EMS Protocol of the Week - General Trauma Care (Adult and Pediatric)

We’ll get more into specific trauma protocols throughout the year, but the protocol in place for general trauma care serves mostly to give the most basic level of approaches to supporting a patient and their ABCs during the initial scene encounter. It serves as a good refresher/reminder of some potentially more emergent injury patterns and what the first interventions should be.

The attached appendix also describes the criteria used in determining whether or not a patient should be brought to a trauma center or general ED. Keep in mind that, while there is some overlap, this is not for EMS to use in determining whether something is a Level 1, Level 2, or Level 3 trauma; it only helps guide them on transportation destination (ie, trauma center or not). The level of activation is done at the hospital level.

Hope that all makes sense! Reach out with questions, www.nycremsco.org and the protocol binder for more.

Dave

Diverticulitis

Diverticulitis used to be thought of as a progressive disease with increasing risk of complications with a greater number of episodes. That general concept drove guidelines for aggressive management, specifically generous antibiotic administration, and surgical interventions. 

More recent data suggests we can be less aggressive with our treatment in the correct patient population.

Epidemiology

·      The incidence of diverticulitis in the United States is 180/100,000 persons per year

·      Diverticulitis is most common in older adults

·      Large increase in cases with younger adults. The incidence of diverticulitis in individuals 40–49 years old increased by 132% from 1980 through 2007 alone

Uncomplicated Diverticulitis vs Complicated Diverticulitis

·      Uncomplicated diverticulitis: thickening of the colon wall and peri-colonic inflammatory changes.

·      Complicated diverticulitis:  abscess, peritonitis, obstruction, stricture, and/or fistula.

·      Small percentage of cases will be complicated

·      Most common complication: abscess or phlegmon

·      Most people recover from, 5% will go on to develop smoldering diverticulitis.

When to Image

·      CT should be performed to confirm diagnosis in previously unimaged patients 

·      Severe presentations

·      Failure of outpatient therapy

·      Immunocompromised

·      Surgical preparation

Immunosuppressed Patients

·      They can present with MILDER symptoms

·      Present with severe or complicated disease

·      Low threshold to image, consult colorectal surgery, and treat with antibiotics

·      Corticosteroid use is a risk factor for diverticulitis and can contribute to complications, including perforation and death.

·      Higher risk to develop complicated diverticulitis from uncomplicated diverticulitis

·      Antibiotics: broad-spectrum agents with gram-negative and anaerobic coverage

·      Longer duration of treatment (10–14 days).

Antibiotics

·      Antibiotic treatment can be used SELECTIVELY, in immunocompetent patients with mild uncomplicated diverticulitis

·      No difference in time to resolution or risk of readmission, progression to a complication, or need for surgery in those treated vs no antibiotics

·      Give antibiotics with uncomplicated diverticulitis who have comorbidities, frail, refractory symptoms, or vomiting

·      Symptoms longer than 5 days

·      CRP >140 mg/L

·      WBC count > 15 x 109 cells/L

Outpatient Antibiotics

·      Regimen includes broad-spectrum agents with gram-negative and anaerobic coverage.

·      Oral fluoroquinolone and metronidazole

·      Or monotherapy with oral amoxicillin/clavulanate.

·      The duration of treatment is usually 4–7 days but can be longer at physicians discretion

Inpatient Antibiotics

·      Ceftriaxone (1 gram IV every 24 hours) + metronidazole (500mg IV every 8 hours)

·      Levofloxacin (500mg IV every 24 hours) + metronidazole (500mg IV every 8 hours)

·      Piperacillin-Tazobactam (3.375 – 4.5g IV every 6 hours)

·      Imipenem-Cilastatin (500mg IV every 6 hours)

Colonoscopy

·      After an episode of complicated diverticulitis and after the first episode of uncomplicated diverticulitis

·      Can defer if within a year colonoscopy was performed

·      Must wait 6–8 weeks or until resolution of symptoms, whichever is longer. Obtain sooner if alarm symptoms

·      Risk of colon cancer complicated diverticulitis (7.9%) vs uncomplicated diverticulitis (1.3%)

When to Admit

·      All complicated diverticulitis

·      Intractable nausea/vomiting

·      Comorbid disease

·      High WBC, fever, elderly, immunocompromised

·      Failed outpatient therapy

·      Large Abscess >3-4cm

When to Discharge

·      Can tolerate PO

·      No significant comorbidities

·      Able to obtain outpatient antibiotics if needed

·      Adequate pain control

·      Uncomplicated disease

·      All newly diagnosed should follow up colonoscopy in 6-8 weeks

·      Surgical referral for all patients with 3rd or 4th episode of diverticulitis

References

https://www.giboardreview.com/wp-content/uploads/2021/12/Guidelines-AGA-diverticulitis-2021.pdf

https://coreem.net/core/diverticular-disease/

http://www.emdocs.net/em3am-diverticulitis/

emDOCs.net – Emergency Medicine EducationEM@3AM - Diverticulitis - emDOCs.net - Emergency Medicine Education

www.emdocs.net

https://wikem.org/wiki/Diverticulitis

Corneal Foreign Bodies

Corneal Foreign Bodies

·      Corneal foreign bodies account for approximately 35% of all eye injuries seen in the ED

·      Corneal foreign bodies are usually superficial and benign, but penetration into the globe can cause loss of vision

·      Foreign bodies are generally small pieces of metal, wood, or plastic

·      The presence of a corneal foreign body causes an inflammatory reaction, dilating blood vessels of the conjunctiva and causing edema of the lids, conjunctiva, and cornea

·      If present for >24 hours, WBCs may migrate into the cornea and anterior chamber as a sign of iritis

·      Occasionally, the foreign body may be visible with the naked eye

·      Evert the lid to identify and remove other foreign bodies

·      When a metallic foreign body is present for more than a few hours, a rust ring develops around the metal

·      The presence of a gross hyphema or a microhyphema evident in the anterior chamber on slit lamp examination suggests globe perforation

·      If the foreign body has penetrated the cornea, the tract of the projectile may be seen. The Seidel test may be positive with penetration of the globe

·      Contact lens use should be avoided until the defect is fully healed or feels normal for at least 1 week.

Foreign Body Removal

·      Anesthetize the cornea with a local anesthetic

·      Anesthetizing both eyes can be helpful, because that can eliminate reflex blinking during attempts at foreign body removal

·      Irrigate with normal saline first, as a very superficial foreign body may be irrigated off the cornea

·      Next, try to dislodge the foreign body with a moistened cotton applicator (Q-tip)

·      If the foreign body is tightly adherent to or embedded in the cornea, inspect the cornea using optic sectioning on the slit lamp to assess the depth of penetration

·      Full-thickness corneal foreign bodies should be removed by an ophthalmologist

·      For superficial foreign bodies, a 25-gauge needle (using needle bevel up) or a sterile foreign body spud (1 mm diameter) on an Alger brush (a low-speed, low-torque, battery-operated hand-held drill) can be used to remove the foreign body

·      Using either the 25-gauge needle or the Alger brush, place the tip into the slit lamp beam using the naked eye

·      Using the bevel-up edge of the tip of the 25-gauge needle, hook the edge of the foreign body and dislodge it. You may then lift it off the cornea using the previously moistened cotton applicator

·      Alternatively, using the spinning tip of the Alger brush, the foreign body may be dislodged and removed with the cotton applicator as above.

·      Administer tetanus toxoid as appropriate.

·      Provide ophthalmology follow-up the NEXT DAY if the foreign body is in the central visual axis or if there is a residual rust ring.

·      Otherwise, after complete removal of the foreign body, advise follow-up in 48 hours.

·      After successful foreign body removal, discharge the patient with a prescription for topical antibiotics, cycloplegics, and oral analgesics.

Antibiotics

·      Does Not Wear Contact Lens

o   Erythromycin ointment qid x 3-5d OR

o   Ciprofloxacin 0.3% ophthalmic solution 2 drops q6 hours OR

o   Ofloxacin 0.3% solution 2 drops q6 hours

·      Wears Contact Lens

o   Antibiotics should cover pseudomonas and favor 3rd or 4th generation fluoroquinolones

o   Moxifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR

o   Tobramycin 0.3% solution 2 drops q6hrs for 5 days OR

o   Gatifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR

o   Gentamicin 0.3% solution 2 drops six times for 5 days

Rust Ring Removal

·      Metallic foreign bodies can create rust rings that are toxic to the corneal tissue.

·      If a rust ring is present, the spud or an ophthalmic burr can remove superficial rust, but rust often reaccumulates by the next day, requiring additional burring.

·      It is therefore not necessary to remove a rust ring in the ED if the patient can be seen by an ophthalmologist the next day

·      Once the metallic foreign body is removed, the rust ring area softens overnight and can be more easily removed in the office the next day

·      The deeper the stromal involvement, the higher is the risk of corneal scarring, so if rust ring removal is done in the ED, only perform superficial burring

·      No ED drill burring should take place if the rust ring is in the visual axis (pupil) owing to the risk of causing visually significant scarring

References

Tintinalli’s Emergency Medicine a Comprehensive Study Guide 8th Edition

https://litfl.com/something-in-my-eye-doc/

https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343806

https://wikem.org/wiki/Ocular_foreign_body