TRAUMA TRIAGE & Hospital

TRAUMA TRIAGE & TRANSPORT

2012

AtlantiCare Regional Medical Center

Capital Health System

at Fuld

Cooper University Hospital

Hackensack

University Medical Center

Jersey City Medical

Center

Jersey Shore University Medical

Center

Morristown Medical Center

Robert Wood Johnson

University Hospital

St. Joseph’s Regional Medical Center

UMDNJ-University

Hospital

1

A Practical Guide for the Prehospital Care Provider ers

l tal, Newark

Emergency – 1-800-252-0911

ospital, New Brunswick

Emergency - 732-828-3000 ext 8687

ity Medical Center, Camden

S

l dical Center, Hackensack

Emergency – 201-996-2217

nter, Paterson

Emergency – 973-774-2222

r, Jersey City

Emergency - 201-915-2200

er, Morristown

Emergency – 1-800-TRAUMA8

uld, Trenton

Emergency – 609-394-6063

edical Center, Neptune

cal Center, Atlantic City

y – 609-441-8153 609-441-8023

Burn Barnabas Health, Livingston

mergency – 973-322-5920 Educator – 973-322-5659

New Jersey Trauma Cent

Leve I Trauma Centers UMDNJ-University Hospi

Educator – 973-972-1598

Robert Wood Johnson University H

Educator – 732-828-3000 ext. 2303

Cooper Hospital/UniversEmergency 1-800-TRAUMAEducator 856-342-2044

Leve II Trauma Centers Hackensack University Me

Educator – 201-996-4785

St. Joseph's Hospital and Medical Ce

Educator – 973-754-2253

Jersey City Medical Cente

Educator – 201-915-2195

Morristown Medical Cent

Educator – 973-971-4960

Capital Health System at F

Educator – 609-394-6145

Jersey Shore University MEmergency - 732-776-4878 Educator – 732-776-4949

Atlanticare Regional MediEmergencEducator –

Center The Burn Center at Saint E

2

PREFACE

ed by the New Jersey Trauma Center Council, e New Jersey Mobile Intensive Care Unit Advisory Council, and the Governor’s Emergency

ossible situations nor substitute for sound medical judgment. hen available, on-line medical control should be utilized; when in doubt, the first consideration

he responsibility of the authors and the NJ Department of ealth and Senior Services, Office of Emergency Medical Services. (There is no copyright, you

Robert Wood Johnson niversity Hospital, New Brunswick, New Jersey. These materials have been updated and edited

by m

This program is designed to supply guidelines for prehospital trauma triage decision-making. The guidelines presented were drafted and approvthMedical Services for Children Advisory Council. No one triage system can address all pWmust be the well-being of the patient. The original text and accompanying slides were supported by a grant from the NJ Department of Health and Senior Services, Office of Emergency Medical Services. Those contents, and the current updated version, are solely tHmay reproduce without permission). Acknowledgement: This program, text and presentation were developed initially by the Central NJ Trauma Network and the Department of EMS and Trauma Education, U

any individuals from Trauma Centers and EMS over the last 20 years.

3


GOAL:

The goal of this program is to provide Prehospital Care Providers with information and guidelines for trauma triage and transport decision-making. The program will also discuss trauma systems, their personnel, equipment, and facilities.

OBJECTIVES:

Upon completion of the program the participants will be able to:

1. Identify the various forms and causes of trauma. 2. Briefly discuss the trauma patients’ needs as they relate to care and prevention of mortality.

3. Describe the mortality/morbidity of trauma and its impact on society. 4. List the various components that make up a trauma system. 5. Discuss the need for and advantages of a systems approach to trauma care.

6. Define “trauma center” and contrast its capabilities and resources with other hospitals. 7. Verbalize the physiologic, anatomic, mechanism-of-injury and special patient or system

considerations indicators used to triage trauma patients.

8. Correctly triage trauma patients to the most appropriate facility, based upon various assessment, mechanism-of-injury, and situational considerations in a scenario format.

9. Discuss the recommendations for the use of air transportation versus ground transportation.

10. Identify how to properly access, interact with, and appropriately utilize the medical helicopter system (also known as the air medical system).

4

TRAUMA TRIAGE AND TRANSPORT

How to Determine the Appropriate Medical Facility for Your Patient

A Practical Guide for the Prehospital Care Provider

Trauma victims need trauma care. As all prehospital providers know, trauma victims are not all alike. Most suffer only minor injuries and may not require extensive medical care. Only 10% to 15% of all injured patients have serious or potentially life-or limb-threatening injuries. WHAT IS TRAUMA?

Trauma is any bodily injury caused by violence or other external forces. Serious trauma puts the patient at risk of death or loss of function.

Most trauma falls into one of three major types: penetrating, blunt, or burns. Other categories, such

as poisoning, hanging, and drowning are sometimes considered under the heading of “trauma,” but won’t be discussed here.

Penetrating Trauma Penetrating trauma is obvious; the body has been pierced by an object such as a bullet or knife. The wound is “open” and therefore, visible. It is useful to consider the energy level of the penetrating object when judging possible injury. High-energy projectiles can cause severe injury to neighboring tissues and organs or cause secondary injuries due to fragmentation. Low energy projectiles generally cause injury only in the pathway that the object entered the body.

Thus, severity of injury depends not only on the type of object involved but also on the object’s speed

and its kinetic energy. The energy of a projectile will be transferred to the object it strikes. While a knife wound’s injury can generally be predicted by tracing the pathway of the knife into the body, high velocity projectiles not only cause immediate damage, but can also damage tissues and organs elsewhere in the body, due to tumbling, fragmentation, and “shock waves.”

5

TRAUMA TRIAGE & TRANSPORT Burn Trauma A burn is an injury to tissue caused by direct thermal injury, exposure to a caustic chemical, or contact with an electrical current. The severity depends upon the depth and the surface area involved, as well as the presence of any associated injuries. Electrical and respiratory burns are often overlooked, because a large amount of the trauma occurs internally. Frostbite is a type of thermal injury, but it is caused by cold, rather than by heat. Remember: When the patient has burns and other forms of trauma, trauma care is always the priority. WHAT ARE THE TRAUMA PATIENT’S NEEDS? The outcome for any patient who is injured depends not only on the severity of injury, but also on the speed and appropriateness of treatment. Delay kills! Most trauma deaths occur within a few hours of the patient’s injury. The longer that the victim is in shock, then the more likely is death. Shock Trauma’s founder, R.A. Cowley, proposed the “Golden Hour” for trauma care, this has been replaced with the “Golden Period”. Research has shown that if a severely injured patient receives definitive care within one hour after the injury, his chances for survival are greatly improved. Within that hour, about 10 minutes are dedicated to on - scene patient care and referred to as the “Platinum 10”. Statistically, trauma death falls into one of three categories: 50% of trauma victims who die, do so at the scene;

of the remaining 50% who die (even though they arrived at the hospital alive), approximately

two-thirds will die within the first four hours (often due to delayed or inadequate resuscitation);

the remainder of those fatalities occurs later because of complications from shock or multiple

organ system failure.

6


The severely injured victim needs access to IMMEDIATE critical care intervention and often requires surgery and the use of specialized equipment. Getting that patient to the APPROPRIATE medical facility improves their chances of survival and reduces the extent of their long-term disability. Even if you deliver a “viable” patient to the hospital, delay in surgical intervention or access to necessary medical equipment or technology can lead to their death. The severely injured patient cannot wait an extra half hour or more for a surgeon or a blood transfusion or an operating room. Surgical treatment must be available the moment the patient is brought through the emergency department door. For these reasons, the trauma call is managed differently from the standard medical emergency call. You should strive for an on scene time of no more than ten minutes. As you start your patient assessment, start your mental stopwatch. DO NOT, however, shortcut proper assessment and treatment vital to your patient’s survival in order to save time. Secondary patient assessment and treatment should be done simultaneously with packaging and transporting the patient to the trauma center. TRAUMA CARE: A SYSTEM APPROACH

The most effective approach to reducing deaths and permanent disability due to trauma is to develop a trauma system. A trauma system organizes and coordinates all the available resources necessary to care for the trauma victim. It strives to match a patient’s need with the resources, whether these are available at local hospitals or specialty centers, such as trauma or burn centers. The system also addresses other requirements, such as research, public education and injury prevention, which are necessary to combat this “disease.”

TRAUMA SYSTEM COMPONENTS Medical Direction Transportation Prevention Hospital Care Communication Public Education Training Rehabilitation Triage Medical Evaluation Prehospital Care Components of a properly operating trauma care system include: medical direction, prevention, communication, training, triage, prehospital care, transportation, hospital care, public education, rehabilitation, and medical evaluation. The providers who are involved in patient care include EMTs, paramedics, fire, police, first responders, hospitals and their personnel, air medical units, specialty care centers (such as burn centers), trauma centers and rehabilitation facilities. The New Jersey Department of Health and Senior Services issued regulations which provide for the designation of three Level I and seven Level II trauma centers, based on population and location throughout the state. The ten designated trauma center hospitals are listed on page 1. The designation

7


process was based on criteria and standards established by the American College of Surgeons and the state regulations. This process also specifies the clinical resources, such as personnel, equipment, and

quality review systems, which are legally required for designation. Hospitals not designated as trauma centers in New Jersey are not permitted to advertise trauma services or make claims regarding availability of trauma services.

HOW DO TRAUMA CENTERS DIFFER FROM HOSPITALS?

Every hospital can provide a degree of trauma care, but not all are physically or economically capable of providing ALL the specialized and expensive services that the seriously injured trauma patient requires. For instance, a local hospital may have many surgeons on staff, but is one available for motor vehicle crash (MVC) victims at two o’clock Sunday morning? A hospital may have numerous operating rooms, but are they open Tuesday evening at six? The incidence of trauma is highest late in the day and on weekends, when routine hospital staffing is minimal.

Trauma centers assure the availability of IMMEDIATE surgical evaluation and treatment of severely injured patients; this is not consistently available at most hospitals.

Trauma care has become a specialty, just like cardiology or neurology. At the trauma center, a trauma team consists of a traumatologist (a physician specializing in trauma surgery), specially trained nurses, anesthesiologists, and operating room staff, all of whom are available 24 hours a day, seven days a week. This team is in place prior to the patient’s arrival, is prepared to perform any required diagnostic and therapeutic procedures, and can operate immediately, when necessary. Other surgical sub-specialists (orthopedists, neurosurgeons, etc.) not available at many other hospitals are also accessible in minutes.

A trauma center must have around-the-clock availability of a radiologist and specialized radiological equipment, such as a CT scanner. A full-time diagnostic clinical lab is also necessary. Other essential trauma center resources include a 24 hour recovery room, a blood bank, a surgical ICU, and a specialized trauma nursing staff. In addition, resources for the emotional and social support of patients and their families must be available.

Trauma care is both labor and resource intensive. Its cost is justified by results: when provided on a regionalized basis through a system of designated trauma hospital, trauma care can reduce death by as much as 20-40%.

8

9

TRAUMA CENTERS State regulations generally follow national standards published by the Committee on Trauma of the American College of Surgeons. In New Jersey, specialized trauma centers are designated as either Level I or Level II, according to their capabilities and roles in the trauma system. Each Trauma Center is required to have a surgeon in-hospital at all times. Level I centers may have additional specialty services, research and education but this does not impact on triage decisions in the field. From a prehospital provider’s point of view, Level I and II trauma centers are the same.

TRAUMA TRIAGE INDICATORS

The trauma triage indicators are the criteria which determine whether your patient should be taken to a local community hospital or to a trauma center. They are divided into four broad categories: physiologic, anatomic, mechanism of injury, and special considerations.

Physiological indicators refer to the patient’s vital signs and neurological status. Anatomic indicators refer to apparent physical evidence such as wounds, and paralysis. Special Considerations include; age, burns, renal disease, bleeding disorders, anticoagulants, and pregnancy over 20 weeks. However, mechanism of injury needs some explanation.

When looking at the trauma scene, ask yourself these questions:

• In a rollover crash, was/were the occupant(s) restrained? • How far did the adult victim fall? More than 20 feet? Did the pediatric patient fall more than 3 times their height? • Was the victim thrown from the car? How far? • Was the damage to the car so great that the injured victims require more than 20 minutes to be extricated from the wreck? TRAUMA TRIAGE INDICATORS Triage indicators are divided into 4 broad groups or parameters: • Physiologic Indicators • Anatomic Indicators • Mechanism-of-Injury Indicators • Special Patient or System Considerations


Certain types of incidents characteristically produce certain types of injuries. Knowing the mechanism of injury will give you a good idea of what types of injuries to suspect. It will also help you anticipate what type of treatment your patient will need. Victims of trauma whose assessment findings match any of the listed indicators should be taken directly to the nearest trauma center. While no triage system is foolproof; under-triage and over-triage cannot be totally eliminated. In addition to the triage indicators based on physiology, anatomy, and mechanism of injury, patients at extremes of age may require trauma center resources. Patients over 55 years of age have increased likelihood of injury and death, and suffer worse outcomes, despite lesser outward appearances of injury. Children are also at increased risk. Specific pediatric triage guidelines can be found at the end of this document. Using these guidelines will take most of the guesswork out of your decision-making. The goal is to match your patient’s present or probable needs with the resources available in the trauma system. This triage system is designed to bring patients likely to have sustained a major injury to the Trauma Center, while taking those who don’t need major trauma care to local hospitals in a safe manner.

10


SPECIAL GUIDELINES FOR BURN PATIENTS For patients whose injuries are burns only (no associated trauma), the American Burn Association has developed these transport guidelines for taking patients to Burn Centers:

Full thickness (3rd degree) burns, in any age group

Chemical, electrical, or inhalation burns Burns to the hands, face, feet, genitalia, or major joints

Patients with pre-existing medical disorders compromising outcome

Patients requiring extensive social, emotional or long term rehabilitation support

Pediatric burns without qualified personnel or equipment

Patients with burns and trauma, transport to a trauma center

11

12

The Field Triage Guidelines from the CDC were updated in late 2011 replacing the 2006 Field Triage Scheme. The New Jersey Trauma Council has adopted the 2011 CDC Field Triage Guidelines and they have been included in this instructor update and in the PowerPoint presentation. Additional information can be found at: www.cdc.gov/Fieldtriage Below are the changes from the 2006 guidelines to the 2011

Step One: Physiologic Criteria • Change GCS <14 to GCS ≤13 • Add “or need for ventilatory support” to respiratory criteria Step Two: Anatomic Criteria • Change “all penetrating injuries to head, neck, torso and extremities proximal to

elbow and knee” to “all penetrating injuries to head, neck, torso and extremities proximal to elbow or knee”

• Change “flail chest” to “chest wall instability or deformity (e.g., flail chest)” • Change “crushed, degloved, or mangled extremity” to “crushed, degloved,

mangled, or pulseless extremity” • Change “amputation proximal to wrist and ankle” to “amputation proximal to

wrist or ankle” Step Three: Mechanism-of-Injury Criteria • Add “including roof” to intrusion criterion Step Four: Special Considerations • Add the following to older adult criteria — SBP <110 might represent shock after age 65 years

— Low-impact mechanisms (e.g., ground-level falls) might result in severe injury • Add “patients with head injury are at high risk for rapid deterioration” to

anticoagulation and bleeding disorders criterion • Remove “end-stage renal disease requiring dialysis” and “time-sensitive

extremity injury” Transition Boxes • Change layout of the figure • Modify specific language of the transition boxes

Abbreviation: GCS = Glasgow Coma Scale; SBP = systolic blood pressure.

13


PEDIATRIC TRAUMA TRIAGE The leading cause of death in children over the age of one year is unintentional injury. Suicide and homicide rank number three and four in this age group. Children have less physiologic reserves than adults. For these reasons, and because of the limited number of hospitals prepared to care for critically injured child, their assessment and triage is critical. Children respond differently than adults, both physically and emotionally, and their needs require different triage systems. Triage criteria for children have been developed for use in New Jersey. These can be applied in a manner similar to the adult guidelines. Physiology, anatomy, mechanism of injury and special considerations are all important.

All trauma centers in New Jersey provide initial emergency and surgical care for children. All level I and level II trauma centers can provide emergency trauma care for injured children. If a child can be safely transported by ground to the nearest trauma center, the trauma center level is not important. The same criteria used for adults should be applied in deciding whether ground or air transport should be used, with one exception: Children in cardiac arrest following injury WILL be transported by air.

Injured children should be transported to the nearest trauma center.

14

15

PEDIATRIC TRAUMA TRIAGE GUIDELINES

STATEMENT OF INTENT: The following pediatric trauma triage guidelines are provided to assist in determining the disposition of children 12 years of age or younger. Use the adult trauma triage guidelines for children older than 12 years of age. It is understood that these are guidelines only and are to be used, whenever possible, in communication with a base station physician. These guidelines are intended to be utilized in conjunction with clinical judgment.

STEP 1: PHYSIOLOGY (any one of the parameters listed below) AVPU = responsive to voice, pain, or unresponsive Evidence of poor perfusion (skin pallor, cool extremities, weak

distal pulses, cyanosis/mottling, etc.) Heart rate:

child < 5 yr old: < 80/min or > 180/min child > 6 yr old: < 60/min or > 160/min

Respiratory rate > 60, or respiratory distress, or apnea Capillary refill > 2 seconds (evaluated on warm body part)

TRAUMA CENTER with ALS if available

STEP II: ANATOMY (any one present)

Penetrating injuries (ex. gunshot/stab wounds) to the head, neck, torso or extremities (above the elbow and knee)

Flail chest Difficulty or inability to maintain a patent airway Fractures - more than one involving the humerus and/or femur Pelvic fractures Paralysis or evidence of spinal cord injury Amputation above the wrist or ankle Burns when combined with other major injuries Seat belt mark on the torso


STEP III : MECHANISM OF INJURY (any one present)

Ejection from motor vehicle Falls > 3x patient's height Extrication time > 20 minutes with an injury High voltage electrical injury Unrestrained passenger in vehicle roll over Pedestrian, motorcyclist or pedal cyclist thrown or run over Front seat passenger with deployment of air bag (same side)


TO LOCAL HOSPITAL


Scenario: Applying the Guidelines…

5:17 PM Monday: Rush hour traffic is heavy as you are dispatched to a motor vehicle crash on a local county highway. Working your way through the long line of backed-up traffic and the crowd of curious onlookers, you see a late model car which has broadsided a minivan in the middle of an intersection. Inside the minivan, a man cries for help. In the car a man lies slumped over the steering wheel. Immediately you get on the radio and request ALS, fire apparatus, and an additional BLS rig. Out of the ambulance, you and your partner survey the scene for safety. Your EMT - driver safely parks the rig. Stepping clear of broken glass, twisted metal and spilled engine coolant, you approach the wrecked vehicles. The front end of the car is heavily damaged; its windshield is starred. The minivan has lateral damage; its driver-side door is compacted at least two feet. You and your partner separate in order to simultaneously assess both patients; you go to the car, your partner goes to the minivan. The middle-aged driver of the car is unconscious and has blood in his mouth. His respirations are slow and gasping. The man in the minivan is conscious and extremely agitated. “What happened? What happened?” he cries. Another BLS unit arrives to assist with patient care. You need to work fast. 5:20PM: Your trauma assessment begins with a quick examination of possible mechanism-of-injury. The top of the car’s steering wheel is bent; the windshield is starred. There is extensive front end damage to the car, indicating a high speed collision. You should immediately suspect that the unrestrained driver of the car has head, neck and possible chest injures, even if they are not readily visible. 5:21PM: The driver of the car is in immediate danger with several life-threatening injuries. You note that the patient appears unconscious and unresponsive. You begin your rapid trauma assessment as the other crew simultaneously prepares to remove the driver from the car, using the rapid takedown method.

AIRWAY: THERE IS BLOOD IN THE MOUTH. As a crew member maintains “manual cervical spine stabilization,” you suction the patient’s mouth. You insert an oral airway to keep his airway patent. A rigid cervical collar is applied to protect the patient against complications of a possible neck injury. There is no response to noise or touch. BREATHING: THE RESPIRATIONS ARE SLOW, IRREGULAR AND LABORED. You ventilate your patient at 20 breaths per minute, using a bag mask resuscitator with a reservoir and 100% oxygen. You examine and palpate the chest: there is no apparent trauma and his lung sounds are clear and equal.

CIRCULATION: YOU QUICKLY FEEL FOR A RADIAL PULSE AND FIND THAT IT IS SLOW AND BOUNDING. You remember from your training that the presence of a radial pulse is a rough estimation of a systolic BP of 80-90 mm Hg. There are no signs of severe bleeding. DISABILITY: The patient is unconscious and unresponsive to voice and painful stimuli.

16

17

EXPOSE: The patient is fully immobilized on a long back board. The secondary assessment (and continued treatment) will begin as his clothes are cut off in the ambulance enroute to the trauma center. DETERMINE SEVERITY: 5:27PM: It is obvious that this patient has life-threatening injuries. You remember that his symptoms match the indicators on the trauma triage chart and, therefore, he is an appropriate candidate for a trauma center. The patient is loaded into the second ambulance and quickly (yet safely) transported to the trauma center by the additional crew and a paramedic, who has just arrived on scene. (The decision whether to drive or fly your patient to the trauma center will be considered later in this text.)

THE SECOND INJURED PERSON But what about the other driver? Does he have serious, life-threatening injuries? Should he go to a trauma center or is his condition stable enough to take him to the nearest hospital? 5:19PM: from the extensive damage to the driver’s door of the minivan, your partner should also assume that the driver has been subjected to tremendous impact and high speed/sudden deceleration force, so your partner should suspect possible internal organ injuries and multiple long bone fractures. Your partner performs the trauma assessment while the patient is still in the wrecked car. As your partner approaches the minivan, he notes that the patient is awake and alert, but restless and agitated.

AIRWAY: PATENT; REQUIRES NO INTERVENTION BREATHING: RESPIRATORY RATE IS RAPID AND SHALLOW, APPROXIMATELY 24/minute). CIRCULATION: RADIAL PULSE IS PRESENT, BUT SOMEWHAT FAST (APPROXIMATELY 110). Capillary refill is normal. There is no apparent bleeding. DETERMINE SEVERITY: No life threatening injures appear to be evident. Based upon the findings of the trauma assessment, your partner believes that the young man is stable enough to be fully immobilized a KED and removed from the wrecked minivan on to a long backboard.

(He should NOT be removed using the rapid takedown method.) As the ambulance driver/EMT applies a cervical collar and the KED and prepares the patient for removal, an EMT from the second rig manually stabilizes the man's head. Your partner continues with the secondary survey. His vital signs are: pulse 110; blood pressure 100/70; respirations 24. 5:28PM: DETAILED PHYSICAL EXAM: In the back of the ambulance, your partner removes the patient’s clothing and rapidly conducts a full head–to-toe assessment. Detailed Physical Exam:

Face: No obvious injury.

Ears: Clear. Eyes: Pupils equal and reactive

Neck: C-collar applied in the minivan. Patient complains of neck pain, but careful palpation revealed no obvious deformities

Chest: A bruise over the left clavicle; pain and crepitus are elicited upon palpation of left side of rib cage. Patient complains of pain upon inspiration. Inspection reveals paradoxical movement of the chest wall upon respiration. Lung sounds are reduced on the left side. Abdomen: Appears normal. No pain on palpation Pelvis: Intact on pelvic rock Extremities: Pain, deformity, discoloration of the left midshaft humerus. Pulses, sensations, and functions are normal. 5:29PM: Your partner, in consultation with one of the MICU paramedics and medical control, must now consider whether the patient should be transported to a trauma center or to the nearest hospital. After seeing that the first patient is safely on the way to the trauma center, you join your partner. According to the trauma triage indicators, “presence of a flail chest” (findings of the chest examination suggest flail chest) is sufficient injury for the patient to be transported to a trauma center for further assessment and treatment. The MICU base station physician’s order confirms that trauma center care is appropriate. En route to the trauma center, your partner performs a second set of vitals. A subtle but alarming change in the man’s clinical presentation becomes evident to all of you. 5:32PM: Your patient’s pulse increases to 140 and becomes thready; the capillary refill is now 3-4 seconds. His blood pressure is now 90/70, his breathing more rapid and shallow. His respiratory rate increases to 28 per minute; his lung sounds have become more diminished on the left side. You see that the man’s skin has become slightly pale and diaphoretic. He is becoming more restless and is now confused. Your patient’s condition is deteriorating; and the downward trend in his vital signs is characteristic of hypoxia (possibly caused by a pulmonary contusion), correlating previous suspicions with your patient’s clinical presentation. The paramedic calls for additional personnel. This trauma patient needs IMMEDIATE critical care intervention, which may include surgery. Your decision to take him to the trauma center was correct.

18

19


CONSIDERATIONS LAND VS. AIR TRANSPORT 1. Ground travel time to the nearest trauma center. 2. The helicopter’s estimated time of arrival (ETA) and its flight time to the trauma center. 3. Multiple patients Private AMU Providers Public AMU Providers • MONOC NorthStar • Atlantic Health SouthStar • MidAtlantic Medevac • Penn Star • Jeff Stat • Stat Fight • Life Net FLY OR DRIVE? The New Jersey state medical helicopter program (JEMSTAR), consisting of the NorthSTAR and SouthSTAR programs, maintains 24 hour operation to provide both Emergency Scene Response, and Critical Care inter-hospital transport. Other commercial air ambulances provide mutual aid backup for the NJ system. The Air Medical System is accessed through a statewide dispatch center: REMCS (1-800-332-4356). Dispatching must be through this center so that the most appropriate air ambulance is sent to a scene, based on availability and response time. A patient who must go to a trauma center can be transported either by ambulance or helicopter. The goal is to get the trauma victims to the trauma center in the least possible time. When making the decision to fly or drive, consider the ground travel time to the nearest trauma center. If you are 30 minutes or less from a trauma center, there is little benefit of airlifting your patient. You need to consider traffic, weather, and road conditions when determining travel time. There is an exception to this rule for entrapment, because the time needed for the helicopter to reach the scene is offset by the time needed for extrication. When you are further away than 30 minutes by ground, the decision is more difficult. The major consideration here is the helicopter’s estimated time of arrival (ETA) and ground transport time to a landing zone (LZ). Will the helicopter be on scene when the patient is ready or will the patient have to wait or be transported to a secondary landing site? Also consider the helicopter’s “warm-up” time and the time required to transfer the patient to the flight crew, this can be 10-15 minutes.

20

The last consideration in deciding whether to request a helicopter transport involves the number of critically injured persons. If there are more than three critical patients, communication with Medical Control to coordinate triage is essential. Additional manpower, communication with Medical Control, and transport options can be obtained by utilizing the medical helicopter system. (NOTE: Adult cardiac arrest patients will not be transported by air.) Call the helicopter dispatch center early and get the aircraft’s ETA. The helicopter already may be there early or it may be delayed because of time needed to warm up prior to flight. There is little benefit waiting 15 minutes for a helicopter when your patient is ready for ground transport and the trauma center is only 30 minutes away as long as ground ALS is present. If your patient needs air transport, CALL FOR A HELICOPTER NO MATTER WHAT TIME IT IS OR WHAT THE WEATHER CONDITONS ARE.

21


ACCESSING THE MEDICAL HELICOPTER SYSTEM

Call the Regional Emergency Medical Communication

System (R.E.M.C.S.) at 1-800-332-4356

At the time of request, the helicopter dispatch center will request the following information: Your name Call back number County and municipality names Nature of incident Incident location with cross streets Requesting unit numbers and/or name VHF radio communication frequency of on scene landing site coordinator Operating number or name of on scene landing zone coordinator

Remember: Your patient should be fully immobilized on a long board Flight policy does not allow any family members or friends to accompany the patient in the helicopter. The following patient information should be made available to the flight team at the time of patient transfer:

Type of injuries Vital signs/assessment results Mechanism-of injury Past medical history Treatment provided on scene

This information is essential for both crew safety and patient care considerations. The helicopter will make contact with the on scene coordinator prior to its arrival. All information will be used to assure a safe landing and patient transfer. The key concern here is rapid transportation to the nearest trauma center. If, after full assessment, it is determined that the patient does not require trauma center services, then the helicopter may be canceled.

22


TRIAGE IN MASS CASUALTY EVENTS

The likelihood of a mass casualty or disaster event in the post-9/11 world is near certainty. Depending upon the scope and nature of the event, EMS providers will play a role in triage, transport, on-scene treatment, rescue, and evacuation activities. Perhaps the most important concept relative to this topic is the EMS provider must view himself or herself as part of a coordinated response, not as an individual unit or provider. Each EMT, paramedic, and health care worker should be familiar with the principles of incident command, as identified by the National Incident Management System (NIMS). The Incident Command System provides a mechanism for functional need to take precedence over titles and turf, bringing order to chaos, reducing miscommunications, avoiding logistic errors, and promoting scene safety. All EMS units should liaison with their county Office of Emergency Management EMS Coordinators before the incident. Trauma triage in mass casualty events, like that in Napoleonic triage, must identify patients who are injured and most likely to benefit from care. Those performing triage must differentiate patients from those with minor injury and those with such severe injury that they are not likely to survive even with optimal care. The resources at the scene, and later at the hospital, must be dedicated to salvageable patients. The focus during a disaster shifts from concentration on the individual to doing the greatest good for the greatest number. Decisions can become difficult: a patient who would normally be the first priority (example: massive head injury with brain matter showing) is now relegated to low priority in favor of patients with less severe but still life threatening injuries. These patients may have a better chance for survival. On the other hand, research has shown that over-triage of minor injuries early in a disaster negatively impacts on survival of the more significantly injured patients who generally present to the hospital later in the event. Among the different triage schema, New Jersey has adopted the Simple Triage And Rapid Treatment (START) and JumpSTART systems, and developed NJ Disaster Triage Tags. Both STARTs are based on the assessment of airway and respiratory effort, mental status and perfusion capillary refill. Patients are identified via a color coded system: green for those uninjured or with minor injury (“walking wounded”), yellow for those with intermediate injuries who can wait for definitive care, red for the injured in need of urgent attention to insure survival, and black for those who are dead or expected to die. Education for these systems is available through the Office of Emergency Medical Services of the Department of Health and Senior Services. A special mechanism for triage exists for mass burn casualties. The guideline for New Jersey, developed by the MEDPREP work group, calls for transport of burn patients after a mass burn event to the nearest appropriate trauma center or facility. That center will then contact their nearest burn center or center with whom they have cooperative agreements. Through a program developed by the American Burn Association, the burn unit or center will then coordinate secondary assignment to regional centers. Finally, all EMS providers should consider some form of debriefing after their involvement in the event. Critical incident stress management has been shown to assist in the processing of feelings subsequent to the extreme stresses of a disaster, and subsequently reduce the rate of post-traumatic stress disorder among health care personnel.

23


POSTSCRIPT: Remember: only 10-15% of your trauma patients require the services of a trauma center. For those who do need trauma services, such care can be lifesaving. Using these indicators and guidelines also will help limit over-triage of less seriously injured patients, which severely strains trauma center facilities and prevents good patient care. There are three conditions when it may be in the best interest of the patient to be transported to a local community hospital. These conditions involve situations in which ALS is not available at the scene, and: 1. You cannot control/maintain a patent airway, or

2. You cannot ventilate the patient adequately, or 3. Traumatic cardiac arrest exists, and you are further than 10 minutes from a trauma center.

It is not possible to ALWAYS make the right decision in the field. Use the system: when working with an MICU, the transport decision should be deferred to the paramedics and their on-line medical control.

When ALS is not available and you must make the transport decision alone, but are uncertain as to how to proceed, it is always best to err in favor of the patient and go to the trauma center.

**************************************************************************************

24

Frequently Asked Questions

Q. If I bypass the nearby hospital and take a seriously injured patient to a trauma center and he dies, won’t I be sued?

A. There is no law or regulation requiring prehospital personnel to take trauma patients to a trauma center; however, courts often judge such matters on what the “reasonable caregiver” would do under similar circumstances. All EMT and paramedic texts, continuing education courses (BTLS, PHTLS, etc.), and professional journals encourage and support the trauma system, and it is likely that these materials would be used to support your actions. Always keep the best interests of the patient in mind, and stay current in your education and training.

Q. My squad is only 10 minutes from the local hospital, but 30 minutes from the trauma center. What do I do if I have a seriously injured trauma patient?

A. Consider medical helicopter transport or transport by ambulance, if the helicopter isn’t available. Remember, it’s getting the patient to definitive care, not just to a facility, that’s important. It may be faster to drive than wait for an AMU.

Q. Transport to a trauma center takes my crew out of our coverage area. We can’t afford to be unavailable for the next call.

A. Your duty is to the patient you’re treating and not to the possibility that another patient may need you. Under the circumstances, rely upon mutual aid from a neighboring squad for another call.

Q. I’m not sure whether to take the patient by ground to the trauma center or to begin ground transport and meet the helicopter, or just go by ambulance to the local hospital.

25


Decisions between air and ground transportation can be difficult to make in the “heat” of a serious trauma call, Preplanning is the answer. Using the trauma triage and transport (TT&T) indicators as a guide, your squad should determine beforehand which medical facility is appropriate for trauma patients in your area. Your TT&T plan should address your squad’s specific geographic area and its unique considerations. Squad members should have a clear idea of possible landing site locations and ground time to hospitals and trauma centers. They also should have relevant policies to ensure that patients receive the proper care in the field and are transported to the appropriate hospital.

Q. I was on a call where the patient’s condition met the criteria for trauma center transports, but the

MICU’s medical control told them to go to the local hospital. Why? Isn’t this wrong? A. The TT&T guidelines are an attempt to triage trauma patients to appropriate medical facilities and

cannot address all situations. On-line medical control takes responsibility for all triaging decisions, whether or not it follows the guidelines. If a physician decides a patient should be taken to a local hospitals-in spite of the guidelines-that decision may be appropriate, based on certain circumstances or conditions that field personnel may not be aware of at the scene. The physician, because of his/her training, is in the best position to decide a patient’s needs. In any event, should a lawsuit occur, it is the physician who must defend his/her decision not to follow the adopted guidelines. Bring your questions and comments (through your squad officer) to the local MICU EMS educator or director, or Trauma Center Director, Educator, or Program Manager. Critiques of calls prove to be one of the best learning tools and also foster a close working relationship between all members of the EMS team.

26

http://cap.totfarm.com/pics/pic_12099596259112.jpg�


PUTTING IT TOGETHER Directions: Read over the given scenarios carefully. Then answer the questions as correctly as possible, based on the mechanism-of-injury, patient information, and travel times. NOTE: There is not an ALS unit available for any of these patients. Exercise #1 Scenario: Your ambulance is dispatched to a high-rise apartment for a fall victim. Upon your

arrival, you find your patient who appears to be in his middle 20s, lying face down on the sidewalk. Bystanders tell you he fell out of a third-story window. He landed on a concrete sidewalk.

Patient Airway: patent, free of any blood or foreign body. Findings: Breathing: respiratory rate=44/minute; the patient has deep respirations. Circulation: BP=200/100, pulse rate=80, skin is pale. The patient is unconscious and unresponsive to verbal and painful stimuli. The patient has a 3-inch laceration of the scalp and both lower legs have deformities.

No other injures are found. Note: You are 15 minutes from a trauma center, 8 minutes from a community hospital.

It is 1:00 p.m. and traffic is light. Questions

1. The patient should be transported to a ______ community hospital ______ trauma center

2. The patient should be transported by

______ ground ambulance ______ helicopter

3. Which of the following are appropriate treatments:

_______ manual cervical spine immobilization _______ rigid cervical collar _______ oxygen 15 lpm by non-rebreathing mask _______ ventilation with a bag-valve-mask resuscitator _______ insertion of an oropharyngeal airway _______ MAST application _______ MAST inflation _______ immobilization on a long backboard _______splinting the leg

27


Exercise #2 Scenario: Your ambulance is alerted to respond to a shooting. Upon your arrival, the police advise

you that the scene is safe and direct you to your patient. You find a man in his late 30s sitting in a living room chair, complaining of a pain in the left thigh associated with the gunshot wound.

Patient Findings: Airway: Patient, free of any blood or foreign body. Breathing: Respiratory rate=24/minute, the patient’s breathing is not labored

Circulation: BP=100/80, pulse rate=130, skin=pale, diaphoretic, capillary refill=3 seconds.

The patient is conscious, alert and oriented, but he appears to possibly be under the influence of drugs and/or alcohol. The patient has a single wound on the front of his thigh; bleeding is minimal. There is a good pulse in the left foot. The patient can feel his toes and move them as well.

Note: You are 35 minutes from a trauma center, 10 minutes from a community hospital. It is 1:30 p.m. and traffic is light. Questions

4. The patient should be transported to a : ________ community hospital ________ trauma center


________ ground ambulance ________ helicopter


________ manual cervical spine immobilization ________ rigid cervical collar ________ oxygen 15 lpm by non-rebreathing mask ________ ventilation with a bag-valve-mask resuscitator ________ insertion of an oropharyngeal airway ________ MAST application ________ MAST inflation ________ immobilization on a long backboard ________ splinting the leg

28


Exercise #3 Scenario: Your ambulance is dispatched to a ski resort. You meet the ski patrol at the base of the

mountain; they have a 35 year old female snowboarder who fell; no loss of consciousness, open fracture of the right femur. She was not wearing a helmet.

Patient Findings: Airway: Patient, free of any blood or foreign body. Breathing: Respiratory rate=24/minute, the patient’s breathing is not labored

Circulation: BP=140/80, pulse rate=116, skin=cool, dry, color good, capillary refill =2 seconds.

The patient is awake, alert, and oriented appropriately. She complains of pain in his right leg. On palpation he has pain mid-shaft in his right thigh, and there is some bleeding through her clothing. You expose her leg to note a possible open femur fracture. No other injuries are found; patient has no other complaints. Note: You are 40 minutes from a trauma center by helicopter (not yet dispatched), and 15 minutes from the local community hospital. Questions






29


Exercise #4 Scenario: Your ambulance is alerted to respond to an “unknown emergency.” Upon arrival you meet police officers in a home which is disheveled, with several lamps overturned, many papers and mail items piled on tables. The patient is a 75 year old female, received sitting in

a chair in no apparent distress. She has multiple abrasions, deformed left forearm and is disorientated. Police were called when a neighbor checked on the woman (as she does every morning) and found the home in more shambles than usual and the woman unusually quiet.

Patient Findings: Airway: Patient, free of any blood or foreign body.

Breathing: Respiratory rate=30/minute, shallow, non labored.

Circulation: BP=106/64, pulse rate=112, skin=pale, warm, dry, capillary refill=3 seconds.

The patient is conscious and alert, answers questions quietly; oriented to her name and her address, but not to date, time, or situation. She has an abrasion on her right forehead, possible broken left arm, and both of her knees have abrasions. She grimaces when you palpate her left ribs. Lung sounds are clear and equal. The neighbor states that the patient is normally alert, oriented, self-sufficient, a lively talker, in good physical shape, takes multiple meds faithfully, and was fine at 9 pm the night before.

Note: You are 20 minutes from a trauma center, 10 minutes from a community hospital. It is 8:30 a.m. and traffic is light.

Questions 10. The patient should be transported to a :

________ community hospital ________ trauma center

11. The patient should be transported by ________ ground ambulance ________ helicopter

12. Which of the following are appropriate treatments: ________ manual cervical spine immobilization ________ rigid cervical collar ________ oxygen 15 lpm by non-rebreathing mask ________ ventilation with a bag-valve-mask resuscitator ________ insertion of an oropharyngeal airway ________ MAST application ________ MAST inflation ________ immobilization on a long backboard ________ splinting the arm

30


Exercise #5 Scenario: Your ambulance is alerted to respond to a local county fair for an “injured child.” On arrival you find an 8 year old male lying on the ground, crying. Bystanders report that the child fell off of the ferris wheel at from approximately 30 feet. An off- duty police officer/first responder has been with the patient; he reports no loss of consciousness. Patient Findings: Airway: Patient, free of any blood or foreign body. Breathing: Respiratory rate=32/minute, the patient’s breathing is labored

Circulation: BP=100/70, pulse rate=136, skin=pale, diaphoretic, capillary refill= 2 seconds.

The patient is conscious and alert, but confused, does not recognize his mother; has a large laceration on his right forehead; neck veins are distended; breathing labored, right chest is painful on palpation; lung sounds are diminished on the right; you note a large bruise on his right chest; and a probable open fracture of the left lower leg. Note You are 45 minutes from a trauma center by ground; a helicopter has been dispatched and is about to land; you are 10 minutes to the local community hospital. Questions






31

32

BIBLIOGRAPHY American College of Surgeons, Committee on Trauma: Resources for the Optimal Care of the Injured Patient: 1999. American College of Surgeons, 1998. Beebe, R.W.O., and Funk, D.L: Fundamentals of Basic Emergency Care, 2nd edition. Thomson-Delmar Learning, 2005. Branas, C.C., et.al: “Access to Trauma Centers in the United States.” Journal of the American Medical Association. 2005; 293: 2626-2633. MacKenzie, E.J., Johns Hopkins Bloomburg School of Public Health, et.al: “A National Evaluation of the effect of Trauma Center Care on Mortality.” New England Journal of Medicine. 354: 366-378, January 2006. McSwain, N.E., and Frame, S. (ed): Basic and Advanced Prehospital Trauma Life Support, 5th edition. Mosby, 2003. Oldham, K.T., et.al. “Children Fare Better at Pediatric Trauma Centers.” Pediatric News. February, 2006. OTHER RESOURCES CD: “Acute Injury Care Research Agenda: Guiding Research for the Future.” DHSS – Centers for Disease Control and Prevention: National Center for Injury Prevention and Control. May, 2005. CD: “ Bioterrorism and Other Public Health Emergencies: Tools and Models for Planning and Prepardedness.” Agency for Healthcare Research and Quality. April, 2004. CD: “National Trauma Data Bank Report 2005.” American College of Surgeons, Committee on Trauma. WEBSITES http://www.state.nj.us/health/ems New Jersey Office of Emergency Medical Services http://www.ahrq.gov Agency for Healthcare Research and Quality http://www.search.medscape.com/uslclient/searchMedLine.do? MedLine http://www.umm.edu/shocktrauma/trauma_nsc.html University of Maryland Shock Trauma http://www.nsc.maryland.edu National Study Center for Trauma and Emergency Medical Services http://www.naemt.org/PHTLS National Association of EMTs, PHTLS site. http://www.amtrauma.org/ American Trauma Society http://www.start-triage.com START Triage System http://www.BTLS.org/education BTLS, American College of Emergency Physicians

http://www.state.nj.us/health/ems

http://www.ahrq.gov/

http://www.search.medscape.com/uslclient/searchMedLine.do

http://www.umm.edu/shocktrauma/trauma_nsc.html

http://www.nsc.maryland.edu/

http://www.naemt.org/PHTLS

http://www.amtrauma.org/

http://www.start-triage.com/

http://www.btls.org/education

33

Trauma Triage and Transport Extra Answer Sheet for Final Evaluation NAME (print)______________________________________________________DATE_____________ 1. hospital _______ or trauma center__________ 10. hospital _______ or trauma center__________ 2. ambulance______or helicopter __________ 11. ambulance______or helicopter __________ 3. _______ manual cervical spine immobilization 12. _____manual C-Spine immobilization _______ rigid cervical collar _____rigid cervical collar _______ oxygen 15 lpm by non-rebreather mask _____ oxygen 15 lpm by non rebreather mask _______ ventilation with a bag-valve-mask _____ventilation with a bag-valve-mask _______ insertion of an oropharyngeal airway _____ insertion of an oropharyngeal airway _______ MAST application _____ MAST application _______ MAST inflation _____ MAST inflation _______ immobilization on a long backboard _____ immobilization on a long backboard _______ splinting the extremity _____ splinting the extremity 4. hospital __________ or trauma center____________ 13. hospital _______ or trauma center__________ 5. ambulance_________or helicopter ______________ 14. ambulance______or helicopter __________ 6. _______ manual cervical spine immobilization 15. _____manual C-Spine immobilization _______ rigid cervical collar _____rigid cervical collar _______ oxygen 15 lpm by non-rebreather mask _____ oxygen 15 lpm by non rebreather mask _______ ventilation with a bag-valve-mask _____ventilation with a bag-valve-mask _______ insertion of an oropharyngeal airway _____ insertion of an oropharyngeal airway _______ MAST application _____ MAST application _______ MAST inflation _____ MAST inflation _______ immobilization on a long backboard _____ immobilization on a long backboard _______ splinting the extremity _____ splinting the extremity 7. hospital __________ or trauma center____________ 8. ambulance_________or helicopter ________ 9. _______ manual cervical spine immobilization _______ rigid cervical collar _______ oxygen 15 lpm by non-rebreather mask _______ ventilation with a bag-valve-mask resuscitator _______ insertion of an oropharyngeal airway _______ MAST application _______ MAST inflation _______ immobilization on a long backboard _______ splinting the extremity

34

PAGE LEFT BLANK FOR NOTES

PAGE LEFT BLANK FOR NOTES

35

Date post:	23-Nov-2021
Category:	Documents
Upload:	others
View:	5 times
Download:	0 times

TRAUMA TRIAGE & Hospital

Documents