Trauma Transport Protocol

Section 1 - ADMINISTRATIVE POLICIES

1.09 TRAUMA TRANSPORT PROTOCOLS

In the Seminole County Emergency Medical Services System, the Trauma Transport Protocols (TTPs) are subject to paramedic discretion. That is to say, if in a paramedic’s judgment he or she believes the patient requires transport to a Trauma Center even though they don’t meet the criteria, the paramedic is empowered to transport that patient to the Trauma Center.

Dispatch Procedures

Communications Center

Seminole County Public Safety E-911 Communications Center is located at 150 Bush Blvd. in the city of Sanford, FL. All EMS calls for Seminole County are received by and dispatched by this center. The entire county has enhanced 911 and a computer aided dispatch system.

List of information to be obtained from caller

Location of patient
Type of trauma (Circumstances)
Number of trauma victims
Extent and severity of trauma injury
Scene security / safety
Name of caller
Callback number

Method used to identify and dispatch the most readily available unit

The Seminole County EMS System operates under a sophisticated “First Response” agreement between 8 cities and two counties. In this agreement the parties agree to provide reciprocal assistance on a joint response/automatic aid based on geographical location. Agencies participating in the First Response Agreement are:

Seminole County	Orange County
Casselberry FD	Maitland FD
Lake Mary FD	Orange County Fire Rescue
Longwood FD	Winter Park FD
Oviedo FD
Sanford FD
Seminole County FD

The closest available unit(s) will be dispatched by the Emergency Medical Services dispatcher based on CAD recommendations and/or Automatic Vehicle Locator (AVL) data.

Prior to the first unit’s arrival, multiple response units may be dispatched by request of the Communications Supervisor or EMS Commander based on information received from caller(s). Paramedics upon arrival can request multiple response units.

Process used to request assistance from emergency response agencies

Fire department is requested to respond to all vehicle accidents, trauma alerts and unconfirmed trauma alerts.
Law enforcement is requested to respond to all vehicle accidents, violent or potential violent crimes.
Public utility agencies are requested when need is identified.
Aero-Medical support may be requested by an on-scene Paramedic. In addition, the Communications Supervisor or EMS Commander can request air support prior to a unit’s arrival on scene based on information received from caller(s). Aero-medical resources are requested through the communications center. The following air resources are assigned by region based on availability and weather conditions:

COUNTY	PRIMARY	SECONDARY	TERTIARY
SEMINOLE	AIR CARE 3 (SSCH)	AIR CARE 1	AIR CARE 2

All Seminole County EMS System units and EMS Command personnel will be dispatched on recorded channels. All other requests for an emergency response agency will be made on recorded phone lines.

Pre-Hospital Procedures

Adult Trauma Triage Criteria & Methodology The EMT or paramedic shall assess the condition of those injured persons with anatomical and physiological characteristics of a person sixteen (16) years of age or older for the presence of at least one of the following four criteria to determine whether to transport as a trauma alert. These four criteria are to be applied in the order listed, and once any one criterion is met that identifies the patient as trauma alert, no further assessment is required to determine the transport destination in accordance to the Adult Trauma Scorecard methodology as set forth in 64J-2.004 FAC.

Adult Criteria

Meets color-coded triage system (see below)
GCS ≤ 12 Patient must be evaluated via GCS if not identified as a trauma alert after application of criterion 1.
Meets local criteria (specify): Likely to require surgery within one to four (1-4) hours.
Paramedic Judgment: Patient does not meet any of the trauma criteria listed above however, in the judgment of the Paramedic, should be transported as a trauma alert (document as required per 64J-1.014, FAC)

ADULT COMPONENT	BLUE	RED
AIRWAY¹	RR ≥ 30	REQUIRES ACTIVE AIRWAY ASSISTANCE²
CIRCULATION	SUSTAINED HR ≥ 120 BPM	LACK OF RADIAL PULSE WITH SUSTAINED RAPID HEART RATE > 120 BPM OR BP < 90 mm hg
BEST MOTOR RESPONSE	BMR = 5	BMR OF ≤ 4 PRESENCE OF PARALYSIS OR SUSPECTED SPINAL INJURY LOSS OF SENSATION
CUTANEOUS	TISSUE LOSS³ OR GSW TO EXTREMITIES	AMPUTATION⁴ OR 2°/3° BURNS TO ≥ 15% TBSA OR ANY PENETRATING INJURY TO HEAD, NECK OR TORSO⁵
LONGBONE FRACTURE	SINGLE LONGBONE FX DUE TO MVA OR FALL > 10’	SIGNS OR SYMPTOMS OF MULTIPLE LONGBONE FX SITES⁶
AGE	≥ 55
MECHANISM OF INJURY	EJECTION FROM VEHICLE⁷ OR DEFORMED STEERING WHEEL⁸

RED = any one (1) transport as a trauma alert BLUE= any two (2) transport as a trauma alert

¹ Airway evaluation is designed to reflect the intervention required for effective care

² Not just Oxygen

³ Degloving injuries, major flap avulsions (> 5 in.)

⁴ Amputations proximal to the wrist or ankle

⁵ Excluding superficial wounds in which the depth of the wound can be easily determined

⁶ Humerus, (radius,ulna), femur, (tibia or fibula)

⁷ Excluding any motorcycle, moped, all terrain vehicle, bicycle, or open body of a pickup truck

⁸ Only applies to driver of the vehicle

Pediatric Trauma Triage Criteria & Methodology

The EMT or paramedic shall assess the condition of those injured persons with anatomical and physiological characteristics of a person (15) years or younger using the scorecard methodology outlined in 64J-2.005 FAC. Seminole County Emergency Medical Services System recognizes that a child is not simply a small adult and that the adult trauma scores cannot be used as a reliable indicator of the degree of injury in the pediatric patient. Therefore, all pediatric patients will be scored using the pediatric trauma score outlined below; the presence of at least one of the following two criteria to determine whether to transport as a trauma alert. These two criteria are to be applied in the order listed, and once any one criterion is met that identifies the patient as trauma alert, no further assessment is required to determine the transport destination.

Pediatric Criteria

Meets color-coded triage system (see below)
Patient does not meet any of the trauma criteria listed above but, in the judgment of the EMT or paramedic, should be transported as a trauma alert (document a required per 64J-1.014, FAC)

COMPONENT	BLUE	RED
AIRWAY¹		REQUIRES ACTIVE AIRWAY ASSISTANCE²
CONSCIOUSNESS	SYMPTOMS OF AMNESIA LOSS OF CONSCIOUSNESS	ALTERED MENTAL STATUS³ PRESENCE OF PARALYSIS OR LOSS OF SENSATION SUSPECTED SPINAL INJURY
CIRCULATION	LOSS OF RADIAL OR PEDAL PULSES⁴ OR SYSTOLIC B/P < 90 mm hg	FAINT / NONPALPABLE CAROTID PULSE OR FAINT / NONPALPABLE FEMORAL PULSE OR BP < 50 mm hg
FRACTURE	SIGNS OR SYMPTOMS OF A CLOSED LONG BONE FRACTURE (DOES NOT INCLUDE ISOLATED WRIST OR ANKLE FXs)	OPEN LONG BONE FX.⁵ OR MULTIPLE FX SITES OR MULTIPLE DISLOCATIONS (EXCEPT FOR ISOLATED WRIST OR ANKLE FX OR DISLOCATIONS)
CUTANEOUS		MAJOR SOFT TISSUE DISRUPTION⁶ OR 2°/3° BURNS TO ≥ 10% TBSA OR AMPUTATION⁷, OR PENETRATING INJURIES TO HEAD, NECK OR TORSO⁸
SIZE	≤ 11 KILOGRAMS⁹ (Kg)

RED = any one (1) transport as a trauma alert BLUE = any two (2) transport as a trauma alert

¹ Airway evaluation is designed to reflect the intervention required for effective care

² Patient requiring intubation, manual jaw thrust, continuous suctioning or use of airway adjuncts to assist ventilatory efforts

³ Including drowsiness, lethargy, inability to follow commands, unresponsive to voice, totally unresponsive or coma

⁴ Carotid and femoral pulses are palpable but, radial or pedal pulses are not palpable

⁵ Humerus, (radius,ulna), femur, (tibia or fibula)

⁶ Major degloving injuries or major flap avulsions

⁷ Amputations proximal to the wrist or ankle

⁸ Excluding superficial wounds in which the depth of the wound can be easily determined

⁹ Or body length is equivalent to this weight on the Broselow tape (the equivalent of 33 inches in measurement or less)

Issuing a Trauma Alert:

A “Trauma Alert” is to be called by the first arriving unit, if and when in the judgment of the Paramedic, EMT or Healthcare Professional in charge, the adult or pediatric trauma patient meets the criteria.
To initiate a “Trauma Alert”:
- Establish direct communication with the Trauma Center, Pediatric Trauma Center or other receiving facility on the appropriate facility’s radio talkgroup utilizing either an 800 MHz or VHF radio frequency.
- Give agency name, unit number and state “Trauma Alert”. Give brief description of the situation, location, criteria for call the “Trauma Alert” and approximate E.T.A.
- Once transporting unit is enroute to the trauma center or receiving facility, a complete radio report will be given as outlined in Administrative Policy – RADIO REPORT FORMAT (1.02).
The transporting agency will provide documentation as prescribed in 64J-2.004 FAC for each adult or 64J-2.005 FAC for each pediatric patient or provide documentation on the Seminole County Abbreviated Report to the hospital staff upon delivery of the patient to the Trauma Center or receiving facility.

Transport Procedures:

All trauma alert patients will be transported to the State Approved Trauma Center (SATC) or State Approved Pediatric Trauma Center (SAPTC) nearest to the location of the incident; that meets all criteria as required in the Department of Health Pamphlet DHP 150-9 (January 2010 revision) and 64J-2.002.

Initial efforts are to direct transportation of the trauma alert patient to the closest SATC.
The EMT, Paramedic or Fire Department Officer that finds any trauma patient that meets the criteria using the appropriate Trauma Scorecard Methodology, as required in sections 64J-2.004 or 64J-2.005 FAC shall immediately notify their Communications Center and issue a “Trauma Alert”.
The Paramedic will advise the Communications Center of the following information about the trauma alert scene:
- Total number of patients
- Total number of trauma alert patients
- Criteria by which the alert was called
- Mechanism of injury
- Additional resources needed

Guidelines for transportation are as follows:

AIR SUPPORT to a State Approved Trauma Center (SATC):
- Air support response time is less than 30 minutes.
GROUND TRANSPORT to a State Approved Trauma Center (SATC):
- The ground transport time is less than 30 minutes.
AIR TRANSPORT TO INITIAL RECEIVING HOSPITAL (IRH)
- The TTP of the Air Transport Agency indicate diversion (e.g. Cardiac Arrest etc.).
- MCI situations*
- GROUND TRANSPORT to an IRH nearest the scene of the incident:
- When air transport is not available or response time is greater than 30 minutes and ground transport to SATC is greater than 30 minutes. **Cardiac arrest secondary to trauma.
- Lack of patent airway.
- MCI situation*.

*For situations with multiple trauma patients, not meeting trauma alert criteria, the critical patients should be transported to the initial receiving hospital nearest the scene of incident. The non-critical patients should be transported to a different initial receiving hospital, if possible. There may be instances in mass casualty situations when the ground units will be overburdened and may need air transport to facilitate movement of multiple patients to initial receiving hospitals. This decision will be made by the Field Supervisor on the scene.

If a trauma center or an initial receiving hospital nearest the scene of the incident notifies EMS that it is temporarily unable to provide adequate care for the trauma alert patient, EMS personnel under the direction of Medical Control, will determine which hospital is in the patient’s best interest.

Emergency inter-facility transfers of Trauma Victims:

In accordance with 64J-2.002 FAC, inter-facility transfers to the Trauma Center shall be conducted by services licensed by the department in appropriately permitted ambulances when the patient needs, or is likely to need, medical attention during transport. A critical care patient shall be transported in a permitted air ambulance or ground vehicle that is staffed and equipped requisite to the patient’s requirements. Under extreme circumstances, such as: a patient requiring immediate life, limb, or bodily function saving surgery; an inability to provide that surgery in a timely manner at the originating hospital; and a lack of timely response by a permitted inter-facility transport vehicle, EMS may need to provide that transfer. The attending physician and the originating hospital will ensure that the level of patient care established in the originating hospital is appropriately provided during the transport. The originating hospital will provide personnel and equipment as necessary for the safest transfer possible. If that level of care is, in the determination of EMS, not being provided for contact the Medical Director on call.
Assess the patient upon arrival.
Transport to the facility where the patient has been accepted by physician.

List of Hospitals

TRAUMA CENTERS

The following is a list of trauma centers to where Seminole County Emergency Medical Services System will routinely transport trauma alert patients. It is preferable that pediatric patients (15 years old and younger) and burn patients be transported to a Level I trauma center.

Orlando Regional Medical Center (TL I) 1414 South Kuhl Avenue Orlando, Florida 32806 Arnold Palmer Hospital for Children (TL I) 92 West Miller Street Orlando, FL 32806	Central Florida Regional Hospital (TL II) 1403 Medical Plaza Dr Sanford, FL 32771 Halifax Hospital Medical Center (TL II) 303 North Clyde Morris Blvd. Daytona Beach, Florida 32015

INITIAL RECEIVING HOSPITALS

The following is a list of initial receiving hospitals to where Seminole County Emergency Medical Services System will routinely transport trauma patients that are not trauma alerts. Initial receiving hospitals are indicated by written documentation.

Seminole County Florida Hospital Altamonte 601 E. Altamonte Dr. Altamonte Springs, Florida 32701 Central Florida Regional Hospital 1401 W Seminole Blvd Sanford, Florida 32773 South Seminole Hospital 555 West State Road 434 Longwood, Florida 32750 Oviedo ER 8300 Red Bug Lake Road Oviedo, FL 32765 Volusia County Florida Hospital Fish Memorial 1055 Saxon Blvd Orange City, Florida 32763	Orange County Florida Hospital Apopka 201 N. Park Ave Apopka, Florida 32703 Florida Hospital East Orlando 7727 Lake Underhill Road Orlando, Florida 32822 Florida Hospital Orlando 601 East Rollins Street Orlando, Florida 32803 Winter Park Memorial Hospital 200 Lakemont Ave Winter Park, Florida 32792 Nemours Children Hospital 13535 Nemours Parkway Orlando, FL 32827 (407) 567-4000

Deviations:

Any deviation from these protocols will be documented and justified on the Patient Care Report.