Comprehensive Emergency Medical Protocols and Trauma Management

Respiratory Management and Hyperventilation Protocols

• Assessment of breath adequacy and oxygen saturation levels is a critical step in patient care.
• If the patient is not breathing adequately, the use of a bag-valve mask (bagging) is necessary to provide ventilation.
• Hyperventilation is indicated for head injury patients ONLY when signs and symptoms of brain herniation are present.
• Signs and symptoms of herniation include:
  • Posturing: The patient lies with limbs twisted in abnormal directions (decorticate or decerebrate posturing).
  • Loss of pupillary light response.
  • Dilation of one or both pupils.
  • Vomiting.
  • Hypertension (noted as hyper attention).
  • Bradycardia (noted as afraid to party up).
  • Irregular respirations.
• Specific ventilation rates for hyperventilation are determined by age:
  • Adults (over the age of $13$): Once every $3$ seconds, achieving a rate of $20$ plus per minute.
  • Children: Once every $2$ seconds.
  • Infants (less than $1$ year old): $35$ times per minute.
• The physiological goals of hyperventilation include:
  • Constricting blood vessels in the cerebellum to manage intracranial pressure.
  • Reducing hemorrhaging.
  • Clearing toxins such as $CO_2$ to prevent hypercapnia (venting the body).

Patient Priorities and General Patient Care

• General patient care protocols categorize medical responses into priorities $1$, $2$, $3$, and $4$.
• These definitions and specific assessment protocols are found on page $19$ of the general patient care manuals.
• The ABPU (Alert, Voice, Pain, Unresponsive) scale should be used first, followed immediately by assigning a Glasgow Coma Scale (GCS) score to the patient at that exact moment.
• Glasgow Coma Scale review information is found on page $172$.

Trauma Protocols and Burn Management

• Trauma protocols, specifically found in Section $8$ starting on page $160$ and $162$, dictate the immediate treatment of burn injuries.
• Primary actions for burn patients include educating the patient and removing/stopping the burning process.
• Specific treatment requirements for burns include:
  • Keeping the patient warm if burns cover more than $10\,\%$ of the body surface area or if distal hypothermia is present.
  • Transporting patients with both trauma and burns to a trauma center.
  • Transporting standalone burn patients to a burn center.
• Criteria for Burn Center destination involve:
  • All third-degree burns.
  • Second-degree burns covering more than $10\,\%$ of the body surface area.
  • Burns involving the face, hands, feet, major joints, genitalia, or perineum.
  • Electrical burns, including lightning strikes or contact with high voltages greater than $120\,\text{volts}$.
  • Thermal burns resulting from smoke inhalation.
  • Circumferential burns involving the body or extremities.
• Transport logistics:
  • If ground transport to a burn center exceeds $30\,\text{minutes}$, air medical transport should be utilized.
  • Chemical burns should be transported to the closest hospital.
  • Children under the age of $15$ must be transported to a pediatric burn center, such as Johns Hopkins Downtown in Maryland.
• Measuring Body Surface Area (BSA):
  • The Palmer method: The size of the patient’s hand represents $1\,\%$ of their total body surface area.
  • The Rule of Nines: An alternative method for calculating BSA percentage.

Specialty Trauma Destinations in Maryland

• Eye Trauma: Patients should be transport to the Wilmer Eye Institute at Johns Hopkins Downtown.
• Hand and Upper/Lower Extremity Trauma: The specialty center is the Curtis Hand Clinic at Union Memorial (MedStar Union Memorial) in Baltimore.
  • Criteria for this clinic include stable patients with isolated extremity injuries, complete or incomplete amputations (excluding distal fingertips), degloving injuries (where skin is ripped from the limb), high-pressure injections, or crush injuries.
• Pediatric Trauma: Johns Hopkins is the primary pediatric trauma center for the state of Maryland.
• Multiple or Severe Trauma:
  • Patients over the age of $15$ go to Shock Trauma.
  • Patients age $15$ or younger go to Hopkins Downtown.
  • Hopkins Downtown is also a Level $1$ trauma center for adults; if a family (e.g., mother and daughter) is injured, they may be kept together at Hopkins.
• Safe Hospitals (Sexual Assault): These facilities (such as Frederick or Carroll) staff forensic nurses capable of treating the patient, conducting interviews, and collecting evidence while maintaining the chain of custody.
  • Counsels should contact EMRC (Emergency Medical Resource Center) to find the closest staffed safe hospital, such as those in the Emmitsburg area.

Spinal Immobilization and Patient Movement

• Deciding whether to use a backboard or only a cervical collar (neck collar) depends on the High Energy Mechanism of Injury (MOI) and potential for spinal cord injury or vertebral instability.
• Indicators for spinal restriction (boarding):
  • Midline spinal pain or issues with the spine itself.
  • Neurological symptoms: Tingling, numbness, or inability to move fingers and toes.
  • Altered mental status.
  • Distracting injuries: Multiple severe injuries, such as those from a long fall (e.g., construction scaffolding) or an intoxicated patient hit by a car.
  • New signs of paraplegia or quadriplegia after trauma.
• Extrication devices:
  • The scoop stretcher or Reeves device is preferred over a backboard for transfers and extrication.
  • Backboards may be used for patients with pelvic injuries, eviscerations, or impaled objects.
• Helmet Removal Protocols:
  • Football helmets: Unscrew the face mask first. If pads are present, the helmet and pads must be removed or kept together to maintain spinal alignment.
  • Motorcycle helmets are significantly different and require specific removal techniques.

Critically Unstable Patient Protocol (Boulevard)

• The "Boulevard" protocol (Section $2.4$) addresses critically unstable patients.
• Key Requirement: Defer patient movement until EMS-reversible conditions are treated.
• Reversible conditions include:
  • Life-threatening bleeding: Apply tourniquets.
  • Hypoxia: Administer oxygen.
  • Shock: Provide oxygen and potentially fluid resuscitation via ALS.

Go Team Specialized Response Activation

• The Go Team (Section $12.18$) is a specialized surgical unit from University Shock Trauma tasked with life-or-limb-threatening injuries in the field.
• The team typically consists of three members: a Surgeon, a Nurse Anesthetist, and a Pharmacist.
• Criteria for activation:
  • Anticipated extrication times exceeding $1\,\text{hour}$.
  • Need for field amputation.
  • Requirement for large volumes of blood.
  • Confined space or trench rescues where advanced medical management is needed.
  • Needs for advanced resuscitative or surgical services (e.g., chest tubes, GI/urinary catheters).
• Activation Procedure:
  • The EMS Medical Commander contacts EMRC and requests a "trauma line console" with Shock Trauma.
  • Specific details regarding why the team is needed should be shared so they can bring appropriate gear.

Case Study: Investigation of Missing Child and Interrogation Techniques

• Background: Investigation into the disappearance of $6$-year-old Katie Jacobs.
• Psychological Profiling and Clues:
  • Bed-wetting in children can be a sign of sexual assault or fear of the dark.
  • A necklace was found in a trash bag in the schoolyard; it served as a connection to the case.
  • Jeremy, a $13$-year-old family member, exhibited nervous ticks, such as biting his inner cheek and pushing his chair away during questioning.
  • Molesters often groom specific children while ignoring their own; Jeremy's father, Richard, could not name his son's friends despite living under the same roof.
• Evidence of Deception:
  • Richard claimed to be working things out with his wife, Susan, but did not know he had quit smoking over a month ago.
  • Susan knew the mall building perfectly and had separated herself from the group during the search.
  • The perpetrator used seasonal storage closets at the end of the pulse gym in the mall to hide the child.
  • The use of duct tape on a child with asthma is a life-threatening risk.

Questions & Discussion

• Question: Are we talking about VAL and Exposure?
• Answer: No, the focus currently is on Section $8$ trauma protocols and burns.
• Question: Where is the trauma section located in the manual?
• Answer: It is in the back, around page $160$ or $162$.
• Question: Is the Go Team the next step in activation?
• Answer: If the extrication is prolonged or requires surgical intervention, the Medical Commander should contact Cisco to request the Go Team.
• Question: Is the Palmer method based on the patient's hand?
• Answer: Yes, the patient's hand represents $1\,\%$ of their total body surface area.
• Question: Is Johns Hopkins a trauma center?
• Answer: Yes, it is a trauma center and the primary pediatric trauma center for Maryland.