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Arizona Emergency Medical Systems, Inc.

RED BOOK CHAPTER 4

Triage: General General Medical Emergencies Triage Guidelines

DISCLAIMER

The AEMS Red Book is designed to be a resource document for use by Medical Direction Authorities responsible for the administrative, organizational and on-line medical direction of pre-hospital EMS personnel. It specifically recognized that variations from the guidelines contained within are not only acceptable, but also appropriate, depending on the individual circumstances of the involved areas and organizations. By Statute and Rule, all advanced life support pre-hospital EMS personnel shall have administrative and online medical direction. These guidelines are not meant to act as a substitute, proxy or alternative to that medical direction. Any conflict between these guidelines and the individual EMS provider's medical direction shall default to the Administrative or On-Line medical direction. This manual sets forth guidelines deemed by AEMS to be within the acceptable standard of medical care. It is specifically recognized that there are acceptable variations from these procedures and protocols, which may also satisfy the standard of care. This manual does NOT define, limit, expand or otherwise purport to establish the legal standard of care.

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ADULT TRIAGE GUIDELINES

Purpose: Triage Guidelines are intended for use by certified EMT'S, IEMTS, and Paramedics when encountering and caring for critically ill or injured patients in the Central Arizona Regional EMS System.

PROCEDURE

1. Triage guidelines should be implemented after evaluation and stabilization of the patient. Consultation with Medical Control may be utilized to assist in triage decisions. 2. If ALS personnel are not available, initial stabilization should be implemented and the patient transported to the closest appropriate categorized facility. 3. Patient choice is a primary consideration in the triage decision. If the patient isunable to make a reasonable choice, or the medical condition of the patient requires a specific level of care, destination may be determined by Medical Control. 4. Triage guidelines are not meant to address all components of Prehospital care. Consultation with Medical Control should be utilized whenever a questionable triage decision arises.

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GENERAL MEDICAL EMERGENCIES

1. Patients presenting in stable* condition may be transported to the patients facility of choice. If no patient preference, transport to the closest appropriate categorized facility. 2. Patients presenting in unstable* condition will be transported to the closest appropriate categorized facility.

**Definitions: · Stable patient: patient with a single or well defined chief complaint(s), that after initial intervention is: · responding favorably to initial treatment (i.e., resolving or improving the s/s)

- without neurological, respiratory and/or cardiovascular compromise

Unstable patient: Any patient with a single, multiple system, or complex chief complaint with or without hemodynamic compromise, that does not respond favorably to initial treatment.

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Trauma Emergencies

Adult Trauma ­ 14 Years and Older (current algorhythm)

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Measure vital signs and level of consciousness

F I E L D T R I A G E D E C I S I O N S C H E M E

Step One

Glasgow Coma Scale . . . . . . . . . . . . . . . . . . . <14 Systolic blood pressure . . . . . . . . . . . . . . . . . .<90 mmHg Respiratory rate . . . . . . . . . . . . . . . . . . . . . .. .<10 or >29 breaths per minute (<20 in infant aged <one year1) YES Take to Trauma Center2. Steps 1 and 2 attempt to identify the most seriously injured patients. These patients should be transported preferentially to the highest level of care within the trauma system. NO Assess anatomy of injury.

Step Two

· · ·

All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee Flail chest Two or more proximal long-bone fractures

· · · · ·

Crushed, degloved or mangled extremity Amputation proximal to wrist and ankle Pelvic fractures Open or depressed skull fractures Paralysis NO Assess mechanism of injury and evidence of high energy impact.

YES Take to Trauma Center2. Steps 1 and 2 attempt to identify the most seriously injured patients. These patients should be transported preferentially to the highest level of care within the trauma system.

Step Three3

· Falls Adults: >20 feet (one story is equal to 10 feet) Children4: >10 feet or two or three times the height of the child · High-risk auto crash: Intrusion5: >12 inches, occupant site; >18 inches, any site Ejection (partial or complete) from automobile Death in the same passenger compartment Vehicle telemetry data consistent with high risk of injury YES

· Auto vs pedestrian / bicyclist thrown, run over, or with significant (>20 mph) impact6 · Motorcycle crash >20 mph

NO Assess special patient or system considerations.

Transport to closest appropriate Trauma Center7 which, depending on the trauma system, need not be the highest level Trauma Center.

Step Four

· Age Older Adults8: Risk of injury/death increases after 55 years Children: Should be triaged preferentially to pediatric-capable Trauma Centers Anticoagulation and bleeding disorders Burns: Without other trauma mechanism: Triage to burn facility9 With trauma mechanism: Triage to Trauma Center Time sensitive extremity injury10 End stage renal disease requiring dialysis YES

· Pregnancy >20 weeks · EMS11 provider judgment

· · · ·

NO Transport according to protocol.12

Contact medical control and consider transport to Trauma Center or a specific resource hospital.13

WHEN IN DOUBT, TRANSPORT TO A TRAUMA CENTER

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FIELD TRIAGE SCHEME FOOTNOTES

upper limit of respiratory rate in infants is >29 breathers per minute to maintain a higher level of over-triage for infants. 2 Trauma Centers are designated Level I-IV, with Level I representing the highest level of trauma care available. 3 Any injury noted in Step Two or Step Three triggers a "YES" response. 4 Age <15 years. 5 Intrusion refers to interior compartment intrusion, as opposed to deformation which refers to exterior damage. 6 Includes pedestrians or bicyclists thrown or run over by a motor vehicle or those with estimated impact >20 mph with a motor vehicle. 7 Local or regional protocols should be used to determine the most appropriate level of Trauma Center; appropriate center need not be Level I. 8 Age >55 years. 9 Patients with both burns and concomitant trauma for whom the burn injury poses the greatest risk for morbidity or mortality should be transferred to a Burn Center. If the non-burn trauma presents a greater immediate risk, the patient may be stabilized in a Trauma Center and then transferred to a Burn Center. 10 Injuries such as open fracture or fracture with neurovascular compromise. 11 Emergency medical services. 12 Patients who do not meet any of the triage criteria in Steps One through Four should be transported to the most appropriate medical facility as outlined in local EMS protocols. 13 In most circumstances patients undergoing CPR should not be transported by Air Ambulance.

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ARIZONA TRAUMA MODE OF TRANSPORT GUIDELINES

The decision for mode of transport for both field and inter-facility patients is based on the premise that the time to definitive care and quality of care are critical to achieving optimal outcomes. Factors of distance, injury severity, road conditions, and traffic patterns must be considered when choosing between air or ground transport. The skill level of the transport team must also be considered. When considering air transport, the amount of time saved should be significant enough to allow a potentially beneficial intervention to take place at the receiving facility. Time considerations should take into account arranging for air transport, patient packaging, transport to the aircraft and transport of the patient from the helipad or airport to the trauma bay. The referring physician will collaborate with the receiving physician and transport service providers to determine the appropriate mode of transport, based on the patient's condition, and the above mentioned factors.

INTER-FACILITY TRANSPORTS

Background: Trauma transports from one hospital to another for higher level of care typically fall into one of two broad types: · Those in which a quicker form of transport may make a difference in treatment/outcome. · Those in which a quicker form of transport may not make a difference in treatment/outcome. Assumptions: Assumptions for the purposes of these examples: · Helicopter transport will be quicker, but more expensive. · There are no weather or road issues that would make air transport preferable to ground transport or ground transport preferable to air transport. Examples: (Not intended to cover all potential circumstances). Quicker Form Of Transport (Helicopter) ­ Quicker Form Of Transport (Helicopter) May Make A Difference In Outcome May Not Make A Difference In Outcome 1. Patient with a suspected aortic injury as seen on chest X-ray or 1. Patient with 2 broken ribs, no pnuemothorax and who is CT scan breathing fine. 2. Patient with an open book pelvis. 2. Patient with a minor pelvic fracture and hemodynamically stable. 3. Patient with Glasgow Coma Scale (GCS) less than 12 and the 3. Patient with concussion and normal CT scan of the brain; or if GCS is decreasing. no CT, then a GCS of 15 and mentating appropriately. 4. Patient with stab wound the abdomen near the upper right 4. Stab wound to the arm with decreased sensation but normal abdomen pulses, no "tightness," and no significant on going blood loss.

5. Patient with gun shot wound to the thigh with decreased pulses. 5. Patient with gun shot wound to the thigh with excellent pulses, no expanding thigh, and no significant ongoing blood loss.

6. Patient with blunt trauma and signs of shock. Adopted by the Arizona State Trauma Advisory Board, January 21, 2010 Approved by AEMS Board June 2011

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**Criteria for Triage of a Burn Patient to a Burn Center

· · · · ·

Partial Thickness (2nd degree) burns > 5% Any full Thickness (3rd degree) burns of any age group Any burns with trauma Burns associated with inhalation injury or airway compromise Full or partial thickness burns involving face, eyes, hands or feet, genitalia, perineum, and major joints All high voltage electric burns including lightning injury Chemical burns Radiation burns Burn injuries in patients with pre-existing medical disorders Burn injury in patients who will require special social and emotional or long-term rehabilitative support, including cases of suspected child abuse and neglect. Burned children in hospital without qualified personnel or equipment.

· · · · ·

·

**Criteria set forth by Arizona Burn Center and ABA (American Burn Association) 2003

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Triage Guideline for Primary Stroke Centers

The Arizona Stroke Consortium has identified specific hospitals as Primary Stroke Centers (PSC) for the Phoenix Metropolitan area. For a list of Primary Stroke Centers, see RED Book Chapter 7, Categorization. For Acute stroke patients with a FAST exam stroke screening score of more than zero AND if it within four hours of symptom onset, EMS personnel should consider transporting these patients to the nearest Primary Stroke Center. If this is not possible or practical, medical control should determine appropriate receiving facility based on local and available resources. Additionally, the patient should have their blood sugar checked to make sure that hypoglycemia is not the etiology of the neurologic symptoms and time of onset of symptoms should be documented. EMS Personnel should attempt to identify family / power of attorney contact phone numbers in case consent is needed or other information. The Arizona Stroke Consortium is an ongoing process and additional hospitals will be identified as Primary Stroke Centers. As this process moves forward it may be feasible to have a regional triage guideline that is more inclusive.

Approved by AEMS Board of Governors ­ 12/2010

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Example of Stroke Screen

1. Time of symptom onset. 2. Blood glucose level. 3. Facial droop (have patient smile). Normal: both sides move equally. Abnormal: one side shows asymmetry. 4. Arm drift (have patient close their eyes and hold both arms out). Normal: both arms move the same or not at all. Abnormal: one arm drifts down compared to the other. 5. Grip strength: both sides should be equal. 6. Speech (have patient say "a rolling stone gathers no moss). Normal: patient repeats saying with no slurred words Abnormal: patient uses inappropriate words, slurred speech, or is unable to talk.

Reprinted with permission by Phoenix Fire Department

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