Organization Prior to Trauma Patient Arrival

I. The Trauma Response

A. Institutional capability

The resources available to manage trauma patients is institution-specific. The American College of Surgeons Committee on Trauma has designated trauma centers as follows:

• Level I. Provides a 24-hour, in-house trauma team with the ability to fully resuscitate injured patients and provide definitive surgical care for the most complex injuries. The trauma team is usually led by an attending trauma surgeon, emergency physician, or senior-level surgical resident. Level I centers are typically located in population-dense areas. In addition to the clinical capabilities, Level I trauma centers also distinguish themselves through training, research, and prevention and outreach programs.
• Level II. Clinical capabilities are similar to Level I centers. However, more specialized resources (e.g., cardiac surgery, microvascular surgery) are not required. Trauma team requirements are less stringent; an in-house trauma surgeon is not required, but must be available to meet the patient on arrival. Level II centers are frequently located in suburban areas.
• Level III. These centers typically serve rural areas not easily accessible to Level I or II trauma centers. Surgical coverage must be available in a timely fashion and certain subspecialties (e.g., neurosurgery) are not required. Formal transfer agreements to higher level centers are paramount to optimize patient outcome.
• Level IV. Designed to provide initial evaluation and assessment of injured patients, these centers are typically located in small hospitals or clinics serving the most remote areas. Surgical coverage is not mandatory and most patients will require transfer to higher levels of care.
• Nondesignated. The majority of hospitals in the United States carry no specific trauma center designation. All hospitals should be aware of the resources available for management of trauma patients with clearly delineated plans for transfer of patients that exceed the “resource threshold.”

B. Levels of response

All hospitals should have some established response to injured patients. In nondesignated hospitals, where a full trauma team is not available, an organized procedure (e.g., personnel, tasks, etc.) will facilitate resuscitation and optimize patient outcome. Many trauma centers use tiered levels of response based on established triage criteria. The composition of the trauma team varies based on the level of trauma response:

• Full response (Trauma code, “code red”). Full trauma team response designed for patients with physiologic instability or who present with life-threatening injuries (e.g., abdominal gunshot wound).
• Modified response (Level II trauma response, “trauma alert”). Modified response typically intended for stable patients with the potential for serious injury based on mechanism or anatomic findings. Exact composition of the trauma team will vary with the trauma center. Emergency physicians often provide the leadership role.
• Trauma consultation. In most trauma centers, this response is reserved for low-energy or single system injuries in stable patients. Patients generally have

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  their evaluation completed by the emergency physician prior to consultation with a trauma surgeon.

II. Trauma Resuscitation Area

A. Physical plant

• A dedicated trauma resuscitation area (TRA) is required for any Level I or II trauma center and should be considered in any hospital emergency department that receives a significant volume of injured patients or where injured patients may arrive without prior notification.
• The TRA should be secure, with limited access to nonmedical personnel.
• Convenient access to the operating room, radiology suite, intensive care unit, and staff call rooms are important considerations in TRA design.
• The TRA must be sufficiently large to accommodate all members of the trauma team (i.e., 5-10 people). Ample space must be provided to allow free movement of prehospital providers into and out of the area, complete resuscitation, basic radiographic evaluation, orthopedic stabilization, and required emergency surgical procedures:
  • Airway intubation
  • Cricothyroidotomy
  • Insertion of central venous catheters
  • Tube thoracostomy
  • Placement of urinary catheters and nasogastric/orgogastric tubes
  • Resuscitative thoracotomy
  • Focused abdominal sonography for trauma (FAST)
  • Diagnostic peritoneal lavage (DPL)
  • Splinting of fractures
  • Wound irrigation and suturing
• Other TRA considerations include:
  • Lighting should be sufficient and must allow free access to the patient and easy movement of personnel and equipment through the workspace.
  • Hypothermia must be actively prevented during trauma resuscitation. Specific measures to prevent hypothermia include individual TRA thermostats and overhead heat lamps.
  • A mechanism to supply the TRA with uncrossmatched packed red blood cells (O-negative) should be implemented, especially for hospitals in which the blood bank is located a significant distance from the emergency department. Ideally, the laboratory or blood bank, as part of the trauma response, can deliver O-neg blood in a cooler to the TRA. This blood should be returned as soon as the need for early transfusion has been excluded.
  • Each institution must have guidelines for resuscitation of multiple trauma patients within the confines of the defined TRA or emergency department.

B. Barrier precautions

• Any bodily fluid should be considered a potential source of transmissible disease and, thus, barrier precautions should be mandated for all members of the trauma team. Specifically, non-sterile gloves, an impervious gown, surgical mask, protective eyewear, and shoe covers are necessary for all team members likely to come in contact with a patient.
• Barrier precaution items should be available in a designated area adjacent to the TRA in full view of those who may enter the area. The trauma team leader or recorder should monitor and enforce compliance with barrier precautions.
• Inevitably, patients will arrive without notification. In these cases, guidelines should be developed for relieving personnel who, by necessity, have entered the TRA without barrier precautions. Protected team members should provide rapid relief for those who have not had the opportunity to don protective equipment. The ultimate goal should be to minimize the total number of unprotected individuals during a given resuscitation.

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C. Equipment

The minimal amount of equipment and supplies necessary to effectively resuscitate should be stored in the TRA. While frequent restocking may be necessary, eliminating superfluous inventory optimizes resuscitation space and facilitates standardization of care.

• Equipment trays should contain only those instruments and materials absolutely necessary to perform a given procedure. Trays should be easily accessible, openly displayed, and clearly labeled for easy identification. One logical approach is to stock supplies in a head-to-toe configuration, with airway equipment and cervical collars stored near the head of the stretcher, thoracostomy trays near the midportion of the stretcher, and splinting materials at the foot of the stretcher.
• Equipment necessary to manage immediately life-threatening conditions should be stocked close to the stretcher, in proximity to the trauma member most likely to use it (Table 9-1; Fig. 9-1).
• Additional equipment and materials listed below can be stored along the walls of the resuscitation workspace. Large, portable equipment must be easily visible and accessible. Smaller items can be stored on shelves and counters or in designated trays or bins. Cabinets are not recommended, as closed doors impede rapid identification and ease of access.
  • Mechanical ventilator
  • Fluid warmer stocked with crystalloid solutions
  • Rapid infusion-warming device
  • Central venous catheter, pulmonary artery catheter kits
  • Instrument trays (e.g., basic surgical trays, plastic surgery trays)
  • Portable monitors
  • Suture cart
  • Traction devices
  • Preformed extremity splints
  • X-ray view boxes/monitors
  • Computers
• A modest inventory of equipment and supplies to replace items used from other areas (e.g., angiocatheters, intravenous tubing) should be readily available.
• Equipment and supplies should be stocked in a portable carrier that can be transported with the patient outside the TRA (e.g., radiology suite). Suggested contents include:
  • Nasal and oral airways
  • Cricothyroidotomy set
  • Suction equipment and tubing

    TABLE 9-1 Immediately Accessible Equipment and Supplies

    Head of Stretcher Equipment for airway management, including multiple endotracheal tubes, oxygen, suction devices, oral/nasal airways, Ambu bags, and laryngoscopes Tray #1 Equipment for intravenous access, intravenous tubing, phlebotomy, arterial blood gases Trays #2 and #3 Thoracostomy trays, chest tubes (36 R 40 F), appropriate suture material Tray #4* Diagnostic peritoneal lavage equipment Foot of Stretcher Chest drainage system (e.g., Pleurovac) Left Side Manual blood pressure cuff, electrocardiogram wires, pulse oximetry monitor *Ultrasound machine.

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    Figure 9-1. Layout of the trauma resuscitation area. (From Committee on Trauma, American College of Surgeons. Resources for the optimal care of the injured patient. Chicago, Ill: American College of Surgeons, 1999, with permission.)

  • Pulse oximetry probe
  • Manual blood pressure cuff
  • Angiocatheters (14, 16, and 18 gauge)
  • Intravenous tubing and adapters
  • Syringes (3, 5, and 10 milliliters [mL])
  • Phlebotomy supplies
  • ABG syringes
  • Irrigating syringe (60 mL)
  • Dressings, gauze, tape
  • Medications (Section II.E)
  • Additional forms for documentation
  • Telephone and pager lists
• Equipment and medications specific for pediatric resuscitation should be stored on a separate cart. The cart should be equipped with a Broselow tape for rapid calculation of medication dosages and selection of appropriately sized equipment.
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• A resuscitation stretcher should be oriented in the center of the resuscitation workspace. Several items ideally should be stored under the stretcher:
  • Patient gowns
  • Blankets
  • Small oxygen tank
  • Nasogastric/orogastric tubes
  • Irrigation tray
  • Automatic blood pressure cuff
  • ECG leads
  • Pulse oximetry leads

D. Medications

In addition to standard medications stocked on the code cart, a small inventory of medications should be stocked in the TRA for immediate use:

• Drugs including those for airway management (e.g., succinylcholine, sodium thiopental, etomidate, vecuronium, midazolam). Ideally, these agents should be stored in labeled syringes for instant administration.
• Sedatives, analgesics, and antimicrobials including lorazepam, morphine sul-fate, fentanyl, naloxone, tetanus toxoid, cefazolin, and an aminoglygoside.
• Medications including diphenylhydantoin, 50% dextrose, methylprednisolone, mannitol, thiamine, magnesium, and calcium.

E. Communication

Reliable communication among members of the trauma team and to areas outside the TRA is essential. Communication in the TRA can be facilitated by the following:

• A podium provides space to document resuscitation events and serves as an area from which the flow of activity in the TRA may be observed.
• Marker board can be useful to record history, physical findings, and test results, and to display pertinent pager numbers of on-call consultants and ancillary personnel.
• Efficient communication throughout the hospital is essential. Dedicated extensions to the operating room (OR), computed tomography (CT) suite, blood bank, and the ICU should be available and use of these extensions should be limited to the trauma team. In high-volume trauma centers a laboratory computer terminal and digital radiology station should be considered.
• Communication between the trauma team and the OR staff is facilitated by a patient classification system. Such a system allows the OR and blood bank staff to organize resources and allocate personnel. The trauma patient classification system described in Table 9-2 provides a template. Early in the

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  resuscitation, a single individual should be responsible for communicating the OR classification to responsible OR staff.

TABLE 9-2 Trauma Patient Classification System

Class A Unstable patient: requires immediate surgical intervention; no further injury evaluation (e.g., x-ray or laboratory studies) required. Immediate access to the operating room is necessary. Initiate massive transfusion protocol for blood and blood products (e.g., fresh frozen plasma, platelets). Class B Unstable patient: high probability of surgical intervention within 15–30 min. Some injury evaluation in progress. Massive transfusion likely. Class C Stable patient: probability of surgical intervention within 2 h. Complete injury evaluation (e.g., CT scan) in progress. Crossmatched blood or type and screen sufficient. Class D Stable patient: minimal probability of surgical intervention (minor injuries).

III. Trauma Team

A. Definition

The trauma team is an organized group of professionals who perform initial assessment and resuscitation of critically injured patients. Team composition, level of response, and responsibilities of each member are institution-specific. Personnel are outlined as follows:

• Trauma surgeon—a general surgeon with demonstrated training and interest in trauma care. In designated trauma centers, the trauma surgeon typically functions as the trauma team leader.
• Emergency medicine physician—in many hospitals, the emergency medicine physician functions as the trauma team leader depending on the perceived severity of injuries. Ideally, these physicians have Advanced Trauma Life Support (ATLS) certification.
• Anesthesiologist—a physician with special skills in airway management, sedation, and analgesia. In many trauma centers, this role may be fulfilled by a certified registered nurse anesthetist (CRNA).
• Trauma nurses—emergency department nurses with specialized training and demonstrated interest in trauma care.
• Resident physicians—residents in emergency medicine or surgery and trauma fellows may assume active roles in the trauma team. In Level I and II trauma centers, senior surgical residents and trauma fellows may function as trauma team leaders.
• Respiratory therapist—therapist available to assist in the evaluation and management of the patient's respiratory status.
• Radiology technicians—technicians available to obtain x-rays as indicated by the initial assessment and secondary survey.
• Surgical subspecialists—although not typically involved in the initial assessment, surgical consultants (e.g., orthopedic surgeons, neurosurgeons) are vital members of the trauma team.
• Other personnel—the trauma team may also include OR nurses, laboratory technicians, ECG technicians, chaplains, social workers, transport personnel, and case managers.

B.

During periods of high volume or high acuity (e.g., multiple victims), some internal mechanism should be available to mobilize additional personnel. In addition, appropriate on-call personnel must be available.

C. Roles and responsibilities.

With adequate prenotification, the trauma team can be organized and positioned prior to arrival of the patient. A generic positioning scheme is illustrated in Fig. 9-2. Specific responsibilities of respective trauma team members are outlined in Table 9-3.

D. Multiple patient scenario

• All hospitals must be prepared for the arrival of multiple trauma patients, a situation that can overwhelm the resources of the best-prepared trauma center. The definition of “multiple patients” is institution specific, based largely on the depth of personnel and the availability of resources.
• The trauma team leader is responsible for assigning available personnel to ensure safe and effective resuscitation of each patient.
• A triage plan for positioning patients and allocating resources should be formulated based on the prehospital report and early clinical findings; for example:
  • Position patients based on perceived needs (e.g., patients with severe head injury should be positioned near the mechanical ventilator).
  • Assign a primary resuscitator for each patient under the direct supervision of a trauma team leader. Effective communication between these individuals is of utmost importance.
  • Recruit additional personnel. Properly trained nursing staff, prehospital providers, and technicians are potential sources of immediate in-house assistance.
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    Figure 9-2. Positions and roles of the trauma team members. (From Resources for the optimal care of the injured patient. Chicago, Ill: American College of Surgeons, 1999, with permission.)

  • On-call personnel (e.g., orthopedic surgeons) may also be mobilized to assist in the resuscitative phase.
  • Reallocate personnel and resources based on results of each patient's primary survey.
  • Move stable patients out of the TRA to other areas of the emergency department based on clinical assessment.

IV. Transfer of Patient to the Trauma Team

A.

A formal report at the time of patient arrival signifies the transition of care from prehospital providers to the trauma team. Assuming adequate pre-notification, the trauma team can assemble prior to arrival of the patient to receive the prehospital report.

B.

With few exceptions (e.g., airway compromise), patients should be maintained on the transport stretcher until the pre-hospital report is completed. Once the patient has been moved to the resuscitation stretcher, the trauma team may not devote full attention to the report.

C.

The pre-hospital report should be a concise (30–45 seconds) summary given by a single pre-hospital provider and directed to the entire trauma team.

D.

Following the report and transfer of the patient, a designated member of the trauma team should attempt to get a more detailed history from the prehospital providers.

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TABLE 9-3 Trauma Team Roles and Responsibilities

Trauma Team Leader Primarily responsible for directing individual trauma team members, coordinating events of the resuscitation, and formulating the plans for definitive management. In larger centers, especially those with training programs, the trauma team leader may be an attending trauma surgeon, emergency physician, trauma fellow, or senior or chief surgical resident (i.e., command physician). Primary Resuscitator A surgeon or emergency medicine physician responsible for the initial assessment and performance of surgical procedures, as necessary. In smaller hospitals, this individual also assumes the role of team leader. Airway Manager Anesthesiologist, certified registered nurse anesthetist (CRNA), emergency physician, or surgeon primarily responsible for assessment and management of the airway. Required procedures can include endotracheal intubation, insertion of nasogastric or orogastric tubes, and assistance with cervical spine immobilization. Also expected to manage paralytics, sedatives, and analgesics relative to intubation and assist with medical management during code situations. Assistant The assistant is responsible for exposing the patient, placing electrocardiographic leads and pulse oximeter, and assisting with patient transfers. In addition, may be asked to assist with any necessary procedures. Depending on the institution, the assistant may be a physician (e.g., surgical resident) or, in nonteaching hospitals, a trauma nurse or emergency medicine technician. Trauma Nurse Prepares the trauma resuscitation area (TRA) for arrival of the patient. Serves as the patient's primary nurse during the resuscitative phase of care. Responsible for monitoring vital signs and performing select procedures (e.g., intravenous access, phlebotomy, urinary catheters). Assists with patient transfers, accompanies patient outside of TRA and reports to the receiving unit. Recorder Should be a nurse with extensive experience in trauma resuscitation. Responsible for documenting events of the resuscitation on an appropriate flowsheet. Facilitates communication and mobilization of additional resources (e.g., blood bank, operating room, consultants). May also assist in coordinating events of the resuscitation. Respiratory Technician Responsible for assessment of the airway and breathing and placement of appropriate monitoring devices (e.g., pulse oximeter). Assists airway manager with intubation and ventilator setup. Radiology Technologist Performs necessary radiographic studies. Assists with positioning the patient for the required studies. Processes films and returns completed radiographs to the TRA. Laboratory Technician Draws blood samples and transports samples to the laboratory for processing. Delivers blood to the TRA before arrival of the patient. Transports additional blood and blood products to the patient as necessary. Chaplain/Social Worker/Case Manager Assists with patient identification. Communicates between trauma team and patient's family.

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Axioms

• Prior notification of patient arrival facilitates an organized response.
• Barrier precautions should be utilized by all trauma team members who may come in direct contact with the patient.
• Equipment and personnel placement in the TRA should be standardized.
• During trauma resuscitation, verbal communication among trauma team members should be minimized.
• The presence of an identified trauma team leader promotes efficiency and facilitates formulation of a definitive plan.
• The trauma team leader should attempt to maintain a panoramic view of the resuscitation.