A. Criteria for a trauma call
A mandatory trauma call will be made when there is one or more of:
The emergency department is notifed 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 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 de nitive care
Major trauma patient transferred from another hospital to the Emergency Department
When the Emergency Department is forewarned of the imminent simultaneous arrival of four or more trauma patients, irrespective of their suspected injury severity.
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):
- 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.
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.
One person talking, everyone listening
Mechanism and time of injury,
Signs at the scene,
Treatment - interventions and the response to intervention. (M.I.S.T.)
Immediate therapy for life threatening injuries and physiological abnormalities detected in the Primary Survey
Monitoring and x-rays, FAST
A thorough “top to toe, front to back” examination of the patient. See the ‘major trauma form’.
NG and IDC. Special investigations including CT or angiography as indicated
A formal hand-over to the accepting speciality.
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:
- 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.
F. Standard precautions
G. Primary Survey (ABCDE)
The primary survey is achieved through parallel tasking. Knowing your role makes this possible.
- Assess the airway and determine its adequacy
- Create or maintain an airway by
- Looking with suction
- Chin lift or jaw thrust
- Naso/Oropharyngeal airway d. Orotracheal intubation
- Airway or breathing compromise (present or predicted)
- Unprotected airway
- GCS < 9
- Combative and uncooperative patients to facilitate on-going investigation and management in a safe environment for patient and staff
- Administer high flow oxygen
- Assess the chest by
- Palpation and feeling for the trachea
- tension pneumothorax
- massive haemothorax
- flail chest
- sucking chest wounds
- pericardial tamponade
Assess circulation by
- Looking for external haemorrhage
- Observing skin colour, temperature and capillary refill
- Feeling the pulse
- Taking the blood pressure
- Checking neck veins
The patient with cold pale peripheries has shock until proved otherwise
- Arrest external haemorrhage by local pressure or tourniquet
- Insert at least two large bore (>16g) IV cannulae
- Tibial or Humeral Intraosseus, Jugular or Femoral vein Vascath, or venous cut down if lines not possible
In massive haemorrhage use the Belmont Rapid Infuser.
Exsanguinating patients get group O blood ASAP.
Patients with on-going haemodynamic instability despite crystalloid resuscitation and suspicion of on-going haemorrhage should receive early blood products – initially O negative blood ± MTP activation as required.
- Are the eyes open ( ‘no’ means E3 or less)
- Talk to the patient
- Use painful stimulus to nger or toe if required (sternal rub has dif culty distinguishing M3, 4 and 5 )
- Assess the pupillary size and response
- Examine for lateralising signs (e.g. differing motor scores on each side) and signs of cord injury
- Blood Sugar Level
- Expose the patient so that an adequate complete examination can be performed.
- Prevent the patient becoming hypothermic, measure their temperature
Ongoing resuscitation of physiological abnormalities detected in the Primary Survey is very important. Monitoring of the progress of this resuscitation requires consideration of the following:
- Respiratory rate
- Pulse (palpation, ECG monitor +/- wave form)
- Blood pressure
- Oxygenation (pulse oximetry, ABG’s)
- Urine output (urethral catheter should be inserted if not contraindicated)
Most trauma patients are in significant pain. Early pain management is essential in conjunction with on-going resuscitation.
- In general pain relief is aided by:
- Establishing rapport with the patient
- Splinting of injured extremities
- Gentle movement and handling
- Prevention of shivering
- Cooling of burns
Opioids should be given intravenously in severe trauma:
- Titrate in small increments until the desired effect is achieved.
- Beware hypotension, respiratory depression and vom- iting.
- May require bolus dose to effectively work in a timely fashion
- Morphine 0.1 mg/Kg
- Fentanyl 1.0 mcg/Kg
Local anaesthetics – Regional Blocks/Local Infiltration
Femoral nerve block is very effective for the pain associated with femoral fracture and is necessary in wounds to allow effective exploration.
- One set of trauma bloods should be sent to the lab for FBC, U&Es, Creat, LFT’s, Coags
- One tube for Group & Hold plus cross-match
- Venous blood gas
The resuscitation room x-rays are as follows:
This is the only x-ray justified in an unresuscitated patient. The obvious clinical tension pneumothorax should be treated before a CXR.
A pelvic fracture that is not clinically obvious can be the site of unexplained blood loss. A dislocated hip can be missed in a patient with multiple injuries, especially if unconscious.
Lateral cervical spine X-ray
This is not performed routinely and is at the discretion of trauma team leader. Allows early diagnosis clinically of C-spine injury, but does not clear the C-spine. The C-spine cannot be cleared in the following circumstances:
- history of loss of consciousness
- abnormal level of consciousness
- unable to communicate
- head or neck injury
- neck symptoms or C-spine tenderness
- a distracting injury
When not cleared clinically, radiological examination is required. This is usually a CT scan.
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”