Welcome & Thank You for Participating

1. Welcome & Thank Youfor Participating in the San Joaquin County EMS Agency’s Policy Update Course

2. Course Objectives • Gain a general understanding and background necessary to successfully implement the following new policies on: • Major Trauma Triage and patient destination • C-Spine Immobilization • Minimally Interrupted Cardiac Resuscitation (MICR)

3. Trauma Triage and Patient Destination

4. EMS Policy No. 5210 Major Trauma Triage Criteria

5. EMS Policy No. 5210 Major Trauma Triage Criteria • Physiologic Criteria: • Glasgow motor score of less than 5. • Systolic blood pressure of less than: • 90 for age 14 and older. • 80 for age 7 to 14 years. • 70 for age 1 to 6 years. • Respiratory rate <10 or >29 (<20 in infant < one year).

6. EMS Policy No. 5210 Major Trauma Triage Criteria • Anatomic Criteria: • Penetrating injuries to the head, neck, chest, abdomen, and proximal to the elbow or knee. • Flail chest. • Two or more long bone fractures (humerus or femur). • Crushed, degloved, or mangled extremity. • Amputation proximal to wrist or ankle.

7. EMS Policy No. 5210 Major Trauma Triage Criteria • Anatomic Criteria (cont): • Pelvic fracture. • Open or depressed skull fracture. • Traumatic paralysis. • Extremity injury with loss of distal circulation. • Partial or full thickness thermal, chemical, or electrical burns greater than 9% total body surface. • Inhalation burns.

8. EMS Policy No. 5210 Major Trauma Triage Criteria • Mechanism of Injury: • Auto versus pedestrian or bicyclist with the patient being: • Run over. • Thrown a significant distance. • Falls involving a pediatric patient from a height greater than 10 feet or twice the height of the child.

9. EMS Policy No. 5210 Major Trauma Triage Criteria • Paramedic judgment: Paramedics may use their judgment to classify a patient as major trauma patient when the patient: • Has a significant complaint or obvious signs of injury, and; • Has experienced a high risk mechanism of injury; and • Has one or more of the following comorbid factors: • Age greater than 55 or less than 10. • Anticoagulation therapy. • Burns. • Time-sensitive extremity injury. • Pregnancy greater than 20 weeks.

10. EMS Policy No. 5210 Major Trauma Triage Criteria • Examples of high risk mechanism of injury include: • High energy motor vehicle or motorcycle crash. • Blast injuries. • Falls: • Adults greater than 20 feet. • Pediatrics greater than 2 feet times the height of the child.

11. EMS Policy No. 5210 Major Trauma Triage Criteria • Examples of the application of paramedic judgment include: • Motor vehicle crash, with a pregnant patient complaining of abdominal pain, with seatbelt marks across abdomen. • Fall from the top of a bunk bed, with a child less than 5 years of age, with an obvious femur fracture. • Fall from an extension ladder, adult greater than 60 years of age, on anticoagulation therapy, complaining of pain all over.

12. EMS Policy No. 5210 Major Trauma Triage Criteria • Multi-casualty Incidents (MCIs): • Initialtriage: • Prehospital personnel shall use START triage methodology for the initial assessment of patients during a trauma MCI. • Patients classified as “Immediate” using START criteria are major trauma patients.

13. EMS Policy No. 5210 Major Trauma Triage Criteria • Multi-casualty Incidents (MCIs): • Secondary triage: • When resources and circumstances allow prehospital personnel shall re-triage patients using the criteria in this policy. • Patients meeting physiologic or anatomic criteria shall be classified as “Immediate” patients. • Patients meeting mechanism of injury or paramedic judgment criteria shall be classified as “Delayed” patients.

14. EMS Policy No. 5215 Trauma Patient Destination

15. EMS Policy No. 5215 Trauma Patient Destination • Two Primary Trauma Catchment Areas • Northern Catchment Area – All of San Joaquin County, except for the southern catchment area. • Southern Catchment Area – South of State Highway 120 in San Joaquin County Ambulance Zones E and F; and the area within the city limits of Escalon.

16. EMS Policy No. 5215 Trauma Patient Destination • Adult Major Trauma Patient Destinations: • Northern catchment area – San Joaquin General Hospital. • Southern catchment area – Doctors Medical Center or Memorial Medical Center. • If the assigned trauma center is unavailable or at capacity, adult major trauma patients shall be transported to the next closest trauma center.

17. EMS Policy No. 5215 Trauma Patient Destination • Pediatric Major Trauma Patients: • Northern catchment area – U.C. Davis Medical Center • Southern catchment area – U.C. Davis Medical Center. • If the U.C. Davis Medical Center is unavailable or at capacity, pediatric major trauma patients shall be transported to the closest trauma center.

18. EMS Policy No. 5215 Trauma Patient Destination • Multi-casualty Incidents (MCIs): • Trauma patients triaged as “Immediate” shall be preferentially transported to designated trauma centers utilizing available trauma centers in San Joaquin, Stanislaus, and Sacramento Counties. • When possible pediatric trauma patients triaged as “Immediate” shall be preferentially transported to the U.C. Davis Medical Center.

19. EMS Policy No. 5215 Trauma Patient Destination • Multi-casualty Incidents (MCIs): • During a trauma MCI, the Disaster Control Facility (DCF) shall include at a minimum all of the following trauma centers in their emergency department poll: • San Joaquin General Hospital; • Doctors Medical Center; • Memorial Medical Center; • U.C. Davis Medical Center; • Kaiser Hospital South Sacramento.

20. EMS Policy No. 5215 Trauma Patient Destination • Multi-casualty Incidents (MCIs): • As specified in EMS Policy No. 5210, on secondary triage an “Immediate” patient includes patients meeting START criteria and patients meeting physiologic or anatomic major trauma triage criteria.

21. EMS Policy No. 5215 Trauma Patient Destination • Specialty Considerations: • Unmanageable Airway: Transport to closest receiving hospital. • Isolated Burn Injuries: • Patients with partial or full thickness thermal, chemical, or electrical burns greater than 9% total body surface shall be transported to the level I trauma center at the UC Davis Medical Center.

22. EMS Policy No. 5215 Trauma Patient Destination • Specialty Considerations: • Isolated Burn Injuries: • Inhalation burns with a manageable airway shall be transported to the closest trauma center based on assigned trauma service area. • Paramedics should consult with the base hospital on all other types of burns injuries to obtain a destination. • Isolated Spinal Cord Injuries: Patients with spinal cord trauma or traumatic paralysis without comorbid trauma injuries shall be transported to the level I trauma center at the UC Davis Medical Center.

23. EMS Policy No. 5215 Trauma Patient Destination • Air Ambulance Transport Considerations: • When ground ambulance transport is readily available air ambulance scene time should be kept to an absolute minimum. • Ground ambulance transport of a major trauma patient should not be delayed for the arrival of an air ambulance.

24. EMS Policy No. 5215 Trauma Patient Destination • Non-Emergent Trauma Patient Destination Considerations:

25. Questions?

26. EMS Policy No. 5115Cervical Spine Immobilization

27. EMS Policy No. 5115 Cervical Spine Immobilization • Turning the approach to C-Spine Immobilization 180 Degrees • Old Approach: Everybody is immobilized • New Approach: Only patients requiring immobilization are immobilized

28. EMS Policy No. 5115 Cervical Spine Immobilization • The policy premise • When to immobilize c-spine • When not to immobilize c-spine • Techniques and equipment to perform immobilization • Pediatrics • Adults • Moving patients on-scene • Special Considerations

29. EMS Policy No. 5115 Cervical Spine Immobilization • What is the basis for the new approach? • Decrease unnecessary immobilizations • Reduce risks and complications • Spinal immobilization may cause harm and interfere with care (e.g. penetrating trauma)

30. EMS Policy No. 5115 Cervical Spine Immobilization • Prehospital personnel shall apply cervical spine immobilization to patients injured from blunt force trauma when: • Conscious patients with one or more of the following: • Posterior midline tenderness or pain; • Distal numbness, tingling, weakness, or parethesia; • Paralysis • Neck guarding or restricted range of motion; • GCS motor score or less than 5 as a result of blunt force trauma or intoxicants • Unconscious adult patients suffering from blunt force mechanism of injury, except ground level falls.

31. EMS Policy No. 5115 Cervical Spine Immobilization • Prehospital personnel shall not apply cervical spine immobilization to patients injured in the following circumstances: • Patients injured solely from penetrating trauma; • Unconscious adult patients experiencing a ground level fall; • Patients in cardiac arrest.

32. EMS Policy No. 5115 Cervical Spine Immobilization • Pediatric cervical spine immobilization shall be performed (depending upon circumstances) as follows: • Soft c-collars, KEDs, or similar device. • If already in a car seat: • Rear-facing seat - may be immobilized and extricated. • High-back front facing seat - may be extricated in seat, but then placed in a pediatric immobilization device (PID). If child too agitated, do not force the use of the immobilization device. • If restrained in booster – place in PID

33. EMS Policy No. 5115 Cervical Spine Immobilization • Adult cervical spine immobilization shall be performed by selecting the most effective methods and tools for the specific situation to prevent gross movement of the spine. Do not interfere with necessary treatment

34. EMS Policy No. 5115 Cervical Spine Immobilization • Approved equipment includes: • Soft cervicle collars. • Kendrick Extrication Device (KED) or Fasplint or similar device. • Any combination of equipment including pillows and blankets or other commercially available immobilization device approved by the EMS Agency to ensure comfort and spinal immobilization on the gurney.

35. EMS Policy No. 5115 Cervical Spine Immobilization • Approved devices for moving patients on scene include: • Pull sheets and other flexible devices. • Scoops, Long backboards and Miller Boards may be used on-scene, but DO NOT transport patients to the hospital on backboards. • Self extrication by patients is allowed. (Easier on patient – less movement)

36. EMS Policy No. 5115 Cervical Spine Immobilization • Special Circumstances: • Agitated patients may need to be removed from spinal immobilization. • Most patients in spinal immobilization will benefit from being placed in semi-fowlers. • ALS personnel may discontinue spinal immobilization upon reassessment of the patient. • Do not use hard collars or apply adhesive tape to the patient’s skin.

37. Questions?

38. Minimally Interrupted Cardiac Resuscitation

39. MICR Section Objectives • Understand the scientific data that supports implementing MICR • Understand the SJCEMSA MICR Policy

40. Discussion Topics • Why Minimally Interrupted Cardiac Resuscitation (MICR)? • Curriculum • SJCEMSA MICR Policy • Pit Crew Concept • Critical Task Approach • Talk through scenarios • Demo the scenarios • Practice the scenarios

41. Why MICR? • MICR optimizes the chance of surviving cardiac arrest with favorable neurological outcomes.

42. Cardiac Arrest Treatment The links in the “Chain of Survival” • Early Recognition and Calling EMS • Early CPR • Early defibrillation • ALS (medications, IV, intubation)

43. THINK ABOUT THIS!!! • What if adding ALS …subtracts chest compressions?

44. “A” ALWAYS COMES FIRST in ABCs …RIGHT??? • How could ADDING intubation with a high success rate fail to improve outcome? • Speculation in 2004: • ANYTHING that interrupts CCs is bad!!! • EVEN AIRWAY?????? • “C” comes BEFORE “A”

45. 2004: Starting to Figure it Out • In Cardiac Arrest…it’s not the ABCs… • It’s the…CABs!!!

46. Starting to Figure it Out in 2004 • The implications: • Less is more: CPR more important than ALS • Rescue breaths create major CC interruptions • Studies from animal lab • Interrupting CCs is REALLY bad • Potential detrimental effects of doing ventilation during CPR

47. Issue #1: Adverse Effects of Positive Pressure Ventilation • During CPR…PPV: • Increases intra-thoracic pressure • Decreases venous return to the chest • Decreases coronary blood flow • Decreases cerebral blood flow Aufderheide: Circulation. 2004;109:1960-1965.

48. Ventilation Rate During Out-of-Hospital CPR --13 OHCA patients --Ventilation during CPR --Mean rate: 37±3 per minute (range 15-49) Aufderheide. Circulation 2004; 109:1960-5

49. Issue #2: Chest Compression Interruptions During CPR • Experienced paramedics: • Conventional CPR (15:2) • Two breaths: 16 seconds • 39 CC/min • 42% of cycle with CC • “CC-only” CPR (50:2) • Two breaths: 3 sec. after 50 • 84 CC/min (119% increase) • 93% of cycle with CC

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