Statement of Why

Denver Health Paramedics have a proud reputation for running critical trauma exceptionally well. This is due to quick scene times, command of the scene, executing skills, and getting the patient to the appropriate trauma center. We have historically measured our success by our short scene times alone. As the teamwork between Denver 911, Denver Fire Department, and the Denver Health Paramedics has strengthened, and the use of data is more advanced, we have matured to the point that our perspective on trauma should continue to evolve. By reassessing the priorities of our tasks and decisions, we can better manage our calls while delivering the best care for our patients.

By analyzing multiple outcome-associated metrics across the continuum of care, we can establish baselines, compare ourselves to other agencies, reassess and continue process improvement, and assess our care directly related to patient outcomes. Ultimately, we should not measure our success only in on- scene times; the total time from Call Pick-Up to Arrival at ED and whether or not we provide the appropriate care for our patients matters more. The small refinements will strengthen an otherwise very strong-link process. Being the best should never stop us from striving to be better.

Six Phases of a Trauma Call

Phase I: All Activity from 911 Activation to 1st First Responder on Scene

• Determine Nature of Call
• Identify potential number of patients Identify Safety Concerns
• Identify Locations of Patient(s)

Phase II: All activity from 1st First Responder on Scene until the Patient is loaded in an ambulance

• Consider Ingress/Egress and position of vehicles Identify all patients
• Triage the scene
• Addition Resources Assessment
• Stop Major Bleeding
• BLS Airway Management Package to load the patient Set-up Ambulance

Phase III: All activity between patient loaded in ambulance and ambulance leaving for ED

Other priorities without inappropriately delaying transport (Ideally <90 seconds) 1st IV Attempt

• Trauma Expose the Patient
• Vital Signs
• Initial Assessment, Identify Life Threats, Treat Life Threats

Phase IV: All activity while transporting the patient

• Airway/Respiratory Management Biophone call
• 2nd IV
• Repeat Vital Signs
• CPR
• Other tasks/skills as appropriate Package patient for delivery to ED

Phase V: All activities once patient is at the hospital until care is in ED hands

• Deliver patient to assigned room
• Handoff report
  • Brief if trauma arrest, and clear patient for ED interventions
• Management of Multiple Patients

Phase VI: Activities involved in personal and system improvement

• Peer Debrief (partner, student, Command)
• Documentation
• Peer Review – QA
• MRI Review Committee

Principles of Trauma

1. Ideal trauma care consists of 3 major components:

• Highly trained, excellent providers (quality)
• Rapid assessment and treatment (speed)
• High functioning system of care (teamwork).

2. Circulatory management

• Hemorrhage control is a top priority
  1. Tourniquets should be used on all extremities with life-threatening bleeding.
  2. Direct pressure and / or wound packing take precedent over other tasks and should not be interrupted.
• NS 500cc boluses
  1. Suspicion of head injury SBP below 100
  2. No suspicion of head injury SBP below 80

3. Traumatic arrest

• Unlike a medical arrest, the number one priority is rapid treatment and transport to definitive care.
• Chest compressions should be done unless a higher priority action is indicated and resources limit what tasks can be performed.
• The following actions/assessments are of higher priority than uninterrupted chest compressions. Examples in no particular order:
  1. IV / IO access
  2. Biophone call to set up hospital
  3. Needle decompression (if indicated)
  4. Airway Management (BVM, iGel, intubation) • Capnography
  5. Moving patient
• Determine and report an accurate time of when pulses were lost.
• Oral intubation is preferred (2 attempts maximum), followed by iGel.

4. Airway Management

Guidance:

• Airway management refers to the skill of assessing and supporting respiratory function and includes all maneuvers from O2 cannula to cricothyroidotomy. It means much more than bagging or intubation.
• In trauma, we do not intubate for “airway protection” of blood / vomitous / fluids alone
• EMS Trauma management is about rapid assessment and treatment; if indicated, intubation should be en route unless there is no other option.
• Intubation in the ED is not the same as intubation prehospital – not because of provider skill, but because of space, lighting, equipment, and resource support, and resuscitation status.

Context:

• Pulseless arrest (blunt or penetrating)
  1. Oral intubation is preferred (2 attempts maximum), followed by iGel.
• Suspicion of head injury
  1. Avoid hypotension, hypoxia, and hyperventilation.
  2. Intubation can cause elevated intracranial pressure.
  3. Nasal intubation is contraindicated in head injury
  4. Supportive respirations – the less invasive, the better: 02, BVM are strongly preferred to iGel, which is strongly preferred to intubation.
• No suspicion of head injury
  1. If unresponsive, intubation is preferred.
     1. Nasal intubation is an option.

• Penetrating trauma with airway involvement
  1. Nasal or oral intubation is indicated and preferred with appropriate care of injured structures.
• Surgical Airway
  1. Cannot ventilate, cannot intubate

5. Communications (ideal biophone call)

• Ideally happens 5-10 minutes PTA at hospital
• If short transport, favor early call over complete information
• Information to include
  1. Reason for call / destination
  2. Age with repeated digits
  3. Mechanism with brief description of major injuries
     1. Blunt (mild / moderate / severe)
     2. Penetrating (Location of wounds)
  4. Mental status
  5. Description of airway status
  6. SBP and heart rate (or descriptions of patient’s circulatory status)
  7. Include your clinical concern (if not obvious)
  8. Estimated Time Enroute

6. Resource utilization

• SALT Triage
  1. Sort, Assess, Life threats, Treat/Transport
     1. 1 ambulance for every red patient
     2. 0.5 ambulance for every yellow patient
     3. 1 ambulance for any number of green patients

• Denver Paramedic prioritization determines transport order

7. Special populations

• Pregnant
  1. Placental abruption can occur with low mechanisms such as fall from standing and minor mech MVC
• Elderly
  1. Consider NAT
  2. Ask about anticoagulation
  3. Have suspicion for serious injury even with a low mechanism and a reassuring exam and vital signs.
• Pediatric
  1. Consider NAT
  2. Have suspicion for serious injury even with a low mechanism and a reassuring exam and vital signs.

Pro-Tips

To be added based on feedback from Providers