Updated Fluid Bolus Protocols 25JUL13

1. Updated Fluid Bolus Protocols25JUL13 Hespan Removed from all Protocols

2. Assess ABC's and life threatening conditions Immediate action required? Correct conditions and reassess Spinal exam requires immobilization? (See spinal assessment protocol) MOI for spinal injury present? Complete applicable diagnostics: Physical Exam: Primary and secondary Vital signs: 2 sets; BP (including diastolic, pulse, respirations Establish IV if indicated: LR or Normal Saline; 250 – 500 cc bolus(es) wide open, Titrate to patient’s hemodynamic status. BP 80-90 Oxygen: Metered to patient condition and medical history Pulse Oximetry: if available Cardiac Monitor: 3 lead, 12 lead if available and applicable Remove all Clothing Full spinal immobilization Patient complaining of pain? Assess with 'Patient Pain Scale' and reassess after each treatment Place patient in position of comfort if possible Patient Pain Scale Assessment Assessed by asking the patient to rate the severity of their pain based on a 1-10 scale; 10 rated as the worst pain they have ever experienced and 1 rated as the least. Go to condition specific protocol Initial Trauma Care Class I Trauma Transport to trauma center Ensure Scene Safety GOAL: On scene < 10 minutes • Glasgow Coma Scale…….< 13 (at time of report) • Systolic blood pressure…..<90 • Respiratory rate…………..<10 or >29 • Airway compromise, flail chest, hemo or pneumothorax • Active hemorrhage • Penetrating injuries to head, neck, torso • Extremity trauma with loss of distal pulse • Amputation proximal to wrist or ankle • Paralysis or signs of spinal cord injury • Major burns of >20% BSA or any signs of inhalation injury • 200 volt or higher electrical injury • Two or more long-bone fractures (humerus/femur) • Paramedic discretion Yes No Yes Yes Class II Trauma Transport to trauma center No No • Initial speed >40 mph • Major auto deformity >20 inches • Intrusion into passenger compartment >12 inches • Death in same passenger compartment • Extrication time >20 minutes • Ejection from automobile or auto rollover • Auto-pedestrian/auto-bicycle injury with (>5 mph) impact • MCC or ATV crash >20 mph or separation of rider from bike • Assault with LOC • Falls >12 feet • Pelvic fractures • All open fractures • All degloving/Crush injuries • Penetrating injuries to extremities proximal to elbow or knee • Amputation distal to wrist or ankle of two or more digits • Pregnancy with acute abdominal pain • Auto crash Yes No Class III Trauma Preferential transport to closest hospital • MVC <40 MPH or UNK speed • Assault without LOC • Burns <20% • Auto-pedestrian and auto-bicycle <5 mph impact • MCC/ATV crash <20 mph • All falls of >5 ft/5 steps • Penetrating injury distal to elbow or knee • Pregnant patients involved in traumatic event Information given to receiving facility includes Glasgow coma scale, revised trauma score, and trauma classification. (Class 1,2, or 3) Reviewed 12/12

3. Correct all immediate life threatening conditions IV LR or Normal Saline: 500 cc bolus repeat in 30 minutes if needed titrate to patient's hemodynamic status Sys BP 80-90 mm Hg And improvement of mental status Consider pain management OPTIONS Specific procedures as indicated: Chest decompression, surgical airway, etc. Patient Trauma Status: Information given to receiving facility includes Glasgow coma scale, revised trauma score and trauma classification (Class 1, 2, or 3) -------------------------------------------------------------------------------------------------------- Initiate transport as soon as possible Multi-System Trauma Initial Trauma Care or Follow TCCC depending on scenario Go to condition specific protocol Antibiotics: Per TCCC (recommended for all open combat wounds) a. If able to take PO: - Moxifloxacin, 400 mg PO qd. b. If unable to take PO (shock, unconsciousness): - Ertapenem/Invanz 1 g IV/IM q24h or - Cefotetan 2 g IV/IM Reviewed 12/12

4. IV LR or Normal Saline: 500cc bolus if indicated Titrate to patient's hemodynamic status; repeat in 30 minutes if needed If intra-abdominal bleeding suspected, then by definition this is a Class I Trauma; notify Medical Control; and titrate systolic BP to 80-90 Pelvis unstable? OPTIONS Per TCCC protocol Titrate to patient's hemodynamic status up to 1L Patient Trauma Status: Information given to receiving facility includes Glasgow coma scale, revised trauma score and trauma classification ( Class 1,2 or 3) ------------------------------------------------------------------------------------------------------------------- Initiate transport as soon as possible Abdominal / Pelvic Trauma Initial Trauma Care Apply splint for abdominal/pelvic stabilization. Yes No Reviewed 12/12

5. Maintain BP systolic 80-90: IV LR or Normal Saline: 500 cc bolus(es) if indicated by hypotension; Titrate to patient's hemodynamic status Ice and splint as applicable Patient complaining of severe pain ? OPTIONS Titrate to patient's hemodynamic status Patient Trauma Status: Information given to receiving facility includes Glasgow coma scale, revised trauma score and trauma classification (Class 1, 2, or 3) -------------------------------------------------------------------------------------------------- Musculoskeletal Injuries Initial Trauma Care Yes Go to Pain Protocol No Reviewed 12/12

6. Yes Determine presence or absence of significant neurological signs and symptoms Significant neurological signs and symptoms may include: Motor function Sensory function Reflex responses Visual inspection of spinal column Bradycardia Priapism Hypotension (possible spinal shock) Hypertension (possible herniation- Cushing syndrome) Loss of sweating or shivering Loss of bowel or bladder control Ensure ventilations are adequate Cardiac Monitor: Manage dysrhythmia(s) per protocol Bradydysrhythmias are commonly seen in high level spinal injuries IV of NS, LR or : 250-500 cc bolus and titrate to patient's hemodynamic status Caution: Persistent hypotension unresponsive to titration may reflect neurogenic (spinal) shock Patient hypotensive? Yes Significant signs and symptoms of spinal cord injury may include: Partial or complete loss of sensation Partial or complete loss of muscle function Partial or complete loss of sympathetic tone Signs and symptoms will present at or below the level of the suspected injury site OPTIONS Additional IV Normal Saline or LR : 250-500 cc bolus(es); titrate to patient's hemodynamic status Dopamine: 2-20 mcg/kg/minute for suspected neurogenic shock without hypovolemia; Titrate to patient's hemodynamic status Levophed: 0.5-30mcg/min ------------------------------------------------------- Initiate transport as soon as possible Spinal Column / Cord Injuries Initial Trauma Care GCS <13 Go To Head Trauma Protocol No No CONSIDER VASOPRESSORS Reviewed 12/12