Pre hospital major trauma prptocol:
The objective of pre-hospital major trauma protocol is to reduce preventable death and permanent
disability and to improve patient outcomes by matching the needs of the injured patient to an
appropriate level of care in a safe and timely manner. The interventions decision in the prehospital
setting is based on anatomic, physiologic and high mechanism risk criteria, available resources, and time
and distance factors to hospital. Major trauma in the pre-hospital setting can be identified when there is
a minimum of one out of three criteria present. These are: the presence of abnormal vital signs; the
presence of an assumed or actual anatomic injury; or the existence of a high-risk mechanism of injury in
Airway management considerations:
Traumatic brain injury:
Rapid sequence induction (RSI) should be provided unless patient is in cardiac arrest. This
includes patients with absent airway reflexes.
Midazolam should not be used to control combativeness prior to RSI in head injury. Judicious
opioid pain relief should be administered. In the rare circumstance where combativeness is
preventing preoxygenation, then all other preparations for the RSI should be undertaken and a
small (20 - 40 mg) bolus of Ketamine may be given to enable preoxygenation.
Unconscious patient unable to be oxygenated and ventilated using BVM and the oropharyngeal
airway (OPA), the nasopharyngeal airway (NPA, the laryngeal mask airway (LMA) or intubation
Massive facial trauma is present and RSI is considered unsafe due to the inability to undertake
the Difficult Airway Guideline.
A commonly reported issue in “can’t intubate/can’t oxygenate” cases that leads to patient harm
is a fixation error, where a provider focuses on trying to achieve a particular task (such as
intubation) instead of progressing to another option to manage the airway. In these
circumstances it may be appropriate for another paramedic (including junior staff) to prompt
the next step in the guideline, balancing the need to remain respectful with the need to protect
the patient from harm.
Intubation does not need to be attempted and be unsuccessful in order to enter the Difficult
Airway Guideline. If a patient appears at assessment to present a difficult airway (e.g. due to
factors such as morbid obesity, short neck, small mouth or facial trauma) this guideline may be
an appropriate starting point for airway management and using another technique such as
(OPA), NPA, and (LMA).
Circulation management considerations:
In patients with uncontrolled bleeding (e.g. ruptured ectopic pregnancy, penetrating truncal
trauma, limb avulsion) ongoing bleeding may lead to poor cerebral perfusion and coma.
RSI in these patients is potentially harmful. The sedation may drop BP further and the added
scene time increases total blood loss. The appropriate treatment for these patients is urgent
transport and immediate surgery.
RSI should NOT be undertaken in patients who become unconscious when the coma is likely to
be secondary to blood loss unless RSI is judged to be absolutely essential due to an
unmanageably combative patient or it is impractical to transport unintubated. This applies to
both air and road transport.
Airway management with a bag-valve-mask (BVM) is to be maintained in conjunction with
prompt transport. Intubation (without drugs) should be considered if airway reflexes are lost.
Normal Saline IV (max. 40 mL/kg) titrated to patient response (unless in the setting of
penetrating truncal trauma or uncontrolled overt bleeding)
• Aim for SBP > 120 mmHg.
If SBP < 100 mmHg after 40 mL/kg:
• Consult with appropriate trauma service, If consult is unavailable, Normal Saline 20 mL/kg IV.
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