1. S-SV EMS MICN Course Module 5 Specialty Systems Of Care (STEMI, Stroke, Burn, & Trauma) S-SV EMS Agency MICN Training (Updated 05-2016) 1

2. STEMI Patients Criteria for EMS transport directly to a STEMI Receiving Center (SRC):  Prehospital 12 lead ECG interpretation of a STEMI with paramedic or AEMT verification  < 45 minute ground ambulance or EMS aircraft transport time to a SRC S-SV EMS Agency MICN Training (Updated 05-2016) 2

3. STEMI Patients Base hospital/SRC destination consultation required for the following:  STEMI patient outside the 45 minute transport catchment area  Suspected STEMI patient without prehospital 12 lead ECG computer confirmation  Critical patients: o Cardiac arrest, unmanageable airway, unstable v-tach, 2 nd degree type 2 or 3 rd degree heart block S-SV EMS Agency MICN Training (Updated 05-2016) 3

4. STEMI Patients Prehospital 12 lead acquisition and transmission:  A minimum of the patients last name and first initial must be entered into the monitor prior to 12 lead acquisition  Any 12 lead consistent with a STEMI (computer or EMS interpretation) shall be transmitted to the appropriate facility if transmission capabilities are available S-SV EMS Agency MICN Training (Updated 05-2016) 4

5. STEMI Patients STEMI patient interfacility transport (IFT):  SRCs have agreed to accept all IFT STEMI patients, unless the SRC is on internal disaster, the cardiac cath lab is out- of-service, or other patients being treated would prevent the IFT patient from receiving intervention in less than 90 minutes from STEMI referral center (SRF) arrival  If SRF arrival-to-SRC intervention is anticipated to be greater than 90 minutes, administration of lytic agents should be considered in patients that meet thrombolytic eligibility criteria S-SV EMS Agency MICN Training (Updated 05-2016) 5

6. STEMI Patients STEMI patient interfacility transport (IFT):  The 911 system may be utilized to request an emergent ambulance for transport of a STEMI patient to a SRC. An air ambulance or contracted ALS/CCT provider may also be utilized if necessary/appropriate  Unless medically necessary, avoid using medication drips that are outside of the paramedic scope of practice to avoid any delays in transferring of STEMI patients S-SV EMS Agency MICN Training (Updated 05-2016) 6

7. Stroke Patients EMS assessment:  Cincinnati Prehospital Stroke Scale (CPSS)  Blood glucose check  Determine time of symptom onset or when patient last seen normal S-SV EMS Agency MICN Training (Updated 05-2016) 7

8. Stroke Patients Criteria for EMS transport directly to a Stroke Receiving Center:  Onset of stroke symptoms ≤ 4 hours  < 30 minute ground ambulance or EMS aircraft transport time to a stroke receiving center S-SV EMS Agency MICN Training (Updated 05-2016) 8

9. Stroke Patients Stroke patient interfacility transport (IFT):  The 911 system may be utilized to request an emergent ambulance for transport of an acute stroke patient to a stroke receiving facility. An air ambulance or contracted ALS/CCT provider may also be utilized if necessary/ appropriate  Patient transport should not be delayed if complete documentation is not available S-SV EMS Agency MICN Training (Updated 05-2016) 9

10. Stroke Patients Additional stroke patient notes:  Blood draws may be obtained by EMS personnel (per pre-arranged agreement with stroke receiving center)  EMS personnel may provide minimum patient identifiable information (name, DOB, MR#, etc.) over a secured line if requested by the stroke receiving center  EMS personnel may contact the closest base/modified base hospital for destination consultation of a possible acute stroke patient if necessary S-SV EMS Agency MICN Training (Updated 05-2016) 10

11. Burn Patients Electrical burn patients shall be transported by EMS for evaluation (patient refusals considered AMA) Base hospital destination consultation required for the following types of patients:  3 rd degree burns of the hands, feet, face, perineum, or > 2% of any body surface  2 nd degree burns > 9% of body surface  Significant electrical or chemical burns  When transport to a burn center may be in the best interest of the patient S-SV EMS Agency MICN Training (Updated 05-2016) 11

12. Trauma Patients Patients meeting trauma triage criteria should be transported as soon as possible On scene procedures should be limited to:  Triage/assessment  Airway management  External hemorrhage control  Immobilization S-SV EMS Agency MICN Training (Updated 05-2016) 12

13. S-SV EMS Trauma Triage Criteria Physiologic trauma triage criteria (one or more of the following):  Respiratory rate 29 breaths per minute (<20 in an infant aged <1 year) or need for ventilatory support  Glasgow Coma Score ≤ 13  Systolic blood pressure < 90 S-SV EMS Agency MICN Training (Updated 05-2016) 13

14. S-SV EMS Trauma Triage Criteria Anatomic Trauma Triage Criteria:  All penetrating injuries to the head, neck, chest, torso, and/or extremities proximal to the elbow or knee  Chest wall instability or deformity (e.g. flail chest)  Two or more proximal long-bone fractures  Paralysis  Pelvic fractures  Amputation proximal to wrist or ankle  Crushed, degloved, mangled, or pulseless extremity  Open or depressed skull fracture S-SV EMS Agency MICN Training (Updated 05-2016) 14

15. S-SV EMS Trauma Triage Criteria Mechanism of Injury Trauma Triage Criteria:  High-risk auto crash (one or more of the following) o Ejections (partial or complete) from automobile o Death in the same passenger compartment o Intrusion, including roof: > 12 inches at occupant site or > 18 inches at any site  Non-automotive crash >20 mph (motorcycle, ATV, go- cart, bicycle, skateboard, watercraft, aircraft, etc.) S-SV EMS Agency MICN Training (Updated 05-2016) 15

16. S-SV EMS Trauma Triage Criteria Mechanism of Injury Trauma Triage Criteria:  Auto vs pedestrian/bicycle: thrown, run over, or with significant impact (>20 mph)  Adults who fall > 20 feet  Children who fall > 10 feet or 2 to 3 times the height of the child  Other high energy impact S-SV EMS Agency MICN Training (Updated 05-2016) 16

17. S-SV EMS Trauma Triage Criteria Special considerations:  Adults > 55 years of age o SBP >110 might represent shock after 65 years of age o Low impact mechanism (e.g. ground level falls) might result in severe injury  Children ≤ 14 years of age should be triaged to pediatric capable trauma centers when possible  Head injury patients on anticoagulants or who have bleeding disorders are at high risk for rapid deterioration S-SV EMS Agency MICN Training (Updated 05-2016) 17

18. S-SV EMS Trauma Triage Criteria Special considerations:  Burns: o With trauma mechanism – triage to trauma center o Without trauma mechanism – triage to burn center  Pregnancy >20 weeks  EMS provider judgement in consultation with medical control S-SV EMS Agency MICN Training (Updated 05-2016) 18

19. Spinal Stabilization Patients with penetrating trauma to the head, neck, or torso and no evidence of spinal injury should not be stabilized on a backboard S-SV EMS Agency MICN Training (Updated 05-2016) 19

20. Spinal Stabilization Spinal stabilization with a backboard should be implemented for trauma patients who meet any of the following criteria:  Midline spinal pain or tenderness  Limited cervical spine active range of motion  Gross motor/sensory deficits or complaints  High energy impact blunt trauma patients meeting anatomical and/or physiological trauma triage criteria S-SV EMS Agency MICN Training (Updated 05-2016) 20

21. Spinal Stabilization Spinal stabilization with or without a backboard should be considered for trauma patients who have an unreliable H&P:  Altered mental status (i.e. dementia or delirium)  Intoxicated (drugs or alcohol  Injury detracting from or preventing reliable hx & exam  Language barrier preventing reliable hx & exam  Extremes of age 65 years old S-SV EMS Agency MICN Training (Updated 05-2016) 21

22. Spinal Stabilization Helmet removal guidelines:  Football helmets should not be removed prior to spinal stabilization unless they fail to hold the head securely, interfere with the airway, or prevent proper stabilization  Motorcycle, bicycle and other types of helmets should be removed prior to spinal stabilization S-SV EMS Agency MICN Training (Updated 05-2016) 22

23. Trauma Patient Destination Adult trauma patient destination:  Unmanageable airway – transport to closest hospital  Anatomic or physiologic criteria: o Level 1 or 2 trauma center closest – transport to that facility o Level 3 trauma center closest – contact that facility for destination consultation  Mechanism of injury and/or special considerations only: o Contact closest base hospital for destination consultation S-SV EMS Agency MICN Training (Updated 05-2016) 23

24. Trauma Patient Destination Pediatric trauma patient destination:  Transport directly to a designated pediatric trauma center (UCDMC) if all the following criteria are met: o Age ≤ 14 years old meeting anatomic or physiologic criteria o Ground ambulance or EMS aircraft transport time does not exceed 45 minutes o Patient condition is not too critical for transport to the pediatric trauma center S-SV EMS Agency MICN Training (Updated 05-2016) 24

25. Trauma Patient Transfers S-SV EMS Agency MICN Training (Updated 05-2016) 25

26. Trauma Patient Transfers S-SV EMS Agency MICN Training (Updated 05-2016) 26

27. Trauma Patient Transfers S-SV EMS Agency MICN Training (Updated 05-2016) 27