for transport directly to Brooke Army Medical
Center Burn Unit:
1) Patient meeting Category 1 or Category 2 trauma classification from burn injury
2) Aero medical resources immediately available
3) BAMC Burn Unit is open, hospital status maybe confirmed via:
Austin/Travis County EMS StarFlight
(512) 974-4500,
(800) 531-STAR
Air Evac Lifeteam
(800) 247-3822
MEDCOM (800) 247-6428, #2
PHI STAT Air
(800) 456-7477
4) Ground units may consider transport to BAMC if:
Operationally feasible and does not by-pass a appropriate trauma center
BAMC is the closest appropriate trauma center
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Capital Area Trauma Regional Advisory Council
Burn patients NOT a candidate for transport directly to Brooke Army
Medical Center Burn Unit:
1) Patient does not meet Category 1 or 2-trauma classification from isolated burn injury
2) Aero medical resources not immediately available
3) Brooke Army Medical Center Burn Unit is on diversion
4) Patients with imminent airway compromise or inability to adequately ventilate the patient
5) Hemodynamic instability
6) Two or more systems injured
7) Ground transport to closet trauma center is less than 20 minutes
8) Any situation that may result in a delay in care for the patient
Patients under twelve (12) years of age should be transported to the closest appropriate trauma center.
NOTE: Chemical burns represent a hazard to both patient and rescuer; extreme care should be taken to avoid exposure to offending agent(s). The care of electrical burns should be guided by safety. Remember that most injuries in electrical burns are internal. Thermal burns should be guided by scene safety, cooling the burn, maintaining normal body temperature and protecting the airway.
*BLS EMS agencies responding to a scene requiring ALS patient care
shall perform early activation of the closest appropriate ALS provider
to obtain the appropriate level of care indicated for patient transport.
Consider rendezvous with ALS where appropriate.
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Capital Area Trauma Regional Advisory Council
Eye Injuries*
BLS
1.
2.
3.
4.
5.
6.
Insure scene safety.
Obtain an initial assessment: i.Chemical injury - continuous flush with normal saline. ii.Open eye injury - bandage both eyes closed. iii.Abrasion and/or foreign objects - cover both eyes. iv.Impaled objects - stabilize in place and cover both eyes.
Obtain vital signs.
Perform a focused assessment (do not delay transport in Category I or II patients).
Place patient in position of comfort unless contraindicated.
Maintain patient warmth as indicated.
ILS
As above
Additional ILS care shall be rendered per local protocols.
ALS
As above
Additional ALS care shall be rendered per local protocols .
*BLS EMS agencies responding to a scene requiring ALS patient care shall
perform early activation of the closest appropriate ALS provider to obtain
the appropriate level of care indicated for patient transport. Consider
rendezvous with ALS where appropriate.
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Capital Area Trauma Regional Advisory Council
Head Injuries*
BLS
1. Insure scene safety.
2. Apply spinal motion restriction, if applicable.
3. Provide high flow oxygen with ventilation as needed with BVM.
ILS
As above
Additional ILS care shall be rendered per local protocols.
ALS
As above
Additional ALS care shall be rendered per local protocols .
Note: Head injury remains a significant cause of death from trauma. Early aggressive management, airway maintenance, oxygenation, spinal motion restriction and rapid transport to a Trauma Center are the goals in pre-hospital management.
Consider early activation of air transport if >30 minutes by ground to a Level I or
II Trauma Center.
*BLS EMS agencies responding to a scene requiring ALS patient care shall
perform early activation of the closest appropriate ALS provider to obtain
the appropriate level of care indicated for patient transport. Consider
rendezvous with ALS where appropriate.
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Capital Area Trauma Regional Advisory Council
Musculo-Skeletal Trauma*
BLS
1. Insure scene safety.
2. Provide high flow oxygen as needed.
3. Control bleeding.
4. Splint as indicated.
ILS
As above
Additional ILS care shall be rendered per local protocols.
ALS
As above
Additional ALS care shall be rendered per local protocols .
*BLS EMS agencies responding to a scene requiring ALS patient care shall
perform early activation of the closest appropriate ALS provider to obtain
the appropriate level of care indicated for patient transport. Consider
rendezvous with ALS where appropriate.
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Capital Area Trauma Regional Advisory Council
Multi-System Trauma*
BLS
1. Insure scene safety.
2. Provide high flow oxygen, consider BVM use if indicated.
3. Correct immediate life threats: a. Sucking chest wounds b. Aspiration c. Uncontrolled bleeding
4. Consider MAST for splinting purposes
ILS
As above
Additional ILS care shall be rendered per local protocols.
ALS
As above
Additional ALS care shall be rendered per local protocols .
NOTE: In the event of a Category I or II trauma patient, scene times should be limited to
Ten Minutes as much as possible; remember the Golden Hour concept. Consider early activation of air transport if ground transport time is >30 minutes to a Level I or II Trauma Center. Interventions such as IV therapy and extremity immobilization are secondary to securing an airway, spinal motion restriction, and rapid transport.
*BLS EMS agencies responding to a scene requiring ALS patient care shall
perform early activation of the closest appropriate ALS provider to obtain
the appropriate level of care indicated for patient transport. Consider
rendezvous with ALS where appropriate.
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Capital Area Trauma Regional Advisory Council
Trauma Induced Cardiac Arrest
BLS
1. Insure scene safety.
2. Provide high flow oxygen via BVM and oral airway.
3. Provide CPR as indicated.
4. Correct immediate life threats: a. b.
Sucking chest wound
Aspiration c. Uncontrolled bleeding
5. Rapid transport if indicated.
ILS
As above
Additional ILS care shall be rendered per local protocols.
ALS
As above
Additional ALS care shall be rendered per local protocols .
NOTE: Patients in cardiopulmonary arrest as a result of trauma, particularly blunt in nature, have a statistically high mortality rate. Penetrating trauma resulting in arrest has a slightly lower mortality rate. Factors to be considered in such care include transport times and proximity to the closest appropriate medical facility.
Prehospital care should focus on basic maneuvers and rapid transport to the closest appropriate facility. Intermediate stabilization at the closest facility should be utilized in lieu of transport to the highest-level trauma facility.
* BLS EMS agencies responding to a scene requiring ALS patient care shall
perform early activation of the closest appropriate ALS provider to obtain
the appropriate level of care indicated for patient transport. Consider
rendezvous with ALS where appropriate.
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Capital Area Trauma Regional Advisory Council
Consider addition of Hazmat response protocols and basic standardized treatments
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