Trauma

TITLE: SECTION NO: EFFECTIVE DATE: PRESENTATION 1. 2. 3. HISTORY TRAUMA 200.16 JANUARY 1, 2000 Mechanism of injury (blunt or penetrating) Blunt trauma: amount and direction of force Penetrating trauma: weapon, size of object, bullet caliber, trajectory of bullet Motor vehicle accident: condition of vehicle, dashboard, and steering wheel, speed of impact, seat belt use, patient trajectory Description of scene Treatment prior to arrival (patient movement) Drug or alcohol use Medical illnesses Current medications Allergies SYMPTOMS Not applicable SIGNS Vital Signs: Skin: Respiratory: Vary Cyanosis, pallor, mottling, entrance and exit wounds, cool, clammy Apnea, abnormal chest wall movements (paradoxical, retractions), abnormal breath sounds, tracheal shift, subcutaneous emphysema STABILIZATION 1. Assess airway patency; if intact, administer 100% O2 via NRBM. question: A. If patient exhibits respiratory effort: i. Perform jaw thrust maneuver to open airway. Maintain immobilization of the cervical spine in the neutral position. Reassess airway status. If jaw thrust successful, maintain position and assist ventilations with 100% O2 via BVM. If patency in ii. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 1 of 25 iii. If unsuccessful, place nasal trumpet and/or oral airway (avoid use of nasal airways in patients with suspected midface trauma). Reassess. If successful, assist ventilations with 100% O2 via BVM. If unsuccessful, perform endotracheal intubation. a. Oral intubation may be performed with assistance in maintaining neutral head position. The nasal route may be used in the trauma victim. Contraindications to nasal intubation include apnea, the presence of midface fractures, or known bleeding disorders. If head injury suspected, administer 1.5 mg/kg lidocaine IVP two minutes prior to intubation as urgency permits. iv. b. c. v. If intubation is unsuccessful or mechanical obstruction prevents adequate ventilation and oxygenation, perform cricothyroidotomy. Assist ventilations with 100% O2 via BVM. B. If patient exhibits minimal or no respiratory effort: i. Proceed as noted above in sections iv and v. 2. Assess respiratory exchange. If adequacy of ventilation is in question: A. B. Assess for signs of chest trauma. If open chest wound: i. C. Place occlusive dressing over wound; tape on three sides only. If flail chest: i. ii. Support chest wall with chest wall taping Provide positive pressure ventilation. D. If tension pneumothorax suspected: i. Place needle thoracotomy (refer to protocol). E. Reassess airway security and position of airway adjuncts. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 2 of 25 3. Assess circulatory status. A. B. Initiate 2 LB IV cannulas. If circulatory status is in question: i. ii. ii. Place patient supine. Place direct pressure on sites of hemorrhage. Refer to shock (hypovolemia) protocol. 4. Assess neurologic status. If in question: A. Immobilize patient with back board and cervical collar as indicated. Patient should be immobilized as soon as possible; however, immobilization should not take priority over assessment and management of the airway, respiratory, or circulatory status. Treatment of these parameters must in turn not be conducted in a fashion which threatens the integrity of the spinal cord or surrounding vertebrae. If head injury suspected, restrict fluids to TKO rate if patient condition permits (systolic blood pressure > 100 mmHg). If patient exhibits decreased level of consciousness, administer dextrose and naloxone in accordance with protocol. Hyperventilation should be provided to patients who exhibit clear signs of increased intracranial pressure such as unequal pupils, seizures, posturing, or a rapid fall in GCS. B. C. D. 5. 6. Undress patient completely; cover with blankets to prevent exposure. Assess extremity status. If in question: A. Place cold pack on suspected fracture sites. B. Splint suspected fracture sites in position found using most appropriate fashion. i. Extremity fractures may be splinted with cardboard, ladder, vacuum, or air splints. Femur fractures may be immobilized with traction splints. ii. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 3 of 25 * C. If distal vascular deficits noted, reduce fracture in anatomical alignment using steady, gentle axial traction. Splint in most appropriate fashion. Recheck pulses after reduction and immobilization. If partial amputation, place dry dressings and splint in line with associated extremity. Avoid torsion or traction on severed part. If complete amputation noted: i. Apply direct pressure to bleeding sites; elevate above the level of the heart as possible. If bleeding profuse despite elevation and direct pressure, place blood pressure cuff just proximal to amputation site and inflate to just above systolic pressure. Maintain cuff pressure during transport. Do not place cuff over joints; if appropriate cuff placement is over a joint, place cuff just proximal to joint and inflate as above. Remove any gross contaminants from the amputated part by gently irrigating with sterile saline solution. Place moistened sterile dressings around the amputated part. D. E. ii. iii. iv. v. Place the amputated part wrapped with moist sterile dressings in a waterproof container. vi. Place the sealed container in iced water or place activated cold packs around the container. Do not allow part to come in direct contact with ice or cold packs. Expeditiously transport amputated part with patient to closest appropriate facility. vii. 7. Administer morphine sulfate 2-4 mg (0.1 mg/kg in children) IVP Q 5-10 minutes for pain control (total dose 10 mg). Special considerations A. Impaled objects should be secured in position and not removed unless their placement interferes with airway management. Penetrating or eviscerating wounds should be primarily covered with moistened sterile dressings. Sterile foil wraps may be applied (when available) as a second layer of dressings to aid in the prevention of hypothermia. The gravid trauma victim: 8. B. C. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 4 of 25 i. ii. The most common cause of fetal mortality is maternal mortality. Treatment of the mother ALWAYS comes first. Assess patient for uterine contractions, vaginal bleeding, or rupture of membranes. Visualize perineum, but do not perform vaginal examination. Place patient in left lateral decubitus position. Support backboard with pillows placed under the right side of the board in the immobilized patient. iii. D. i. If patient at risk of crush syndrome: Run 2 LB IV at wide open rate (20 cc/kg initial bolus in children, followed by 10 cc/kg further fluid boluses). Add one (1) ampule of sodium bicarbonate (NaHCO3) to every other liter bag of fluid used. Request slow release of compressive forces over 10-15 minutes from extrication team. In the event that rapid extrication is required, appropriately sized blood pressure cuffs placed proximally over the affected extremities may be used to slowly restore extremity blood flow over 10-15 minutes. ii. iii. 9. EARLY TRANSPORT OF THE TRAUMA PATIENT OFFERS THE BEST CHANCE OF SURVIVAL. FIELD TIME SHOULD NOT BE PROLONGED IN ORDER TO PERFORM PROCEDURES NOT ABSOLUTELY CRITICAL TO THE WELL-BEING OF THE PATIENT DURING TRANSPORT. EDMCP CONTACT Transport notification SPECIAL CONSIDERATIONS 1. 2. 3. 4. 5. Airway, breathing, circulation should always be the order of patient assessment and management. Initial assessment in multiple trauma patients is performed at the same time as treatment. Treat unstable patients enroute. LOAD N GO - transport immediately. Repeated vital signs and neurologic assessments are imperative. Typical LOAD N GO situations are: a. Penetrating Chest Wounds/Chest Wounds With Shock b. Crushing Injuries to the Face/Neck c. Single/Multiple Amputations d. Abdominal Evisceration Volusia County EMS Protocols Section 200.16 pg 5 of 25 Revised 08/25/00 e. Any trauma with the signs and symptoms of respiratory distress or shock TOPICS IN PREHOSPITAL TRAUMA CARE: SYNOPSIS HEAD TRAUMA PRESENTATION 1. 2. 3. HISTORY Time of injury Mechanism of injury (blunt vs. penetrating) Estimate of force involved Helmet (motorcycle, bicycle) Loss of or change in consciousness (duration and progression) Amnesia for events Medical illnesses (especially diabetes, seizures, etc.) Current medications Allergies Drug or alcohol use SYMPTOMS Nausea, vomiting Neck pain Headache Diplopia (double vision) or blurred vision Abnormal gait Numbness or tingling of extremities Paralysis of extremities SIGNS Vital Signs: Skin: HEENT: Neck: Neurologic: Hypotension or tachycardia may be indicative of internal hemmorhage Contusions, abrasions, lacerations Abnormal breath odor (especially ETOH), bleeding or CSF from nose and ears Tenderness (suspect neck injury in ALL head injured patients) Decreased level of consciousness, restlessness, abnormal pupillary size and response, focal neuro deficits, seizures, coma EDMCP CONTACT Transport notification Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 6 of 25 SPECIAL CONSIDERATIONS 1. 2. 3. Assume cervical spine injury in all patients with head injury. Always check airway, oxygenation and blood pressure before attributing deterioration to neurological causes. All patients with actual or potential head injury should receive adequate oxygenation and ventilation. However, hyperventilation should be restricted to patients who exhibit clear signs of increased intracranial pressure such as those with unequal pupils, seizures, posturing, or a rapid fall in GCS. Scalp lacerations can cause profuse bleeding; hemostasis with direct local pressure is indicated. Elevated blood pressure and bradycardia may be indicative of increased intracranial pressure. GLASGOW COMA SCALE Scale Points EYE OPENING: Spontaneous To Speech To Pain None 4 3 2 1 4. 5. BEST VERBAL RESPONSE: Oriented Confused Conversation Inappropriate Words Incomprehensible Sounds None BEST MOTOR RESPONSE: Obeys Commands Localizes Pain Withdraws From Pain Flexion To Pain Extension To Pain None TOTAL FACIAL & CERVICAL TRAUMA 6 5 4 3 2 5 4 3 2 1 ____________ Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 7 of 25 PRESENTATION 1. 2. 3. HISTORY Mechanism of injury: blunt or penetrating, impact with steering wheel, windshield, other objects, clothesline-type injury to neck, hanging, athletics Description of scene Force involved Treatment prior to arrival (patient movement, etc.) Medical illnesses Current medications Allergies SYMPTOMS Areas of pain Visual problems Hearing problems Abnormal bite Respiratory distress SIGNS Vary Lid laceration, blood anterior to pupil, pupil abnormalities, abnormal globe position or softness Head: Evidence of trauma Ears/Nose: Blood, drainage of CSF Mouth/Throat: Jaw or tongue instability, loose or missing teeth, vomitus or blood in airway, hoarseness Neck: Tenderness, crepitus, bruising, swelling Neurologic: Decreased level of consciousness, coma Vital Signs: Eyes: EDMCP CONTACT Transport notification SPECIAL CONSIDERATIONS 1. 2. Airway obstruction is the primary cause of death from facial and neck trauma. Meticulous attention to airway management is imperative. Fracture of the larynx should be suspected in patients with respiratory distress, abnormal voice, and a history of direct blow to the neck. Transport patients with this potentially lethal injury immediately (LOAD N GO). Remember that the apex of the lungs extends into the lower neck. Penetrating neck injuries can result in hemothorax or pneumothorax. Place dislodged teeth in a moistened saline dressing and bring to the emergency 3. 4. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 8 of 25 department. CHEST TRAUMA PRESENTATION 1. 2. 3. HISTORY Mechanism of injury (blunt or penetrating) Blunt trauma: amount and direction of force Penetrating trauma: weapon, size of object, bullet caliber, trajectory of bullet Motor vehicle accident: condition of vehicle, dashboard, and steering wheel, speed of impact, seat belt use, patient trajectory Description of scene Treatment prior to arrival (patient movement, etc.) Drug or alcohol use Medical illnesses Current medications Allergies SYMPTOMS Respiratory distress Chest pain Neck pain Hemoptysis SIGNS Vital Signs: Skin: Vary - abnormal respiratory rates Cyanosis, subcutaneous emphysema, presence or absence of chest wound - Respiratory: - Abnormal chest wall movements (paradoxical movement, retractions), chest wall tenderness, abnormal breath sounds, tracheal Cardiovascular:Muffled heart sounds, distended neck veins, narrowed pulse pressure, EMD Neurologic: Decreased level of consciousness, change in mental status (hypoxia) EDMCP CONTACT Transport notification Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 9 of 25 SPECIAL CONSIDERATIONS 1. 2. 3. Treatment of chest trauma, especially penetrating injury, should not be delayed in the field. Rapid transport is critical. Hypovolemia secondary to major chest injury is common. Myocardial contusion can cause pain similar to that of myocardial infarction (MI); hypoxemia and hypovolemia should be considered first as potential causes of dysrhythmias. A tension pneumothorax, penetrating chest injuries and chest injuries (closed or open) with shock are LOAD AND GO situations - stabilize enroute to the hospital 4. ABDOMINAL TRAUMA PRESENTATION 1. 2. 3. C. HISTORY Mechanism of injury (blunt or penetrating) Blunt trauma: amount and direction of force Penetrating trauma: weapon, size of object, bullet caliber, trajectory Motor vehicle accident: condition of vehicle, dashboard, and steering wheel, speed of impact, seat belt use, patient trajectory Treatment prior to arrival (patient movement, etc.) Drug or alcohol use Medical illnesses Current medications Allergies SYMPTOMS Abdominal pain Respiratory distress Syncope SIGNS Vital Signs: Skin: Abdomen: Vary Bruising, entrance and exit wounds Tenderness, distention, guarding, pelvic instability EDMCP CONTACT Transport notification D. SPECIAL CONSIDERATIONS Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 10 of 25 1. 2. 3. Patients with an altered mental status secondary to alcohol, drugs, or head injury may have a significant abdominal injury, but may not have specific abdominal complaints. Consider the mechanism of injury. It is difficult to assess the extent of abdominal trauma in the field. SPINAL TRAUMA PRESENTATION 1. 2. 3. HISTORY Mechanism of injury (high index of suspicion with falls, diving, deceleration accidents, electrocution, near-drownings, lightning strikes, athletics) Force involved Drug or alcohol use Medical illnesses Current medications Allergies SYMPTOMS Neck or back pain Sensory loss or parethesia Muscle weakness or paralysis Respiratory distress SIGNS Vital Signs: Neck: Respiratory: GU: Neurologic: Hypotension (spinal shock) Tenderness, deformity Diaphragmatic breathing, apnea Priapism, incontinence Sensory loss or paresthesias, muscle weakness or paralysis, focal neuro signs EDMCP CONTACT Transport notification SPECIAL CONSIDERATIONS 1. The patient with mechanism of injury and little or no neurological deficit should not be treated casually. This patient may benefit most from precautions against further injury. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 11 of 25 2. Cervical spine injuries are the #1 cause of death for high school athletes. FRACTURES AND DISLOCATIONS PRESENTATION 1. 2. 3. HISTORY Mechanism of injury Direction of force Description of scene (athletic event, motor vehicle accident, fall, etc.) Treatment prior to arrival (dislocation reduction, patient movement, etc.) Previous injury Drug or alcohol use Medical illnesses Current medications Allergies SYMPTOMS Pain or limited movement Deformity SIGNS Vital Signs: Musculoskeletal: Neurovascular: Routine Obvious deformity, swelling, tenderness, crepitus, ecchymosis, discoloration, loss of function Weak or absent distal pulses and sensation EDMCP CONTACT If distal pulses are absent after axial traction and splinting has taken place Transport notification SPECIAL CONSIDERATIONS 1. 2. 3. 4. Transport of seriously injured individuals should not be delayed for extensive stabilization of non-critical extremity injuries. Alcohol or drugs may mask the individual's sense of pain; carefully examine injury. Splinting should be done prior to moving the stable patient. Closed femur fractures may be reduced in the field to accomodate traction splint Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 12 of 25 5. application (with or without distal pulses). Crepitus should not be deliberately elicited to aid in assessment. Not only is it painful to the patient, but nerves and blood vessels could be severed by this movement. AMPUTATIONS PRESENTATION 1. 2. 3. HISTORY Time of injury Mechanism of injury Care for severed part Medical illnesses (especially bleeding problems, etc.) Current medications Allergies SYMPTOMS Not applicable SIGNS Vital Signs: Skin: Extremity: Other: Vary (hypotension, tachycardia) Cyanosis, pallor, clammy Structural attachments in partial amputations Assess blood loss at scene and other injuries EDMCP CONTACT Transport notification SPECIAL CONSIDERATIONS 1. Tourniquets should be used only as a LAST RESORT! Never clamp bleeding vessels. Control bleeding by direct pressure and elevation (if spinal injury is not suspected). The most profuse bleeding may occur in partial amputations, when the transected vessel cannot constrict to stop bleeding. If a tourniquet is applied, document the time the tourniquet was applied. Partial amputations should be dressed and splinted in alignment with the extremity to ensure optimal blood flow to distal tissue. Attempt to remove any gross contaminants from the amputated part by irrigating with sterile saline solution or gently cleanse with saline solution on a sterile gauze 4x4, if time allows. Do not attempt a thorough cleansing of the amputated part as this will be done later at the hospital. 2. 3. 4. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 13 of 25 5. 6. Transport amputated part with patient, but out of patient's sight. It is important the amputated part be transported to the Emergency Room as quickly as possible. An amputated part will remain viable for 4-6 hours at room temperature or up to 18 hours if cooled. If the patient is not a candidate for reattachment consider saving the amputated part(s) for graft on other injured parts of the body. TRAUMA IN PREGNANCY INTRODUCTION Treatment priorities for an injured pregnant patient remain the same as for the non-pregnant patient. PHYSIOLOGIC CHANGES OF PREGNANCY A. Hemodynamic 1. Cardiac Output After the tenth (10th) week of pregnancy, cardiac output is increased significantly. However, when the patient lies supine, compression due to the uterus pushing on the vena cava may decrease cardiac output by up to 40%. 2. Heart Rate Heart rate increases throughout pregnancy. During the third (3rd) trimester, it may be 20 beats per minute more than the non-pregnant state. Blood Pressure Pregnancy results in a 5-15 mmHg fall in systolic and diastolic pressures during the second (2nd) trimester. Some women may exhibit profound hypotension when placed in the supine position. This condition is relieved by turning the patient to the left lateral recumbent position. 3. 4. Blood Volume After 34 weeks of gestation, plasma volume reaches a level 50% more than non-pregnancy. With hemorrhage, blood loss of 30-35% may occur before otherwise healthy pregnant patients exhibit symptoms of shock. B. Respiratory Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 14 of 25 The respiratory rate is often slightly increased in late pregnancy; volume per breath is reduced, and respirations are often shallow due to limited diaphragmatic excursion. C. Gastrointestinal The intestines are relocated to the upper abdomen and may be shielded by the uterus. The spleen and liver are essentially unchanged by pregnancy. D. Reproductive The uterus increases in size during gestation, reaching the level of the pubis at twelve (12) weeks, the umbilicus at twenty (20) weeks and costal margin at thirty-six (36) weeks gestation. This increases the size and high uterine blood flow, making the uterus and its contents susceptible to injury later in pregnancy. E. Neurologic Eclampsia is a complication of late pregnancy and may mimic a head injury. Eclampsia should be considered if seizures, with or without hypertension occur, especially if hyperreflexia is present. POSITIONING Unless a spinal injury is suspected, the pregnant patient should be transported and evaluated on her left side. If the patient is supine on a long backboard (LBB), the right side of the LBB should be elevated and the uterus manually displaced to the left side to minimize uterine compression on the inferior vena cava. EDMCP CONTACT Transport notification If the Paramedic requires clarification as to hospital destination, contact Halifax Medical Center's EDMCP. All unstable and potentially unstable patients must be accompanied by a Paramedic during transport. SPECIAL CONSIDERATIONS 1. Note any vaginal bleeding or leaking of fluid. Vaginal bleeding in the third (3rd) trimester may indicate disruption of the placenta and pending death to the fetus and is a "LOAD & GO" situation. Because of increased intravascular volume and the rapid contraction of the 2. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 15 of 25 uteroplacental circulation shunting blood away from the fetus, the traumatized pregnant patient may lose up to 35% of her blood volume before tachycardia, hypotension, and other signs of hypovolemia occur. Thus, the fetus may be in severe distress, while the mother's condition and vital signs appear stable. PEDIATRIC TRAUMA INTRODUCTION The multiple injured child has unique characteristics. There is a much higher instance of blunt vs. penetrating trauma in this age group. Falls and vehicular accidents account for almost 80% of all pediatric injuries. Multi-system injury is common. All organ systems must assume to be injured until proven otherwise. A. Size and Shape The child's smaller size results in applied forces being dissipated over a smaller mass of the child resulting in greater force and injury sustained. At this point, tense energy is applied to a body with less body fat, less elastic connective tissue, and closer proximity of multiple organs, resulting in a high frequency of multiple organ injuries. B. Skeleton The child's skeleton is incompletely calcified and contains multiple active growth centers, which makes it more resilient. It is, therefore, less able to absorb significant forces applied during a traumatic event. This results in internal organ damage without overlying bone fracture. For example, rib fractures in the child are not common, but pulmonary contusion is. C. Surface Area The ratio between a child's body surface and body volume is highest at birth and diminishes throughout infancy and childhood. As a result, dermal energy loss becomes a significant stress factor in the smaller child. Hypothermia frequently adds additional stress to the hypotensive child and may be life threatening. D. Psychological Status The child's ability to interact with unfamiliar individuals and strange environments is usually limited, making history taking and cooperative manipulation very difficult. The emergency care provider will have to be willing to spend extra time speaking to and soothing an injured child in order to establish a good rapport. This will facilitate a better assessment of the child. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 16 of 25 E. Long Term Effects Unlike the adult, the child must not only recover from the events of the traumatic event, but must also continue the normal process of growth and development. Inadequate and inappropriate care in the immediate post-traumatic period may affect not only the child's survival, but just as importantly, the quality of the child's life for years to come. F. Equipment Immediately available equipment of the appropriate size is essential for successful initial management of the child. AIRWAY MANAGEMENT The primary goal in the initial assessment of the injured child is to restore adequate tissue oxygenation as effectively and completely as possible. The standard principles of airway control, breathing, and circulation are applied no differently in the injured child than in the injured adult. As always, the child's airway is the first priority of assessment. A. Anatomy The smaller the child the greater the disproportion between size of the cranium and mid-face and the greater the tendency of the posterior pharyngeal area to "buckle" as the relatively larger occiput forces flexion on the cervical spine. As a result, the child's airway is best protected by a slightly superior anterior position of the mid-face known as the "sniffing" position. Careful attention to maintain this position while maintaining cervical spinal immobilization is especially important in the obtunded child who's level of consciousness is varying. In the infant, the tongue is relatively large compared to the oral cavity, which may make visualization of the larynx difficult. The child's larynx is smaller than an adult's and also slightly more anterior making it more difficult to visualize during direct intubation. The infant's trachea is short (5cm) and grows to about 7cm by l8 months. Failure to appreciate this length may lead not only to bronchial intubation but hypoxia or perforation. B. Management In a spontaneously breathing child the airways should be secured by the chin-lift or jaw-thrust maneuver. Supplemental oxygen should be delivered after the mouth and oral pharynx have been cleared of secretions and/or debris. If the patient is unconscious, mechanical methods of maintaining the airway may be required. l. Oral Airway Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 17 of 25 The practice of inserting the airway backwards and inserting it l80 degrees is not recommended in the pediatric patient. Trauma to the teeth or soft tissue of the oropharynx may occur. Gently direct the oral airway into the oropharynx using a tongue blade to depress the tongue. 2. Orotracheal Intubation Endotracheal intubation is the most reliable means of ventilating the child with airway compromise. Uncuffed, specially sized pediatric tubes should be used to avoid subglottic edema and injury. The technique to gauge the size of the endotracheal tube is to approximate the diameter of the child's external nares. Another method is to equate the size of the child's fifth finger to the appropriate sized tube. The "Broselow" tape is also recommended for finding appropriate sized equipment. Once the vocal cords are visualized during direct intubation, the endotracheal tube should be carefully positioned 2-3cm below the level of the cords and careful auscultation of lung fields and the axilla should be done to assure equal breath sounds. Breath sounds should be periodically re-checked, not only to assure adequate position of the endotracheal tube, but also to rule out evolving ventilatory dysfunction, particularly due to excess tidal volume delivery to the tracheobronchial tree. 3. Cricothyroidotomy Surgical cricothyroidotomy is not indicated for the infant or small child. When airway access or control cannot be accomplished by bag valve mask or oral endotracheal intubation, needle cricothyroidotomy is the preferred method. (See "Needle Cricothyroidotomy Procedure", Section 300.04) SHOCK A. Recognition Injury in childhood frequently results in significant blood loss. The increased physiologic reserve of the child may result in vital signs that are only slightly abnormal. The organs of primary importance in the child suffering hypovolemic shock are the heart, central nervous system, skin and kidneys. Each can be monitored to identify the severity of the hypovolemia. The primary response to hypovolemia in the child is tachycardia. Caution must be exercised in monitoring only the heart rate because tachycardia may also be caused by stress, pain or fear. Hypovolemic shock in the pediatric patient can be described in terms of blood volume loss (normal blood volume = 80cc/kg weight), and changes in monitored vital organ function. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 18 of 25 Although signs of frank hypovolemic shock may be unmistakable, minimal or evolving shock may be very subtle demanding careful observation. The association of tachycardia, cool extremities, and a systolic blood pressure of less than 70 are clear indications of evolving shock. A child's systolic blood pressure should be 80 plus twice the age in years, and diastolic pressure two-thirds of the systolic blood pressure. B. Fluid Resuscitation Fluid resuscitation for the child follows the same basic principles as for the adult. Because approximately 25% of blood volume loss is required to demonstrate manifestations of shock, a fluid challenge of 20cc/kg, which represents 25% of the normal blood volume of a child (80cc/kg) is an appropriate initial bolus. As with adults, crystalloid fluid replacement is given at three times the estimated actual blood loss. To achieve a 25% blood volume replacement in the child requires 60cc/kg of crystalloid fluid. Failure to obtain hemodynamic stability following the first bolus should be followed by communication with the EDMCP for orders for a second bolus. This situation, this would indicate severe volume loss. C. Venous access Severe hypovolemic shock usually occurs as a result of disruption of intrathoracic or intra-abdominal organ systems. Venous access should be established via a percutaneous route. If this route in unsuccessful, consideration for an intraosseous puncture should be considered. (See "Pediatric Intraosseous Infusion", Section No. 300.07) D. Dermal regulation The high ratio of body surface to body mass in children increases the rate of heat loss and the ability to regulate core temperature. Small patients who are hypothermic may be more difficult to treat when trying to correct for shock. Be sure to bundle these patients well with blankets if available. CHEST TRAUMA Penetrating injury is rare in children. Blunt thoracic trauma, which is much more common, requires immediate correction to establish adequate ventilation. The child's chest wall is very compliant and allows injury to transfer into the intrathoracic structures frequently without any evidence of injury to the external chest wall. Potential pneumothorax or hemopneumothorax, the result of high energy accidents, are not well tolerated by the pediatric patients due to the mobility of the mediastinal structures. This Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 19 of 25 mobility also makes the child sensitive to flail segments. This elastic chest wall, thus, increases the frequency of pulmonary contusions and direct intrapulmonary hemorrhage, usually without overlying rib fractures. Children sustain bronchial injuries and diaphragmatic ruptures with increased frequency due to these blunt crushing forces. Injury to the great vessels is less frequent compared to the adult which may result from lack of atherosclerotic vascular disease. The diagnostic and therapeutic approach to chest trauma is the same for children as for adults. Significant thoracic injuries rarely occur alone and are often a factor of major multi-system injury. ABDOMINAL TRAUMA Blunt injuries are much more common than penetrating injuries in this age group. A. Assessment The conscious infant or young child will be greatly frightened by the events post-injury. While talking quietly and slowly to the child, gently press on the abdomen and assess the tone of the abdominal musculature. Avoid deep palpation at the onset of exam as this will cause the child to voluntarily guard against further abdominal compression. Almost all infants and young children who are stressed and crying will swallow a large amount of air causing gastric distention which may affect the examination. Abdominal examination in the unconscious patient will not vary greatly with age. HEAD TRAUMA Principal differences of injuries in children vs. adults: A. Assessment 1. Children generally recover better than adults. However, children less than three years of age have worse outcomes from severe head injuries than older children. Secondary brain injury from hypoxemia and hypovolemia must be avoided. Although uncommon, infants may become hypotensive from a head injury due to blood loss either from a large scalp hematoma or epidural bleed. Always consider hypovolemia and provide adequate volume resuscitation. The young child with an open fontanelle and mobile features is more tolerant of an expanding intracranial mass. Other signs of expanding mass may be hidden until rapid decompensation occurs. Therefore, a bulging fontanelle or suture diastasis in an infant who is not in a coma should be treated aggressively as this may represent a serious injury. 2. 3. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 20 of 25 4. Vomiting is common after head injury in children, and does not necessarily mean increased intracranial pressure. However, persistent vomiting or vomiting that worsens is of concern and will probably require CT scan. Seizures occurring shortly after injury are more common in children. They are usually self-limiting. Seizures will require investigation by CT scanning at appropriate facility. Children have less instance of focal mass lesions (bleeds) than adults. However, they have increased incidence of increased intracranial pressure without masses. Therefore, a child with a lucid interval and subsequent delayed neurological function occurs more commonly from brain swelling and increased intracranial pressure. Glasgow Coma Scale is useful but must be modified for the pediatric age group. The verbal response scores are as follows: Score 5 Score 4 Score 3 Score 2 Score l social smile, fixes and follows cries but consolable persistently irritable breathless and agitated none 5. 6. 7. B. Management. l. Rapid early assessment and management of the airway and circulatory systems. Sequential assessment to prevent secondary injuries from hypoxia or ischemia. Early endotracheal intubation with adequate oxygenation and ventilation when indicated. 2. SPINAL CORD INJURY Pediatric spinal cord injury is rare with only 5% of all spinal cord injuries occurring in the pediatric age group. For children less than ten years of age, motor vehicle accidents are the most commonly cause spinal cord injuries. A. Anatomical Differences. l. 2. 3. Ligaments and joint capsules are more flexible. Vertebral bodies are wedged anteriorly and can slide forward with flexion. The facet joints are flat. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 21 of 25 4. 5. The child has a relatively large head compared to the adult and more momentum may be generated during flexion or extension. More common than adults, children can suffer spinal cord injury with no x-ray findings of the vertebral column. Subsequent normal spine films can be found in up to two-thirds of children suffering spinal cord injury. Spinal cord injury, when suspect, is based upon neurologic examination or history. EXTREMITY TRAUMA A. History Information about the magnitude, mechanism, and time of injury will greatly aid the physician later in evaluating these injuries. B. Blood Loss Blood loss associated with long bone and/or pelvic fractures is proportionately greater in the child than the adult. Even a small child can lose up to one unit of blood into the muscle mass of the thigh and develop hemodynamic instability as a result of a fractured femur. C. Growth Plate Fracture Bone grows in length as new bone is laid down by the growth plate near the end of the bone. For a child whose growth plate is not closed there is a potential for further bone growth. An injury near a joint may lead to a fracture through the growth plate. These fractures are graded by the Salter method, types l-5, depending on their x-ray findings. D. Greenstick Fracture Because of the nature of immature bones, only one cortex of the long bone may fracture. Diagnosis is made only after x-ray studies and may not require subsequent casting. E. Buckle Fracture A torus or buckle fracture is seen exclusively in small children. This is an angulation deformity of the relatively malleable bones of a young child without actual fracture to the bone. F. Supracondylar Fracture These fractures of the elbow have a high propensity for growth deformity. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 22 of 25 THE BATTERED, ABUSED CHILD The battered child syndrome or physical child abuse refers to any child who has sustained a non-accidental injury as a result of acts by parents, guardians, or acquaintances. Most children who die of abuse have had multiple, re-current episodes of batterings. Therefore, a history and careful examination of a child suspected of being abused is critically important to prevent eventual death. The paramedic should suspect abuse if: l. 2. 3. 4. 5. A discrepancy exists between the history and degree of physical injury. A prolonged interval is spent between the time of the injury and the seeking of medical advice. The history includes repeated trauma. The parents respond inappropriately to or do not comply with the medical advice given. The history of injury changes or differs between parents or guardians. The following findings on physical exam should suggest child abuse and indicate the need for referral: l. 2. 3. 4. 5. 6. 7. 8. Perioral injuries. Ruptured internal viscera without any history of major blunt trauma. Trauma to the genitalia or perianal area. Evidence of frequent injury typified by old scars. Fractures of long bones of children under three years of age. Bizarre injuries such as human bites, cigarette burns, or rope marks. Sharply demarcated second and third degree burns in unusual areas. Multiple ecchymotic areas in various stages of resolution. ** NOTE ** Should the paramedic suspect child abuse, the child should be transported for medical evaluation. Call 1 (800) 96-ABUSE. A written report is required in addition to telephone notification. TRAUMATIC CARDIOPULMONARY ARREST PRESENTATION 1. HISTORY Mechanism of injury (blunt or penetrating) Blunt trauma: amount and direction of force Penetrating trauma: weapon, size of object, bullet caliber, trajectory of bullet Motor vehicle accident: condition of vehicle, dashboard, and steering wheel, speed of impact, seat belt use, patient trajectory Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 23 of 25 2. 3. - Description of scene Treatment prior to arrival (patient movement) Drug or alcohol use Medical illnesses Current medications Allergies SYMPTOMS Not applicable SIGNS Vital Signs: Skin: Respiratory: Absent, PEA Cyanosis, pallor, mottling, entrance and exit wounds Apnea, tracheal shift, subcutaneous emphysema The outcome of patients who suffer cardiopulmonary arrest from trauma is uniformly poor. These patients do not benefit from further intervention. The criteria for "trauma codes" is as follows: present history of trauma pulseless apneic no palpable blood pressure no heart sounds Any victim of trauma who presents meeting the criteria above can be assumed to have sustained a terminal injury. A paramedic from an ALS agency may determine resuscitative measures are not warranted and therefore, may discontinue BLS intervention. Any victim of trauma who receives advanced life support measures including adequate airway control and ventilation and deteriorates to meet the criteria above has sustained a terminal injury. Resuscitative measures may be discontinued (refer to Determination of Death protocol 110.02, Section H). EDMCP CONTACT At the discretion of EMS personnel SPECIAL CONSIDERATIONS 1. Special circumstances may override this protocol. Paramedic discretion prevails. Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 24 of 25 Revised 08/25/00 Volusia County EMS Protocols Section 200.16 pg 25 of 25