Hemorrhagic Shock W/W/O Suspected Head Injury


  • Trauma WITH head injury
    • Fluid resuscitation to maintain SBP ≥90 and
    • O2 saturation >90%
  • Trauma
    • 2 large bore IVs of 0.9% NaCl
    • Fluid bolus of 500 ml
    • Reassess mental status
    • Repeat fluid bolus

Hemorrhage Control


  • Tourniquets
    • 1-2″ proximal to hemorrhage
    • Tightened until controlled
    • Record application time
  • Wound packing
    • Wound to groin, axilla, or neck
    • Place gauze as deeply as possible
    • apply pressure dressing
    • Apply manual direct pressure for at least 3 minutes
  • Tranexamic Acid (TXA)

Regional Trauma Guidelines


  • Pulse >120 or <50 or SBP <90
  • RR <10 or >29
  • Intubated
  • Evidence of head injury
    • GCS ≤13
    • Alteration in LOC or LOC > 5 min
    • Failure to localize pain
  • Suspected spinal cord injury
  • Penetrating trauma to head, chest, abdomen, neck, extremities proximal to knee or elbow
  • Amputation proximal to wrist or ankle
  • Fractures of 2 or more proximal long bones
  • Evidence of neurovascular compromise
  • tension pneumothorax that is relieved
  • Head, neck, or torso visible crush injury
  • Abdominal tenderness, distention or seat belt sign
  • Pelvic fracture
  • Flail chest
  • Burn injury >10% TBSA and other traumatic injuries
  • Significant mechanism of injury = high index of suspicion
  • Ground <30 min transport time to Level 1 trauma center

Tranexamic Acid (TXA)


  • Evidence of significant blunt or penetrating trauma AND
  • Age ≥16 y.o. AND
  • Presence of hemodynamic instability AND
  • Sustained SBP <90 or <100 if age >55 AND
  • Sustained heart rate >110 AND
  • Time since injury is KNOWN to be <3 hours


  •  Mix 1 g TXA in 100 ml of 0.9% NaCl or LR and infuse over approximately 10 minutes IV or IO
  • Use a dedicated line
  • Notify receiving trauma center



  • Assess for spinal injuries and treat/immobilize appropriately
  • If actively seizing give Versed 10mg IM
  • Versed 2-4mg/min IV/IM/IO, until seizure resolves or a total of 10mg is given
  • Dextrose 50% 12.5 – 25g IV/IO or Glucagon 1 mg IM if Glucose < 70
  • Narcan 0.4 to 2mg IV if suspect narcotic OD
  • If in the 3rd trimester of pregnancy- or up to 6 wks postpartum -actively seizing with no seizure history consider magnesium sulfate 4g IVP slowly over 15 mins
  • Transport to hospital with OB services

Geriatric Trauma


  • GCS ≤ 14
  • Pulse > 90, SBP < 110
  • Fall from any height with evidence of traumatic brain injury, even from standing
  • Pedestrian struck by motor vehicle
  • Suspected long bone fx from motor vehicle crash
  • Injuries sustained in two or more body regions
  • Anticoagulation and head injury

Eye Injuries


  • Stabilize impaled objects in place and cover other eye
  • Cover penetrating eye injuries with metal eye patch—do not press on globe
  • Irrigate chemicals or non-penetrating foreign matter from eye with copious amounts of water or normal saline
  • Instill 2 drops of 0.5% proparacaine (Alcaine) or tetracaine into affected eye for pain (note it may sting initially, < 20 sec)
  • Can repeat Alcaine in 20 min if necessary

Burns – Major


  • Scene safety; remove patient from source of burn, including clothing
  • Maintain airway and administer oxygen
  • If respiratory distress or unconscious, intubate immediately
  • Cover burns with clean, dry sheet(s) or loose, dry sterile dressing
  • Remove all prostheses, rings, and constricting bands from all extremities
  • Consider pain management, per pain management protocol
  • If hypovolemic, initiate fluid resuscitation

Backboard / Spinal Immob


  • Age >16, <65
  • Mechanism of injury concerning for spinal injury

Immobilization is indicated only if any of the following are present:

  • Altered mental status
  • Suspicion of intoxication
  • Distractions – either painful injuries or psychosocial distractions
  • Midline spinal tenderness (careful palpation exam required)
  • Focal neurological deficit (anything less than a full & symmetric motor and sensory exam in all limbs)

If patient has isolated midline cervical spine tenderness with none of the above indicators, it is appropriate to immobilize a cooperative patient using a rigid cervical collar and ambulance stretcher without a long spine board

If a patient has penetrating trauma to the head, neck, and/or torso, spinal immobilization only required if a neurologic deficit exists



  • Age >16; may or may not have altered level of consciousness
  • Assess ABCs and suspicion for trauma
  • Assess patient with Cincinnati Stroke Scale
    • Facial droop (big smile)
    • Pronator drift (extend arms, palms up, eyes closed: one arm drift = positive; both = unclear)
    • Speech (“The sky is blue in Cincinnati”)
  • Assess and record the exact time the patient was last known to be normal
  • Glucose level should be >70mg/dL
  • Rapid transport and pre-notify destination Emergency Department
  • Minimize scene time to <10 mins; do not delay unnecessarily for procedures; attempt IVs and other procedures during transport
  • Refer to ED capability chart for transport destination selection
  • Consider transport to a JCC Primary or Comprehensive Stroke Center if:
    • Stroke center is <15 mins farther than a non-stroke center
    • Last known normal <12 hours