Basic concepts of resuscitation in trauma patients

ATLS: Initial assessment and Resuscitation

concepts in trauma patients

Pakorn HusenEmergency Physician, Nopparat Rajthani Hospital

Time Matters

TIME MATTERS(…sometimes)

• Replacing avulsed permanent tooth

(30 minutes)

• CPR (4 minutes)

• Multiple Trauma (minutes-1 hour)

• Stroke (3 hours treatment window,

door-drug 60 minutes)

• STEMI (cath lab in 60-90 min;

thrombolysis in 30 minutes)

• Antibiotics in pneumonia (4 hours)

• Antibiotics in meningitis (1 hr)

• Dysrhythmia (seconds-minutes)

• Wound repairs (6-24 hours)

• Hypoglycemia (seconds-minutes)

• Traumatic aortic rupture (1 hour)

• Pseudomonas corneal ulcer (12

hours)

• Prolapsed umbilical cord (10

minutes)

• ECG with chest pain (10 minutes)

• Bell’s palsy (< 72 hours)

• Herpes zoster (shingles) (< 72

hours)

• Influenza (< 48 hours)

• Airway control/ventilation (sec-min)

• Status seizure control (minutes)

• Pulseless extremity (6 hours)

• Antidote nerve agent poisoning

(seconds)

• Antidote for cyanide poisoning

(minutes)

• Sexual assault evidence collection

(< 72 hours)

• Blunt spinal cord injury (4 hours, 8

hours)

• Caustic eye exposures (minutes)

• Severe drug or heat induced

hyperthermia (immediately)

• Testicular torsion (minutes-hours)

• Trauma c-section (minutes)

The Golden Hour

• originated by R Adams Cowley

• first sixty minutes after the occurrence of multi-system trauma

• victim's chances of survival are greatest if they receive definitive care in the OR within the first hour after a severe injury

The Golden Hour

• "There is a golden hour between life and death.

If you are critically injured you have less than

60 minutes to survive. You might not die right

then; it may be three days or two weeks later --

but something has happened in your body that

is irreparable."

- R Adams Cowley

Trauma Deaths

• Trimodal Distribution

• Minutes – massive injury to brain, brain

stem, heart, aorta, great vessels

• Hours – “golden hour”**

• Days- sepsis or multisystem organ failure

CONCEPTS OF INITIAL ASSESSMENT

1. Preparation

2. Triage

3. Primary survey

4. Resuscitation

5. Adjuncts to primary survey and resuscitation

6. Secondary survey

7. Adjuncts to secondary survey

8. Continued postresuscitation monitoring and reevaluation

9. Definitive care

Preparation

Preparation

-Prehospital phase

-Inhospital phase

Preparation

• Prehospital phase➣ coordination of EMS with hospital physicians

before the patient transport from the scene

• Time of injury

• Mechanism of injury

• Patient history

➣ airway maintenance

➣ control external bleeding and shock

➣ immobilization

➣ immediate transport to closest, appropriate facility

Triage Decision Scheme

Triage Decision SchemeStep1 Measure vital signs and level of conscious

Step2 Assess anatomy of injury

Step3 Evaluate for mechanism of injury/evidence of high-energy impact

Step4 Assess Age, status,

underlying disease

Step 1

Measure of vital signs and level of consciousness

• GCS < 14

• RR < 10 or > 29

• Systolic BP < 90

• RTS < 11

YES - Take to Trauma center

NO - Assess Anatomy of Injury

Triage decision scheme


Step2 Assess Anatomy of Injury

• Pelvic fracture

• Flail chest

• Two or more proximal long-bone fractures

• Combination trauma with burns of 10% or inhalation

injuries

• All penetrating injuries to head, neck, torso, and

extremities proximal to elbow and knee


NO – Evaluate for evidence of mechanism of injury and

high-energy impact


Step3. Evaluation for evidence of mechanism

of injury and high-energy impact

• Ejection from automobile

• Death in same passenger compartment

• Pedestrian thrown or run over

• High speed autocrash

– Initial speed > 40 mph

– Velocity change > 20 mph

• Major auto deformity > 20 inches


Step3. Evaluation for evidence of mechanism

of injury and high-energy impact

• Intrusion into pasenger compartment > 12 inches

• Extrication time > 20 min

• Falls > 20 feet

• Roll over

• Auto-pedestrian injury with significant (>5 mph) impact

• Motocycle crash > 20 mph or with separation or rider and bike


NO – Take Anamnesis

Initial trauma management


Step 4

• Age <5 or > 55 years

• Known cardiac disease; respiratory disease; or psychotics taking medication

• Diabetics taking insulin; cirrhosis; malignancy; obesity; or coagulopathy

YES – contact medical control and consider transport to trauma center

NO – re-evaluate with medical control

WHEN IN DOUBT, TAKE TO A TRAUMA CENTER!

Inhospital phase

• Planning arrival

• Trauma room with equipment:

– For resuscitation

– Monitoring

– Warmed solutions

• Trauma staff

• Laboratory and radiology personnel

• Personnel protection from communicable

diseases (hepatitis & AIDS)

Minimum precautions

• Face mask

• Eye protection - goggles

• Water impervious apron

• Leggings

• Gloves

• Head covering

• Needles, blades, body fluids and tissues –

strictly enforced

Triage

Triage

• The term triage, derived from

the French word “to sort,”

military application involves

prioritizing victims into

categories based on severity of

injury, likelihood of survival,

and urgency of care

• Goal of triage is to identify

high-risk injured patients who

would benefit from the

resources available

• A second goal of triage is to

limit the excessive transport of

non–severely injured patients

so as not to overwhelm the

trauma center

Triage

Two types of triage situation - Multiple Casualties- Mass Casualties

Sorting of patients based on the need of treatment and the available resources to provide that treatment

Triage

Triage

Multiple Casualties

Number and severity of patients do not exceed the ability of the facility to render care.

Patients with life-threatening problems and sustaining multiple system injury are treated first

Triage

Mass Casualties

Number and severity of patients exceedthe capability of the facility and staff.

Patients with greatest chance of survival and with the least expenditure of time, equipment, supplies, and personel are managed first

Primary survey

Primary survey

A B C D E

A : Airway maintenance with cervical spine protection B : Breathing and ventilation C : Circulation with hemorrhage control D : Disability : Neurologic status E : Exposure / Environment control

A : Airway maintenance with cervical spine

protection

A : Airway maintenance with

cervical spine protection

1.Rapid assessment for sing of airway obstruction inspection for ;

- abnormal breathing: dyspnea, FB, aspiration- snoring, gurgling, stridor- maxillofacial Injuries- neck,chest injuries : tracheal/laryngeal fx.- unconscious

If pt. able to communicate verbally , the airway is not likely to be in immediate jeopardy



2.Protection C- spineAssume C - spine injury in any pt. with ;

- Unconscious- Multiple system trauma- Blunt injury above clavicle (head and neck)

- Pain of neck with neurologic deficit.- Unable to active flexion of neck due to pain.



If C-spine injury can’t be rule out

•Initially, the chin lift or jaw thrust maneuvers are recommended to open airway and protect C - spine

•Immobilizing devices: Philadelphia collar (prevent excessive movement of the C-spine)

•If Immobilizing devices must be removed temporary , 1 members of team should manually stabilize the patient‘s head and neck using inline immobilization technique



Head tilt

Philadelphia collar

manual in-line stabilisation of the

neck (MILS)



- Neurological examination alone dose not exclude C- spine injury.

Role out C – spine injury by;- Active neck flexion if the patient cooperate.(not tender)- Film x-ray lateral C-spine is normal.



-Remove particular matter

-Chin lift/ modified jaw thrust

-Oropharyngeal or Nasopharyngeal

airway

-Laryngeal mask airway

-Definitive airway -Reassess frequently



Definitive airway ( Advance )Three Varities:

1. Orotracheal tube2. Nasotracheal tube3. Surgical airway.

( Cricothyroidotomy , Tracheostomy )

Definitive airway

Airway protection

-Unconscious

-Severe maxillofacial injury

-Risk for aspiration

Vomiting

bleeding

-Risk of obstruction

Neck hematoma

Laryngeal/tracheal hematoma

Stridor

Ventilation

-Apnea

-Inadequate respiratory

efforts

-Severe, closed head injury

Definitive airway

Surgical airway

Indication: inability to intubate the trachea

- Edema of Glottis

- Fracture larynx

- Severe oropharyngeal hemorrhage

Needle cricothyroidotomy

Surgical cricothyroidotomyTracheostomy

cricothyroidotomy

Tracheostomy

Airway Algorithm

B : Breathing and Ventilation


• Ventilation requires adequires adequate fuction of the lungs, chest wall, diaphragm. Each component must be examined and evaluation.

• The patient’ s chest should be exposed to adequately assess chest wall excursion.

• Auscultation should be performed to assure gas flow in lungs.

• Percussion may demonstrate the presence of air or blood in the lungs.

• Visual inpection and palpation may detect injuries to the chest wall that may compromise ventilation.


• Severe life threatening condition

Tension pnuemothorax

Massive hemothorax

Open pneumothorax

Flail chest

• Need emergency care


• Tension pnuemothorax

– Temporary : needle (no.14-16) at

second intercostal space ,midclavicular

line

– ICD : fifth intercostal space ,midaxillary

line

• Massive hemothorax

– ICD : fifth intercostal space ,midaxillary

line

– Rapid bolus of IV : RLS

– Blood transfusion


• Massive hemothorax

Indication for surgery

– Bleed > 1500 cc on first ICD attempted

– Continuous bleed > 200 cc/hr in 3-4 hrs

and hemodynamic unstable

– Caked hemothorax


• Open pneumothorax

– Vaseline guaze ปิดแผลโดยปิดพลาสเตอร์ 3 ด้าน

– ใส่ ICD

– ท าความสะอาดและรักษาบาดแผลต่อไป


• Flail chest

– Analgesic drugs

– If respiratory discomfort present :

• endotracheal intubation

• on volume respirator

• treat pulomary contusion

• may use up to 3 weeks)


C : Circulation

Shock

• Initial step in managing shock in the

injured patient : Recognize its presence

and clinical presence of inadequate

tissue perfusion and oxygenation.

Blood volume and cardiac output

• rapid and accurate assessment of the

injured patient’s hemodynamic status is

essential.

• Elements of clinical observation

: Level of consciousness

: Skin color

: Pulse

Shock

• Second step : Identify the probable

cause of the shock state. For the trauma

patient is related to mechanism of injury.

• Hemorrhage is the most common cause

of shock in the injured patient.

Shock

Obstructive

Tension

pneumo

Nonobstructive

Cardiac

tamponadeDistributive Nondistributive

Sepsis/SIRS

Anaphylaxis

Neurogenic

Hypovolemic

Cardiogenic

Hemorrhagic

Third spacing

C = Circulation

• Verify pulses, bilateral blood

pressures

– Radial pulse = SBP 90

mmHg

– Femoral pulse = SBP 70-

80 mmHg

– Carotid pulse = SBP 60

mmHg

• Largest blood loss in thorax,

abdomen, pelvis, extremities

Shock in traumatic patients

1. Hemorrhagic shock

- External hemorrhage

- Internal hemorrhage

- Combine

External hemorrhage

• External hemorrhage is identified and

controlled in the primary survey.

• Hemorrhage control :

– Manual compression

– Splint

– Elastic bandage

Internal hemorrhage

Major sources of occult blood loss :

• Thoracic

• Abdominal cavities

• Soft tissue surrounding major long bone

fracture

• Retroperitoneal space from pelvic fracture

Classification of hemorrhage Class I Class II Class III Class IV

Blood loss(ml) < 750 750-1500 1500-2000 >2000

Blood loss(%BV) <15 15-30 30-40 >40

Pulse rate <100 >100 >120 >140

Blood pressure normal normal decrease decrease

Pulse pressure normal decrease decrease decrease

CNS/mental Slightly Mildly Anxious, Confused,

anxious anxious confused lethargic

Fluid Crystalloid Crystalloid Crystalloid, Crystalloid,

replacement Blood Blood

Shock in traumatic patients

2. Non-hemorrhagic shock

- Cardiogenic shock

- Tension pneumothorax

- Neurogenic shock

- Hypovolemic shock

- Septic Shock

Initial Management of Hemorrhagic Shock

• Stop bleeding and replaces the volume loss.

• Vascular access lines : insert 2 large caliber (#16

gauge)

• Vital sign stable (class 1,2) :

– IV fluid 1 extremity

• Vital sign change (class 3,4) :

– IV fluid 2 extremities

• basilic or saphenous venous cutdown

• Central line – internal jugular v., subclavian v.

Initial Management of Hemorrhagic Shock

• Initial fluid therapy : crystalloid solution (Ringer lactated solution) อัตราเร็วตามภาวะของผู้บาดเจ็บ

• ถ้าอยู่ในภาวะ shock จะให้ load 2 litres in 15 min

(adult) , Ringer lactate bolus 20 ml/kg in

pediatric

Evaluation of fluid resuscitation

• General : sign & symptoms of inadequate

perfusion

• Urinary Output : 0.5 ml/kg/hour in adult

• Acid/Base Balance : respiratory alkalosis

follow by metabolic acidosis

Therapeutic decision based on response

to initial fluid resuscitation1

• Rapid Response

• Transient Response

• Minimal or no response

12000 mL RLS in adult, 20 mL/kg Ringer’s lactate bolus in children

Responses to Initial Fluid

ResuscitationRAPID

RESPONSE

TRANSIENT

RESPONSE

NO RESPONSE

Vital signs Return to normal Transient

improvement,

recurrence of BP

drop and HR

increase

Remain abnormal

Estimated blood

loss

Minimal (10%-20%) Moderate and

ongoing (20%-40%)

Severe (>40%)

Need for more

crystalloid

Low High High

Need for blood Low Moderate to high Immediate

Blood preparation Type and

crossmatch

Type-specific Emergency blood

release

Need for operative

intervention

Possibly Likely Highly likely

Early presence of

surgeon

Yes Yes Yes

Type of initial fluid

- Crystalloid solution :

• Lactate Ringer

• Acetate Ringer

• Normal saline solution

- การเสียเลือดไป 1 มล. ต้องให้ สารน้้าทดแทน 3 มล.

- ถ้ามีการเสียเลือดมาก เช่นใน class 3,4 ต้องให้เลือดทดแทนด้วย

- ส่วนการให้ colloid เช่น Hemaccel จะให้ในกรณีที่มีการเสียเลือดมาก แต่

เลือดยังไม่พร้อมก็จะให้ทดแทนไปก่อน

D : Disbility

Disability/Neurogenic

• Primary brain damage : Contusion,

Laceration, Hemorrhage (Cerebral, Brain

stem)

• Secondary Expanding lesion : Epidural,

Subdural hematoma Brain Herniation

Cushing’s reflex (bradycardia, systolic

hypertension)

Stage of brain herniation

• Early

- Ipsilateral pupillary dilation

- Progressive decrease in mental status

- Respiratory pattern changes

(Chyne-Strokes)


• Progressing

- Decreasing level of consciousness

- Hyperventilation

- Contralateral hemiplegia

- Decerebrate posturing

- Pupillary constriction


• Advanced

- Biliateral decerebrate rigidity

(uncal herniation)

- Irregular respiration

- Flaccidity (central herniation)

- Death

Neurologic Evaluation

• Level of consciousness

• Pupillary size and reaction

• Lateralizing signs

• Spinal cord injury level

• Serial neuro sign reevaluation

Neurologic Evaluation

Brief neurologic examination

• A – Alert

• V – Responds to Vocal stimuli

• P – Responds to Painful stimuli

• U – Unresponsive

• Pupillary size & reaction

➣ More detailed evaluation - during the

secondary survey

E : Exposure/

Enveronmental control

Exposure

• Undresses for assessment

• After assessment is completed, it is

imperative to cover patient with warm

blankets or external warming devices to

prevent ‘Hypothermia’

• IV should be warmed before infusion and

warm environment

Resuscitation

Resuscitation

• Airway

• Breathing/Ventilation/Oxygenation

• Circulation

Resuscitation

• Airway protection

– Manual• Jaw thrust maneuver

• Chin lift maneuver

– Device• Nasopharyngeal airway in consciousness

• Oropharyngeal airway in unconsciousness, no gag

reflex

– Definitive airway

Resuscitation

• Breathing/Ventilation/Oxygenation

– Every injured patient should receive

supplemental oxygen

– Endotracheal intubation with C-spine

protection

– Surgical airway for contraindicated patient

– Use pulse oximeter to ensure adequate Hb

saturation

Resuscitation

• Circulation

– The minimum fluid infusion : • 2 large-caliber IV catheter (warm IV)

– The maximum rate : • internal diameter of cetheter, not the size of the vein

– Type of IV fluid• Ringer’s lactate solution is preferred

• also draw blood for type, crossmatch, UPT before IV

insertion

• If remain unresponsive to bolus IV, give type-specific blood

(O-negative blood as a substitute)

Resuscitation

• Hypothermia : – a potentially lethal complication in the injured patient

– Use a high-flow fluid warmer or microwave oven to

heat crystalloid fluids to 39oC is recommened

– Blood products should not be warmed in a microwave

oven

• Aggressive and continued volume

resuscitation is not a substitute for manual or

operative control of hemorrhage

ADJUNCTS TO PRIMARY SURVEY

AND RESUSCITATION

Adjuncts to primary survey

and resuscitation

ECG monitoring

Urinary and Gastric Catheters

Monitoring

X-rays and Diagnostics Studies


and resuscitation

ECG monitoring

Should be performed in all trauma patients

Dysrhythmia, including unexplained tachycardia,

AF, PVC, and ST segment changes : Blunt cadiac

injury

PEA : cardiac tamponade, tension pneumothorax,

profound hypovolemic shock

Bradycardia, aberant conduction and premature

beats : hypoxia and hypoperfusion should be

suspected immediately


and resuscitation

Urinary and Gastric Catheters

1. Urinary Catheters

Urine output is a sensitive indicator of volume status of

the patient and reflects renal perfusion

Urinary Catheters should not be inserted before an

examination of the rectum and genitalia


and resuscitationUrinary and Gastric Catheters

1. Urinary Catheters

Contraindication : Suspected urethral injury

- Blood at penile meatus

- Perineal ecchymosis

- Blood in scrotum

- High riding or nonpalpaple prostate

- Pelvic fracture

In suspected case : Retrograde urethrogram


and resuscitation Urinary and Gastric Catheters

2.Gastric Catheters

A gastric tube is indicated to reduce stomach distention and

decrease the risk of aspiration.

For the tube to be effective, it must be positioned properly,

attached to appropriate suction and be functioning.

Blood in the gastric aspirate may represent oropharyngeal

(swallowed) blood, traumatic insertion, or actual injury to the

upper digestive tract.

If the cribiform plate is fractured is suspected, the gastric

tube should be inserted orally to prevent intracranial

passage.


and resuscitation Monitoring

1. Ventilatory rate and ABG

Monitor the adequacy of respiration

Confirm that the ETT is located somewhere in the airway

2. Pulse oximetryMeasure the oxygen saturation of hemoglobin colorimetrically

Not measure the partial pressure of oxygen

Should not be placed distal to the blood pressure cuff

3. Blood pressure


and resuscitation

X-rays and Diagnostics Studies

Chest x-rays AP

Pelvis AP

Lateral C-spine

DPL or FAST

• Films can be taken in resuscitation area, usually with

portable x-ray

• Should not interrupt the resuscitation process

Indication for DPL

Equivocal abdominal sign

Unexplained hypotension

Impaired mental status

Paraplegia or spinal cord injueries

Contraindication for DPL

absolute contraindication existing indication for explore laparotomy

relative contraindication previous abdominal operation

morbid obesity

advance cirrhosis

coagulopathy

DPL

Criteria for positive DPL

> 10 ml of gross blood in blunt trauma first aspirated

RBC count >100,000 /mm3 for blunt trauma

RBC count >10,000 /mm3 for penetrating trauma

WBC count > 500 /mm3

Amylase > 200 u/ml

Smear show bacteria or enteric content

if positive : explore laparotomy

DPL procedure

infraumbilical technique

supraumbilical approach : pelvic fracture (avoid entering

a pelvic hematoma)

: advance pregnancy (avoid

damage the enlarge uterus)

DPL procedure

Peritoneal catheter in cul de sac aspiration

if gross blood or GI content not aspirate larvage with 1000 ml warm LRS (10 ml/kg in child) adequate mixing

larvage fluid for analysis

DPL procedure

Focused Assessment with

Sonography for Trauma (FAST)

Detect intraabdominal fluid

Rapid, noninvasive, accurate, inexpensive, can

repeat frequently

Indication same as DPL

Factors that compromise its utility are obesity,

presence of subcutaneous air, previous

abdominal operation

DPL

• Advantages

– Fast

– Sensitive

– Can be performed while resuscitation ongoing

• Disadvantages

– Invasive

– Learning curve

– Organ spacific

FAST

• Advantages

– Fast

– Noninvasive

– Can be performed while resuscitation ongoing

– Can be very sensitive

• Disadvantages

– Operator dependent

– Body habitus may limit quality/sensitivity

– Organ spacific, hollow viscous and retroperitoneal

injuries

Abdominal CT

• Advantages

– Noninvasive

– Fairly sensitive and specific

• Disadvantages

– Inexperienced radiologist may miss injuries

– A bad place to be if patient “crashes”

Secondary survey

Secondary Survey

• Does not begin until the primary survey

(ABCDEs) is completed

• Head-to-toe evaluation (complete history,

physical examination, reassessment of all

vital signs)

History

• A Allergy

• M Medication currently being taken by the

patient

• P Past illness and operation

• L Last meal

• E Event and Environment related to the injury

History

• Mechanism of injury (Blunt or penetrating

trauma)

Blunt trauma

• Automobile collisions, falls, transportation-,

recreation- and occupation-related injuries

• Automobile collisions: seat belt usage,

steering wheel deformation, direction or

impact, ejection of the passenger from

vehicle (ejection increases the chance of

major injury)

Penetrating Trauma

• Firearms, stabbings

• Velocity, caliber, path of bullet, distance

from the weapon to the wound

Mechanisms of Injury and Related

Suspected Injury Patterns

Frontal Impact

- Bent steering wheel

- Knee imprint, dashboard

- Bull’s-eye fracture,

windscreen

• Cervical spine fracture

• Anterior flail chest

• Myocardial contusion

• Pneumothorax

• Traumatic aortic

disruption

• Fractured spleen or liver

• Posterior

fracture/dislocation of hip,

knee



• Side Impact • Contralateral neck sprain

• Cervical spine fracture

• Lateral flail chest

• Pneumothorax

• Traumatic aortic disruption

• Diaphragmatic rupture

• Fractured spleen/liver, kidney depending on side of impact

• Fractured pelvis or acetabulum



• Rear Impact • Cervical spine injury

• Soft-tissue injury to

neck



• Motor vehicle

impact with

pedestrian

• Head injury

• Traumatic aortic

disruption

• Abdominal visceral

injuries

• Fractured lower

extremities/pelvis

Secondary SurveyRapid Head-to-Toe Examination

• HEENT: scalp, pupils, ears, face,

mouth

• Neck: distended neck veins, trachea

midline, posterior midline deformity

• Chest wall: paradoxical movement,

breath sounds

• Abdomen: scaphoid or distended,

tender

• Pelvis: stable or unstable

• Genitourinary: blood, bruising

• Rectal: tone, blood

• Back: spinal deformity, exit wounds

• Extremities: deformity, pulses

• Neurologic: feels all four/moves all

four

Adjuncts to the Secondary survey

Adjuncts to the Secondary survey

Further investigation for specific injuries that non-life threatening condition e.g.

- x-ray spine and extremities

- CT scan

- contrast urography and angiography

- Transesophageal ultrasound

- Bronchoscopy

- Esophagoscopy

Re-evaluation

• Continuous monitoring of - vital signs, Hct

- urinary output: adult keep > 0.5 mL/kg/hr

children keep > 1 mL/kg/hr

- Arterial blood gas

- Cardiac monitoring

- Pulse oximetry

- End tidal CO2

• Relief of severe pain and anxiety- IV opiates and anxiolytics

- Small dose: avoiding respiratory depression

Definitive Treatment

Trauma team

Level 1

(Not Required of Levels II, III, and IV

Trauma Centers)

• 24hr availability of all surgical subspecialties (including cardiac surgery/bypasscapability)

• Neuroradiology and hemodialysis available 24hr/day

• Program that establishes and monitors effect of injury prevention/educationefforts

• Trauma research and QA programs in place

Level 2(not Required of Levels III and

IV Trauma Centers)

• Cardiology, ophthalmology, plastic

surgery, gynecologic surgery available

• Operating room ready 24hr/day

• Neurosurgery dept.. In hospital

• Trauma multidisciplinary quality assurance

committee

Level 3 (Not Required of Level IV

Trauma Centers)

• Trauma and emergency medicine services

• 24 hr x-ray capability

• Pulse ox, central and arterial catheter monitoring capability

• Thermal control equipment for blood products

• On call schedule for surgeons

• Trauma registry

Level 4

• Believe me, you don’t want to crash your

car way out the middle of nowhere next

the the town that has this level of support.

• Consists of anything less than previously

mentioned.

Trauma Team MembersTeam Leader: Surgeon, Emergency Physician,

Mid-level provider

Anesthesia, CRNA, OR Team

Emergency/Other RNs (X 2-3)

Charge/House Nursing Supervisor

EMTs stay/assist

Respiratory therapy

XRAY, CT, Radiologist

Lab, Blood bank

Documentation/Scribe

LPN, Aide, HUC, Support Staff

Social Services, Chaplain

Other Medical Specialties if/as available: ENT, Ortho, GU, Pediatricians, etc.

Procedure:

• The charge nurse, House Supervisor or designee will assign roles if possible prior to patient arrival. Roles will be assigned as described below if enough staff is available.

• If staff is not available, roles will be assigned and adapted as indicated by the charge nurse and/or provider.

Guidelines for Roles and Responsibilities

Role Staff/Type Duties Position

Airway: RT/EMT Ventilation, Head of Trauma bed

Assist with intubation

Keep patient informed

C-Spine: EMT Maintain c-spine stabilization Head of Trauma Bed

Alert MD of any change in LOC

IV/Procedures: RN Insert large bore IV On patient LEFT side

Remove clothing from left side of body,

Neuro assessment, assist with procedures

Intake/output

Provider Assistant: RN Assist with procedures as directed On patient LEFT side

Vitals & Recorder: LPN/EMT Take, monitor and record vitals On patient LEFT side, toward foot of bed

Scribe: EMT/LPN Record case on white board White board

IV/Med: RN Insert large bore IV, On patient RIGHT side

Remove clothing from right side of body On patient RIGHT side

Attach/observe cardiac monitor On patient RIGHT side

Prepare/administer medications

Foley as appropriate

Runner: Ward Clerk/Secretary/EMT Retrieve equipment, supplies, ED Desk

Make copies, assist with ER traffic control,

Answer/make phone calls

Team Captain Provider: Manage/direct team efforts Head/foot of patient Initiate interventions, care as indicated

Patient

Airway: RT/EMTVentilation,assist with intubation,

keep patient informed

Vitals & Recorder: LPN/EMTTakes serial vitals and records on Trauma Form

Other duties as needed

IV /Procedures: RNInsert large bore IV, remove clothing

from left side of body, Intake/Output

neuro assessment, assist w/procedures PRN

Scribe: EMT/LPNRecord case on white board

Provider Assist: RNAssist with procedures as directed

ProviderRunner: EMT/CNA/Secretary

Retrieve equipment/supplies, assist with

ER traffic control, answer phone

TRAUMA TEAM ROLES - Guidelines

IV/Meds: RNInsert large bore IV, remove clothing

from right side of body,

attach/observe monitor, access crash cart

Prepare/Administer Meds

Foley as appropriate

C-Spine: EMTAlert physician of any

change in LOC

Thank You

Basic concepts of resuscitation in trauma patients

Health & Medicine

Transcript of Basic concepts of resuscitation in trauma patients