*Sample 6-50*

*(Note: This SOP contains some intricate clinical information. For
additional clinical information or clarification, you may contact Dr.
Margie Scott or Dr. Linda H. Williams via the VA Global Address in
Outlook, or your local trauma/ER specialist.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Trauma Management in a Mass Casualty Event - All Hazards
Considerations**

1\. ***Description of the Threat/Event***.

> a\. **Trauma and the Mass Casualty Incident (MCI) in the US.** Many
> physicians throughout the U.S. treat trauma-related injuries daily.
> However, relatively few health care providers have managed a mass
> casualty event with multiple trauma victims. Even fewer US providers
> have been involved in a MCI with overwhelming numbers of living
> victims. Such numbers would have occurred in this country on September
> 11, 2001 if injuries rather than fatalities had resulted. Even greater
> casualties could occur if a tsunami similar to the devastating one of
> December 2004 in the Indian Ocean, which killed approximately 226,000
> in Asia, were to strike the US coastline. The rapid surge of victims
> that can occur following a MCI was illustrated in the Madrid bombings
> of March 2004, when 272 patients were received within 2.5 hours by the
> closest hospital.
>
> Either non-natural (such as terrorism) or natural phenomena may result
> in a MCI with multiple trauma victims. Terrorists frequently select
> explosives as their weapon of choice. According to statistics of the
> Federal Bureau of Investigation, bombing was involved in 209 (65.7%)
> of the 318 terrorist events investigated from 1980-2005. In the US,
> skills in the diagnosis, treatment, and management of blast injuries
> from bombs and explosive events are usually limited to those
> practitioners with military experience. Natural disasters such as
> earthquakes, hurricanes, tornados, tsunamis, and others may result in
> hundreds to tens-of-thousands of trauma victims. A comparison of
> photographic documentation of terrorist bombings with natural
> disasters, industrial chemical accidents, or nuclear accidents quickly
> reveals their similarities, indicating that trauma is highly probable
> in all such events. As the population density in certain areas of the
> country increases, the possibility of overwhelming numbers of trauma
> casualties in a disaster is rising. The risk of terrorism is also
> increasing. Thus, the national capacity to manage events with trauma
> patients must increase as both the risk of terrorism and the
> population density in the United States increase.
>
> An MCI is any event in which the number of patients and the severity
> of injuries exceed the resources of the healthcare facility. The
> imbalance of needs to resources may be due to the large number of
> patients, to the number or severity of the injuries, to limited
> equipment, supplies or staff, or to the presentation of victims with
> conditions beyond the medical capability of staff. During usual daily
> events, accurate Emergency Medical Service (EMS) pre-hospital triage
> and transport of trauma victims to the hospital of the appropriate
> trauma level for definitive trauma care mitigate this problem.
> However, in a true mass casualty event, all appropriate trauma
> treatment facilities may be completely overwhelmed and other
> healthcare facilities that do not routinely provide trauma care may
> receive victims out of dire necessity.
>
> Additionally, non-trauma hospitals may receive trauma patients through
> self-referral, delivery by privately owned vehicle, and by default
> when transportation routes to the usual sites of trauma care are
> blocked. Thus, these non-designated facilities will become de facto
> triage and emergency treatment areas. Arrivals must not be denied life
> saving measures simply because the facility is not designated as a
> Trauma facility, but must receive emergency care and stabilization
> until transport to the appropriate site is possible. Although this SOP
> addresses such a contingency, the victim should **not** be transported
> to a non-trauma or lower level facility when access is available to an
> appropriately designated facility or a facility with more appropriate
> resources. Activation of this SOP will occur primarily in response to
> a Mass Casualty Incident. (*Note to Writer: Refer to the sample Mass
> Casualty Incident SOP in the Emergency Management Program Guidebook,
> Section 6.*)
>
> This sample Trauma SOP is a component of the sample Trauma Readiness
> for All-Hazards Disaster Response (TRADR) Plan, which is a component
> of the VA Medical Center (VAMC) Emergency Management Plan (EMP). The
> VAMC Emergency Operating Plan (EOP) uses the Incident Command System
> (ICS), and implements the Trauma SOP for any specific disaster that is
> likely to involve mass casualty trauma victims.
>
> b\. **Goal of Trauma Care and the Critical Timing of Intervention**.
> An effective trauma response plan has the primary goal of reducing the
> morbidity and mortality of injured victims through timely provision of
> the most appropriate care available. Achieving this goal requires
> rapid stabilization of the patient by providing safe and effective
> treatment at the earliest possible time, with maximum efficiency of
> patient transfer and transport to an appropriate facility for
> definitive care.
>
> Following acute trauma, three peaks in death occur. The first peak
> occurs within seconds to minutes following the trauma, and salvage of
> the victim is unlikely due to the severity of injury. The second peak
> in deaths occurs within the next few minutes to two to three hours
> following the trauma and is the primary focus of acute intervention.
> The third peak in deaths occurs between three and five weeks
> post-trauma. Rapid intervention can significantly mitigate the second
> peak through the immediate saving of life, and has given rise to the
> concept of the "golden hour" of trauma care delivery. Effective rapid
> trauma intervention may also reduce the delayed third peak in deaths
> by reducing the time spent in hypotension-related organ hypo-perfusion
> that leads to delayed organ failure and by reducing the risk of
> infection.
>
> To achieve these goals the plan must incorporate effective internal
> and external communication pathways. The VAMC utilizes the ICS to
> affect these communication pathways. Ongoing local needs analysis and
> situation status reports enhance the efficiency of the response.
>
> VAMC facilities must have trauma response policies in place
> authorizing rapid implementation of appropriate measures by the
> appropriate staff to a potential or actual event. A community
> emergency department communication system, with a pre-event Memorandum
> of Understanding (MOU) between all community medical facilities and a
> well-developed community-transfer coordination center are essential in
> achieving the maximum patient outcome from a community or larger mass
> casualty event.
>
> c\. **Characteristics of Trauma and Event Mitigation**. Important
> characteristics of trauma include the mechanism of injury; the
> severity, type and extent of injury; prior health status or special
> characteristics of the victim (i.e., pregnancy, pediatric or geriatric
> patient, pre-existing disabilities, underlying medical conditions,
> etc.), and wound contamination.
>
> Management of an event with multiple trauma victims necessitates an
> understanding of the epidemiology of patient presentation. The
> availability of effective trauma response protocols will serve as a
> major mitigation strategy. Sufficient personnel and equipment, along
> with the availability of decontamination, and an understanding of
> indications for decontamination, are critical to a safe and effective
> response plan. A cooperative response plan including the Medical
> Center surgical team, emergency department providers, primary care and
> medical providers, along with clinical leadership, hospital
> administration and clinical support services working together as a
> team, make an effective trauma response plan possible.
>
> In an event requiring activation of the TRADR Plan, an extensive
> internal communication network is needed. This network must include:
> the hospital Director, Police, Chief of Staff, Chief of the Emergency
> Department, Chief of Surgery and surgical subspecialty chiefs, Chief
> of Anesthesiology, Operating Room personnel, Chief of Medicine, Blood
> Bank and Clinical Laboratory personnel, Radiology personnel, Chaplain
> Service, Social Work Service, Acquisition and Materiel Management
> Service, Public Affairs Officer, hospital Safety, Engineering and
> Environmental Management Services.  Indeed, all other clinical and
> administrative service chiefs and healthcare providers will probably
> be needed. External notification will include the Network Director,
> and may include the Federal Bureau of Investigation (FBI) field
> office, the American Red Cross Blood Bank, burn centers and organ
> transplantation affiliates.
>
> Commitment to periodic disaster preparedness drills is necessary to
> assure operative capability. The use of both mini-drills to refine
> components of the plan and major full-scale drills to test program
> effectiveness will promote improvement in readiness and response
> capacity. In addition, encouragement of participation by physicians
> and nurses in specific training in trauma management will improve the
> ability to minimize morbidity and mortality in such events.
>
> Skillful dissemination of information will enhance the community
> response and reduce panic. Thus, pre-event training in risk
> communication is helpful. On-going communication with other local
> medical facilities will be necessary to ensure appropriate transfer of
> the victims at the proper time and best utilization of beds available
> within the community.
>
> d\. **Psychological Aspects of Trauma**. The personal response to an
> event involving trauma is likely to be one of anxiety, fear and panic,
> although this has been debated. The psychological management of
> patients, staff, family and members of the community is pivotal in
> reducing long-term effects of psychological stress. (*Note to Writer:
> Please refer to further discussion of this in the sample TRADR
> Readiness Plan in the Emergency Management Program Guidebook, Section
> 7*. Further information is also available through the CDC at
> <http://www.bt.cdc.gov/masscasualties/copingpub.asp>.)
>
> e\. **Trauma and Contamination**. Whenever patients present from a
> mass casualty incident, the possibility of terrorism with secondary
> contamination must be considered. Appropriate inquiry upon initial
> facility contact regarding a potential event and by appropriate
> inquiry and screening at the point of perimeter entry upon arrival of
> victims will facilitate identification of potential contamination.
> Signs of involvement with a chemical event may include:

-   Notation of chemical warning placards or identifiers in the vicinity
    of the event.

-   Characteristic or peculiar odors in the vicinity.

-   The sudden onset of symptoms and signs not related to the trauma.

-   Notation of dead birds/animals/foliage in a pattern that would not
    be anticipated from the event itself.

-   Other victims presenting with a cluster of similar signs and
    symptoms who were not close enough to be involved in the trauma.

> Signs of involvement in a radiation event include:

-   Patients presenting with a cluster of symptoms that may include
    nausea and vomiting, diarrhea, red skin, headache, confusion and
    fever.

-   Notation of radiation warning symbols in the area.

-   Contact with or observation of a metal cylindrical object or objects
    in the area, especially objects noted to be excessively warm but
    without an apparent source of the heat.

> Radiation screening at the point of perimeter entry with a standard
> radiation survey meter will aid in early identification of
> contamination with radioactive material. (*Note to Writer: Please
> refer to Section 7 in the Emergency Management Program Guidebook for
> further information on decontamination, biological, chemical and
> radiological event detection and management*.)
>
> When the trauma victim is contaminated with chemicals, decontamination
> takes precedence over treatment to avoid contamination of personnel
> and the facility, which may result in the facility being unavailable
> for reception of patients. When the trauma occurs from an incident
> involving radioactive materials, treatment of traumatic injuries
> [always]{.underline} takes precedence over concerns about radiation.
> This SOP is intended to cover the aspects of such an event that is
> related to trauma. \[*Note to Writer: Please refer to the sample
> Radiological Event and Terrorism Readiness Plan and sample Trauma
> Readiness for All-Hazards Disaster Response Plan in Section 7 of the
> Emergency Management Program Guidebook for management of these
> additional problems*.\]
>
> Factors that must be considered in implementation of the response plan
> include:
>
> • How many victims are involved?
>
> • What is the type of event and the commonly associated injuries? (See
> Attachments A, B and C.)
>
> • Is it likely from the estimated number of victims that the VAMC will
> need to receive trauma victims and provide emergency care and
> stabilization until another facility can accept them for definitive
> care or until the definitive care can be made available at the VAMC?
>
> • Are the involved victims also contaminated?
>
> • If victims are contaminated, what is the contaminant?
>
> • What victim-specific factors must be considered? Is a special
> population involved, such as infant, pregnant, elderly or frail
> victims, etc?
>
> The number of victims and mechanism of injuries (i.e., degree of
> explosive force if blast involved) will be the prime determinant of
> the extent of response required. An MCI (such as a transportation
> accident involving explosive materials, detonation of an improvised
> nuclear weapon or the structural collapse of a stadium during a
> tornado) may require activation of the facility and community disaster
> plans.
>
> f\. **Legal Aspects of an MCI with Trauma**. The importance of
> maintaining the legal chain-of-custody in these procedures must be
> recognized. (*Note to Writer For additional information, please refer
> to the sample Chain-of-Custody Readiness Plan, Section 7 in the
> Emergency Management Program Guidebook*.) Exclusions to the Emergency
> Medical Treatment and Active Labor Act (EMTALA) may apply when an
> MCI/disaster has occurred.

2\. ***Impact on Mission Critical Systems***. A mass casualty incident
with trauma may quickly overwhelm several mission-critical systems
including staffing, critical supplies (i.e., ventilators, blood supply,
antibiotics) and operational space.  If the incident is due to terrorism
and contamination is involved, all the risks related to the type of
contamination must be mitigated. (*Note to Writer: Please refer to the
appropriate sections of the Emergency Management Program Guidebook when
contamination is involved*.) 

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event***.  The facility Emergency Medical Response Team
(EMRT), or equivalent, should be a component of the TRADR Plan. Use of
the all-hazards approach to disaster management, with screening for
chemical and radiation contamination in any potentially deliberate
incident, should be considered. The Radiation Safety Officer (RSO) is a
critical member of the team responding to an incident involving
radiation, and involvement with the existing facility disaster- response
team rather than establishing a separate team should be considered.

4\. ***Responsibilities***.

> • *Medical Center Director or Designee i*s responsible to act as the
> Incident Commander/Manager (IC), and is responsible for all VAMC
> response planning and actions.
>
> • *Emergency Program Coordinator (EPC)* is responsible to ensure that
> the EOP is current, assists the IC with internal (Key Operations
> Managers) and external (community or agency) coordination.
>
> • *Chief of Staff* is responsible for providing proper medical, health
> and treatment care services. 
>
> • *Associate Director* is responsible for monitoring and ensuring VAMC
> operations and services as they relate to patient services are
> implemented.
>
> • *Emergency Department Director* (EDD*)* is responsible for ensuring
> Emergency Department personnel are familiar with the TRADR Plan and
> SOP, and participate in trauma-related educational endeavors and
> drills to assure ability to respond to an MCI with trauma. The EDD
> also has a key role in developing and maintaining functional trauma
> procedures/protocols in conjunction with Chief of Surgery for an MCI
> with trauma.
>
> • *Emergency Room Personnel* have key roles in patient reception,
> triage, stabilization, treatment and disposition. They also have a key
> role in ensuring that all other medical emergency capabilities (i.e.,
> cardiac emergencies) are maintained and operational.
>
> • *Chief of Surgery* is responsible for developing and maintaining
> functional trauma procedures/protocols in conjunction with the
> Emergency Department Director.
>
> • *Chief of Anesthesiology/Anesthesiology Staff* are responsible for
> providing supportive services to assist with intubation and airway
> access, intravenous access and anesthesiology services as indicated.
>
> • *Chief of Medicine* is responsible for assuring ongoing patient
> care, providing appropriate medical services as needed in support of
> patients from the event, for collaborating with the Emergency
> Department Director and Chief of Surgery as needed to assure optimum
> patient support. 
>
> • *Medical Service* has a key role in clinical care of patients in
> conjunction with Surgery Service to assure timely and appropriate
> stabilization and treatment of patients. This service also has a key
> role in maintaining continuity of patient care operations and
> monitoring clinical patient workload. An additional key role is in
> identifying clusters of clinical signs or symptoms that could indicate
> exposure to a chemical, biological or radioactive contaminant in the
> incident.
>
> • *Chief of Nursing/Nursing Service has a key* role in tracking
> patient census, staffing utilization and need for additional staff.
> Another key role is to encourage nursing staff in educational
> endeavors on trauma management.
>
> • *Chief of Radiology/Radiology Staff* are responsible for providing
> radiological support services. In a MCI with trauma, the number of
> functional x-ray machines and the rate of processing may be the
> limiting factor in the processing of victims. Interventional Radiology
> services will probably be needed to assist with line placement and
> diagnostic testing. CT, MRI, and Ultrasound services will have key
> roles in patient assessment.
>
> • *Infection Control Team* will have a key role in providing
> information as needed, for healthcare providers, employees and
> patients regarding concerns related to infection control, with
> emphasis on exposure to blood and body fluids.
>
> • *Clinical Laboratory* plays a key role in collection and analysis of
> biological specimens as needed to support clinical care. Blood Bank is
> responsible for providing type and cross matching and blood components
> as indicated.
>
> • *Safety Officer* is responsible for monitoring and initiating
> actions to ensure safe actions are taken during the emergency event.
>
> • *Safety Officer/Industrial Hygienist* - When potential or actual
> contamination is involved, key role as the point of contact with
> HAZMAT agencies in substance sampling or environmental sampling. Key
> role in monitoring and proper use of specialized PPE resources as
> needed.
>
> • *Public Affairs* will act as the point of contact for the media and
> other governmental agencies that may request information concerning
> the incident and its impact upon patients, staff and facility.
>
> • *Police Chief* ensures that lockdown and police procedures such as
> traffic and crowd control, crime scene and investigation, and
> perimeter control are implemented.
>
> • *Police Service* is responsible for perimeter control and incident
> site access. Police Service also has a key role in maintaining
> chain-of-custody for all potential evidence during investigation of
> potential terrorist events when the event occurs within the VAMC or
> when victims of the incident enter the VAMC.
>
> • *Occupational/Employee Health* has a key role in monitoring
> occupational health conditions/risks and employee concerns and
> prophylactic therapy as needed. An additional role is tracking and
> providing care and documentation for any employee exposed to blood or
> body fluids.
>
> • *Chief Engineer* is responsible for protecting, repairing and
> maintaining plant utility systems, communications and medical
> equipment necessary for patient care and VAMC operation.
>
> • *Chief A&MMS* is responsible for logistical function as it relates
> to providing facilities, transportation, supplies, equipment,
> services, etc.
>
> • *Chief Fiscal* is responsible for providing funding and tracking
> expenses that relate to VAMC response to the emergency event.
>
> • *Social Work is responsible for* coordinating information between
> victims and their significant other and family.
>
> • *Chaplain* has a key role in providing spiritual counsel and comfort
> to the victims and their significant other and family, with special
> emphasis on those victims who are terminal.
>
> • *Human Resource Management* has a key role in a Mass Casualty
> Incident involving the community, to provide information to
> significant others or family of workers on site and acts as liaison
> during an extended event in coordination with Public Affairs.

5\. ***Mitigation/Preparedness Activities for the Threat/Event***.

> a\. *Hazard Reduction Strategies and Resource Issues*. N/A.
>
> b\. *Preparedness Strategies and Resource Issues*. Develop a basic
> capability to organize a response to an MCI with trauma. Pre-event
> education and planning may include:
>
> 1\) Staff Training:  Train staff on the principles of trauma
> management (e.g., triage, first aid, stabilization and emergency
> treatment of the trauma victim, appropriate transfer and transport,
> and psychological, ethical and legal issues) and on recognition of
> symbols indicating hazardous materials.
>
> 2\) Provider Training: Encourage providers to pursue training in
> trauma management through recognized courses, such as:
>
> a\) Advanced Trauma Life Support for Doctors (American College of
> Surgeons).
>
> b\) Advanced Trauma Course for Nurses (Society of Trauma Nurses).
>
> c\) Pre-hospital Trauma Life Support course (National Association of
> Emergency Medical Technicians).
>
> d)    Advanced Burn Life Support Pre-Hospital Course
> (<http://www.ameriburn.org/ABLSCourseDescriptions.htm>.
>
> e\) Advanced Disaster Life Support.
>
> f\) Basic Disaster Life Support.
>
> g\) Community Emergency Response team (CERT) Training (Federal
> Emergency Management Association).
>
> h\) Transport Nurse Advanced Trauma Course (Air & Surface Transport
> Nurses Association)
>
> 3\) Protocol Development: Encourage development of appropriate
> cooperative inter-departmental protocols for management of
> overwhelming numbers of patients from an MCI with trauma.
> Determination of which screening and assessment tools the facility
> will have available for use for rapid patient intake, assessment and
> tracking prior to an event is important. Appropriate training must
> follow protocol development.
>
> 4\) Development of lists of closest referral centers (local, regional,
> state and national) and their referral procedures:
>
> a\) Trauma centers.
>
> b\) Burn centers.
>
> c\) Micro-vascular replantation centers.
>
> d\) Dialysis centers.
>
> 5\) MOU and Mutual Aid: Encourage development of appropriate
> Memorandum of Understanding for mutual aid with area healthcare
> facilities. Participate with the Emergency Medical Transport Services
> and community healthcare facilities in community-wide drills with
> simulated patients.
>
> 6\) Contingency Provider Resource Development: Encourage development
> of appropriate policies and procedures to allow development of a
> contingency list of surgeons trained in trauma in the community who
> would provide services in the facility on an emergency basis in the
> event of an MCI with trauma. Develop the list; obtain their
> credentials; and maintain them up-to-date.
>
> 7\) Equipment Readiness: Have ready the basic equipment that may be
> necessary (e.g., command vests, signage, forms/tags, backboards, crash
> cart, oxygen, ventilators, IV fluids, thoracotomy trays, chest tubes,
> cricothyroidotomy kits, Dopplers, ultrasound units, etc.). Pre-stocked
> disaster/trauma carts are helpful.

6\. ***Response/Recovery from the Threat/Event***.

> a\. *Hazard Control Strategies*:  Preparation for Patient Arrival and
> Reception.
>
> 1\) Receive/Verify Notification: Receive and confirm the information
> that an MCI with multiple trauma victims has occurred by a callback to
> the source, unless the source is verified at the time the call is
> received.
>
> 2\) Provide Internal Notification: Alert the VAMC Director, Police,
> Chief of Staff, Chief of the Emergency Department, Chief of Surgery
> and surgical subspecialty chiefs, Chief of Anesthesiology, Operating
> Room personnel, Chief of Medicine, Chief of Nursing, all other
> clinical and administrative service chiefs, healthcare providers,
> clinic supervisors, Blood Bank and clinical Laboratory personnel,
> Radiology personnel, Infection Control, Chaplain Service, Social Work
> Service, Acquisition and Materiel Management Service, the Public
> Affairs Officer, hospital Safety, Engineering and Environmental
> Management Service to prepare for the arrival of casualties. If the
> event could be terroristic, then include the Radiation Safety Officer
> in the responding personnel.
>
> 3\) Facility Lockdown and Restricted Access: Alert Police to establish
> traffic and access control procedures, including facility lockdown,
> when appropriate.  If contamination is considered possible or if it is
> an intentional act, consider activation of the hospital
> decontamination program and include the include the Radiation Safety
> Officer until contamination can be ruled out.
>
> 4\) Staff Briefing: Brief the nurses and other involved personnel on
> the anticipated arrival of trauma victims. The physicians most
> skilled/experienced in trauma and emergency medicine at the facility
> should report to the Emergency Department, and roles clarified.
>
> 5\) Designate Triage and Treatment Areas: Prepare the areas by having
> pre-stocked disaster or trauma treatment carts delivered to the area.
> Each designated Treatment Area should have equipment prepared and
> ready to use to allow proper airway access such as laryngoscopes, ET
> tubes, LMA and/or Combitubes. Crash carts, oxygen, IV fluids (warmed
> Ringer's lactate or Normal Saline), thoracotomy trays, chest tubes,
> cricothyroidotomy kits and Dopplers should be immediately available.
> If radiation-contaminated victims are likely, then prepare an area for
> stabilization prior to decontamination (see appropriate sections on
> management of radiation emergencies in Sections 6 and 7 of the
> Emergency Management Program Guidebook).
>
> b\. *Patient Reception*.
>
> 1\) General Triage: Triage, the sorting of victims according to the
> severity of injury and need for treatment, will have been initiated in
> the pre-hospital setting if the patient is transported by Emergency
> Medical Service transportation. However, many victims arrive by
> private conveyance and have not received any medical screening. All
> patients will need to receive triage immediately upon arrival; repeat
> triage for those arriving by medical transport, and initial triage for
> the others. This should not take over 1 minute per patient. The triage
> method and tagging system used may vary according to local facility
> practices. (*Note to Writer: Refer to sample Trauma Readiness for
> All-Hazards Disaster Response Plan, Section 7 of the Emergency
> Management Program Guidebook*.)
>
> An understanding of the "upside down" presentation of disaster victims
> is necessary to avoid delay in attention to critical arrivals that may
> result from early congestion of treatment rooms by the "walking
> wounded." In a mass casualty incident, the less severely injured will
> present themselves initially to the closest hospitals at which they
> can obtain care, with subsequent arrival of the more severely injured.
> Plans must be in place to anticipate these later arrivals with greater
> injuries, and provide appropriate access to the needed level of care.
>
> 2\) Prioritization of Patients: Patients triaged as Immediate should
> be transported directly to the prepared treatment areas and the
> Primary Survey performed. Patients triaged as Urgent should be
> monitored with close observation and ongoing reassessment for
> destabilization and the need to redesignate their status.
>
> 3\) Estimation of Casualties for Needs Assessment: Following an event
> that involves blast trauma, approximately half of the initial
> casualties are expected to seek medical care within the first hour.
>
> c\. *Patient Stabilization and Treatment*. A general principle to
> follow with [all]{.underline} trauma patients is that continued
> re-evaluation of the patient is necessary to identify all injuries.
> Regardless of the type or mechanism of injury, the following
> sequential approach is helpful in assuring the most rapid provision of
> optimum care:
>
> 1\) Primary Survey: The following sequential assessment, which may be
> performed simultaneously, constitutes the Primary Survey. During the
> primary survey, **life-threatening conditions are treated when they
> are identified**.
>
> A Airway establishment/maintenance with cervical spine protection.
>
> B Breathing and ventilation.
>
> C Circulation and Control of hemorrhage:

-   Level of consciousness (LOC).

-   Skin color.

-   Pulse.

> D Disability/Neurological status.
>
> E Exposure and Environmental Control.
>
> Specific points to note regarding the Primary Survey:
>
> a\) Any patient with multi-system trauma should be assumed to have a
> cervical spine injury, and the neck must be stabilized and remain so
> until ruled out with cervical spine x-rays. These x-rays may be
> obtained as soon as life-threatening conditions have been sufficiently
> stabilized. Cervical Spine X-rays or other imagings are required
> unless the history is not suggestive of neck trauma. The neurological
> examination alone will [not]{.underline} exclude a cervical spine
> injury.
>
> b\) Airway compromise: Adequate speech usually indicates adequate
> airway patency; this can deteriorate, so reassessment is mandatory.
>
> c\) Assess the airway for foreign bodies, ENT fractures.
>
> d\) Auscult the chest for adequacy of ventilation. Percuss the chest
> for evidence of pneumothorax (increased resonance) or internal
> bleeding (dullness).
>
> e\) Inspect the chest visibly and by palpation for flail chest, rib
> fractures, major hematomas.
>
> f\) Identify and control external hemorrhage in the primary survey.
> Assume low blood pressure indicates blood loss until this is ruled
> out. Signs which may indicate significant hypovolemia include:
>
> Reduced LOC.
>
> Ashen, grey, or white skin.
>
> Loss of femoral or carotid arterial pulses.
>
> Loss of peripheral pulses.
>
> Rapid thready pulse (other etiologies also).
>
> g\) Control visible hemorrhage with direct pressure on the wound
> and/or primary pressure points. Do [not]{.underline} use tourniquets
> except in extreme cases such as traumatic amputation; they promote
> tissue loss.
>
> h\) Rapid Neurological Examination:
>
> • Mental Status: AVPU ([A]{.underline}lert, [V]{.underline}erbal,
> [P]{.underline}ain response, [U]{.underline}nresponsive).
>
> • Consider performance of the Glasgow Coma Scale (GCS), this may be
> deferred to the Secondary Survey. (See Attachment D.)
>
> • Check pupillary size, reactivity and equality; check for
> lateralizing signs, and check for spinal cord injury level. If closed
> head injury has occurred, frequent reassessment [is
> necessary]{.underline} with rapid consultation with a Neurosurgeon if
> neurological level deteriorates.
>
> i\) Exposure: Clothing should be entirely removed from each patient
> and a quick but thorough head-to-toe front and back examination for
> injuries performed.
>
> j\) Environmental Control: Hypothermia is a major life-threatening
> risk to trauma patients. Use warming blankets with attention to the
> warming of infusing solutions in most situations.
>
> k\) Patient factors may obscure appropriate diagnosis (i.e., Beta
> Blockers may mask tachycardia as a sign of blood loss).
>
> 2\) Trauma Resuscitation: Follow standard treatment practices for the
> resuscitation of the trauma patient. Specific points include:
>
> a\) Provide supplemental oxygen to all patients with significant
> trauma.
>
> b\) Establish a definitive airway if maintenance of airway integrity
> is in question or the level of consciousness is reduced with a risk of
> aspiration, with caution to [maintain cervical spine
> stability]{.underline}. Use a CO~2~ monitor with all endotracheal
> tubes to detect incorrect placement or dislodgement. Note: These do
> [not]{.underline} verify correct placement.
>
> c\) Insert a minimum of two large bore IV catheters and obtain lab.
> Lab should include blood for type and cross match, CBC, basic
> metabolic studies including electrolytes and renal function, and
> clotting functions. Include a pregnancy test in all females of
> childbearing age, and a fibrinogen and Rh factor test in all pregnant
> patients.
>
> d\) Control bleeding by direct pressure or operative intervention.
>
> e\) Administer warmed (98.6-104°F/37-40°C) IV fluid rapidly,
> preferably Ringer's lactate. Large volumes may be required in the
> adult patients, such as 2-3 liters of solution.
>
> f\) If hypovolemia persists, give blood:
>
> • 1^st^ choice - cross-matched blood.
>
> • 2^nd^ choice - type-specific uncross-matched blood.
>
> • 3^rd^ choice - O negative blood.
>
> g\) Control continued hemorrhage by operative intervention. Avoid
> vasopressor use for control of hypovolemic hypotension.
>
> h\) Hypothermia may develop rapidly, be lethal, and should be avoided.
>
> i\) Monitor the EKG in all trauma patients. (See Attachment E -
> Dysrhythmias in the Trauma Patient.)
>
> j\) Check Arterial Blood Gases (ABGs) in all trauma patients.
>
> k\) Monitoring of pulse oximetry is indicated in most trauma patients.
> However, this should [not]{.underline} replace a check of the Arterial
> Blood Gases (ABGs).
>
> l\) Perform a rectal and genitourinary examination, and consider
> placement of a urinary catheter unless urethral injury is suspected,
> in which case obtain a retrograde urethrogram. Signs of possible
> urethral injury include: Hematuria, blood in the penile meatus, blood
> in the scrotum, pelvic fracture, or a non-palpable or very high
> prostate.
>
> m\) If gastric distension is present, consider decompression with a
> nasogastric tube.  Do [not]{.underline} use a nasogastric tube if a
> cribiform plate fracture is suspected (tube may go intracranially).
>
> 3\) Diagnostic Studies in the Trauma Patient:
>
> a\) Obtain a Stat portable AP CXR, lateral cervical spine film, AP
> pelvic x-ray as soon as possible during the Initial Survey without
> interfering with resuscitation measures. Note: CXR should be obtained
> regardless of pregnancy.
>
> b\) Other techniques that may be indicated depending upon the skill of
> the provider and the clinical situation are diagnostic peritoneal
> lavage (DPL) and abdominal ultrasonography; but these are generally
> performed during the Secondary Survey.
>
> c\) Other diagnostic studies such as CT scanning and MRI may be
> indicated at a later point in patient evaluation, but are usually
> accomplished after the Secondary Survey.
>
> 4\) Secondary Survey:
>
> a\) The Secondary Survey is done [after]{.underline} completion of the
> primary survey and after resuscitation efforts are stabilizing the
> patient.
>
> b\) The Secondary Survey consists of the complete history and physical
> and includes:
>
> [1]{.underline}. Complete history including allergies, current
> medications, past medical history, pregnancy and ob-gyn history, time
> of the last meal, and history of the events and environment related to
> the trauma with specific questioning for contaminants and exposure to
> chemicals, biologicals, and radioactive materials.
>
> [2]{.underline}. Complete examination or re-examination of the entire
> body.
>
> [3]{.underline}. Complete neurological examination.
>
> [4]{.underline}. Glasgow Coma Scale, if not done earlier.
>
> 5\) Diagnostic Procedures Following the Secondary Survey: Following
> the Secondary Survey and stabilization of the patient, further
> diagnostic studies may be obtained as indicated.
>
> 6\) Re-evaluation and Pain Control: Ongoing re-evaluation is necessary
> in trauma patients, with attention to the emergence of previously
> unrecognized problems as they appear. Continuous monitoring of vital
> signs, pulse oximetry for the critical patient, end-tidal carbon
> dioxide monitoring for the intubated patient, EKG monitoring in the
> critical patient, and urinary output is indicated. Target urine output
> in the adult patient is 0.5ml/kg/hour. Target urine output in the
> pediatric patient older than 1 year is 1ml/kg/hour.
>
> 7\) Transfer and Definitive Care Issues: As soon as the physician
> determines that the patient will require more resources than are
> available at the facility, arrangements for transfer to an institution
> with an appropriate level of care can be started. Administrative
> personnel can begin these arrangements, but direct communication from
> transferring physician to receiving physician is essential.
>
> 8\) Legal Issues:
>
> a\) Careful record keeping and documentation is essential.
>
> b\) Informed consent should be obtained prior to treatment if
> possible. However, life-saving treatment should be provided with the
> presumption of consent in a life-threatening emergency.
>
> 9\) Immunization: If the wound is clean, non-punctured, adequately
> debrided, and the patient has had at least 3 prior doses of adsorbed
> tetanus toxoid, no tetanus prophylaxis is needed if the last dose was
> given in less than 10 years for non-tetanus prone wounds or less than
> 5 years for tetanus-prone wounds (CDC). Regardless of the wound, if
> less than three prior doses have been given, then Td prophylaxis is
> recommended. If the wound is tetanus-prone (puncture or question
> regarding adequacy of debridement) and less than 3 prior tetanus
> immunization doses have been received, then passive immunization with
> 250 units of human tetanus immune globulin (TIG) should be given IM.
> For patients over the age of 7 years, Td (tetanus and diphtheria
> toxoids, absorbed) are preferred to Tetanus Toxoid alone.
>
> 10\) Follow-up: Appropriate discharge includes identifying appropriate
> follow-up and providing instructions appropriate to the specific
> injury. Many, if not most, trauma patients will require discharge to a
> situation where they are checked at appropriate intervals by another
> person who can identify a need for attention, should signs of further
> injury or complications develop. The caregiver should be provided with
> specific instructions on symptoms and signs that would indicate the
> need to return.  Similarly, the time and site for follow-up of
> injuries should be specified. Written instructions should be provided
> if at all possible. Wounds and injuries of the head, eye or ear, as
> well as stress-related complaints, should have close follow-up.
>
> d\. *Other Issues in Management of the Trauma Patient*.
>
> 1\) If Radioactive Contamination Is Discovered After Patient Has Been
> Admitted - Continue attending to the patient\'s medical needs. Secure
> entire area where victim and attending staff have been. Do not allow
> *anyone* or *anything* to leave the area until cleared by the
> Radiation Safety Officer. Establish control lines, and prevent the
> spread of contamination. Completely assess the patient\'s radiological
> status. Personnel should remove contaminated clothing before exiting
> area; they should be surveyed; shower, dress in clean clothing and be
> re-surveyed before leaving area.  (*Note to Writer: Refer to sample
> SOP, Section 6, Patients with Radiation Exposure or Radioactive
> Contamination, in the Emergency Management Program Guidebook for
> further details*.) See specific information on the necessity of
> primary wound closure for all wounds in the irradiated patient and on
> the early timing of operative intervention.
>
> 2\) If Chemical Contamination Is Discovered After Patient Has Been
> Admitted - Immediately notify the Safety Officer and HAZMAT Team;
> follow appropriate notification procedures and facility protocol for
> dealing with a HAZMAT Incident.  If the type of chemical is known,
> immediately consult with the Safety Officer/Industrial Hygienist and
> check the Material Safety Data Sheet or with Poison Control for
> determination of toxicity and the need for evacuation, decontamination
> or other actions. (*Note to Writer: Refer to the Emergency Management
> Program Guidebook, Section 7, for further information on sample
> Decontamination, Chemical, Biological and Radiological Emergency
> Response Readiness Plans.)*
>
> e\. *Special Considerations for Specific Trauma Types*. Detailed
> discussion is beyond the scope of this SOP. A few major considerations
> are mentioned here. Please refer to provided references and pursue
> further study.
>
> 1\) Blast Injuries.
>
> a\) Components of Blast Injury:
>
> • Compression wave.
>
> • Thermal wave.
>
> • Flying debris.
>
> • Structural Collapse.
>
> • Psychological Trauma.
>
> • Physical Exertion (Escape or rescue efforts).
>
> b\) Blast injuries associated with a bomb or explosion are classified
> into three types:
>
> • Primary blast injuries result from the pressure wave produced by the
> blast and result in greatest injury to the gas-containing organs.
>
> • Secondary blast injuries result from flying debris.
>
> • Tertiary blast injury results from the person being thrown against
> an object or the ground.
>
> c\) Greater morbidity and mortality occur when explosions occur within
> a confined space or when structural collapse occurs.
>
> d\) Tympanic membrane (eardrum) rupture is a sensitive indicator of
> the force of the Primary Blast Wave and may rupture at a pressure
> exceeding 2 atmospheres.  Thus, examination of the tympanic membrane
> should be done in all victims presenting from a blast injury. However,
> tympanic membrane rupture alone is not a predictor of mortality.
>
> e\) Injuries from the secondary blast effects are typical of
> penetrating trauma.
>
> f\) In a secondary blast injury related to terrorism, penetrating
> objects may have been embedded in the bomb and include nails, screws,
> glass, or other objects. Such objects may be intentionally coated with
> toxins, infectious agents, or drugs such as the superwarfarins
> (long-acting anticoagulants).
>
> g\) Injuries from the tertiary blast effects are typical of blunt
> trauma.
>
> h\) Traumatic amputation in association with a blast injury is a
> predictor of mortality.
>
> i\) Blast injury produces certain specific organ injuries:
>
> [1]{.underline}. Blast Lung:
>
> • Is the most common fatal injury in initial survivors, and presents
> immediately and up to 48 hours post-blast.
>
> • Symptoms are dyspnea or apnea, cough, hemoptysis or chest pain.
>
> • Clinical Triad - Apnea, bradycardia and hypotension.
>
> • CXR (obtain in all blast victims):  Classic "butterfly" pattern.
>
> • Chest tube recommended prior to general anesthesia or air transport.
>
> • Results from bleeding into the lung tissue, ranging from scattered
> petechiae to frank hemorrhage, resulting from the pressure wave.
>
> [2]{.underline}. Blast Abdomen:
>
> • May present immediately or only later after complications arise.
>
> • Symptoms are abdominal pain, nausea, vomiting, hematemesis (vomiting
> blood), rectal pain, testicular pain and tenesmus.
>
> • Clinical Findings - Any suggesting an acute abdomen, unexplained
> hypovolemia (low fluid volume usually manifested as low blood
> pressure.)
>
> • Results from bowel perforation/rupture, abdominal/intestinal
> hemorrhage (as in blast lung), lacerations of the solid organs,
> mesenteric shear injuries, testicular rupture.
>
> [3]{.underline}. Blast Brain Injury:
>
> • Traumatic Brain Injury may be minimal or major.
>
> • If minimal, may mimic Post Traumatic Stress Disorder (PTSD).
>
> • Symptoms are headache, fatigue, lethargy, depression, anxiety, poor
> concentration and insomnia.
>
> • Results from the primary blast wave.
>
> j\) Other Blast Complications:
>
> [1]{.underline}. Air Embolism:
>
> • Presentation - stroke, MI, acute abdomen, spinal cord injury,
> blindness, deafness, claudication.
>
> • Consider hyperbaric oxygen; may be effective.
>
> [2]{.underline}. Inhaled Toxins:
>
> • Carbon Monoxide, cyanide, phosgene, and other chemicals released
> secondary to associated fires.
>
> • Check for methemoglobinemia:
>
> \-- Treatment includes high concentration oxygen.
>
> \-- When cyanide is involved, the Cyanide Antidote Kit can be life
> saving.
>
> [3]{.underline}. Hearing Impairment:
>
> • Sudden temporary or permanent deafness may occur. Tinnitus (ringing
> in the ears) may occur.
>
> • May have to communicate in writing to obtain history and provide
> instructions.
>
> [4]{.underline}. Wound Contamination:
>
> • Consider delayed primary closure for contaminated wounds
> [unless]{.underline} patient is a victim of significant radiation.
>
> • Assess the need for tetanus prophylaxis.
>
> • Assess the need for antibiotic prophylaxis.
>
> • In radiation events with significant irradiation of the patient,
> [all]{.underline} wounds should be closed primarily if at all
> possible. (*Note to Writer: Refer to sample Radiation SOP, Sample
> 6-23, Section 6, in the Emergency Management Program Guidebook*.)
>
> k\) For further information, refer to:  Centers for Disease Control
> and Prevention publication *Explosions and Blast Injuries: A Primer
> for Clinicians*
> (<http://www.bt.cdc.gov/masscasualties/explosions.asp>).
>
> 2\) Burns.
>
> a\) Respiratory tract burns should be suspected if:
>
> • Soot is noted in the nose, mouth or sputum; may also appear
> inflamed.
>
> • The eyebrows, nasal or facial hair is singed.
>
> • Face or neck is burned.
>
> • Hoarseness is noted.
>
> • History of confinement in a burning area.
>
> • Greater than 10% carboxyhemoglobin level after a fire.
>
> b\) Respiratory tract burns require immediate care including airway
> support; and transfer to a burn center is indicated.
>
> c\) If stridor is present, [immediate]{.underline} intubation is
> indicated.
>
> d\) Early intubation is indicated in any patient with circumferential
> neck burns due to the risk of airway compression from progressive
> tissue swelling.
>
> e\) Burns of the eyes require urgent examination before swelling
> prevents adequate examination.
>
> f\) IV fluid support is indicated for any patient with more than a 20%
> BSA burn area, unless the burn is only first degree.  Place Foley
> catheter for hourly measurement of urinary output.  (See Management
> portion below.)
>
> g\) Estimation of the percent of Body Surface Area burned is
> essential.  The rule of nines is useful in the adult patient.
>
> h\) Assessment of the depth of the burn is also essential. 
>
> • Third degree, full-thickness burns are painless and usually dry; may
> be red but does not blanch; may appear dark and leathery or waxy white
> or mottled.
>
> • Second degree, partial-thickness burns are very painful, appear red
> or mottled with blistering and swelling; may be weeping and wet.
>
> • First degree, relatively minor burns (i.e., sunburn) have varying
> degrees of pain; are red and dry; do not have blisters; are not life
> threatening and do not require fluid resuscitation.
>
> i\) Management of **thermal** burns includes following the primary and
> secondary trauma survey protocols, [and]{.underline}:
>
> • High-flow oxygen by non-rebreathing mask (facilitates CO removal).
>
> • Fluid resuscitation for 2^nd^ and 3^rd^ degree burns (need is
> greatest for 3^rd^ degree burns):
>
> [1]{.underline}. Burn Resuscitation Formula: 2-4ml Ringer's Lactate x
> body wt (kg) x % BSA with 2^nd^ and 3^rd^ degree burns = total volume
> to give [within]{.underline} the first 24 hours from the time of burn
> (TOB). Give ½ of this total calculated volume within the first 8 hours
> from TOB; give the remaining ½ calculated fluid volume over the next
> 16 hours.
>
> [2]{.underline}. For 3^rd^ degree burns, begin with 4ml/kg/% burn and
> reduce quantity as indicated clinically.
>
> [3]{.underline}. Urine output goal: Adults: 0.5-1.0ml/kg/hour
>
> Children less than 30kg:  1.0ml/kg/hour

Place Foley catheter for hourly measurement of urinary output.

> • Frequently monitor electrolytes to avoid electrolyte imbalance.
>
> • Provide continuous EKG monitoring.
>
> • Airway management as indicated and as discussed above.
>
> • Initiate a burn management flow sheet upon admission.
>
> • Obtain lab as discussed for trauma patients, with carboxyhemaglobin.
>
> • Remove all jewelry from burned areas.
>
> • Assess for peripheral pulses (Doppler if available) and intact
> sensation, with repetitive reassessment to monitor for development of
> a compartment syndrome and need for fasciotomy or escharotomy.
>
> • Pain management should be by small frequent intravenous doses, not
> the intramuscular route; for example, Morphine Sulfate 2mg IV every 5
> minutes until pain relieved. To avoid respiratory depression, follow
> pulse oximetry and respiratory rate.
>
> • Cover burns with clean linen to relieve pain; do not apply ointment,
> unless advised by Burn Center. Maintain blisters intact. 
>
> • Provide tetanus prophylaxis.
>
> • With burns over 20% BSA, insert a gastric tube to suction.
>
> • Reserve antibiotics for treatment of infection.
>
> • Contact the local or regional burn center to discuss criteria for
> transfer. (See Attachment F, Burn Center Transfer Guidelines.)
>
> j\) Management of **chemical** burns includes following the primary
> and secondary trauma survey protocols [and]{.underline}:
>
> • Do [not]{.underline} flush dry chemicals with liquid;
> [brush]{.underline} them away first.  Some chemicals ignite with
> water, such as white phosphorus.
>
> • Flush with large amounts of water for 20-30 minutes, longer for
> alkali burns.
>
> • Continuously irrigate the eye in the case of alkali burn for 8
> hours.
>
> • Do [not]{.underline} replace fluid by the Burn Formula for most
> chemical burns.  Fluid loss in a chemical burn is less than for
> thermal burns. Use of the standard burn formula for IV fluid
> replacement in a chemical burn patient may result in fluid overload
> and pulmonary edema.
>
> 3\) Fractures.
>
> a\) Fractures of the long bones and pelvis indicate that major force
> was involved in the trauma and that other injuries should be sought.
>
> b\) Long bone and pelvic fractures can result in major hemorrhage,
> which may result in shock. Several units of blood can be lost into the
> surrounding tissue space.  Pelvic fractures have the potential for 1
> to more than 5 liters (L) of blood; femur fractures, 1-4 L; spine
> fractures, 1-2 L; leg fractures 0.5-1 L; and arm fractures, 0.5-0.75
> L.
>
> c\) Initial fracture splinting and immobilization will:
>
> • Reduce motion, thus reducing further tissue damage.
>
> • Assist with hemorrhage control.
>
> • Reduce pain.
>
> • Assist in realignment toward an anatomic position.
>
> d\) Hemorrhage in an open fracture can usually be controlled by
> application of a sterile dressing.
>
> e\) Physical examination should include notation of:
>
> • Perfusion (color, capillary refill, pulses).
>
> • Deformity (position, rotation or angulation, shortening).
>
> • Sensation (verification of intact nerve supply).
>
> • Edema.
>
> • Bruising or open wounds.
>
> • Palpation for areas of tenderness, especially focal point tenderness
> over bone, which frequently indicates a fracture.
>
> • Cautious range of motion testing and checks for ligamentous
> instability.
>
> f\) Cervical or spine fractures should be evaluated by a lateral
> C-spine x-ray if possible during the primary survey and followed by a
> full C-spine series during the secondary survey. The C-spine or
> portion of the spine with possible fracture must be immobilized until
> fully assessed.
>
> g\) All open fractures require surgical exploration and debridement.
>
> h\) With hemorrhage and swelling from a fracture involving an
> extremity, pulses and sensation must be monitored for development of a
> compartment syndrome and the need for decompression with a fasciotomy.
>
> i\) Pelvic fractures may be associated with genitourinary system
> injury.
>
> j\) Fat embolization can result in hypoxia and Central Nervous System
> (CNS) impairment.
>
> k\) Consult with Orthopedics for further management.
>
> 4\) Crush Injuries (Traumatic Rhabdomyolysis).
>
> a\) Characteristics - Hemorrhage into soft tissue with massive
> swelling, bruising and hematoma formation.
>
> b\) Major history point - How long was the tissue crushed prior to
> removal of the crushing object?
>
> c\) Crush injury to the chest may produce traumatic asphyxia.
> Petechiae, swelling (may include cerebral edema) and redness from
> vascular congestion may be present over the face, arms and upper body
> due to compression of the superior vena cava.
>
> d\) Risk of compartment syndrome, neurovascular damage, rhabdomyolysis
> and tissue necrosis, hyperkalemia, myoglobinuria, acute renal failure
> (may require dialysis), hypocalcemia, metabolic acidosis, hypovolemia,
> and disseminated intravascular coagulation (DIC).
>
> e\) Testing - Follow serum creatine phosphokinase (CK), potassium (K),
> acid-base status; check urine for myoglobulin; urine will appear dark
> amber and hemoglobin test will be positive.
>
> f\) Prevention of Renal Failure - Usual goal for urine output is 100
> ml/hour; may alkalinize urine with sodium bicarbonate to prevent
> precipitation of myoglobin.
>
> g\) Prevention of Limb Loss - Aggressive monitoring for compartment
> syndrome with fasciotomy for circulatory compromise.
>
> h\) Crush injuries in children may involve the growth areas of the
> bones and result in abnormal growth and development.
>
> 5\) Traumatic Amputation.
>
> a\) Do [not]{.underline} let this divert your attention from more
> life-threatening injuries, which may be missed while attending to the
> amputation.
>
> b\) Immediate Care - control bleeding with direct pressure and
> elevation; re-establish normal intravascular volume; gently cleanse
> the wound and cover with a sterile dressing; immobilize extremity
> until evacuation; reduce dislocations and angular deformities with
> monitoring of neurovascular status; obtain early surgical debridement.
> Use tourniquets [only]{.underline} for life-threatening bleeding when
> other methods of control have failed, due to risk of distal tissue
> loss.
>
> c\) Intervening care in event of delayed definitive treatment -
> antibiotics (parenteral cephalosporin, such as cefazolin 1 gram IV,
> unless allergic), tetanus prophylaxis; limited open wound irrigation
> and debridement; splint or cast extremities; monitor for compartment
> syndrome; consider other complications, such as deep vein thrombosis,
> osteomyelitis and fat embolus syndrome.
>
> d\) Limb loss may be considered as a severe type of open fracture.
>
> e\) Severe open fractures may result in amputation when limb cannot be
> salvaged, due to prolonged ischemia and severe tissue injury.
>
> f\) Vascular injuries to a limb must be repaired within 6 hours to
> avoid tissue necrosis and potential limb loss.
>
> g\) Psychological, as well as physical, trauma; anticipate grief
> reaction from loss.
>
> h\) Reimplantation:
>
> • Is [not]{.underline} indicated in the critical patient with multiple
> injuries requiring resuscitation or surgery for other injuries, or in
> the patient with pre-existing major systemic disease.
>
> • Is [not]{.underline} indicated when the amputated limb has been
> severely crushed.
>
> • [May]{.underline} be indicated in a clean, sharp amputation of an
> extremity (sharp guillotine injuries are best candidates).
>
> • Amputated limb care:
>
> [1]{.underline}. Avoid freezing; do [not]{.underline} use dry ice; do
> [not]{.underline} allow direct contact of ice with tissue.
>
> [2]{.underline}. Do [not]{.underline} soak limb in container of
> solution.
>
> [3]{.underline}. Wash well in isotonic solution (Ringer's Lactate or
> Normal Saline); wrap in sterile gauze soaked in the solution
> containing 100,000 units of aqueous penicillin per 50 ml of isotonic
> solution (if NOT penicillin allergic); then wrap in sterile towel
> moistened with the same solution; place in plastic bag; transport
> (preferably with the patient) in an ice chest (use crushed wet ice,
> [not]{.underline} dry ice) or in a refrigerated container at 4°C (\~
> 40°F).
>
> • Immediate cooling may increase the time of amputated limb salvage
> from the usual 6 hour maximum to 12-24 hours.
>
> 6\) Abdominal Wounds with Evisceration.
>
> a\) Do not replace exposed organs into the abdominal cavity.
>
> b\) Cover with gauze wet with normal saline.
>
> c\) Obtain surgical consultation immediately.
>
> 7\) Sucking Chest Wounds.
>
> a\) Do not place a chest tube through the site of the wound.
>
> b\) Occlude the wound with Vaseline impregnated gauze, plastic wrap or
> other occlusive dressing taped on three sides. This allows the
> dressing to seal the wound with inspiration, and lets the leaking air
> escape with exhalation. Occluding on all 4 sides with[out]{.underline}
> a chest tube inserted may allow the leaking air to accumulate in the
> chest, producing a tension pneumothorax.
>
> c\) Placement of a chest tube through uninvolved skin is indicated by
> an experienced practitioner.
>
> 8\) Closed Chest Trauma.
>
> a\) Evaluate for signs of a pneumothorax or hemothorax. Respiratory
> distress and if unilateral decreased breath sounds with increased
> resonance on percussion, r/o pneumothorax; with decreased resonance on
> percussion, r/o hemothorax.
>
> b\) Immediately obtain pulse ox, ABGs, chest x-ray. Do not delay
> intervention for results in a life-threatening situation when the
> clinical diagnosis warrants immediate intervention.
>
> c\) Recognize signs of Tension Pneumothorax: chest pain, respiratory
> distress, absent breath sounds with hyper-resonance on the affected
> side of the chest, hypotension, tracheal deviation, may have jugular
> venous distention.  If tension pneumothorax is diagnosed, immediate
> decompression is indicated.  Inset a large-bore needle in the second
> intercostal space in the mid-clavicular line on the affected side.
> Follow when indicated (in most cases) with chest tube insertion,
> usually just anterior to the mid-clavicular line in the 5^th^
> intercostals space.
>
> d\) Recognize signs of Cardiac Tamponade: The classic triad is jugular
> venous distension plus muffled heart sounds plus reduced blood
> pressure.  However, these signs are not specific and may be absent.
> Electrical Alternans is an infrequent but diagnostic sign; the QRS
> complex on the EKG alternates between positive and negative. Also on
> the EKG, the QRS voltage may be low (less than 5 mm in amplitude).
>
> f\. *Special Considerations in Specific Trauma Patients*. In no
> situation when other more appropriate resources are available should
> pregnant trauma patients or pediatric trauma patients be transported
> to or treated at the VAMC. However, when such patients arrive, every
> effort should be made to minimize morbidity and mortality by providing
> emergency care and stabilization until more appropriate care is
> available.  Two methods of obtaining this care are possible: the
> preferable solution is the rapid transfer of the patient to an
> appropriate facility; a less optimal contingency that should be
> considered is establishment and maintenance of a credentialing file of
> Obstetricians and Pediatricians who can be called to report to the
> hospital when indicated in a Mass Casualty Incident.  Consideration
> should be given to developing a contingency plan that includes
> pre-event identification and credential verification for qualified
> Obstetricians, Surgeons and Pediatricians skilled in management of
> obstetric and pediatric trauma patients who would plan to report to
> the facility Emergency Department for activation of temporary
> privileges when the EOP and Trauma SOP are activated due to an event,
> and local pediatric facilities are overwhelmed or inaccessible.
>
> 1\) The Pregnant Trauma Patient:
>
> a\) Pregnancy should be considered in girls and women between the ages
> of 10 and 50 years of age, and pregnancy testing should be considered
> in females in this age range. Inquiry into the menstrual history will
> assist in excluding this possibility in younger and older patients.
>
> b\) Two patients are being assessed and treated: both the mother and
> the unborn.  The life of the unborn depends upon the mother's health;
> thus, direct initial management toward maternal resuscitation.
>
> c\) The best initial care for the unborn is the provision of optimum
> resuscitation and care for the mother and early assessment of the
> unborn.
>
> d\) Order of care should be: Initial Survey and Resuscitation for the
> Mother; Fetal Assessment; Secondary Survey of the Mother to include
> Pelvic Examination preferably by an Obstetrician. Fetal heart rate
> monitoring is indicated at greater than 20-24 weeks gestation.
>
> e\) Pregnancy produces changes in both anatomy and physiology that
> alter both injury patterns and the response to trauma.
>
> f\) Significant change includes increased oxygen consumption, thus
> early provision of supplemental oxygen is indicated and hypervolemia
> of pregnancy indicating the need for early fluid resuscitation.
>
> g\) Early consultation with both a qualified Obstetrician and a
> Surgeon should be obtained in all pregnant trauma patients.
>
> h\) Full discussion of this is beyond the scope of this document, and
> qualified medical practitioners must attend to these patients as soon
> as possible. (See Attachment G for a summary of some of the
> considerations in management of the pregnant trauma patient.) Some
> conditions of concern include uterine rupture, abruption placenta or
> placental separation, amniotic fluid embolization, disseminated
> intravascular coagulation and fetal loss (See Attachment H).
>
> i\) Peri-mortem Cesarean Section within 4-5 minutes of maternal
> cardiac arrest may be successful, unless the mother has been
> hypovolemic. In cases of hypovolemia, this is unlikely to be
> successful due to prolonged fetal compromise.
>
> j\) Disseminated intravascular coagulation (DIC) may occur rapidly in
> the pregnant trauma patient.  Findings include low fibrinogen (less
> than 250mg/dl), low platelet count and reduction in other coagulation
> factors. Management includes urgent uterine evacuation and management
> of the depleted factors.
>
> k\) Consider Rh immunoglobulin therapy within 72 hours in
> [all]{.underline} Rh-negative pregnant trauma patients with possible
> fetomaternal hemorrhage (any degree of trauma of the abdomen or
> thorax) to avoid Rh sensitization.
>
> 2\) The Pediatric Trauma Patient. Treatment of the pediatric patient
> requires specialized knowledge of normal developmental stages,
> pharmacology with calculation of drug dosages on a weight basis and
> avoidance of specific drugs, and specialized knowledge of Pediatric
> Advanced Life Support. Consideration should be given to developing a
> contingency plan that includes pre-event identification and credential
> verification for qualified Pediatricians and Surgeons skilled in
> management of pediatric trauma patients who would plan to report to
> the facility Emergency Department for activation of temporary
> privileges in an event when the EOP and Trauma SOP are activated, and
> when local pediatric facilities are overwhelmed or inaccessible.
> Sources must be identified for rapid availability of pediatric
> supplies and equipment, and these must rapidly be obtained as soon as
> such a situation is recognized.
>
> 3\) The Elderly Trauma Patient. Fatality rates with trauma are
> increased in the elderly patient, but no good criteria exist to
> determine which factors are determinants of mortality. Aggressive
> early treatment has been shown to improve survival in the elderly
> trauma patient. Many of these patients return to their pre-injury
> level of function after recovery. Ethical considerations warrant that
> the patient's right to self-determination as expressed in pre-existing
> Advance Directives should be considered in the massively-injured
> elderly patient. It is inappropriate to withhold care based upon
> consideration of age. Consideration of age-related changes in
> physiology and reduced reserve capacity is necessary to provide
> optimal care.
>
> g\. *Event Monitoring Strategies*. Police should coordinate with local
> authorities and monitor the progress and duration of the event.
> Nursing, Chief of Staff, Hospital Director and Clinical Services
> should document clinical data and assist in patient tracking and
> disposition.
>
> h\. *Recovery Strategies and Resource Issues*. An assessment of
> mission-critical systems, medical resources, and personnel needs
> should be conducted every 12 to 24 hours during the event and
> forwarded to the Emergency Operations Center (EOC) so that a Situation
> Report (SITREP) can be compiled.

7\. ***Notification Procedures***.

> a\. Provide notification and situation reports (SITREPS) to the
> Network Director.
>
> b\. Contact secondary VA Medical Centers, if necessary.
>
> c\. Coordinate with local, county and state emergency response
> agencies as appropriate.
>
> d\. State/Local Office of Emergency Services.
>
> e\. Coordinate with local, county and state emergency response
> agencies as appropriate.

8\. ***Specialized Staff Training***.

> a\. Train staff on the principles of trauma management (e.g., triage,
> first aid, stabilization and emergency treatment of the trauma victim;
> appropriate transfer and transport; and psychological, ethical and
> legal issues).
>
> b\. Encourage providers to pursue training in trauma management
> through recognized courses, such as:
>
> • Advanced Trauma Life Support for Doctors (American College of
> Surgeons).
>
> • Advanced Trauma Course for Nurses (Society of Trauma Nurses).
>
> Advanced Burn Life Support Pre-Hospital Course
>
> • Pre-hospital Trauma Life Support course (National Association of
> Emergency Medical Technicians).
>
> • Basic Disaster Life Support.
>
> • Advanced Disaster Life Support.
>
> • Community Emergency Response Team (CERT) Training (Federal Emergency
> Management Association).

-   Transport Nurse Advanced Trauma Course (Air & Surface Transport
    Nurses Association)

> c\. Conduct tabletop exercises to evaluate response readiness.
>
> d\. Participate in community-wide exercises.
>
> e\. Conduct drills and mini-drills.

9\. ***References and Resources***.

> a\. *Advanced Trauma Life Support for Doctors* Student Course manual
> 7^th^ Edition; 2004 American College of Surgeons; ISBN 1-880696-14-2.
>
> b\. Air & Surface Transport Nurses Association. *Transport Nurse
> Advanced Trauma Course (TNATC)* (<http://www.astna.org/TNATC.html>.)
>
> c\. The American Association for the Surgery of Trauma Web net
> (<http://www.aast.org/>).
>
> d\. Centers for Disease Control and Prevention, *Mass Trauma Data
> Instrument*
> (<http://www.cdc.gov/masstrauma/response/rapidassessment_notes.pdf>).
>
> e\. Centers for Disease Control and Prevention, *Mass Casualty
> Information for Health Professionals*
> (<http://www.bt.cdc.gov/masscasualties/essentialspro.asp>).
>
> f\. Centers for Disease Control and Prevention, *Coping With a
> Traumatic Event;* More about post-traumatic stress disorder and what
> you can do. (<http://www.bt.cdc.gov/masscasualties/copingpub.asp>).
>
> g\. Centers for Disease Control and Prevention, *Explosions and Blast
> Injuries: A Primer for Clinicians*
> (<http://www.bt.cdc.gov/masscasualties/explosions.asp>).
>
> h\. Centers for Disease Control and Prevention, *Blast Lung Injury:
> What Clinicians Need to Know*
> (<http://www.bt.cdc.gov/masscasualties/blastlunginjury.asp>).

# i. Centers for Disease Control and Prevention, Blast Lung Injury: An Overview for Prehospital Care Providers ([***http://www.bt.cdc.gov/masscasualties/blastlunginjury_prehospital.asp***](http://www.bt.cdc.gov/masscasualties/blastlunginjury_prehospital.asp)).

> j\. Centers for Disease Control and Prevention; National Center for
> Injury Prevention and Control; Sasser SM, et al. *In a Moment's
> Notice: Surge Capacity in Terrorist Bombings.* 2007
> (<http://www.bt.cdc.gov/masscasualties/pdf/surgecapacity.pdf>).
>
> k\. Centers for Disease Control and Prevention, *Traumatic Incident
> Stress: Information For Emergency Response Workers*.
> (<http://www.cdc.gov/niosh/unp-trinstrs.html>).
>
> l\. Center for Mental Health Services/Division of Prevention,
> Traumatic Stress, and Special Programs/Emergency Mental Health and
> Traumatic Stress Services Branch, *Emergency Mental Health and
> Traumatic Stress.*
> (<http://www.mentalhealth.org/cmhs/EmergencyServices/links.asp>).
>
> m\. Community Emergency Response Team (CERT) Training, FEMA:Chapter
> III. Disaster Medical Operations Part ; Chapter IV. Disaster Medical
> Operations Part 2
> (<http://transit-safety.volpe.dot.gov/training/Archived/EPSSeminarReg/CD/documents/CERT/tcintro.doc>).
>
> n\. *Current Emergency Diagnosis and Treatment*; Stone KC, Humphries
> RL; 2004 5^th^ edition; Lange Medical Books/McGraw-Hill.
>
> o\. Emergency Nurses Association. *Course in Advanced Trauma Nursing*
> (<http://www.ena.org/catn_enpc_tncc/catn/main.asp>).
>
> p\. International Atomic Energy Agency and World Health Organization.
> *How to Recognize and Initially Respond to an Accidental Radiation
> Injury*
> (<http://www-pub.iaea.org/MTCD/publications/PDF/IAEA-WHO-L-Eng.pdf>).
>
> q\. [Lavonas E and Pennardt A., *Blast Injury.* Online in eMedicine
> from Webb MD]{.underline} Last Updated: January 17, 2006.
> (<http://www.emedicine.com/emerg/topic63.htm>).
>
> r\. National Center for Post Traumatic Stress Disorder (PTSD),
> Department of Veterans Affairs. (<http://www.ncptsd.org/>).
>
> s\. Disaster Mental Health: Dealing with the Aftereffects of
> Terrorism. Brief Information for the Public and the Professional.
> National Center for PTSD, Veterans Affairs
> (<http://www.ncptsd.org/disaster.html>).
>
> t\. US Department of Justice, Federal Bureau of Investigation.
> *Terrorism 2002-2005*.
> (<http://www.fbi.gov/publications/terror/terrorism2002_2005.pdf>).
>
> u\. VHA Emergency Management Program Guidebook.
>
> v\. *ER Trauma Guide*, (1^st^ Edition), 2004, Stanford, CT, MIS Inc.
> (This is a pocket card.)
>
> w\. Lekawa, ME; *Trauma in Surgery*; Wilson SE (ed); Current Clinical
> Strategies Publishing, Laguna Hills, CA, 6^th^ Edition, 2005; ISBN
> 1929622-57-0.
>
> x\. Livingston, DH; Hauser, CJ; Trauma to the Chest Wall and Lung; in
> *Trauma*; McGraw-Hill Medical Publishing Division, New York, NY; 5^th^
> Edition, 2004; ISBM 0-07-137069-2.
>
> y\. Morgan OW, et al; Mass Fatality Management following the South
> Asian Tsunami Disaster: Case Studies in Thailand, Indonesia, and Sri
> Lanka. PLOS Med 3:6; June 2006.
> (<http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16737348>).
>
> z\. *The Mont Reid Surgical Handbook*; Fischer, DR, Kelly, BS (eds);
> Elsevier Mosby Publisher, Cincinnati, OH; 5^th^ Edition, 2005.
>
> aa. *Trauma*; Moore, EE; Feliciano, DV; Mattox, KL (eds); McGraw-Hill
> Medical Publishing Division, New York, NY; 5^th^ Edition, 2004; ISBM
> 0-07-137069-2.

10\. ***Review Date***.

(Name)

Chief, (Service)

Attachments:

A. [Common Trauma in Natural
Disasters](../Encl%206-50-A%20%20Nat%20Disaster%20Trauma.doc)

B. [Common Trauma in Non-Natural
Disasters](../Encl%206-50-B%20Non-Nat%20Disaster.doc)

C. [Secondary Effects of
Disasters](../Encl%206-50-C%20Secondary%20Effects.doc)

D. [Glasgow Coma Scale](../Encl%206-50-D%20%20Glasgow%20Scale.doc)

E. [Dysrhythmias in the Trauma
Patient](../Encl%206-50-E%20Disrythmia.doc)

F. [Burn Center Transfer
Guidelines](../Encl%206-50-F%20%20Burn%20Center.doc)

G. [Special Considerations in the Pregnant Trauma
Patient](../Encl%206-50-G%20%20Special%20Consider.doc)

H. [Assessment of the Unborn and Uterine Injury: Approach to Selected
Issues](../Encl%206-50-H%20%20Unborn.doc)