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 has the northern region inter-hospital transfer guideline 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 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
- 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.
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):
- Penetrating truncal mechanism of injury
- Systolic Blood pressure of 90mmHg or less
- Pulse of 120/ min or more
- 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:
- Surgical Consultant on call
- Emergency Department Consultant if they are not in the ED
- Level 8 Anesthetist
- Level 8 Nursing coordinator
- Radiology registrar who will contact the on call Interventional Radiologist
- 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.
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.
The principles of the EMST course form the basis of these guidelines. Adaptations to the local ‘environment’ are included.
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:
- Team Leader
- Critical Care Medicine Registrar
- Emergency Medicine Registrar
- General Surgical Registrar
- Procedural Nurse
- Circulation Nurse
- Nurse Co-ordinator
- Ensure team is complete and roles allocated prior to patient arrival
- Obtain essential history from pre-hospital care providers
- Ensure team members perform their roles in a timely fashion
- Prioritise injuries and the investigation and management thereof
- Facilitate passage of patient to de nitive care and radiology
- Reach agreement with the trauma team members on treatment plan and timeframe
- Contact other specialities (e.g. Orthopaedics or Neurosurgery)
- Initiate Massive Transfusion Protocol as required http://adhbintranet/anaesthesia/guidelines/mtp13.pdf
- Speak with relatives
- Ensure appropriate documentation is completed by team members
When possible this should be a ‘hands off’ role.
- Primary Survey: A, B and D.
- Communicate with the patient
- Establish patent airway and give oxygen
- Ensure in-line stabilisation of the cervical spine
- Establish and maintain ventilation
- Evaluate neurological status
- Monitor ECG and vital signs
- Insert arterial line as required
- Place a gastric tube (orally if the nasal route is contra-indicated)
- Primary survey: C and E
- Arrange trauma radiology
- Secondary survey
- Stop external bleeding with pressure
- Complete primary survey (C & E)
- Insert large bore cannulae (14g/16g in antecubital fossae)
- Take trauma bloods (including ethanol) and cross match suspended red cells
- Start uid resuscitation with crystalloid
- Complete secondary survey including FAST scan where relevant
- Expedite surgical and radiological intervention.
- Confirm the secondary survey ndings.
- Perform invasive examinations.
- Intercostal drainage
- Arrest external bleeding
- Urinary catheterisation
- FAST scan and/or Diagnostic peritoneal lavage (DPL) where indicated
- Review secondary survey
- During logroll, examine back and perform rectal examination
- Arrange CT, angiography if indicated
- 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
- 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 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
- 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
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
- 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
- Document time / drug / dose etc
- 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
- Patient identity – name, age, gender
- Mechanism of injury
- Location of injury
- Signs and Symptoms
- Relevant Medical history
- Medications prescribed
- Other Information
- Print e-PRF for inclusion in patient notes.
The primary survey is achieved through parallel tasking. Knowing your role makes this possible.
This assessment is a complete examination of the patient from top to toe, both front and back.
Use the “Major Trauma Form”
Part2: Standard approach for treatment of injuries
Algorithm for management of head injury patient is found in Part 3.
Head injury is common and is frequently one of several injuries. Head injury is a part of ‘D’, and as such A, B and C injuries take priority. Once initial stabilisation has been undertaken patients with GCS < 14 will require neurosurgical assessment including CT scanning at some stage (Figure 1).
Basic neurological examination should include assessment of the Glasgow Coma Scale noting not only the best response but also any lateralising signs (i.e. also the worst response).
It should be remembered that hypoxaemia, shock, alcohol and other drugs all depress the level of consciousness and worsen the neurological signs. Analgesic and anaesthetic drugs and muscle relaxants also interfere with neurological assessment.
Glasgow Coma Scale
To voice *
|Best verbal response||Oriented|
|Best motor response||Obeying|
Algorithm for management of head injured patients is found in Part 3.
- Adequate Oxygenation
- Prevent Hypercarbia and Hypocarbia (Hypoventilation and Hyperventilation)
- Adequate Perfusion
- Pressure Prevention of Hypoglycaemia
- Reduce agitation
- Early decompression when indicated
- Use of:
- 4 Molar salt
Algorithm for management of cervical spine injury is found in Part 3.
Physical signs of spinal cord trauma include:
- No movement of arms and/or legs
- Abnormal peripheral vasodilatation
- Lax anal sphincter tone
- Contusions/tenderness/deformity/crepitus on clinical examination of the spine during the logroll
- Subjective and objective sensory changes
The only cervical spine view indicated in the emergency room is the lateral view. The cervical spine must remain protected until the patient is stable enough to undergo the 3 film cervical series, performed either in the radiology suite or in DCCM. “Clearance” of the cervical spine is undertaken according to the guidelines in Figure 2 (Appendix).
Any patient who has a cervical spine injury or severe blunt trauma requiring admission to DCCM should have screening AP and Lateral x-rays of the entire thoracic and lumbar spine. Patients with clinical signs of thoracic or lumbar spine injury similarly require radiologic evaluation.
Presently at ACH steroids are not used in the acute management of cord injuries.
Any patient with isolated spinal cord impairment, refer to the Supra-Regional Spinal Cord Injury Guidelines. These patients are transferred as soon as possible to Middlemore Hospital.
Algorithms for management of blunt and penetrating chest trauma are found in Part 3.
Injuries that immediately compromise ventilation and oxygenation should be identi ed during the initial assessment of the trauma patient and treated appropriately. Examples include pneumothorax and haemothorax. These patients are always admitted.
Some injuries result in severe respiratory compromise hours or even days after injury. Minor injuries can be a marker
for more severe injuries. The Trauma Service has a liberal admission policy for patients with seemingly minimal chest trauma.
Patients with the following conditions will be admitted:
- Sternal fractures
- Any 1st, 2nd or 3rd rib fractures
- More than 1 rib fracture in any region (We might not admit an otherwise t and healthy patient on the basis of a single rib fracture)
- Pulmonary contusion
- Subcutaneous emphysema
- Traumatic asphyxia
- Flail segment
- Chest trauma associated with an arrhythmia or other evidence of myocardial injury.
Co-morbid (e.g. CORD, warfarin etc.) and elderly patients may be admitted following any chest trauma.
Patients with chest injuries are admitted under general surgery unless they require admission for another injury requiring surgery i.e. orthopaedic/neurosurgical. They can be referred to the Trauma Service for continuing care as a ward referral. Chest injury patients should not be admitted under medical service due to pain service availability and differing nursing skills. All should receive supplemental oxygen as needed, chest physiotherapy, and adequate analgesia. Consultation with the Pain Service on the day following injury should be considered.
Indications for tube thoracostomy
Tube thoracostomy (chest tube insertion) is indicated in the following circumstances.
- Haemothorax on chest x-ray
- Signi cant pneumothorax (>20% loss of diameter on chest x-ray)
- Severe lung injury or any pneumothorax, no matter how small on chest x-ray, in a patient who is to be transported by ground or air, or is to undergo GA or positive pressure ventilation
- As a diagnostic / therapeutic procedure in the unstable multi-trauma patient with suspected internal haemorrhage into the chest
- Small pneumothorax or surgical emphysema if patient is to undergo positive pressure ventilation.
All trauma patients with an “appropriate mechanism of injury” (total body acceleration/deceleration e.g. road crashes [incl. pedestrians and cyclists] and falls >1 storey) are at risk for thoracic great vessel injury. Concerns must be discussed with consultants.
Suspicious clinical signs include:
- neck haematoma
- unilateral diminution or loss of pulse, asymmetric BP • radiofemoral delay (pseudocoarctation)
- severe searing transthoracic pain
AP chest x-ray signs include:
- Widened mediastinum >8cm
- Loss of normal aortic contour
- Opaci cation of aorta-pulmonary window
- Apical capping
- Displacement of main stem bronchi (left down, right up), NG tube to the right
- Fracture of rst rib, scapula
The widened mediastinum requires further investigation, most commonly with CT aortogram.
A widened mediastinum does not necessarily mean an abnormal mediastinum and an abnormal mediastinum may not necessarily be widened.
The investigations for great vessel injury are:
- Can be helpful in resolving the diagnosis of abnormal mediastinum
- Requires the appropriate CT protocol (thoracic aorta dissection protocol)
- Can identify injuries that may otherwise be missed on plain lms
- Is not useful for mediastinal haematoma if anatomical boundaries are obliterated by undrained haemothorax etc.
In general, the investigation and the treatment of aortic rupture should follow treatment of expanding intracranial haemorrhage or active chest, abdominal, or pelvic bleeding.
Algorithms for management penetrating chest trauma are found in Part 3.
Penetrating wounds to the chest are relatively uncommon presentations to Auckland City Hospital. Many will cause pneumothorax or haemothorax and require chest drain. Occasionally mediastinal or cardiac injuries occur. Penetrating cardiac injuries have a high mortality and only 25% than waiting for cardiac arrest.
Any patient who is haemodynamically unstable after a stab wound to the chest needs the cause established as soon
as possible. Finger thoracostomy and tube or chest drains will identify tension pneumothorax or massive haemothorax. Undertake a FAST scan to assess bleeding into the abdomen or pericardium.
In stable patients, clinical examination combined with chest x-ray can be used to evaluate the lungs and pleural cavities but these modalities are insensitive for cardiac injury. When patients have been stabbed in “the box” the possibility of cardiac injury exists. (“The box” is that part of the anterior chest and abdomen bounded by the clavicles superiorly,
the mid-clavicular lines laterally, and the costal margin in the mid-clavicular line.)
Cardiac injury can be identi ed by: FAST scan, echocardiography, pericardial window or thoracotomy. All of these are operator and skill dependent. Get consultant input immediately for suspected cardiac injury.
Emergency Department Thoracotomy
This procedure is a desperate measure performed to try and save “agonal” patients. Most patients will die A penetrating injury to the chest, where the patient is dying in front of you and will not survive the trip to theatre, and vital signs were present either on arrival in the ED or within the previous 15 minutes but are now absent. Vital signs include a palpable pulse, electrical cardiac activity on an ECG monitor, spontaneous respiration, or reactive pupils.
Tell the consultant surgeon on call this is happening.
The airway doctor advances the ET tube into the right main bronchus. The operating doctor makes a long left thoracotomy incision before proceeding.
Then (dependent upon findings):
- Identify the phrenic nerve. Open the pericardium anterior to the phrenic nerve. Evacuate the clot. Plug the hole in the heart ( finger, IDC, suture, skin stapler).
Algorithm for evaluation of the abdomen is found in Part 3.
Refer to Appendix I: Evaluation of abdomen in the blunt trauma patient
Injuries may be identified in the primary survey (breathing: diaphragmatic hernia, circulation: blood loss). Decisions for laparotomy may be based on history and exam ndings or via the primary survey adjuncts (FAST scan).
The FAST scan should take between 1-5 minutes and has the advantage that it is repeatable and non-invasive. The FAST operator should document the ndings in the notes. When
a credentialed operator is present, this investigation has acceptable sensitivity to exclude haemoperitoneum, cardiac tamponade and pleural uid or blood.
The history of abdominal pain, may be all that points to signi cant intra abdominal injury. Signs may include the ‘seat belt’ sign, abrasion or bruising, and/or abdominal tenderness and/or gross haematuria. Abdominal CT may identify occult injuries in stable patients.
Patients with altered GCS or who are or will be intubated cannot be reliably assessed for these ndings, or monitored for evolving peritonitis. Abdominal CT scan can be used to ‘screen’ these patients for occult injury.
Abdominal CT reports should include: organ injuries (or absence of), free uid, air or contrast and fractures identified.
Blunt Splenic Trauma
Imaging will be performed as detailed below* on blunt trauma patients who do not have immediate indications for theatre i.e. peritonitis, hypotension.
Evidence of splenic trauma with contrast extravasation, false aneurysm, and/or arteriovenous stula will proceed directly to angiography from emergency department. This will be organised by phone call from the most senior surgical registrar/ consultant available to the interventional consultant.
Any grade 3+ splenic injury without the above ndings will prompt a phone call from the surgical consultant to the interventional consultant. If the surgical consultant is not available within 20 minutes to make this call, the most senior surgical fellow/registrar will initiate the communication.
Factors that may prompt angiography in the absence of contrast extravasation, false aneurysm, and/or arteriovenous stula include but are not limited to:
- Significant hemoperitoneum
- Clinical findings concerning for impending instability
- Haemoglobin drop
- Fluid requirement >1L or blood product requirement
- Patients who are higher risk for complications from hypotension and/or laparotomy
If it is decided that the patient not require immediate angiography, a plan will be put in place to allow for prompt reconsideration should the patient’s condition change. Ideally the patient will be admitted to a monitored setting i.e. HDU.
*Imaging (pertains only to those patients who do not require a chest CT; these patients will continue as before)
- Dual phase abdominal CT (arterial upper abdomen, portal venous abdo and pelvis)
- Resus patients coming through as a trauma call
- Non resus patients with positive FAST
- Dual phase abdominal CT including pelvis (arterial abdo and pelvis, portal venous abdo and pelvis):
- Patients with unstable pelvic fractures.
- Single phase abdominal CT (portal venous phase abdo and pelvis)
Algorithm for management of penetrating lower chest or abdomen stab wound is found in Part 3.
Because the diaphragm reaches the level of the fourth intercostal space on full expiration, any penetrating wound below the nipples anteriorly or tips of the scapulae posteriorly are considered potentially abdominal. Gunshot wounds mandate laparotomy.
Algorithm for management of fractured pelvis is found in Part 3.
The pelvis should be assessed clinically as part of the Secondary Survey. Be gentle when examining the patient
- Abrasion or bruising over bony prominences.
- Scrotal or perineal haematoma.
- Blood at the urethral meatus.
- Leg length discrepancy
- Posterior compression of iliac wings
- Medial compression of iliac wings
- Compression of pubic symphysis
- Hip flexion and rotation
All “impaired” patients and any patient with signs or symptoms of pelvic injury should have a plain AP x-ray of the pelvis. When fractures are identi ed, orthopaedic consultation is necessary.
If a patient with a pelvic fracture is haemodynamically unstable a FAST scan is required:
- If grossly positive, the patient must go to the OR for a laparotomy.
- If grossly negative then pelvic angiography and embolisation of arterial bleeders is next step.
In major pelvic injury, stressing the pelvis should be avoided as it may dislodge vital clot.
- Orthopaedic stabilisation of mechanically unstable pelvic fractures follows laparotomy or angiography to reduce venous loss.
- Intensivist, orthopaedic and trauma specialists should be involved early.
Anterior pelvic fractures are associated with a high rate of bladder and urethral injuries.
Cystogram can be used to investigate these injuries. Gross haematuria with anterior pelvic fractures will likely have bladder rupture as a cause.
An alternative to cystography in the screening room is a CT cystogram. (The bladder is lled with 300 ml of contrast prior to obtaining a CT ‘run’ through the pelvis. Post-drainage views of the bladder are then taken).
Retrograde urethrogram is required for the patient with: blood at the urethral meatus, scrotal bruising, high-riding prostate on PR or the stable patient with multiple grossly displaced superior and inferior pubic rami fractures.
An IDC may still be passed with gentle advancement but any resistance should stop procedure and alternate bladder drainage sought.
Look for deformity or bruising, feel for pain and listen for bruits over haematomas.
Do a neurovascular exam.
X-ray suspicious areas, including the joint either side. A common missed injury is the fracture distal to a fracture in the same limb.
Wounds should be accurately described, so subsequent examinations are not required. Repeated examination of wounds that are under sterile dressings is counterproductive.
After splinting or traction the neurovascular state of the limb is reassessed.
Femur fractures should be immobilised and femoral nerve blocks done.
Dislocated joints (except native hip joints) and fractures should primarily be managed with relocation within resus rst prior to OT or other de nitive treatment.
Native hip joint dislocations should go to OR for proper assessment. Always come if intubated and ventilated already. Check with Ortho.
Make sure you have seen the entire patient.
External injuries are rarely life-threatening, however active bleeding should be stopped.
In penetrating injury the most obvious injury may well not be the most important injury.
Multiple injuries are common.
In blunt injury, external signs often provide clues to other more serious but less obvious injuries. Clinical rib fractures and the seat-belt sign are good examples.