Trauma Management 

Assessment

Pediatric Pearls:	Signs & Symptoms:	Differential:
□ Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg □ TXA dosing	□ Massive Hemorrhage  □ Airway  □ Respirations (decompression)  □ Circulation (IV, TXA)  □ Hypothermia / Head injury  □ Pain  □ Wound Care  □ Splinting  □ AMS	□ Respiratory failure  □ Foreign body airway obstruction  □ Hypovolemia  □ Trauma  □ Tension pneumothorax  □ Hypothermia  □ Toxins or Overdose  □ Hypoglycemia  □ Acidosis  □ Acute MI or PE  □ Stroke

Clinical Management Options

EMT-B

• Control external hemorrhage and apply tourniquet(s) as necessary, including junctional tourniquets if needed and available.  • Wound packing (junctional/extremity) with pressure dressing as appropriate and apply hemostatic gauze if available  • BLS airway management  • Place occlusive dressing/chest seal over penetrating torso trauma between supraclavicular areas to umbilicus  • Evaluate the need for spinal motion restriction  • Assess GCS score  • Keep patient supine and warm  • Administer Oxygen via NRB to all serious trauma patients.  • Bandage/splint injuries as appropriate for patient condition

Paramedic

• Needle Decompression of the chest as indicated  • If evidence of brain herniation, then initially hyperventilate the patient 20-24 breaths per minute. Then titrate ventilation rate to Adult & Pediatric ETCO2 30-35 mmHg, otherwise aim for 35-45 mmHg.   • Vascular access  • For hemorrhagic shock, Tranexamic Acid and Calcium Chloride  • For TBI who are not alert (GCS 3-12), Tranexamic Acid  • If Hypotensive, IV Crystalloid in 250 mL increments until MAP > 65 or SBP > 90 or until patient mentation improves • Pain Management Guideline as needed  • 12-lead placement and acquisition  • ETCO2 assessment  • Consider Simple Thoracostomy if concern for chest trauma • Advance airway management as needed  • If Adult Spinal Shock – push-dose epi until MAP > 65

Pearls

• Consider Chest Decompression with signs of shock and diminished/absent breath sounds. If patient arrests, then immediately perform bilateral decompression. 
• See East Central EMS Regional Trauma Guidelines for criteria when declaring trauma alert.  
• Minimize Scene time. If patient meets Trauma Alert criteria, then interventions should be performed enroute. 
• Severe bleeding from an extremity not rapidly controlled by direct pressure may necessitate the application of a tourniquet. 
• Permissive hypotension (target fluid resuscitation to MAP 55-65) should be used in the absence of neurologic injury, pregnancy, hypertensive history, and age < 45 years old. If neurological injury is suspected, maintain Adult SBP > 90 mmHg.
  • Hypotension, hypoxia are independent predictors of death in patients with neurological injury
• Hypotension is devastating to neurologic injury and should be aggressively treated. 
• MAP calculation [(2 x diastolic) + systolic] divided by 3 
• Peripheral neurovascular status should be document on all extremity injuries and before and after splinting procedures. Same for neuro status before and after extrication, placement for LSB and before/after transport. 
• In amputations, time is critical. Transport and notify medical control immediately, so that the appropriate destination can be determined. 
• Hip dislocations and knee and elbow fracture / dislocations have a high incidence of neuro-vascular compromise.  Document pulse, motor, and sensation.
• Urgently transport any injury with vascular compromise. 
• Blood loss may be concealed or not apparent with extremity injuries. 
• Lacerations should be evaluated for repair as soon as possible after injury. 
• If evidence of brain herniation (blown pupil, Cushing’s reflex, rapid decline in GCS, or bradycardia) and in absence of capnometer, hyperventilate the patient 20 – 24 breaths per minute. If available titrate to: Adult and Pediatric ETCO2 30 – 35 mmHg. ETCO2 < 30 is associated with poor neurologic outcomes. 
• Increased intracranial pressure (ICP) may cause hypertension and bradycardia with altered breathing (Cushing’s Response). 
• If hypotension, consider spinal shock or additional occult injury as source. 
• Consider Altered Mental Status guideline. 
• The most important item to monitor and document is a change in the level of consciousness and GCS. 
• Avoid hypoxia and hypotension if possible in patients with significant head trauma, as this can significantly increased mortality.
  • Avoid nasal airways in patient’s with significant facial trauma
• Consider Restraints if necessary, for patient’s and/or personnel’s protection per the Restraining Procedure. 
• For dental trauma, collect teeth and place then in a cup of normal saline. Avoid touching the root of the tooth as much as possible.

Level 1 traumas can be found at this link: LevelITraumaCenters.pdf (mo.gov)

• Barnes-Jewish Hospital
• Mercy Hospital
• SLU Hospital

GCS Score

Eyes Open	Best Verbal	Best Motor
4 – Eyes Open	5 – Oriented	6 – Obeys Commands
3 – To Voice	4 – Confused	5 – Localizes Pain
2 – To Pain	3 – Inappropriate	4 – Withdraws from Pain
1 – None	2 – Incomprehensible	3 – Pain-Flexion
	1 – None	2 – Pain-Extended
		1 – None

Spinal Motion Restriction

Spinal motion restriction can be accomplished by securing the patient to the stretcher. Do not transport patients on rigid long boards unless the clinical situation warrants long board use. C-collars should be placed for the following:

• Patient complains of midline neck or spine pain
• Any midline neck or spinal tenderness with palpation
• Any abnormal mental status (including extreme agitation)
• Focal or neurologic deficit
• Any evidence of alcohol or drug intoxication
• Another severe or painful distracting injury is present
• A communication barrier that prevents accurate assessment
• If none of the above apply, patient may be managed without a cervical collar

Do not place a C-collar if the patient has a penetrating injury to the neck as it can delay identification of injury and potentially compromise the airway.

Finger Thoracostomy

Clinical Indications: 

1. Traumatic cardiac arrest with known or suspected injury to the chest/abdomen. 
2. Hemodynamically unstable patient with clinical presentation of a tension pneumothorax.

Contraindications: 

1. Definitive loss of pulse for > 10 minutes prior to arrival of first unit. 
2. May consider the procedure if PEA is present at a rate > 60 
3. Any patient that has adequate cardiac output. 
4. Injuries incompatible with life. 
5. Any pediatric patient that appears too small for utilization of simple thoracostomy. 

Preparation for Use: 

1. Don appropriate PPE 
2. Ensure all equipment is readily available: Scalpel, Curved Kelly Forceps, Chlorhexidine Sponge, Permanent Marker, Chest Seals 
3. Ventilation, oxygenation, and IV access should be performed by other crew members and not delay thoracostomy. 

Procedure (link to video): 

1. Ensure patient is in the supine position and begin on the side most likely to be affected by a tension pneumothorax. Abduct the patient’s arm on the same side of the procedure. 
2. Identify lateral chest wall site directly over 5th or 6th rib between anterior axillary and midaxillary lines. 
3. Cleanse the site with Alcohol 
4. Using a scalpel, make a 1–2-inch incision directly over the 5th or 6th rib, between the anterior axillary line and midaxillary line. 
5. It is important not to extend or make incisions in or through penetrating wounds when at all possible. 
6. Use scalpel for skin only, there after use blunt dissection to pass through the intercostal muscles. 
7. Utilizing curved forceps, penetrate the thoracic cavity over the rib making sure to control the depth by grasping the forceps near the curved portion while inserting. 
8. Following penetration into the thoracic cavity and with the tips of the forceps, open the forceps maintaining control of the depth and withdraw to create an adequate opening sufficient to place your finger in the chest. 
9. Insert finger into pleural space. Ensure the lung is palpated and, if possible, feel caudally for the diaphragm. 
10. Allow the soft tissues to fall back over the wound to act as a flutter valve. 
11. Repeat the procedure on the opposite side. 

Post Procedure: 

1. If ROSC, then place an occlusive dressing over the wound (Pediatric defib pad, vent chest seal, etc). 
2. If no ROSC, then prior to pronouncement circle simple thoracostomy site and/or other incisions made by EMS. Label each with “EMS” to aid in identification for postmortem examination. 
3. If evidence of tension pneumothorax occurs, including cardiac arrest following ROSC, then remove occlusive dressing(s) and re-insert finger to relieve tension.