Reminder, while based an EMT guide, this is for roleplay, please do not use this as actual medical guidelines.
Treatment Procedure Guidelines
Agitation
Restrain if needed
Give IV Fluids
Give Midazolam or haloperidol
Agitation with Delirium
Restrain if needed
Give Ketamine
Amputation
A limb being removed during surgery is called ‘amputation’
A limb being removed due to an injury is called ‘traumatic amputation’
Airway, breathing, circulation
Hemorrhage Control
Pain Management
Rush to ER
Doctor Follow-Ups
Use proper anesthesia methods as needed
See surgical > understanding anesthesia
Ensure bleeding is under control / tourniquet
Wherever the amputation is located, the next joint area is going to be where the amputation will be closed off
Finger amputations could be any part of the finger up to the knuckle
The lower leg would be above or below the knee, etc.
See if there is enough skin to create a flap that will fit over the area once cleaned up
If not, create a skin graft, or use an artificial skin graft
Clean the area well of any debris, and remove any bones (if partial), bone shards etc.
Make sure any remaining joint being left behind is smooth. As is any surrounding bone. If not, file bone to make it smooth.
If tissues are damaged, cut away the tissue until it starts to bleed.
Bleeding tissue indicates living and healthy tissue. Then control bleeding.
Cut and seal all veins, arteries, and nerve endings.
Suture any tissues you can back together.
Ideally, you want to have enough tissue to make a layer of padding at the bottom of the stump. This is not always possible.
Close the stump area either with the leftover skin tissue, or a skin graft, suturing it closed.
Wrap it a ton.
Warning, amputations for the first few days can swell up to double their normal size, this is normal. Keep the bleeding under control and pain management.
Some Types of Artificial Skin Grafts
Biobrane
Epicel
Alloderm
Dermagraft
GraftJacket
TheraSkin
Epifix
Blood Pressure Stabilization
Airway, breathing, circulation
Give
Epinephrine
Stabilizes blood pressure
Opens airway
Increases heart rate
Increases blood flow
OR
Norepinephrine
if you only need to increase bp
These two drugs can be used together in cases of Septic Shock
Watch for confusion, altered state of consciousness
Use alertness scale
Check pupil reaction
Check head and neck for signs of trauma
Check to see if the patient is drunk, dehydrated, feverish, etc.
Document everything and transport them to the hospital
Burns - General
Airway, breathing, circulation
If evidence of possible airway burn, consider aggressive airway management
Stop the burning
Remove wet clothing if not stuck to patient
Remove jewelry
Leave blisters alone
Minimize burn wound contamination
Cover burns with dressings
Give oxygen and IV saline
Pain management and nausea medication
Keep patient warm
Burns - Topical Chemical Burn
Airway, breathing, circulation
Don the appropriate PPE
Remove the patient's clothing, if necessary
Contaminated clothing should preferably be placed in double bags
Pain management
Give oxygen
Give IV fluids
If dry chemical contamination
carefully brush off solid chemicals prior to flushing the site as the irrigating solution may activate a chemical reaction
If wet chemical contamination
flush the patient's skin (and eyes, if involved) with copious amounts of water or normal saline
For eye exposure
administer continuous flushing of irrigation fluid to eye — Morgan lens may facilitate administration
Carbon Monoxide / Smoke Inhalation
Remove patient from toxic environment
Monitor all vitals
Give 100% oxygen via a non-rebreather mask
Consider transporting patients with severe carbon monoxide poisoning directly to a facility with hyperbaric oxygen capabilities if feasible and the patient does not meet criteria for other specialty care (e.g., trauma or burn)CBRN - Chemical, biological, radiological and nuclear
CBRN - Chemical, biological, radiological and nuclear
Airway Respiratory Irritants
Don appropriate PPE — respiratory protection critical
Remove the patient from the toxic environment
Remove the patient's clothing that may retain gases or decontaminate if liquid or solid contamination
Flush irrigated effected/burned areas
Give oxygen and IV fluids
Give a nebulizer with albuterol and lpratropium
Pain management
Morphine sulfate or fentanyl
Irrigate eyes if needed with saline
Treat topical burns as needed
Maintain airway
Monitor vitals
Cyanide Exposure
Remove the patient from the environment
Keep the patient warm
Give oxygen
Get blood sample
Administer Hydroxocobalamin
There is no widely available, rapid, confirmatory cyanide blood test.
Nerve Agents
Don the appropriate PPE Gear
Remove the patient's clothing and wash the skin with soap and warm water
Give auto-injectors - atropine and pralidoxime chloride
Give Diazepam
Administer oxygen
CHEMPACK
Antidotes provided for EMS/Hospitals for rapid doses of antidote in cases of emergency.
EMS - autoinjectors - can treat 454 patients
Hospital - multidose vials and powders - can treat 1,000 patients.
Radiation Exposure
Don standard PPE capable of preventing skin exposure to liquids and solids
Gown and gloves
Face mask and eye protection
N95 mask or respirator
As long as a safety precautions like this are used, irradiated patients post no threat to medical clinicians
Treatment of life-threatening injuries or medical conditions takes priority over assessment for contamination or initiation of decontamination
Decontaminate patient and remove all contaminated clothing
Medications for internal contamination
Potassium Iodide (KI)
Prussian Blue
DTPA (Diethylenetriamine pentaacetate)
Medical Countermeasures for Radiation Exposure
Neupogen
Riot Control Agents
Remove contaminated clothing as able
Have the patient remove contact lenses if appropriate
Wash skin with soap and water
Rinse eyes with saline
Wash any glasses, jewelry, et with soap and water
Treat for respiratory distress and topical burns
Give oxygen
Childbirth
Airway, breathing, circulation
Assess the imminent delivery and transport to the hospital if possible
If a natural birth, support the infant's head as it comes out
Do not routinely suction the infant's airway during delivery
Gently guide the head downward to help the shoulder through, and then the rest of the body
After 1 min clamp the cord 5-6 inches from the abdomen between two clamps and cut the cord between the clamps
Dry, warm, and stimulate the infant, wrap in a towel and place on the maternal chest unless resuscitation is needed
After delivery, massaging the uterus (which should be located at about the umbilicus) and allowing the infant to nurse will promote uterine contraction and help control bleeding
Estimate maternal blood loss
Treat mother for blood loss as needed
Do not pull on the umbilical cord while the placenta is delivering
Secure newborn to mother and secure mother in ambulance, transport to hospital
Conducted Electrical Weapon Injury (i.e., TASER®)
Airway, breathing, circulation
Make sure the patient is safely restrained
Get an EKG
Leave barbs to be removed by physicians
Treat for any traumatic injuries
Doctor Follow-Ups
Reminder that these are the barbs
Barb Removal Process
Use a Probe Removal Tool
Probe Removal Tool Use
Place hand around area to stabilize skin
Slide the tool over the barbs to hook them to it
At a 90-degree angle, in one motion, pull the tool and remove barbs
Clean wound area
Probe Removal Tool Not Available
Same as above using pliers
Crush Injury / Crush Syndrome
Airway, breathing, circulation
Treat hemorrhage
Give IV fluids immediately
Use normal saline, NOT ringers solution
crush injury without adequate fluid resuscitation develops into crush syndrome
If the patient has been trapped for a long time
Add sodium bicarbonate
Monitor vitals
Pain control
Morality causes
Immediate
Severe head trauma
Asphyxia
Torso injury with internal damage
Early
Sudden release of a crushed extremity may result in reperfusion syndrome
Shock
Late
Kidney injury via toxins being released from injured muscle cells
Hemorrhage
Sepsis
Doctors:
Monitor for the need for Burn Escharotomy
Escharotomy is usually done within the first 2 to 6 hours of a burn injury. Unlike fasciotomies, where incisions are made specifically to decompress tissue compartments, escharotomy incisions do not breach the deep fascial layer.
Diabetic Coma
Airway, breathing, circulation
Give Glucagon shot
Rapidly raises blood sugar
An IV with added dextrose does the same thing
Drowning
Airway, breathing, circulation
CPR will naturally push air out of the lungs
Put in c-spine Collar
Roll on their side/recovery position to keep from choking if they throw up
Give Oxygen
Consider CPAP in awake patients with respiratory distress
If needed treat for hypothermia
Monitor vital signs
Transport to hospital and observation for Dry/Secondary Drowning
This is mandatory if the patient has at any point lost consciousness, even if they have regained consciousness.
Dry Drowning / Secondary Drowning
Secondary drowning is the result of injuries obtained during drowning, usually when the lungs fill with water
Airway, breathing, circulation
The patient must be monitored for a full 8 hours
Symptoms usually show within an hour
Difficulty breathing or speaking
Irritability or unusual behavior
Coughing
Chest pain
Low energy or sleepiness
Monitor airway
Give oxygen
Give IV fluids
Give dopamine
Xray to rule out water in the lungs
Nasogastric tube placement can be used for removal of swallowed water and debris.
Bronchoscopy may be needed to remove foreign material, such as aspirated debris or vomitus plugs from the airway.
Electrical Injuries
Monitor cardiac outcome
Identify all sites of burn injury
Electrical burns are often full thickness and involve significant deep tissue damage, and there may be multiple burn sites
Assess for potential compartment syndrome from significant extremity tissue damage
Identify dysrhythmias or cardiac arrest
Apply spinal motion restriction if associated trauma suspected
Apply dry dressing to any wounds
Remove constricting clothing and jewelry since additional swelling is possible
Give IV fluids
Pain Management
Transport to a burn center
Facial / Dental Trauma
Airway, breathing, circulation
If breathing is compromised due to damage, see Respiratory Airway Management
Administer oxygen
If needed give IV
Pain control
Eyes
If needed place eye shields over the eye or eyes to protect them.
If the eye is removed, do not put it back into the socket. Cover with saline dressing and transport asap.
Cover an injured eye with moist saline dressing and place a cup over it, taping it into place.
Mouth and Nose
Have suction available if the patient can’t use their mouth
Put protective sterile dressings over major lacerations
Transport sitting upright if possible
Any dislocated tissues
Wrap in dry sterile gauze
Put in a plastic bag
Put that bag in another bag of ice to transport
Fluids
IV types
IV Solutions
Hextend (Blood Volume)
Hypertonic Saline (Blood Volume)
Ringer’s Lactate (Blood Volume)
Various dilutions of normal saline
Potassium Chloride in 5% Dextrose (Electrolyte/Hydration)
Normosol -R (Electrolyte/Hydration)
Plasma-Lyte 148 (Electrolyte/Hydration)
Can include
Plasma
Blood Transfusions
Gastroenteritis / Nausea
Airway, breathing, circulation
Treat for nausea
Mild Nausea
Have the patient inhale the vapor from an alcohol wipe for 15 mins
Major Nausea
Give ondansetron
Head Trauma
Airway, breathing, circulation
Maintain cervical stabilization
Give oxygen
Maintain airway
Control bleeding
Give IV with Ringers Solution
Evaluate mental state
Transport to hospital
Patients with penetrating injury to the neck should not be placed in a cervical collar or other spinal precautions regardless of whether they are exhibiting neurologic symptoms or not. Doing so can lead to delayed identification of injury or airway compromise and has been associated with increased mortality
Head trauma needs to be immediately treated by doctors as this can range from minor concussion to fatal brain bleeding or pressure.
Heart Attack
Airway, breathing, circulation
Have the patient chew 2 tablets of aspirin
Give nitroglycerin
Transport to the hospital while maintaining vitals and treating as needed
Hyperglycemia
Airway, breathing, circulation
Check mental state
Check glucose level
Give IV Saline and calcium chloride
If potassium is too high:
Add sodium bicarbonate to IV
Give a nebulizer with albuterol
Can release patient if feeling better afterward
Hyperthermia / Heat Exposure
Basic Treatment
Airway, breathing, circulation
Move the victim to a cool area and shield from the sun or any external heat source
Remove as much clothing as is practical and loosen any restrictive garments
Give sips of cool liquids
Manage airway and vitals
Give IV with cool fluids
Active Cooling
If body temp is greater than 104°F (40°C) or altered mental status
Ice bath immersion provides the most rapid cooling mechanism
If that is not possible
use a tarp with fans
rotate ice water-soaked towels or sheets
Continuously mist exposed skin with tepid water whale fanning skin
Ice packs can be used but are less effective than evaporation
If shivering starts, and is preventing the individual from cooling down
Give midazolam
Do NOT apply wet cloths or wet clothing as they may trap heat and prevent cooling
Cooling efforts should continue until the patient's temperature is less than 102.2°F (39°C) or, if continuous temperature monitoring is not available until the patient demonstrates improvement in mental status
Stages:
Heat Cramps:
are muscle cramps usually in the legs and abdominal wall. Patient temperature is normal
Heat Exhaustion:
has both salt and water depletion usually of a gradual onset. As it progresses tachycardia, hypotension, elevated temperature, and very painful cramps occur. Symptoms of headache, nausea, and vomiting occur. Heat exhaustion can progress to heat stroke
Heat Stroke:
occurs when the cooling mechanism of the body ceases due to temperature overload and/or electrolyte imbalances. The patient's core temperature is usually greater than 104°F. When no thermometer is available, it is distinguished from heat exhaustion by an altered level of consciousness, seizures, or coma
Heat Syncope:
transient loss of consciousness with spontaneous return to normal mentation, attributable to heat exposure
Hypoglycemia
Airway, breathing, circulation
Administer glucose orally
If the patient is unconscious
Give IV and Dextrose
Can release patient if feeling better afterward
Hypothermia / Cold Exposure
Airway, breathing, circulation
Maintain airway
Follow Field Rewarming Techniques
Remove patient from environment
Field Rewarming Techniques
Remove any wet clothing and dry skin
Cover patient and try to keep them warm
Use items such as Rescue Blanket
Provide drinks and food with glucose if the patient is awake and responsive
Use heat packs, or heat blankets, or forced air warming blankets
IV fluids with warmed fluids
Moderate or severe hypothermia:
Core temperatures can be measured by esophageal probe
Manage airway
Use field rewarming techniques
Attempt to keep the patient in the horizontal position, especially limiting motion of the extremities to avoid the increasing return of cold blood to the heart
Once in a warm environment, clothing should be cut off (rather than removed by manipulating the extremities)
IV and warmed fluids
Transport to hospital
Frost bite:
If the patient has evidence of frostbite avoid rewarming of extremities until definitive treatment is possible.
Additive injury occurs when the area of frostbite is rewarmed and then inadvertently refrozen.
Only initiate rewarming if refreezing is preventable
If rewarming is feasible and refreezing can be prevented, use circulating warm water (37°–39°C/98.6°–102°F) to the affected body part
Thaw the injury completely. If warm water is not available, rewarm frostbitten parts by contact with nonaffected body surfaces.
Do not rub or cause physical trauma
After rewarming
cover injured parts with loose sterile dressing.
If blisters are causing significant pain, and the clinician is so trained, these may be aspirated, however, should not be de-roofed.
Pain management
Scrotal Trauma
Circulation, Airway, Breathing
Get any bleeding under control
Pain management
Assess the damage, what kind, and the location of damage
Doctor Follow-Ups
Check for urethra damage
Check damage to the skin and tissues
Surgical intervention if needed
If needed, surgical removal of the testicle or testicles is called an orchidectomy.
If anything was removed from injury due to trauma, it’s called traumatic amputation
Seizures
Airway, breathing, circulation
Roll the patient on their side and wait for convulsions to stop.
NEVER put anything in a patient’s mouth when they are having a seizure.
Administer oxygen
Give IV, add Diazepam
If the patient is in the third trimester of pregnancy
Give magnesium sulfate
Shock
Airway, breathing, circulation
Check and monitor vitals
Administer Oxygen
Give IV or (IO if needed)
Give Norepinephrine
If not responsive to norep., give epinephrine
Spinal Care
Airway, breathing, circulation
Assess injury
Determine if the patient needs either a cervical collar, or full restriction
Patients with penetrating injury to the neck should not be placed in a cervical collar or other spinal precautions regardless of whether they are exhibiting neurologic symptoms or not. Doing so can lead to delayed identification of injury or airway compromise and has been associated with increased mortality
Cervical collar
Midline neck or spine pain or tenderness
Altered mental status
Alcohol or drug intoxication
Another severe or painful distracting injury
Full restriction
Unable to move fingers/toes, or feel body
High-risk injuries
Falls greater than 10 feet
Motor vehicle crashes, especially via a motorcycle, or off-road vehicle
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