- .No documentation of active or passive warming of the patient
- The amount of fluid given was not documented or generically stated as 1000 ml. NS. The amount of actual fluid administered should be documented under dosage; this is extremely important in burn trauma
- Extrication delays are not documented despite a greater than 30 minute on-scene time.
- Procedures are not documented appropriately in procedure sections. (IV, C-spine)
- Medication complications listed were why the medication was given, not a complication of medication administration.
- Major trauma criteria were checked, but the narrative did not support documentation of major trauma.
- Stop the Bleed and document method used to control bleeding
Trauma Documentation Review-
Major Trauma Criteria Documented
110 Charts had Major Trauma Criteria Documented
25 Charts with Scene Times <10 min
15 Charts with Scene Times >30 min.
Full Review of 15 Charts > 30 min.
- 100% Received IV Access
- 23% of the chart’s narratives did not support the documentation field of major trauma
- 30% no delay documented
- 30% amount of fluid given not documented
Documenting Care: Major Trauma
Stop the Bleed – Managing life-threatening hemorrhage is a critical intervention for trauma patients and should be done during your primary assessment. Death due to bleeding can occur in minutes! Based on the clinical presentation, use sound clinical judgment on the method needed to control bleeding—direct pressure, wound packing, or tourniquet. A tourniquet is no longer a method of last resort if it is clinically indicated! Make sure to document the method and if it was successful- If not, what steps did you take for success.
On-scene Time: 10 minutes or less- In cases of extrication, the on-scene time goal should be less than 10 minutes from the time of successful patient extrication. Documentation of extrication and scene delays is essential and should be documented in the drop-down scene delay box and the narrative.
Prehospital Notification: Should be completed as soon as possible, preferably within 5 minutes of identifying a patient with major trauma.
Spinal Motion Restriction: Spinal motion restriction should be performed and documented when not indicated—document in procedures and narrative.
Temperature Management: Document how you kept your trauma patient warm in the narrative.
Large Bore Vascular Access: BLS providers should request ALS for vascular access and document if ALS is unavailable. ALS providers should document vascular access in procedures. * BLS providers should not delay transport while waiting for ALS
Fluid Resuscitation: The amount of fluid given in the prehospital setting should be carefully documented.
Patients with significant trauma should be expediently moved to a level 1 trauma center for definitive care. It is important to document when the patient was extricated if extrication is required. One of the challenges for rural EMS is the distance of level 1 trauma centers. Good clinical judgment has to be utilized to determine the appropriate destination based on the circumstances and clinical presentation of the patient. Consider using air medical; if unavailable, consider transfer to another level trauma center. Document the reasoning behind your transport destination decision, especially if it is not a trauma center. Involve medical control in the decision..
Receiving trauma center notification within 5 minutes of identifying a patient with significant trauma provides early activation of trauma teams and mobilizes essential hospital resources before the patient’s arrival.
Spinal Motion Restriction:
In major trauma, long backboards may be indicated as an extrication device and/or splint for multiple fractures. Longboards can facilitate the rapid movement of the patient while maintaining spinal motion restriction. Good clinical judgment should prevail in the decision to remove the board or not.
If the patient is restrained with a law enforcement-based restraint intervention (handcuffs, flex-cuffs, hobble restraint, etc.), which are not sanctioned Victims of trauma rapidly lose body heat, which leads to hypothermia, coagulopathy, and increased mortality. Active and passive warming measures are indicated in all major trauma cases to maintain body temperature. Large amounts of room temperature Normal Saline can contribute to hypothermia.
Large Bore Vascular Access
Establishing large bore vascular access in a trauma patient allows for efficient and rapid fluid resuscitation. An 18-gauge catheter is sufficient for large bore vascular access.
Fluid resuscitation is indicated only in patients with hypotension. Aggressive fluid resuscitation should be given to maintain a MAP >65 mmHg. Large volume fluid resuscitation can lead to acidosis.
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