6000: Trauma & Enviromental Protocols

A 25-year-old male is involved in an MVC with multiple injuries, BP 82/50, HR 140, GCS 10. What must you check for and exclude first?

- Confirm multisystem trauma with shock signs
- Exclude tension PTX → Protocol #6007
- Exclude isolated musculoskeletal injury → Protocol #6003
- Exclude isolated head injury → Protocol #6011
Next: Begin trauma resuscitation steps
Protocol: 6002 – Multisystem Trauma/Traumatic Shock

A 32-year-old female with penetrating trauma, GCS 7, SpO₂ 88% on RA. What is your immediate management?

- Airway and O₂ (avoid hyperventilation unless herniation suspected)
- Assist ventilations as needed
- Spinal motion restriction if indicated
- Cover chest wounds/eviscerations with occlusive dressings
Next: Move to circulation/shock control
Protocol: 6002 – Multisystem Trauma/Traumatic Shock

A 45-year-old male with blunt trauma is hypotensive, GCS 12, but not actively bleeding. What is your fluid strategy?

- Establish IV/IO NSS
- Adults: Permissive hypotension, bolus NSS to keep SBP >90 (limit 1000 mL before OLMC)
- Pediatrics: Bolus 20 mL/kg, repeat up to 40 mL/kg before OLMC
- Avoid overhydration unless severe TBI present
Protocol: 6002 – Multisystem Trauma/Traumatic Shock

A 19-year-old with blunt chest trauma becomes hypotensive, tachycardic, and develops absent breath sounds on the right. What is your treatment?

- Suspect tension pneumothorax
- Perform needle decompression
- Continue trauma resuscitation
Protocol: 6002 – Multisystem Trauma/Traumatic Shock

A 23-year-old with GSW to the spine is hypotensive despite fluids. What medication may be indicated?

- Consider neurogenic shock
- Initiate vasopressor infusion (norepi, epi, or dopamine)
- Titrate to maintain SBP >90
Protocol: 6002 – Multisystem Trauma/Traumatic Shock

What are the destination/transport considerations for a trauma patient in extremis?

- Transport to closest appropriate trauma center
- Consider air medical transport if faster
- Follow trauma destination protocol #180
Protocol: 6002 – Multisystem Trauma/Traumatic Shock

A 35-year-old male with open tibia fracture and severe pain. What must you manage first?

- Airway and O₂ if needed
- Control bleeding
- Splint and immobilize fractures
- Cover open wounds with sterile dressings
Protocol: 6003 – Musculoskeletal Trauma

What analgesic options are available for musculoskeletal trauma?

- Fentanyl 1 mcg/kg (50–100 mcg/dose; repeat half dose q5 min; max 300 mcg; peds max 3 mcg/kg)
- Morphine 0.1 mg/kg (2–5 mg; repeat q5 min; max 20 mg; peds max 0.2 mg/kg)
- Nitrous oxide (self-administered only)
- Ketorolac 15 mg IV/IO or 30 mg IM (peds 0.5 mg/kg)
- Acetaminophen 15 mg/kg IV or PO (adult max 1000 mg; ped max 650 mg)
- Ketamine 0.3 mg/kg infusion over 10 min (max 30 mg; not for

What splinting considerations apply to musculoskeletal trauma?

- Traction splint preferred for isolated femur fracture
- Straighten angulated fractures if no distal pulse
- Immobilize above and below joint
Protocol: 6003 – Musculoskeletal Trauma

What are the contraindications for some analgesics in musculoskeletal trauma?

- Avoid NSAIDs (ketorolac) with bleeding or renal disease
- Avoid opioids if SBP

What additional analgesia may Medical Command approve?

- Additional opioid dosing if pain persists and BP stable
Protocol: 6003 – Musculoskeletal Trauma

A construction worker pinned under rubble for 2 hours. What steps must you take before extrication?

- Place on monitor/ECG
- Establish 2 large-bore IV/IO
- Provide pain control per #6003
Protocol: 6004 – Crush Syndrome

What fluid management is indicated before extrication of a crush patient?

- NSS 20 mL/kg bolus (warm if available)
- Additional bolus if hypotension or entrapment >1 hr
Protocol: 6004 – Crush Syndrome

What medication is indicated immediately before extrication?

- Sodium bicarbonate 1 mEq/kg IV/IO
- If hyperkalemia suspected → Calcium chloride 10 mL 10% IV (peds 0.2 mL/kg)
Protocol: 6004 – Crush Syndrome

What is your fluid plan after extrication of a crush victim?

- IV fluids wide open to keep SBP >100 (adult) or >70 + 2(age) (pediatric)
Protocol: 6004 – Crush Syndrome

What other complications must you anticipate in crush syndrome?

- Hyperkalemia → repeat bicarb/CaCl if QRS widens
- Anticipate cardiac arrest immediately after release
Protocol: 6004 – Crush Syndrome

At an explosion scene, what must you ensure before patient care?

- Scene safety: beware of secondary explosions, unstable structures, radiation, PPE
Protocol: 6005 – Blast/Explosive Injury

During triage of multiple blast victims, what should you do?

- Apply tourniquets for uncontrolled hemorrhage
- Use MCI triage plan
Protocol: 6005 – Blast/Explosive Injury

What are the four categories of blast injury and their features?

- Primary: lungs, ears, bowel (barotrauma)
- Secondary: penetrating/projectile trauma
- Tertiary: blunt trauma/crush injuries
- Quaternary: burns, dust inhalation, exacerbation of existing conditions
Protocol: 6005 – Blast/Explosive Injury

What fluid considerations apply to patients with blast lung injury?

- Avoid fluid boluses >250 mL in adults or >20 mL/kg in peds if blast lung suspected
Protocol: 6005 – Blast/Explosive Injury

Where should blast-injured patients be transported?

- Trauma center if Category I/II
- Closest ED may not be most appropriate
Protocol: 6005 – Blast/Explosive Injury

A 20-year-old male with blunt trauma has repetitive questioning and confusion. What protocol applies and what is the first step?

- Suspect head injury/TBI
- Provide high-flow O₂ regardless of SpO₂
Protocol: 6011 – Head Injury/TBI

What ventilation strategy is indicated for TBI patients?

- Adult: 10 breaths/min
- Child: 20 breaths/min
- Infant: 25 breaths/min
- Target ETCO₂ 35–45 (40 ideal); if herniation signs → target 35
Protocol: 6011 – Head Injury/TBI

How do you manage hypotension in an adult TBI patient?

- NSS 1000 mL bolus, repeat 500 mL to max 2000 mL before OLMC
Protocol: 6011 – Head Injury/TBI

How do you manage hypotension in a pediatric TBI patient?

- NSS 20 mL/kg bolus, repeat up to 60 mL/kg total
Protocol: 6011 – Head Injury/TBI

What other precautions are required in TBI management?

- Spinal motion restriction if indicated
- Sterile dressings for open wounds
- Avoid pressure on depressed skull fractures
- Check glucose if GCS

What key clinical axioms apply in TBI?

- One episode of SpO₂

A 20-year-old male with blunt trauma has repetitive questioning and confusion. What protocol applies and what is the first step?

- Suspect head injury/TBI
- Provide high-flow O₂ regardless of SpO₂
Protocol: 6011 – Head Injury/TBI

What ventilation strategy is indicated for TBI patients?

- Adult: 10 breaths/min
- Child: 20 breaths/min
- Infant: 25 breaths/min
- Target ETCO₂ 35–45 (40 ideal); if herniation signs → target 35
Protocol: 6011 – Head Injury/TBI

How do you manage hypotension in an adult TBI patient?

- NSS 1000 mL bolus, repeat 500 mL to max 2000 mL before OLMC
Protocol: 6011 – Head Injury/TBI

How do you manage hypotension in a pediatric TBI patient?

- NSS 20 mL/kg bolus, repeat up to 60 mL/kg total
Protocol: 6011 – Head Injury/TBI

What other precautions are required in TBI management?

- Spinal motion restriction if indicated
- Sterile dressings for open wounds
- Avoid pressure on depressed skull fractures
- Check glucose if GCS

What key clinical axioms apply in TBI?

- One episode of SpO₂

A patient is found outside in the snow, cold, with slow respirations. What exclusions must you consider?

- Exclude cardiac arrest → Protocol 3035
- Exclude DOA: frozen solid, submersion >1 hr
Protocol: 6081 – Hypothermia

What are the first steps in hypothermia management?

- Move to warm, dry environment
- Remove wet clothes
- Apply warm blankets
- External rewarming (heat packs to groin, axilla, neck)
Protocol: 6081 – Hypothermia

What fluids are indicated in hypothermia?

- Warmed NSS 20 mL/kg up to 2000 mL
- May repeat up to 60 mL/kg (max 3000 mL)
Protocol: 6081 – Hypothermia

What is the management for a hypothermic but alert patient?

- Provide warm, non-caffeinated beverages
Protocol: 6081 – Hypothermia

What are the transport considerations for severe hypothermia?

- If core temp

A 28-year-old landscaper has painful leg cramps, hot diaphoretic skin, alert, normotensive. What is your management?

- Rest in cool environment
- Oral fluids if alert
- O₂ to maintain SpO₂ >95%
Protocol: 6086 – Heat Emergencies

A 19-year-old marathon runner is dizzy, nauseated, temp 102°F, tachycardic, BP 110/70. What is your management?

- Move to cool environment, remove excess clothing
- O₂ >95%
- NSS 500 mL IV bolus (peds 20 mL/kg)
- Transport
Protocol: 6086 – Heat Emergencies

A 45-year-old roofer is confused, skin hot/dry, temp 105°F, BP 90/60. What is your management?

- Airway/O₂
- Immediate cooling (avoid shivering/chilling)
- IV NSS 500 mL bolus
- Rapid transport
Protocol: 6086 – Heat Emergencies

What are the key differences between heat cramps, heat exhaustion, and heat stroke?

- Cramps: painful, alert, diaphoretic, normal BP
- Exhaustion: dizziness, N/V, syncope, temp

What may Medical Command authorize in heat emergencies?

- Release mild cramps/exhaustion without transport
- Additional IV fluids if needed
Protocol: 6086 – Heat Emergencies

When is antibiotic administration indicated for trauma?

- Suspected open fracture with angulation/crepitus and laceration over site
Protocol: 6093 – Open Fracture Antibiotics

What are the antibiotic doses for open fracture?

- Adult ≥50 kg: cefazolin 2 g IV/IO
- Child 30–50 kg: cefazolin 1 g IV/IO
Protocol: 6093 – Open Fracture Antibiotics

What are the exclusions and notes for open fracture antibiotics?

- Allergy to cephalosporins
- Anaphylaxis to penicillin
- Do not delay critical interventions/transport
- Requires ALS CE and credentialing
Protocol: 6093 – Open Fracture Antibiotics

When is TXA indicated in trauma/hemorrhage?

- Both must be present:
- Suspected uncontrolled bleeding (trauma or postpartum)
- Shock (SBP

What is the dosing for TXA?

- 1 g TXA in 100 mL NSS over 10 min IV/IO
Protocol: 6094 – TXA

What are the exclusions and transport considerations for TXA?

- Exclude: allergy, >3 hrs since injury, age