clinical advisory subcommittee of the emergency … advisory subcommittee of the emergency medical...

Clinical Advisory Subcommittee of the Emergency Medical Care Committee

Meeting Agenda 11:00 A.M., Tuesday May 13.2014 Health Agency Second Floor Large Conference Room 2180 Johnson Avenue San Luis Obispo Members Chair: Dr. Mark Eckert, County Medical Society Sue Fortier, RN, MICNs TBD, Fire Service Paramedics Joe Piedalue, Ambulance Paramedics Paul Quinlan, Fire Service EMTs Dr. Jana Reed, Non-Base Station ED Physicians Chad Robertson, ad hoc Dr. Joe Robinson, Base Station ED Physicians Dr. Stefan Teitge, County Medical Society

Staff STAFF LIAISON: Kathy Collins, RN, SCS Coordinator Steve Lieberman, EMS Division Director Dr. Tom Ronay, Medical Director Vicci Stone, EMS Specialist Tracy Eby, Administrative Assistant

Marigrace Waage, Ambulance EMTs TBD, Non-Base Station Hospital ED Nurses John Prickett, Lead Field Training Officer

AGENDA ITEM LEAD

Call to Order Introductions Dr. Eckert

Public Comment

Discussion Discussion on field use and need:

Dopamine – policy change to make “optional” for non-transporting ALS agencies

V-fib with ROSC to STEMI Centers -discussion

Trauma o Spinal Immobilization – draft policy o Trauma polices-

General Trauma Head/Neck/Facial Trauma Chest/Abdomen Trauma Extremity Trauma Traumatic Arrest Triage criteria (staff summary)

Saline shortage

Intranasal Narcan

Dr. Ronay- staff

Adjourn Announcements Dr. Eckert

Adjourn Declaration of Future Agenda Items

Updating/reformatting polices

Dr. Eckert

Next Meeting – May 13, 2014 11:00 a.m. – 12:30 p.m. 2

nd floor Conference Room, Health Agency

Policy No XXX

[Type text]

San Luis Obispo County

Emergency Medical Services Agency

Spinal Motion Restriction (SMR) ADULT PEDIATRIC

BLS PROCEDURES

o UNIVERSAL ALGORITHM

o Scene Safety / PPE

o ABCs

o Administer Oxygen Per Policy 580

o PURPOSE

o Full spinal immobilization/motion restriction (SMR) is to

protect the patient from further injury when an unstable

spinal fracture exists

o Routine use of full SMR should be avoided and reserved for

patients with confirmatory physical findings or high suspicion

of spinal fracture.

o Full SMR may cause airway or respiratory compromise. Lead

to skin breakdown and may cause significant pain

o INDICATIONS

o ASSOCIATED RISK FACTORS

Age > 65 years

Patients meeting STEP 3 MIO trauma criteria

Axial loading to head - i.e. diving accidents

Numbness or tingling in extremities

o FULL SMR IS NOT REQUIRED FOR:

Awake patients not under the influence of alcohol or

drugs with whom one can communicate effectively

That deny neck pain

Are neurologically intact

And do not have distracting injuries

o CONSIDER FULL SMR

BLUNT TRAUMA with any of the following

ALOC

Spinal tenderness – Mid-line for patients

<65 yrs or any neck pain for patients > 65yrs

Neurologic deficit or complaint

Anatomic deformity of the spine

SAME AS ADULT

Effective Date: November 1, 2012 Next Review Date: November 2015 ____________________________________________ Thomas Ronay, MD, EMS Medical Director

Evidence of alcohol or drugs

Distracting injury(s)

Inability to communicate

PENETRATING INJURY to head, neck or torso with:

Neurologic deficit or complaint

If in doubt “immobilize”

o SPECIAL CONSIDERATIONS

o Acute or chronic difficulty in breathing – consider elevation or

positioning patient/board

o Anatomic variations may require padding to place spine in a

neutral position

o Pediatric -

Utilize car seat if appropriate

Pad shoulders and head for anatomic alignment

o Pregnancy – tilt board to left to facilitate blood flow and aid in

respiratory comfort

Optional Scope

None

ALS Prior to Base Hospital Contact

o REMOVAL Of C-SPINE IMOBILIZATION

o My be done BY ALS for patients that have been placed in full

SMR but meet the criteria to NOT place in full SMR

SAME AS ADULT

Base Hospital Orders Only

o None

DOCUMENTATION

o Neurologic status before and after spinal immobilization

o When full SMR is NOT done and/or a paramedic removes spinal

precautions - PCR documentation must include all of the exclusion

criteria

o Awake and cooperative without influence of drugs/alcohol

o Deny neck pain

o Neurologically intact

o No distracting injuries

Effective Date: November 1, 2012 Next Review Date: November 2015 ____________________________________________ Thomas Ronay, MD, EMS Medical Director

o

Policy No XXX



General Trauma ADULT PEDIATRIC

BLS PROCEDURES


o Do not delay transport with non-essential treatment of the

non-entrapped/transport ready critical trauma patient.

o Attempt to limit on scene time to 10 min or less when Trauma

Triage Criteria are met

CONSIDERATIONS

o Assess for injuries that meet trauma triage guidelines Policy #

153

o Step 1 - Physiologic findings

Hemodynamic compromise (BP<90 mmHg)

Respiratory compromise - <10 or >29

Mental status – GCS <13 (AVPU??)

o Step 2 – Anatomic Injuries

Penetrating - number of wounds and type of

weapon

o Step 3 – Mechanism of Injury (MOI)

Vehicle collision

Estimated speed

Type of vehicle

Type of impact (i.e. head-on, roll-

over, auto-ped, etc.)

Damage (passenger space, steering

wheel, windshield, etc.)

Protective devices ( helmet, seatbelt,

airbag, child seat, etc)

Patient complaints/injuries ( seat belt

marks, etc)

Falls

Precipitating factors/cause

(mechanical vs syncope)

Height and direction

Landing surface

Patient complaints/injuries

o Step 4 – Special Considerations

Modifying factors

Age

Pregnancy

CONSIDERATIONS - same as adults except for age specific

findings

o Assess for injuries that meet trauma triage guidelines

Policy # 153

o Step I – Physiologic findings

Pediatric hemodynamic compromise –

poor perfusion - capillary refill > 2 sec.

Respiratory rate >60 or < 20 in

infants < 1yr.

Mental status – GCS <13

o Assess for Steps 2-4 – Same as Adult

Effective Date: Next Review Date: ____________________________________________ Thomas Ronay, MD, EMS Medical Director

Medications/blood thinners

o Remove clothing to expose injuries

o Cover to keep patient warm

o Control bleeding

o Direct pressure

o Elevate

o Pressure point

o Consider tourniquet application if appropriate for

uncontrolled bleeding – policy #XXX

o Dressing/Splinting per Trauma Extremity Policy # XXX

o Consider early transport with treatmens in route for critical

patients utilizing Trauma Triage and Destination Policy # 153

o Consider EMS Air resources early when appropriate – Policy

#155

o Complete secondary and reassess frequently

ADULT PEDIATRIC

BLS Optional Scope

o Pulse Oximetry o Pulse Oximetry


o Advanced airway – as needed

o Utilize pulse oximetry and capnography as indicated

o IV Normal Saline X 1 with extension tubing TKO

o Hypotension

o BP of <90 mmHg (manual) or unable to palpate

peripheral pulses - administer a 250-500cc fluid

challenge

o lf hypotension continues and initial fluid bolus is

ineffective - establish a second IV with saline lock and

consult with base for additional fluid boluses

o Pain Control – Isolated extremity fractures or dislocations

o Morphine Sulfate 5 mg slowly IVP/IM may repeat

X 1 not to exceed 10 mg

o Consider Ondansetron for nausea – ADULT DOSE

4mg SLOW IV push over 1min - (rapid

administration may result in syncope) or

4mg IM or PO

May repeat every 20 min to a total of 12 mg

o Advanced airway – as needed

o Utilize pulse oximetry and capnography as

indicated


o Hypotension

o Normal Saline (NS) IV Fluid Bolus -20 ml/kg

o May repeat once if no change in SBP

o Pain Control – Isolated extremity or dislocations

o Morphine 0.1 mg/kg slow IVP/IM, may

repeat once, not to exceed 5 mg


o Additional pain medication or fluid boluses o Additional pain medication or fluid boluses

o Ondansetron for nausea

o PEDIATRIC DOSE <34 kg

4 mg SLOW IV push over 1 min -

(rapid administration may result in

syncope)

4 mg IM or PO (oral disintegrating

tablet - ODT)


Repeat per base physician order

DOCUMENTATION

o Destination and documentation per Trauma Policy # 153 –

including MIVT

o Communicate if BP <90mmHg at ANY time

o Document medications and procedures

o Pain level prior and post any treatments, and/or medications

o Document use of tourniquet application per Policy #XXX

Same as Adult

ADDITIONAL INFORMATION

GLASCOW COMA SCALE

ADULT 1-5 YEARS 0-1 YEARS

EYE OPENING

4 Spontaneously Spontaneously Spontaneously

3 To Command To Command To Command

2 To Pain To Pain To Pain

1 No response No response No response

BEST VERBAL RESPONSE

5 Oriented Appropriate words, phrases

Coos , babbles, smiles

4 Confused Inappropriate words Cries

3 Inappropriate words Cries, scrams Inappropriate cries, screams

2 Incomprehensible Grunts Grunts


BEST MOTOR RESPONSE

6 Obeys commands Spontaneous Spontaneous

5 Localizes pain Localizes pain Localizes pain

4 Withdraws from pain Withdraws from pain Withdraws from pain

3 Abnormal flexion Abnormal flexion Abnormal flexion

2 Extension Extension Extension


Policy No XXX



Head, Neck and Facial Trauma ADULT PEDIATRIC

BLS PROCEDURES


o GENERAL TRAUMA ALGORITHM

CONSIDERATIONS



o Monitor and maintain airway

o Be prepared to suction

o Avoid hyperventilation (adults 10-12 breaths per

minute)

o Control bleeding

o Direct pressure

o Elevate

o Pressure point

o Eye Injuries

o Trauma/foreign body

Cover both eyes with dressings

Do not remove foreign body or impaled

object – stabilize with bulky dressings

o Chemical Contamination

Flush continuously with NS for at least

15 min or until arrival at the hospital

o Avulsed Teeth

o Place in saline gauze and transport with patient

SAME AS ADULT

CONSIDERATIONS

o Avoid hyperventilation

o Use small tidal volumes

ADULT PEDIATRIC

BLS Optional Scope

o Pulse Oximetry

o Pulse Oximetry



o Advanced airway as indicated while maintaining spinal

immobilization

o Monitor airway for obstruction (suction as

necessary)

o Utilize plus oximetry

o Utilize end-tidal CO2


o Hypotension



challenge


ineffective -establish a second IV with saline

lock and consult with base for additional fluid

boluses


o Morphine Sulfate 5 mg slowly IVP/IM - may

repeat X1 not to exceed 10 mg




4mg IM or PO

May repeat every 20 min to a total of 12

mg


o Hypotension

o Normal Saline (NS) IV Fluid Bolus -20 ml/kg



o Morphine 0.1 mg/kg slow IVP/IM, may repeat

once, not to exceed 5 mg





4 mg SLOW IV push over 1 min - (rapid

administration may result in syncope)

4 mg IM or PO (oral disintegrating

tablet - ODT)


DOCUMENTATION

o Destination and documentation per Trauma Policy # 153

– including MIVT

o Pain level prior and post treatments and/or medications

o Document use of tourniquet application per Policy #XXX

Same as Adult

ADDITIONAL INFORMATION


GLASCOW COMA SCALE

ADULT 1-5 YEARS 0-1 YEARS

EYE OPENING

4 Spontaneously Spontaneously Spontaneously

3 To Command To Command To Command

2 To Pain To Pain To Pain


BEST VERBAL RESPONSE

5 Oriented Appropriate words, phrases

Coos , babbles, smiles

4 Confused Inappropriate words Cries

3 Inappropriate words Cries, scrams Inappropriate cries, screams

2 Incomprehensible Grunts Grunts


BEST MOTOR RESPONSE

6 Obeys commands Spontaneous Spontaneous

5 Localizes pain Localizes pain Localizes pain

4 Withdraws from pain Withdraws from pain Withdraws from pain

3 Abnormal flexion Abnormal flexion Abnormal flexion

2 Extension Extension Extension


Policy No XXX



Chest and Abdomen Trauma ADULT PEDIATRIC

BLS PROCEDURES


o Scene Safety/PPE

o Do not delay transport with non-essential

treatment of the non-entrapped/transport ready

critical trauma patient.

o Attempt to limit on scene time to 10 min or less

when Trauma Triage Criteria are met

o CONSIDERATIONS



o Control bleeding

o Communicate if BP <90 mmHg at ANY time

o Evaluate and communicate mechanism of injury

o Evaluate for seatbelt signs or other points of

impact

o IMPALDED OBJECTS

o Immobilize the object to prevent further

movement

o CHEST

o Open Wounds – With air leak - cover with

Vaseline impregnated dressing and tape on 3

sides or use chest seal device seal

o Flail Chest – support fail segment and monitor

respirations – support if necessary

o ABDOMINAL

o Eviscerations – cover with moist saline dressing

o PREGNANCY

o If > 20 weeks pregnant place in left lateral

position for transport ( if in spinal immobilization

tilt spine board to left)

SAME AS ADULT

ADULT PEDIATRIC

Optional Scope

o Pulse Oximetry

Pulse Oximetry



o Advanced airway if indicated

o Utilize pulse oximetry and capnography

o Needle thoracotomy for suspected tension

pneumothorax


o Hypotension

o BP of <90 mmHg (manual) or unable to

palpate peripheral pulses - administer a

250-500cc fluid challenge

o lf hypotension continues and initial fluid

bolus is ineffective - establish a second IV

with saline lock and consult with base for

additional fluid boluses

o Pain Control – Isolated extremity or dislocations or

Burns without multisystem trauma

o Morphine Sulfate 5 mg slowly IVP/IM –

may repeat X1 not to exceed 10 mg

o Consider Ondansetron for nausea – ADULT

DOSE

4mg SLOW IV push over 1min -

(rapid administration may result in

syncope) or

4mg IM or PO

o May repeat every 20 min to a total of 12 mg

o Advanced airway if indicated

o Utilize pulse oximetry and capnography


pneumothorax


o Hypotension

o Normal Saline (NS) IV Fluid Bolus -20

ml/kg


o Pain Control – Isolated extremity or dislocations or

burns without multisystem trauma




o Pain control not covered above

o Additional fluid boluses

o Pain control not covered above

o Additional fluid boluses

DOCUMENTATION

Policy No XXX



Extremity and Pelvic Trauma ADULT PEDIATRIC

BLS PROCEDURES


o GENERAL TRAUMA ALGORITHM

CONSIDERATIONS


o Remover rings or other item possible of constriction


o Monitor and maintain airway

o Control bleeding

1. Direct pressure

2. Elevate

3. Pressure point

4. Consider tourniquet application if appropriate

for uncontrolled bleeding – Policy # 583

Tourniquet Use

o Dressing/Splinting

1. Confirm and mark distal pluses before and

after splinting, traction and patient movement

2. Cover open wound with sterile dressing

3. Fractures – open and closed

Splint with traction or other splining

devices after gentle realignment

4. Dislocations

Splint in position found

5. Amputations

Wrap amputated part in dry dressing

and place in waterproof

container/bag. Place on ice/cooling

pack (do not freeze) and transport

with patient.

Consider tourniquet use with

uncontrolled bleeding

6. Avulsions

Return flap to normal position and

apply moist sterile dressing

o Mangled extremity

1. Check for distal pulses and sensation before

and after splinting

2. Control the bleeding

3. Stabilize/splint after gentle realignment

SAME AS ADULT


4. Cover with dry dressing

ADULT PEDIATRIC

BLS Optional Scope

o Pulse Oximetry o Pulse Oximetry


o Dressing/Splinting

o Dislocation

Splint in position found

With signs of neurovascular compromise

attempt to place in anatomic position with

gentle traction

o Pelvic instability

Adult patients with mechanism of injury and

complaint of severe pelvic pain with a BP<90

mmHg – consider applying binder (sheet or

commercial device)


o Hypotension



challenge


ineffective - establish a second IV with saline lock and

consult with base for additional fluid boluses


o Morphine Sulfate 5 mg slowly IVP/IM – may repeat

X1 not to exceed 10 mg




4mg IM or PO

May repeat every 20 min to a total of 12 mg


o Hypotension

o Normal Saline (NS) IV Fluid Bolus -20

ml/kg









4 mg SLOW IV push over 1 min -

(rapid administration may result

in syncope)

4 mg IM or PO (oral

disintegrating tablet - ODT)


DOCUMENTATION


o Destination and documentation per Trauma Policy # 153 –

including MIVT

o Pain level prior and post pain reduction treatments and

medications

o Document use of tourniquet application per Policy #583

Same as Adult

Policy No XXX

Review: 2016 ____________________________________________ Thomas Ronay, MD, EMS Medical Director



Traumatic Cardiac Arrest

(Transport if 15 min or less from time of arrest to (Trauma Center vs ED?) ADULT PEDIATRIC

BLS PROCEDURES

o UNIVERSAL ALGORYTHM – TRAUMA

o ABC /CPR

o Control Bleeding

SAME AS ADULT

BLS Optional Scope

o AED

o Pulse Oximetry

SAME AS ADULT

ALS Standing orders

ADULT PEDIATRIC

ASYSTOLE- If asystolic with no signs of life (absent of vital

signs, respiratory effort and asystole in two leads) consider

pronouncement in the field – Policy # 126 Prehospital

Determination of Death

V-FIB or PEA and Penetrating Trauma - Resuscitate

o V-FIB - Transport Early

o May administer up to 3 shock(s) prior to

extrication/transport

o Follow Policy #610 Pulseless Arrest

o IV s performed enroute – fluid challenges of

500 ml, reassess and repeat PRN

o PEA – resuscitate for possible cause and perform

resuscitative measures during transport

o Assess for Hypoxia, hypovolemia, tension

pneumothorax


pneumothorax


SAME AS ADULT?

DOCUMENTATION or Additional Information

Effective Date: January 1, 2014 Review: 2016 ____________________________________________ Thomas Ronay, MD, EMS Medical Director

CONSIDERATIONS

o Cardiac etiology in older patients with low probable

mechanism of injury

o Unsafe scene may warrant transport despite low

potential for survival

o Consider minimal disturbance of potential crime scene

SAME AS ADULT

K:\PublicData\COMMITTEES\Clinical Advisory Subcommittee\2014\May.13.2014\Staff Report Summary_Policy 153 trauma triage 4.3 ops 05022014 SL.docx

Public Health Department

Emergency Medical Services Agency 2156 Sierra Way, San Luis Obispo, CA 93401

805-788-2511 ▪ FAX 805-788-2517

www.sloemsa.org

Policy 153 Trauma Triage

MEETING DATE Clinical Advisory Committee

STAFF CONTACT Kathy Collins, Specialty Care Systems Coordinator, 788-2514

SUBJECT Policy 153 Trauma Triage and Destination

SUMMARY The current triage guidelines in SLO county are not in line with triage guidelines of neighboring counties or the CDC recommendations. Specifically the following falls out occur in Step 2 Mechanism of Injury for patients with” significant injures”:

Two proximal long bone fractures

Crushed, degloved, mangled or pulseless extremity

Amputation proximal to the wrist or ankle

Pelvic instability/fractures

When the State EMS Authority approved the SLO Trauma Plan it was with the direction that a QI process would review the criteria that were not in line with the CDC recommendations. The Trauma Center and the EMS Agency reviewed trauma consults in 2013 with “two or more proximal long bone fractures” and identified 8 patients with two more proximal long bone fractures. Of these patients, 6 were associated with other injuries, 4 were transferred to higher level of care, and 3 did not meet any other triage criteria but had serious injuries.

REVIEWED BY Trauma Advisory Committee EMS Staff Thomas Ronay, MD, SLO County Medical Director Steve Lieberman, EMS Division Director Sierra Vista Trauma Advisory

RECOMMENDED ACTION(S)

A high association of serious injury for patients with two proximal long bone fractures was demonstrated though a review of the SLO data, and noting it is also national and regional standard in other programs - staff is recommending “two proximal long bone fractures” be moved to Step 2 for patients that are “significantly injured” and that the other anatomic injures continued to be monitored over the coming years.

ATTACHMENT(S) Policy 153 trauma triage and destination matrix

SAN LUIS OBISPO COUNTY HEALTH AGENCY

DRAFT 5.6.2014 TRAUMA TRIAGE DECISION SCHEME

“significantly injured” patients meeting one or more criteria activates

Adult Physiologic Criteria · Glasgow Coma Scale ≤ 13 · Systolic blood pressure <90mmHg · Respiratory rate <10 or >29 breaths per minute Pediatric Physiologic Criteria - <14 years or < 34Kg · Glasgow Come Scale ≤ 13· Evidence of poor perfusion – color, temperature, etc · Respiratory Rate >60/min or respiratory distress or apnea <20/min in infants <1 yr ● Heart Rate

≤5 yrs (<22 Kg) - <80/min or >180/min≥6 yrs (23-34 Kg) - <60/min or >160/min

● Blood Pressure- Newborn (<1mo) SBP<60 - Infant (1mo-1yr) SBP<70- Child (1yr-10yrs) SBP <70 + (2x age in yrs)

- Child (11-14yrs) SBP <90

Anatomic Criteria· All penetrating injuries to head, neck, torso, and extremities

proximal to elbow or knee · Chest wall instability or deformity (e.g. flail chest)· Open or depressed skull fracture· Two or more proximal long bone fractures· Paralysis

Special Patient and System Considerations (*)· EMS provider judgment· Age >65 or <14 yrs (SBP <110mmHg in elderly may represent shock)· Anticoagulation therapy (excluding aspirin) or other bleeding

disorder with head injury (excluding minor injuries) · Pregnancy >20 weeks· Burns with trauma mechanism(*) Trauma Consultation is not required for ground level/low impact falls with GCS ≥ 14 (or when GCS is normal for patient) – follow SLO County patient destination policy

Mechanism of Injury and PARAMEDIC JUDGMENT for Injuries· Falls

- Adults: >20 feet (one story is equal to 10 feet)- Children: >10 feet or two or three times the height of the child

· High-risk auto crash - Intrusion of passenger compartment >12 inches occupant site or

>18 inches any site including roof/floor - Ejection (partial or complete) from automobile - Death in same passenger compartment· Auto vs. pedestrian/bicyclist thrown, run over, or with significant

(>20 mph) impact· Motorcycle or unenclosed transport vehicle crash >20 mph

TRAUMA ALERT and transport to

closest TC

Assess for mechanism

Follow SLO County destination policy

Contact TC and transport to closest ED with· Unmanageable airway· Uncontrollable bleeding· Penetrating injury w/ traumatic

cardiac arrest

Assess for anatomic injury

Assess for special patient or system considerations

CONSULT TC for destination

YES

YES

YES

YES

NO

NO

NO

NO

2

3

4

TRAUMA ALERT and transport to

closest TC

Assess for physiologic findings

1

CONSULT TC for destination

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