Trauma Team Activation

Introduction

Health care facilities designated as trauma centers maintain the resources to provide initial definitive care, regardless of injury severity.

A.

As designated by the American College of Surgeons (ACS), Level I trauma centers possess the capabilities and physical resources necessary to provide comprehensive trauma care, including rehabilitation, education, prevention, and research components. Level II centers possess similar clinical resources, but have less ongoing commitments to research and education. Level III centers generally have limited staff and resources for clinical care. They provide care for many patients, and identify those with more serious injuries who are better treated at a Level I or II center.

B.

The most crucial triage decision for Emergency Medical Services (EMS) systems involves ensuring that injured patients are transported to appropriate-level trauma centers. The trauma centers must then decide for which patients the trauma team should be activated.

C.

The trauma team is at the hub of the trauma center activities. Ensuring the ongoing availability of a qualified trauma team represents a costly investment by the trauma center, indicating its commitment to providing quality trauma care for the community.

II. Activation Criteria

A.

Although the trauma team can be made available to all injured patients at the trauma center, it is a limited resource. It is important that the trauma team be activated for patients whose injuries, as reported by EMS personnel, are likely to demand an immediate operation, critical care, or multidisciplinary management.

B.

To some degree, “tiering,” or grading of responses, occurs in all facilities that care for trauma patients. Not all injuries demand the attention of the entire trauma team (e.g., simple extremity fractures resulting from low-force mechanisms of injury). Varying levels of trauma team response may be developed to match patients' anticipated needs with available resources and expertise. These should be institution specific.

C.

Many Level I and II trauma centers currently employ triage criteria to guide the initial evaluation of trauma victims, including deployment of personnel and equipment. Development of such criteria follows recognition that primarily three categories of patients arrive at the trauma center.

• Patients whose injuries are obviously severe and demand an immediate multidisciplinary approach. The trauma team should be activated before arrival at the center. These patients have clear potential of life-threatening injury as evidenced by abnormal physiology (vital signs and sensorium) or penetrating truncal injury. Additionally, patients with less evidence of severe injuries, but who are arriving in numbers such that local resources would be overwhelmed, are often placed in this most serious category.
• Patients whose injuries, or potential for injury, may not seem immediately life-threatening, but deterioration is possible. These patients may not require the immediate activation of the entire trauma team, and most may be appropriately evaluated immediately by qualified emergency department

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  staff together with other trauma team members. Nevertheless, they are treated where multidisciplinary resources are immediately available should they be needed. Such patients may have experienced significant mechanisms of injury, but have no apparent serious anatomic or physiologic abnormalities.
• Patients who could be managed at most acute care facilities. These patients require evaluations by qualified emergency department staffs, including consultation with other providers and similar resources needed to evaluate and treat most other acutely ill, non-trauma patients.

D.

Variations in activation criteria and responses

• Trauma team activation criteria, in general, include components similar to those of the ACS Triage Decision Scheme. Physiologic and anatomic factors, as strong predictors of the need for early operation or critical care, should be the primary determinants. Mechanism of injury information by itself is less predictive of the need for operation or critical care, but should be a consideration in activation criteria.
• Trauma team activation criteria reflect each institution's patient volume and resources. In general, activation criteria identify the resources and personnel assembled initially to care for a seriously injured patient. Some centers choose a singular response type (“all or none”), which eases implementation but can expose the system to inefficient use of resources. Many trauma centers use a graded system of activation (e.g., full trauma team and modified trauma team) which helps ensure prompt response without waste.
• An example of trauma team activation criteria is shown in Table 8-1. Full team activation occurs for patients whose injuries, as reported by EMS personnel, are or have potential to be severe. In such cases, the entire trauma team, including the attending trauma surgeon, responds to the emergency department. Partial or modified team activations do not require anesthesiology, respiratory therapy, and certain surgical housestaff to respond. Furthermore, the attending trauma surgeon is notified immediately via the paging system,

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  but may not be required to respond initially for partial team activation. At any time, a partial response can be upgraded to a full response, if necessary. Similarly, a full response can be downgraded as the patient's condition permits.

  TABLE 8-1 Sample Trauma Team Activation Criteria

  Level I trauma team activation Full trauma team response: Attending emergency medicine physician, attending trauma surgeon, trauma fellow or senior surgical resident, two junior residents, radiology technician, respiratory technician, three emergency department nurses (attending or resident anesthesiologist immediately available). Physiologic criteria: -Intubated or question of airway security -Respiratory distress -Current decreased level of consciousness -Any period of systolic blood pressure < 100 mmHg Anatomic criteria: -Penetrating wound other than distal to the knee or elbow -Amputation or degloving injury proximal to knee or elbow -Spinal cord injury -Flail chest -Pelvic fracture -Two or more long bone fractures Other: -Request by attending physician for Level I activation Level II trauma team activation Partial trauma team response: Attending emergency medicine physician, trauma fellow or senior surgical resident, one junior resident, two emergency department nurses, radiology technician; notification of attending trauma surgeon; others called as needed. Physiologic criteria: -History of loss of consciousness, now neurologically normal Mechanism of injury criteria: -Fall >15 ft -Major deformity of vehicle -Intrusion into passenger compartment of vehicle -Death of another vehicle occupant -Rollover vehicle crash -Pedestrian struck at >20 mph -Ejection from vehicle -Extrication time >20 min Other: -Helicopter scene flight -EMS personnel request for trauma team

• Level I trauma centers using tiered trauma team activations have reported that 52% to 57% of trauma patients meet the criteria for lesser responses. Furthermore, such guidelines have achieved 85% to 95% sensitivity in terms of requiring full trauma team response for those patients who require early operations or admission to a critical care unit. Patients initially met by a partial team who subsequently require a full team response have outcomes comparable to those met initially by the entire trauma team. Thus, trauma centers have reported that the immediate availability of multidisciplinary expertise and resources is crucial, but that their deployment during the initial evaluation of all trauma patients is not always necessary. Performance improvement of level of team activation and patient outcome is essential.
• For Level II trauma centers, which are often community hospitals with the trauma surgeon on call outside the facility, the issue of trauma team triage criteria is also important. Resources, including qualified surgeons, may not be as plentiful as at tertiary medical facilities. Their conservation for those situations when they are truly needed, while minimizing undertriage, is an important concern. When EMS personnel report that a trauma patient suffers respiratory compromise, altered mentation (e.g., Glasgow Coma Scale score <13), or hypotension, qualified emergency medicine and trauma surgery staff should be prepared to care for the victim on arrival. For other patients, evaluation by a qualified emergency physician and support staff, in consultation with an attending trauma surgeon, may be appropriate. When such guidelines have been used, no differences were found between observed and predicted mortality.

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III. Summary

The trauma team brings the comprehensive multidisciplinary capabilities of the trauma center to the emergency evaluation and management of injured patients. Its activation is crucial if the trauma center is to effect favorable outcomes for critically injured patients. However, judicious utilization of this resource is appropriate. As no standard criteria exist for trauma team activation, it is important for all centers to evaluate their trauma system components and quality and availability of resources, and prospectively create trauma team activation guidelines that are adequately dispersed and evaluated on an ongoing basis. Such efforts enhance the efficiency of care for trauma patients.

Axioms

• Trauma team activation criteria must be developed locally, and consider the response capabilities and input of EMS, emergency medicine, trauma surgery, anesthesiology, and other related specialists.
• Grading of trauma team responses can help tailor resources, but guidelines should be planned, monitored, and adjusted, as needed.