Things you need to memorize

Why should you collar?

1. Patient with significantly painful distracting injury

2. Significant multi system trauma

3. Severe Head or Face Trauma

4. Any fall with the evidence of striking head

5. Spinal Pain or tenderness (including neck pain with a history of trauma)

6. Numbness or weakness in any extremity after trauma

7. Found in a position of trauma with altered mental status and no available history

8. Loss of consciousness after trauma

Why should you call a channel?

1. Altered Mental Status

2. Dementia

3. SI/HI

4. ETOH

5. Head Injury

6. Abnormal Vitals

7. Respiratory Distress

8. Intervention by a healthcare provided

9. Summoned by a healthcare provider

10. ALS recalled

11. Minor

When is it not necessary to call a channel for a refusal?

1. Hypoglycemia

2. Overdoses

3. Taser Probe Removal

AEIOU TIPS (Special considerations for causes of AMS)

A- Alcohol and Abuse

E- Epilepsy, Electrolytes, Encephalopathy

I- Insulin

O- Opiates, Overdose

U- Uremia

T- Trauma, Temperature

I- Infection

P- Poison, Psychogenic

S- Shock, Seizure, Stroke, Space occupying lesions, Subarachnoid Hemorrhage (SAH)

Injuries incompatible with life

1. decapitation

2. body fragmentation

3. severe crush injury to the head (without vital signs)

4. severe crush injury to the chest (without vital signs)

5. severe thermal burns (without vital signs)

6. gunshot wounds to the head lateral entrance wound and an opposite side exit wound (without vital signs)

signs of decomposition of the body

1. skeletalization

2. severe bloating (without vital signs)

3. skin slough (without vital signs)

when should CPR efforts be witheld:

1. resuscitation would place provider at significant risk of physical injury

2. patient is pulseless and apneic (without vital signs), cold in a warm environment, with dependent lividity

3. injuries incompatible with life

4. decomposition of the body

PAT

use during pediatric patient care

• Appearance (the way they act - consolability/interactiveness)

• Work of Breathing (retractions, nasal flaring, rapid breathing, etc)

• Circulation (skin appearance - pallor, cyanosis, mottling)

5 reasons to CPAP

• Tachypnea (RR>24)

• Tachycardia (HR>100)

• Hypertension (BP>120)

• Hypoxia (SpO₂<90)

• Labored breathing resulting in patient not being to finish a sentence

3 reasons not to CPAP

1. When intubation or surgical airway might be preferred

2. If patient doesnt improve or continues to deteriorate despite CPAP administration (BVM follows)

3. Respiratory distress secondary to trauma (possible pneumo)

when to get BGL

• Syncope

• Stroke

• Seizures

• Sepsis

(not necessary on ETOH but do to rule it out)

SIRS Criteria

systemic inflammatory response syndrome

* suspicion of infection + suspicion of 2 or more of these meets criteria (must contact med control for SEPSIS alert)

• temp greater than 38C or 100.4F - less than 36C or 96.8F

• HR>90

• RR>20

• Systolic BP<90

request ALS?

Risk factors for infection

• Elderly Patients with AMS from baseline

• Nursing home patients

• Chronic disease

• Immunosuppresion

• Indwelling catheters and central lines

VAN negative and LKW less than 4.5 hrs

go to nearest certified stroke center

VAN positive and LKW less than 4.5 hrs

contact local medical control to discuss destination

VAN positive and LKW greater than 4.5 hrs (including wake up stroke or unkown LKW) or considering hemorrhagic stroke

transport to certified Thrombectomy capable or comprehensive stroke center

what do you need to communicate to the receiving facility when you have a stroke patient

use of anticoagulants

NSAIDS

spinal motion restriction algorithm

• Neuro exam (focal deficit?)

• Significant mechanism of injury

• Alertness (AMS?)

• Intoxication (Evidence?)

• Distracting Injury

• Spinal Exam (tenderness?)

when to contact ALS regarding burns

• Singed facial or nasal hairs

• hoarse voice or stridor

• Difficulty breathing

• carbonaceous sputum (smoky spit)

• burns on face

Adult GCS

Eyes

1. No response

2. To pain

3. To verbal

4. Spontaneous

Verbal

1. No response

2. Incomprehensible

3. Inappropriate

4. Confused

5. Oriented

Motor

1. No response

2. Extension (Decerebrate)

3. Flexion (Decorticate)

4. Withdraws to pain

5. Localizes pain

6. Obeys commands

Pediatric GCS

Eyes

1. No response

2. to painful

3. to verbal

4. spontaneous

Verbal

1. no response

2. inconsolable, agitated

3. inconsistently consolable/moans

4. consolable cry

5. coos, babbles

Motor

1. No response

2. extension (decerebrate)

3. flexion (decorticate)

4. withdraws to pain

5. withdraws to touch

6. normal spontaneous movement

10-1

situation under control

10-2

arriving at scene

10-3

go ahead with message

10-4

ok, received message

10-5

relay

10-6

busy unless urgent

10-7

out of service (not available by radio)

10-8

in service, available

10-9

repeat message

10-10

accident PD, PI, H&R

Criteria for a trauma alert

Vital Signs and Level of Consciousness

• diminished mental status (GCS 9-13) with mechanism attributed to trauma

Anatomy of Injury

• flail chest

• two or more proximal long bone fractures

• pelvic fractures

• limb paralysis or pulselessness

• amputation proximal to wrist and ankle

Mechanism of Injury

• ejection from automobile

• death in same passenger compartment

• extrication time >20 minutes

• Falls - Adult: >20 ft - Pediatric >10 ft

• high speed auto crash

• auto vs. pedestrian/cyclist thrown, run over or with significant impact

• motorcycle crash > 20 mph or with separation of rider and bike

• significant burns

Significant Co-Morbid Factors

• extremes of age <5 or >60 y/o

• hostile environment (extreme temperatures or hazmats)

• medical conditions (diabetes, COPD, CHF, renal failure, liver disease, morbid obesity, pregnancy)

• coagulopathy/anticoagulant use

• presence of intoxicants

**severe animal bites, envenomation, drowning, hypothermia, hanging, strangulation

Criteria for a trauma code

Vital signs and level of consciousness

• Confirmed systolic BP of <90 mm Hg

  • absence of radial pulses may be used as a confirmatory finding if a blood pressure is unobtainable

• respiratory compromise, obstruction and/or intubation

• intubated patients from another facility with ongoing respiratory compromise

• GCS < or = 8 with mechanism attributed to trauma

Anatomy of injury

• obvious major vascular injury external hemorrhage

• severe maxillofacial injury with potential airway compromise

• major amputation proximal to elbow or knee

• suspected head injury (GCS < 12 with major torso or extremity injury suspected or present)

Mechanism of injury

• gunshot to the head, face, neck, or torso (anterior/posterior chest and abdomen, pelvis, groin, and butthocks)

• gunshot or stab wounds to extremities proximal to elbow/knee or with hard vascular signs

• stab wounds to the neck with hard signs

• major impaling injury to torso

• inhalation injury with need for airway intervention and/or associated with significant BSA burn

Logistical

• transfer patients from other hospitals receiving blood to maintain vital signs

• emergency medicine physician’s discretion

• major surgical crises

**severe animal bites, envenomation, drowning, hypothermia, hanging, strangulation

giving aspirin

for: chest pain suspected to have cardiac origin

325 mg max dose

• allergic?

• hemophilia?

• pregnant?

• over 15?

• internal bleeds?

giving benadryl

for: mild allergic reactions (hives, swelling, exposure to allergen, respiratory distress)

25-50 mg orally for Adults (>15 y/o) (>66 lbs/ >33 kg)

25 mg for pediatrics (7-15 y/o) (33-66 lbs/15-30 kg)

12.5 mg for pediatrics (2-6 y/o)

• allergic?

giving epinephrine

for: severe allergic reactions - compromise of 2 body systems - anaphylactic reactions)

0.3 mg epi-pen or 5 ml draw up for adults (>66 lbs)

0.15 mg epi-pen for pediatrics (33-66 lbs)

can readminister after 10 minutes

giving glucose

for: blood glucose below 60 mg/dl

14-25 mg orally

can readminister after 10 minutes

• can patient follow commands?

• patent airway?

• able to swallow?

giving acetaminophen

for: musculoskeletal pain

1000 mg max dose (325 mg cups)

• liver disease?

• alcohol use?

• over 15 years old?

• acetaminophen within last 4 hrs?

giving nitro

for: chest pain with suspicion of cardiac origin

0.4 mg tablets (max limit of 3 every 3-5 minutes) → recheck BP before giving more

• ED drugs within last 48 hrs? (Viagra, Levitra)

• Systolic BP below 90 mmHg?

giving zofran

for: nausea, vomiting

8 mg max

• above 15?

• intoxication due to alcohol or toxin?

giving narcan

for: opioid overdose (pin point pupils, respiratory distress, apnea, decreased mental status/responsiveness)

2 mg IN with 4 mg max dose

can repeat after 4 minutes

• SpO2 above 92%?

giving albuterol

for: wheezing, signs of respiratory distress due to asthma, COPD, reactive airway disease, allergic reactions

5 ml of albuterol with 0.5 mg of atrovent for >6 y/o

2.5 ml of albuterol for 1-5 y/o

med control for <1 y/o

• allergies?

• heart rate above 150 for adults?

• heart rate above 180 for kids?

giving MDI

for: respiratory distress due to asthma, COPD, reactive airway disease, wheezing, allergic reactions

8 puffs max for adults (4 puffs 5 mins apart)

8 puffs max for pediatrics kg>20

4 puffs max for pediatrics 10-20 kg

2 puffs max for pediatrics >10 kg

• allergic?

• heart rate above 150 for adults?

• heart rate above 180 for kids?