Page 255 - 2023 SMOG Digital

to flight. If compartment syndrome is suspected during flight, place extremity at the
level of the heart. Pain out of proportion to the injury and paresthesia are symptoms
of compartment syndrome, as well as pallor, paralysis, pulselessness, and
poikilothermia. Patients who are sedated, paralyzed or have an epidural or block in
place are at increased risk and require judicious hands on assessment of at risk
abdomen and extremities. (JTTS CPG–Compartment Syndrome and Fasciotomy)
3) Burns: For patients with partial and/or full-thickness burns to >20% TBSA, use of the
Burn Patient Admission Orders and JTTS Burn Resuscitation Flow Sheet are
REQUIRED and should be continued during transfer to another facility. (JTTS CPG –
Burn)
4) Advanced pain management modalities: For patients with epidurals, continuous
peripheral nerve blocks, PCA infusions, or other pain medicine infusions, a pain note
should be completed prior to transport as it is a vital part of provider communication.
(JTTS CPG–Management of Pain, Anxiety and Delirium in Injured Warfighters)
5) Sedation and pain management must be maintained at appropriate levels throughout
transport. As appropriate and as directed by transferring physician, attempt to
maintain sedation target as follows using the Riker Sedation-Agitation Scale (SAS)
Riker Sedation-Agitation Scale (SAS): Used as sedation target goal for Post Surgical/CC
• Non-intubated patients, provide sedation as needed to maintain a goal SAS Score of 3-4.
• Intubated patients, provided sedation as needed to maintain a goal SAS Score of 1-2.
Definition
7 Dangerous Pulling at endotracheal tube, trying to remove catheters, climbing over bedrail,
agitation striking at staff, thrashing from side-to-side
6 Very Does not calm despite frequent verbal reminding of limits, requires physical
agitated restraints, biting endotracheal tube
5 Agitated Anxious or physically agitated, attempting to sit up, calms down on verbal
instructions
4 Calm, Calm, arousals easily, follows commands
cooperative
3 Sedated Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again,
follows simple commands
2 Very Arouses to physical stimuli but does not communicate or follow commands, may
sedated move spontaneously
1 Unarousable Minimal or no response to noxious stimuli, does not communicate or follow
commands
ECC Nurse Protocols May 2012
d. Patient Care Enroute to the Receiving Hospital
1) Patient vital signs will be monitored continuously enroute and documented at least
every 5–15 minutes (q5min if on pressors) per transferring physician’s orders.
2) Reassess patient at least q15min and address events as necessary following
transferring physician’s orders and protocols for the specific illness or injury.

255