Trauma Transport Protocol

1.10 Trauma Transport Protocol
 
 

BROWARD COUNTY UNIFORM TRAUMA TRANSPORT PROTOCOL

(revised December 2011)

  1. COMMUNICATION (DISPATCH ) CENTER PROCEDURE
    1. All EMS systems utilize the 911-phone system in conjunction with either manual or Computer Aided Dispatch (CAD) programs. The call taker confirms all emergency information, including address and callback data prior to the end of the telephone conversation. Emergency information is immediately transmitted to the Fire-Rescue/EMS Dispatcher who selects the nearest available unit(s) for response; dispatches the call and provides all unit(s) with all available information concerning the incident.
    2. Call taker personnel/dispatchers shall make every attempt to obtain the following information from the 911 caller:
      1. Nature of the emergency;
      2. Location of the incident;
      3. Call back number;
      4. Number of patients;
      5. Severity of the illness/injury;
      6. Name of the caller.
  2. Should on scene personnel recognize a need for other emergency agencies (e.g. law enforcement, fire, EMS, Coast Guard) they shall notify Dispatch immediately. On scene personnel must identify the agencies needed and the specific amount of personnel, equipment, etc. required. The communications center shall make contact with the appropriate services (mutual aid/automatic aid). A contact list of all available emergency services is maintained and available through the Broward County Warning Point (Broward Sheriff's Office Communications Center).

  3. ON SCENE PROCEDURE - Ground
    1. Upon arrival at the scene, EMS personnel shall conduct a size up of the scene, to include, but not limited to, Trauma Alert Criteria (Section IV), safe entry, severity, and number of patients, the need for extrication, and the need for additional help. Dispatch and the nearest appropriate trauma center will be notified, as soon as possible, of "Trauma Alert" patient(s). Dispatchers shall immediately transfer this information, using the words "Trauma Alert" to the supervisor on duty.
    2. EMS personnel shall transport patient(s) to the nearest appropriate trauma center
      (catchment area identified in the Broward County Trauma Plan).
    3. EMS personnel shall submit the treatment data for each trauma patient to the trauma center as required in 64J-1.014, F.A.C. and their respective agency.
  4. TRANSPORT PROCEDURE (Rescue Helicopter)
    Three steps to follow when Broward Sheriff's Office, Dept. of Fire Rescue's (BSODFR) Rescue Helicopter is used for rapid transport of the trauma patient. The first two are directed toward the safety of the helicopter pilot and crew, ground personnel, patient, and bystanders; and the third is to establish operational guidelines as to when and/or if the helicopter is used to transport these patients.
    1. Severe weather at scene, helicopter hanger, landing zone (LZ), or Trauma Center reduces the use of the Rescue Helicopter.
    2. Safety considerations for landing zone (if any of 4 below, use ground transport or move the landing zone):
      1. Power lines around landing zone;
      2. Trees, signs, poles, or other obstacles in immediate landing area;
      3. Pedestrians and large gatherings of civilians in the area;
      4. An expectation that the area may not remain safe.
    3. Rescue helicopter to be used if:
      1. The Trauma Center that the patient would be transported to by ground, is farther away than twenty (20) minutes (30 Minutes for Level II patients) driving time;
      2. Ground transportation is not available and is not expected to be available within a reasonable time;
      3. The helicopter is needed to gain access to a patient for transport from an inaccessible area;
      4. Extrication time greater than twenty (20) minutes.
    4. Operational Guidelines by ground EMS crews for Rescue helicopter use:
      1. Secure a TAC radio channel through the County's dispatch center and keep open until Helicopter has left scene.
      2. Ground Crew PRE-ALERT Trauma Center.
      3. Start CUTT REPORT (County Unified Trauma Telemetry Report) or respective agency's modified patient treatment form. (see 1.10.1)
      4. Airway - advise Air Crew on airway status and if airway assistance or RSI (Rapid Sequence Intubation) is required.
        NOTE: (for pediatric patients only) if using the landing pad at North Broward Medical Center and crew feels that the patient requires immediate attention, advise helicopter crew that the patient will be seen by the Trauma Services physicians prior to transport to pediatric trauma center (BGH or Memorial)
      5. Begin Packaging Patient (remove shoes and clothes from vital areas). Advise Air Crew of the weight of the patient.
      6. Have a minimum of three (3) unobstructed lanes of traffic for roadway landings whenever possible.
      7. Pilot may require traffic stopped in both directions.
      8. Landing Zone units must remain at their post until helicopter has left the scene.
      9. Headlights should be turned off at night.
      10. Only clear landing zone upon direction of Air Rescue crew and law enforcement on scene.
  5. TRAUMA ALERT CRITERIA
    The following guidelines are to be used to establish the criteria for a "Trauma Alert" patient and determine which patient(s) will be transported to a trauma center. Any patient that meets any one of the "RED" criteria will be a trauma alert, while any patient that meets any two of the "BLUE" criteria will be a trauma alert.
    1. ADULT TRAUMA SCORECARD METHODOLOGY
      1. Each EMS provider shall ensure that upon arrival at the location of an incident, EMS personnel shall:
        1. Assess the condition of each adult trauma patient using the adult trauma scorecard methodology, as provided in this section to determine whether the patient should be a trauma alert.
        2. In assessing the condition of each adult trauma patient, the EMS personnel shall evaluate the patient's status for each of the following components: airway, circulation, best motor response (a component of the Glasgow Coma Scale), cutaneous, long bone fracture, patient's age, and mechanism of injury. The patient=s age and mechanism of injury (ejection from a vehicle or deformed steering wheel) shall only be assessment factors when used in conjunction with assessment criteria included in # 3 (Level II) of this section. (NOTE: Glasgow Coma Scale included for quick reference.)
      2. The EMS personnel shall assess all adult trauma patients using the following "RED" criteria in the order presented and if any one of the following conditions is identified, the patient shall be considered a trauma alert patient:
        1. AIRWAY: Active ventilation assistance required due to injury(ies) causing ineffective or labored breathing beyond the administration of oxygen.
        2. CIRCULATION: Patient lacks a radial pulse with a sustained heart rate greater than 120 beats per minute or has a blood pressure of less than 90mmHg.
        3. BEST MOTOR RESPONSE (BMR): Patient exhibits a score of four or less on the motor assessment component of the Glasgow Coma Scale; exhibits the presence of paralysis; suspicion of a spinal cord injury; or the loss of sensation.
        4. CUTANEOUS: 2nd or 3rd degree burns to 15 percent or more of the total body surface area; electrical burns (high voltage/direct lightening) regardless of surface area calculations; an amputation proximal to the wrist or ankle; any penetrating injury to the head, neck, or torso (excluding superficial wounds where the depth of the wound can be determined).
        5. LONGBONE FRACTURE: Patient reveals signs or symptoms of two or more long bone fractures sites (humerus, radius/ulna, femur, or tibia/fibula).
      3. Should the patient not be identified as a trauma alert using the red criteria listed in #2 of this section, the trauma patient shall be further assessed using the "BLUE" criteria in this section and shall be considered a trauma alert patient when a condition is identified from any two of the seven components included in this section.
        1. AIRWAY: Respiratory rate of 30 or greater.
        2. CIRCULATION: Sustained heart rate of 120 beats per minute or greater.
        3. BEST MOTOR RESPONSE (BMR): BMR of 5 on the motor component of the Glasgow Coma Scale.
        4. CUTANEOUS: Soft tissue loss from either a major degloving injury, or a major flap avulsion greater than 5 inches, or has sustained a gunshot wound to the extremities of the body.
        5. LONGBONE FRACTURE: Patient reveals signs or symptoms of a single long bone fracture resulting from a motor vehicle collision or a fall from an elevation of 10 feet or greater.
        6. AGE: Patient is 55 years of age or older.
        7. MECHANISM OF INJURY: Patient has been ejected from a motor vehicle,(excluding any motorcycle, moped, all terrain vehicle, bicycle or the open body of a pick-up truck), or the driver of the motor vehicle has impacted with the steering wheel causing steering wheel deformity.
      4. If the patient is not identified as a trauma alert after evaluation using the criteria in sections 2 or 3 above, the trauma patient will be evaluated using all elements of the Glasgow Coma Scale. If the score is 12 or less, the patient shall be considered a trauma alert (excluding patients whose normal Glasgow Coma Scale Score is 12 or less, as established by medical history or pre-existing medical condition when known).
      5. Where additional trauma alert criteria has been approved by the medical director of the EMS service and approved for use in conjunction with Broward County trauma alert criteria as the basis for calling a trauma alert shall be documented as required in section 64J-1.014, F.A.C. of the patient care record. Such local trauma assessment criteria can only be applied after the patient has been assessed as provided in sections #2, #3, and #4 above of the Adult Trauma Alert Criteria.
      6. In the event that none of the conditions are identified using the criteria in sections #2, #3, #4 or #5 above, during the assessment of the adult trauma patient, the paramedic can call a trauma alert if, in his or her judgment, the patient's condition warrants such action. Where paramedic judgment is used as the basis for calling a trauma alert, it shall be documented on all patient data records as required in section 64J-1.014, F.A.C.
      7. The results of the patient assessment shall be recorded and reported on all patient data records in accordance with the requirements of section 64J-1.014, F.A.C.
    2. Patients found to meet Trauma Alert criteria upon arrival at or subsequent to arrival at a non- trauma center will be expeditiously transferred to the appropriate trauma center. (See Section V)

    3. PEDIATRIC TRAUMA SCORECARD METHODOLOGY
      (Pediatric patients are those age 15 or younger) Pediatric Trauma Alert patients will be transported to the nearest appropriate Pediatric Trauma Center.
      1. The EMS personnel shall assess all pediatric trauma patients using the following "RED" criteria and if any of the following conditions are identified, the patient shall be considered a pediatric trauma alert patient:
        1. Airway: Active ventilation assistance required due to injury(ies) causing ineffective or labored breathing beyond the administration of oxygen.
        2. Consciousness: Patient exhibits an altered mental status that includes drowsiness; lethargy; inability to follow commands; unresponsiveness to voice or painful stimuli; or suspicion of a spinal cord injury with/without the presence of paralysis or loss of sensation.
        3. Circulation: Faint or non-palpable carotid or femoral pulse or the patient has a systolic blood pressure of less than 50 mmHg.
        4. Fracture: Evidence of an open long bone (humerus, radius/ulna, femur, or tibia/fibula) fracture or there are multiple fracture sites or multiple dislocations (except for isolated wrist or ankle fractures or dislocations).
        5. Cutaneous: Major soft tissue disruption, including major degloving injury; or major flap avulsions; or 2nd or 3rd degree burns to 10 percent or more of the total body surface area; electrical burns (high voltage/direct lightening) regardless of surface area calculations; or amputation proximal to the wrist or ankle; or any penetrating injury to the head, neck or torso (excluding superficial wounds where the depth of the wound can be determined).
      2. In addition to the criteria listed above in (1) of this section, a trauma alert shall be called when "Blue" criteria is identified from any two of the components included below:
        1. Consciousness: Exhibits symptoms of amnesia, or there is loss of consciousness.
        2. Circulation: Carotid or femoral pulse is palpable, but the radial or pedal pulses are not palpable or the systolic blood pressure is less than 90 mmHg.
        3. Fracture: Reveals signs or symptoms of a single closed long bone fracture. Long bone fractures do not include isolated wrist or ankle fractures.
        4. Size: Pediatric trauma patients weighing 11 kilograms or less, or the body length is equivalent to this weight on a pediatric length and weight emergency tape (the equivalent of 33 inches in measurement or less).
      3. In the event none of the above criteria is identified in the assessment of the pediatric patient, the paramedic can call a Trauma Alert if, in his or her judgment, the trauma patient's condition warrants such action. Where paramedic judgment is used as the basis for calling a trauma alert, it shall be documented as required in the 64J-1.014 F.A.C., on the patient care report and the County Unified Trauma Telemetry Report (CUTT) (see 1.10.1).
    4. LEVEL II TRAUMA PATIENTS: (ADULT AND PEDIATRIC)
      Non-trauma alert patients that present with a mechanism of injury suggestive of a significant injury or in the paramedic's judgment present with a non-significant injury and/or taking an anti-coagulant (i.e., Coumadin) or anti-platelet (i.e., Plavix), the EMS unit will be required to triage and transport this patient to the nearest appropriate Trauma Center. Level II Trauma criteria are as follows:
      1. Falls > 12 feet (adults); falls > 6 feet (pediatrics);
      2. Extrication time > 15 minutes;
      3. Rollover;
      4. Death of occupant in the same passenger compartment;
      5. Major intrusion into passenger compartment;
      6. Ejection from a bicycle;
      7. Pedestrian struck by vehicles not meeting the preceding automatic criteria (i.e. adults < 15 mph and pediatrics < 5 mph);
      8. Age 55 or greater;
      9. Electrical burns (high voltage/direct lightning);
      10. Paramedic judgment.
  6. TRANSFER PROCEDURES FOR EMERGENCY INTER-HOSPITAL TRAUMA TRANSFERS
    Any hospital in Broward County may transfer a patient meeting a Trauma Alert criteria by:
    1. Calling 911 and reporting a Trauma Alert in their Emergency Department. This call will automatically initiate a response from the local EMS rescue agency.
    2. Calling the closest Trauma Center (adult vs. pediatric) and advising the trauma section of the Trauma Alert completes the initiation of the transfer. This call should be from the sending emergency department physician to the receiving trauma surgeon.
    3. The Fire-Rescue/EMS Provider that is responsible for the area where the sending hospital is located, shall respond to the emergency department and transport the patient to the nearest trauma center as identified by the sending hospital.
    4. At the start of the transport, the Fire Rescue/EMS Provider shall notify the receiving trauma center that the unit is enroute to their facility and provide the trauma center with an estimated time of arrival.
  7. GLASGOW COMA SCALE SCORING
    The Glasgow Coma Score (GCS) measures cognitive abilities. It is composed of three parameters, (eye, verbal, and motor responses) and uses numerical scoring to assist in the correlation of brain injury. Those scores are as follows:

    Adult GCS:

    Best Eye Response:

    1. No eye opening;
    2. Eye opening to pain;
    3. Eye opening to verbal command;
    4. Eyes open spontaneously.

    Best Verbal Response:

    1. No verbal response;
    2. Incomprehensible sounds;
    3. Inappropriate words;
    4. Confused;
    5. Oriented.

    Best Motor Response:

    1. No motor response;
    2. Extension to pain;
    3. Flexion to pain;
    4. Withdrawal from pain;
    5. Localizing pain;
    6. Obeys commands.

    A GCS score is between 3 and 15, 3 being the worst and 15 the best. A Coma score of 13 or higher correlates with a mild brain injury; 9 to 12 is a moderate injury, and 8 or less a severe brain injury. (Note a phrase "GCS of 11" is essentially meaningless, and it is important to break the figure down into its components, such as eye 3+verbal 3+motor 5=GCS 11)

    Pediatric GCS:

    Eye Opening

    <1 Year

    >1 Year

     

    Spontaneously

    Spontaneously

    To verbal command

    To verbal command

    To pain

    To pain

    No response

    No response

     

    Motor Response

    <1 Year

    >1 Year

     

    Obeys

    Localizes pain

    Localizes pain

    Flexion – normal

    Flexion – withdrawal

    Flexion – abnormal
    (decorticate rigidity)

    Flexion – abnormal
    (decorticate rigidity)

    Extension
    (decerebrate rigidity)

    Extension
    (decerebrate rigidity)

    No response

    No response

     

    Verbal Response

    0-23 Months

    <2-5 Years

    >5 Years

    Smiles, coos, cries
    appropriately

    Appropriate words and
    phrases

    Oriented and
    converses

    Cries

    Inappropriate words

    Disoriented and
    converses

    Inappropriate crying
    and/or screaming

    Cries and/or screams

    Inappropriate words

    Grunts

    Grunts

    Incomprehensible

    No response

    No response

    No response


    A GCS score is between 3 and 15, 3 being the worst and 15 the best. A Coma score of 13 or higher correlates with a mild brain injury; 9 to 12 is a moderate injury, and 8 or less a severe brain injury. (Note a phrase "GCS of 11" is essentially meaningless, and it is important to break the figure down into its components, such as eye 3+verbal 3+motor 5=GCS 11)

  1. DESIGNATED FACILITIES
    Trauma Alert patients will be transported to the nearest appropriate trauma center. Should this Trauma Center be temporarily unable to provide adequate trauma care, the patient will be transported to the next closest Trauma Center.

    Listed below are the Trauma Centers that Fire-Rescue/EMS Providers in Broward County will transport adult Trauma Alert patients:

    North Broward Medical Center
    201 E. Sample Road
    Deerfield Beach, Florida 33064

    Broward General Medical Center
    1500 S. Andrews Avenue
    Fort Lauderdale, Florida 33316

    Memorial Regional Hospital
    3501 Johnson Street
    Hollywood, Florida 33021

    Listed below are the Pediatric Trauma Referral Centers that Fire-Rescue/EMS Providers in
    Broward County will transport pediatric Trauma Alert patients:

    Broward General Medical Center
    1500 S. Andrews Avenue
    Fort Lauderdale, Florida 33316

    Memorial Regional Hospital
    3501 Johnson Street
    Hollywood, Florida 33021

  1. RUN REPORTS
    The Fire Rescue/EMS provider issuing the "Trauma Alert" shall provide the trauma center (Adult or Pediatric) with information required under section 64J-2.002(5), F.A.C., as well as ensuring the timely delivery of a copy of the Patient Care Run report. In addition, the EMS crew will complete the County Unified Trauma Telemetry Report (CUTT) (see 1.10.1) for rapid transfer of patient information to Air Rescue and leave a copy of this report with the trauma center staff if utilized by respective EMS agency.
  2. TRANSPORT DEVIATION
    1. Any deviation from these Trauma Transport Protocols must be documented and justified on the patient-care incident report.
    2. Pre-hospital providers covered under these Uniform Trauma Transport Protocols are:

      American Medical Response American Ambulance Service
      Broward Sheriff's Office Fire Rescue Coral Springs Fire Rescue
      Dania Beach Fire Rescue Davie Fire Rescue
      Deerfield Beach Fire Rescue Fort Lauderdale Fire Rescue
      Hallandale Beach Fire Rescue Hollywood Fire Rescue
      Lauderhill Fire Rescue Lighthouse Point Fire
      Rescue Margate Fire Rescue Medics Ambulance Service
      Miramar Fire Rescue North Lauderdale Fire Rescue
      Oakland Park Fire Rescue Pembroke Pines Fire Rescue
      Plantation Fire Rescue Pompano Beach Fire Rescue
      Seminole Tribe Fire Rescue Sunrise Fire Rescue
      Tamarac Fire Rescue Miami-Dade Fire Rescue***

      (*** agency notified of TTPs but utilizing TTPs for Miami-Dade County only)