Trauma Guidelines

for Auckland Hospital

Trauma Guidelines

for Auckland Hospital

Introduction

Auckland City Hospital (ACH) is the regional tertiary referral hospital for the care of the severely injured adults.

ACH receives patients with a wide range of injuries, both directly from the scene and following transfer from other hospitals. ACH provides de nitive care for these injuries.

Delays to definitive care increase morbidity and mortality.

ACH has a Trauma Team system which provides immediate skilled emergency care for trauma patients in the Department of Emergency Medicine and facilitates early progress to de nitive care. These guidelines describe the approach to major trauma patients.

Read and know them before you take on a role within the trauma team.

These guidelines have been developed following extensive consultation and review. They are endorsed by the Auckland City Hospital Trauma Service in collaboration with other services.

The treatment of severe trauma is ‘time critical’. Timely and appropriate intervention reduces preventable levels of mortality, complications and lifelong disability amongst people who sustain a major trauma.

The initial assessment of a trauma patient is a team process. Most patients with major trauma require the input of a number of different specialty groups. Often this does not extend outside the trauma team however the input of orthopaedic, neurosurgical, maxillofacial or plastic surgical teams may be required. Notify specialists early about severely injured patients

Multiple major trauma patients at the same time are common and can place considerable stress on the system. This can lead to situations where patients who have severe but not immediately obvious injures are overlooked. When this situation arises assistance should be summoned early.

The intent of these guidelines is to provide clear consistent guidelines around the process of care and treatment for trauma patients. It is expected these guidelines will be followed by all staff. Variation from these guidelines are made only after careful consideration.

These guidelines are in four parts.

  • Part one explains the trauma call process.
  • Part two outlines they standard approach for treatment of injuries
  • Part three has the algorithms for treatment of common injuries
  • Part four is the Northern Regional Trauma Network Transfer Guidelines that indicate which patients should stay at Auckland City Hospital, and which should be transferred to Middlemore. They also identify specific conditions which indicate transfer into Auckland from regional referral centres.

Part1: Trauma calls

A. Criteria for a trauma call

A mandatory trauma call will be made when there is one or more of: 

The emergency department is notified of the imminent arrival of an unstable patient (Status 1 or 2, see appendix for ambulance condition status codes).

  • Respiratory rate < 10 or > 29
  • Systolic blood pressure < 90 mmHg for patients under 55 OR <110 mmHg for patients over 55
  • Heart Rate > 120 bpm
  • Glasgow Coma Scale < 13

These physiological parameters may be met in the ambu- lance, noted at triage or deteriorated to in the emergency department.

  • Penetrating injury to the head, neck or torso
  • Flail chest
  • Complex pelvic injury
  • Two or more proximal long bone fractures
  • Traumatic amputation proximal to knee or elbow
  • Major crush injury
  • Penetrating trauma to a limb with arterial injury
  • Crushed, mangled, amputated or pulseless limb
  • Paraplegia or quadriplegia
  • Major burns

A discretionary trauma call can be made by the Emergency Medicine registrar or consultant. This may be made for mech- anism, physiology, co-morbidities or a combination of these.

These might include:

  • Fall > 3 metres
  • Entrapment > 30 minute
  • Cyclist or motorcyclist versus car
  • Beta-blockers
  • Pedestrian versus car or train
  • Relative hypotension
  • Ejection from a vehicle
  • Anti coagulation
  • Fatality in the vehicle
  • Elderly patient with moderate trauma

A trauma call ends with acceptance to a hospital service (DCCM, a surgical service or the Emergency Department) with a clear plan for definitive care.

B. Activitating a Code Crimson Call

A Code Crimson call is made either by HEMS or once the patient is in ED and assessed as potentially requiring surgical or interventional radiology to control haemorrhage post trauma.

Assessment is based on the four parameters of the Assessment of Blood Consumption score (ABC):

  1. Penetrating truncal mechanism of injury
  2. Systolic Blood pressure of 90mmHg or less
  3. Pulse of 120/ min or more
  4. Positive trauma E-FAST ultrasound scan

You score one point for each parameter met. If the patient scores ≥ 2 points they meet the criteria for Code Crimson activation.

Code Crimson activation will be sent via Switch to all the personnel on the standard Trauma Call activation as well as the following personnel:

  1. Surgical Consultant on call
  2. Emergency Department Consultant if they are not in the ED
  3. Level 8 Anesthetist
  4. Level 8 Nursing coordinator
  5. Radiology registrar who will contact the on call Interventional Radiologist
  6. Blood bank

The aim of the Code Crimson activation is to get all the surgical decision makers and facilitators in the resuscitation room to facilitate rapid access to theatre or interventional radiology 24 hours a day, 7 days a week.

See Part 3 for the Code Crimson algorithm.

C. Initiating a Trauma Team Call

The trauma call may be initiated at any time: from the re- ceiving of an RT call to de nitive care as may otherwise have been arranged. The trauma call and response is designed to decrease time to de nitive care, when there is the potential for delays to worsen outcomes.

The nurse co-ordinator dials 777 and requests a trauma call to the adult ED in xx number of minutes. The trauma team will not be activated by any other mechanism. There are no partial calls.

The telephone operator initiates the trauma team group page and then will log the call from the Emergency Department.

It is the responsibility of all members of the trauma team to respond immediately to the call. Delegate to an individual of equal or greater seniority when attendance is not possible. It is the on-call general surgical registrar’s responsibility to ensure a representative from one of the surgical services attends every trauma call. If unavailable, the general surgical registrar should first nominate the orthopaedic registrar, next the neurosurgical registrar, next the urology registrar. At night, when neurosurgical and urology registrars are not in the hospital, call the paediatric surgical registrar.

D. Process of care for a trauma call patient

The principles of the EMST course form the basis of these guidelines. Adaptations to the local ‘environment’ are included.

E. Trauma Team Membership and Roles

Know your role prior to being a team member. The Trauma Team leader will delegate specific tasks when required. 

The trauma team leader is a consultant. This responsibility may be delegated to another individual. Overnight this delegation is automatically given to the senior ED doctor.

The trauma team leader is clearly identified by placing the “trauma team leader” sticker on the scrubs. All trauma team members must have their roles delineated before the arrival of the patient.

The team leader does not change during a trauma call.

All doctors make themselves known to the team leader before becoming clinically involved with the patient.

Membership & Roles

The team membership is as follows:

  • Decisions
  • Direction
  • Destination
  • Documentation
Responsibilities:
  1. Ensure team is complete and roles allocated prior to patient arrival
  2. Obtain essential history from pre-hospital care providers
  3. Ensure team members perform their roles in a timely fashion
  4. Prioritise injuries and the investigation and management thereof
  5. Facilitate passage of patient to de nitive care and radiology
  6. Reach agreement with the trauma team members on treatment plan and timeframe
  7. Contact other specialities (e.g. Orthopaedics or Neurosurgery)
  8. Initiate Massive Transfusion Protocol as required http://adhbintranet/anaesthesia/guidelines/mtp13.pdf
  9. Speak with relatives
  10. Ensure appropriate documentation is completed by team members

When possible this should be a ‘hands off’ role. 

  • Primary Survey: A, B and D.

Responsibilities:

  1. Communicate with the patient
  2. Establish patent airway and give oxygen
  3. Ensure in-line stabilisation of the cervical spine
  4. Establish and maintain ventilation
  5. Evaluate neurological status
  6. Monitor ECG and vital signs
  7. Insert arterial line as required
  8. Place a gastric tube (orally if the nasal route is contra-indicated) 

 

  • Primary survey: C and E
  • Arrange trauma radiology
  • Secondary survey
Responsibilities:
  1. Stop external bleeding with pressure
  2. Complete primary survey (C & E)
  3. Insert large bore cannulae (14g/16g in antecubital fossae)
  4. Take trauma bloods (including ethanol) and cross match suspended red cells
  5. Start uid resuscitation with crystalloid
  6. Complete secondary survey including FAST scan where relevant 

 

  • Expedite surgical and radiological intervention.
  • Confirm the secondary survey ndings.
  • Perform invasive examinations.

Responsibilities:

  1. Intercostal drainage
  2. Arrest external bleeding
  3. Urinary catheterisation
  4. FAST scan and/or Diagnostic peritoneal lavage (DPL) where indicated
  5. Review secondary survey
  6. During logroll, examine back and perform rectal examination
  7. Arrange CT, angiography if indicated
  8. Arrange OR appropriate and gain consent 

Prior to patient arrival

  • Check and prepare airway equipment
    • oxygen & suction
    • intubation equipment - ventilator/capnograph
  • Draws up intubation drugs

On patient arrival

  • Ensure C-spine stabilisation
  • Assist with patient transfer onto bed
  • Assist with initial airway management
  • Cut clothes on patient’s right when airway secure

During intubation

  • Assist with intubation
  • Ensure cricoid pressure is applied (by another member of the team) if request from airway doctor
  • Secure ET tube and attach to ventilator & capnograph • Assist with insertion of NG tube
  • Apply lacrilube

Ongoing care

  • Ongoing monitoring of airway & ventilation
  • Record ECG
  • Assist with/performs IDC - dipsticks & sends spec
  • Assist with chest drain insertion / DPL /USS / other procedures

Prior to transfer

  • Total drainage output – IDC / chest drain & informs documentation nurse
  • Ensure portable oxygen available
  • Prepare transport box & drugs 

Prior to patient arrival

  • Ensure IV trolley available
  • Prime IV lines
  • On patient arrival
  • Switch timer on
  • Assist with patient transfer onto bed
  • Cut clothes on patients left
  • Attach Propaq
  • Perform initial obs (place saturation probe on as 1st action) - BP, P, RR, temp, GCS, 02 sats. Inform team of readings
  • Assist with control of haemorrhage
  • During intubation /iv access
  • Assist with IV lines & uid infusion
  • Administer IV drugs

Ongoing care

  • Continued obs - BP, P, RR, temp, GCS, 02, CO2, MAP - & informs team
  • Set up arterial line monitoring
  • Continue with administration of IV uids / drugs
  • Apply splints / dressings
  • Notify documentation nurse of uids/drugs administered

Prior to transfer

  • Ensure necessary equipment & uids available
  • If patient is going to a ward ensure arterial line is re- moved 
Senior Nurse at Foot of Bed

Prior to patient arrival

  • Designate nursing roles & liaise with team leader
  • Identify team members
  • Prepare documentation – ensures R40 attached to front of resus record
  • Inform blood bank and x-ray as appropriate
  • Ensure rapid infusion device is set up as indicated
  • Ensure art line is set up as indicated

On patient arrival

  • Document:
    • time of arrival
    • history from ambulance of cers
    • patient status
    • baseline recordings including GCS and pupil reaction
  • Prepare paperwork
  • Liaise with clerks re: patient details / valuables / sending bloods
  • Attach ID band
  • Label and secure property
During intubation/iv access
  • Document time / drug / dose etc

 

Ongoing care

  • Co-ordinate nurses to assist with log roll
  • Continue with documentation
  • Provide team with regular updates
  • Access drugs
  • Double check all infusions where necessary (e.g. blood)
  • Ensure specimens are labelled & sent
  • Liaise with social worker or ED charge nurse for the ongoing care of the family

Prior to patient transfer

  • Liaise with MBOR / DCCM charge nurse/ duty manager
  • Keep ED charge nurse informed
  • Ensure documentation completed
  • If transferring patient to a ward ensure:
    • Fluid total input / output is transcribed onto hospital uid balance chart
    • Ongoing medication is transcribed
  • Makes decision regarding most appropriate transfer nurse 

Document on white board: 
  • Patient identity – name, age, gender
    • Mechanism of injury
    • Location of injury
  • Injuries
    • Signs and Symptoms
  • Relevant Medical history
  • Allergies
  • Medications prescribed
  • Other Information
  • Print e-PRF for inclusion in patient notes. 
F. Standard precautions
Standard infection control and safety precautions should be maintained for all patients including trauma calls.
G. Primary Survey (ABCDE)

The primary survey is achieved through parallel tasking. Knowing your role makes this possible. 

H. Secondary survey

This assessment is a complete examination of the patient from top to toe, both front and back.

Use the “Major Trauma Form”

Part3: Trauma Algorithms

Penetrating Neck Trauma
CTA Neck
Penetrating Chest Trauma
Suspected Blunt Cardiac Injury
Rib Fracture Pain Management 1
Rib Fracture Pain Management 2
Penetrating Abdominal Injury
Blunt Abdominal Trauma
Fractured Pelvis - UNSTABLE
Fractured Pelvis - STABLE
Traumatic Cardiac Arrest
PanScan Radiology Protocol
Code Crimson MTP
Trauma Code Crimson

Part4: Interhospital Transfer

Part5: Patient Information Sheets

Rib & Sternal Fractures

Complex Chest Injuries

Understanding your Liver Injury

Injuries of the Spleen