+ Table of Contents

  1. Contributors
  2. Objectives
  3. Chapter 1: The importance of initial trauma management
  4. Chapter 2: Patient and staff safety
  5. Chapter 3: Introduction to the Trauma Team
  6. Chapter 4: Initial assessment of a trauma patient
  7. Chapter 5: Trauma resuscitation and management
    1. (H) Haemorrhage: Life-threatening external haemorrhage
    2. (A) Airway: Management of an unconscious trauma patient (airway management and spinal immobilization)
    3. (B) Breathing: Management of a trauma patient in Respiratory Distress (tension pneumothorax, haemothorax and open pneumothorax)
    4. (C) Circulation: Management of a trauma patient in Shock (recognising shock, haemorrhage control, IV fluid resuscitation)

Chapter 3: Introduction to the Trauma Team

The reception and resuscitation of the seriously injured requires rapid attention to assessment, priorities, and interventions. Multiple decisions and procedures need to be completed in a limited time period. This involves multiple staff and is essential to optimize patient outcomes.

Optimal care of the major trauma patient places high demands on available resources, including the doctors and nurses working in a busy Emergency Department/Trauma Centre.

Often, seriously injured people arrive with no or little warning. There is little information regarding what has happened and there is no immediate knowledge of the patient’s past medical history.

A coordinated and organized response by a team of doctors and nurses is required during the reception and resuscitation of major trauma patients. Importantly the team should be trained in the technical and team skills of trauma resuscitation. This enables the rapid assessment and management of major trauma patients and improves the patients’ immediate and longer-term outcomes.

Recognized as being essential to improved trauma resuscitation is the need for a systematic and co-ordinated approach to the initial assessment of Haemorrhage Control, the Airway, Breathing, Circulation support and neurological Disability. Simultaneous attention is placed on prioritising immediate life-saving interventions based on initial assessment findings. Central to effective trauma resuscitation is an effective and highly functioning trauma team.

Members of the trauma resuscitation team include doctors and nurses who have specialized training in the life-saving technical skills required during trauma resuscitation. For team members to work quickly, efficiently and effectively, each member of the team must have a clear understanding of what is expected.

Before patient arrival Trauma Team members must be confident that they have the skills required to perform the role and tasks allocated to them. In addition, communication among team members and the team as a whole is essential to this process. Clear communication of assessment findings and outcomes is essential for effective trauma resuscitation.

Trauma team composition varies depending on resources available and the number of patients requiring immediate resuscitation. On the commencement of any rostered shift, it is important to assign doctors and nurses to the trauma resuscitation team, clearly delegating roles and responsibilities. On patient arrival, pre-established members of the trauma resuscitation team can focus their attention on the systematic assessment of the patient and intervene with life-saving priorities when necessary. As there are many tasks to be carried out simultaneously, team members must focus on the tasks allocated to them.

Trauma Team Roles

  • Medical Team Leader
  • Nurse Team Leader
  • Airway Doctor
  • Airway Nurse
  • Procedure Doctor
  • Procedure Nurse

 

Figure 2.  Initial Trauma Team set up

 

Medical Team Leader

  • Communicates closely with Nurse Team Leader to ensure pre-arrival preparation is completed
  • Receives/collects relevant information regarding patient presentation, for example, mechanism of injury, relevant past medical history, allergy status, any treatment to date
  • Co-ordinates team activities during initialtrauma resuscitation and beyond
  • Remains focused/ensures a systematic approach (ABCs) to trauma assessment and resuscitation
  • Remains ‘hands free’ if possible
  • Identifies interventional priorities based on team members assessment findings and ensures effective interventions are undertaken and completed
  • Ensures appropriate radiological investigations are available and completed
  • Communicates with other specialties as required based on initial assessment findings – including the need for urgent theatre, the need for urgent blood products and consultation by trauma surgeons, orthopaedic surgeons, neurosurgeons
  • Communicates plan of interventional priorities to the whole team based on an initial assessment findings
  • Supports/guides all members of the trauma team
  • Promotes teamwork through effective clear and concise communication, remains calm and is a role model for other members of the team
  • Encourages team members to talk out loudly and clearly so that all team members are aware of the priorities in patient management
  • Gathers the whole team together after the trauma resuscitation and discusses what went well and opportunities for improvement

Nurse Team Leader

  • Communicates and co-ordinates trauma team activities alongside the medical team leader
  • Ensures that all team members are following universal precautions and that roles are clearly delegated
  • Ensures adequatenumber of team members present with the ‘right’ skill mix
  • Documents the initial history following patient arrival
  • Documents baseline set of vital signs and ongoing patient monitoring including all interventions and procedures
  • Ensures that a chronological order of treatment interventions and procedures is documentedand maintained
  • Ensures that the primary and secondary surveys have been completed and outcomes documented
  • Communicates with other departments based on patient needs and as directed by the Medical Team Leader, for example, blood bank (blood products), operating suite (urgent transfer to theatre)
  • Communicates with family members regarding patient progress in consultation with MedicalTeam Leader
  • Arranges disposition of the patient, admission and transfer

Airway Doctor

  • Introduces self to the Airway Nurse
  • Ensures a clear understanding of the expected role and responsibilities
  • Prepares and checks all essential airway equipment is available and functioning, bag valve mask circuit, oxygen source, suction equipment, intubation equipment, drugs available for rapid sequence intubation if required
  • Communicates clearly and effectively to the whole team but importantly remains in close communication with Medical Team Leader
  • Performs a systematic assessment of Airway and Breathing on patient arrival and communicates assessment findings to the Medical and Nurse Team Leaders
  • Assesses the patient’s Disability status using AVPU scale initially then the Glasgow Coma Scale including pupil size and reactivity. Clearly delegates team responsibilities and tasks in preparing for rapid sequence intubation if required
  • Performs rapid sequence intubation if necessary
  • Maintains patient’s airway and ventilation requirements and continues to monitor requirements

Airway Nurse

  • Introduces self to the Airway Doctor
  • Ensures a safety check of all necessary airway equipment has been completed prior to arrival of patient
  • Ensures that a functioning bag valve mask circuit attached to oxygen flow meter is ready for use
  • Ensures drugs are available for rapid sequence intubation if required
  • Ensures that oxygen is being delivered via a face mask with high flow oxygen
  • Assists Airway Doctor in the initial assessment and maintenance of a patent Airway
  • Assists in the assessment of Breathing – looks for equal rise and fall ofchest
  • Ensures that a well sized and fitting cervical collar is on the patient if necessary according to mechanism of injury
  • Ensures spinal immobilization ismaintainedas required
  • Counts the patient’s respiratory rate and monitors oxygen saturation on patient arrival and ongoing as required. Reports findings to the Nurse Team Leader for documentation
  • Assesses the patient’s Disability status using AVPU scale initially then the Glasgow Coma Scale including pupil size and reactivity. Reports findings to Nurse Team Leader for documentation
  • Reassures the conscious trauma patient, explaining what is happening and why
  • Assists with drug administration
  • Assists with rapid sequence intubation if necessary – performs cricoid pressure
  • Ensures that the endotracheal tube is tied securely
  • Ensures ongoing monitoring of patient’s airway and breathing status
  • Prepares equipment for portable monitoring for transfer to CT or operating suite

Procedure Doctor

  • Introduce self to the Procedure Nurse
  • Assist with attaching monitoring equipment and undressing of patient
  • Assesses the patient’s Circulation status – feels the pulse (rhythm and quality), assesses adequacy of the blood pressure
  • Ensures external Haemorrhage Control
  • Obtain/ensure patent large bore intravenous access X2
  • Obtain trauma pathology bloods and ensure the bloods are processed/sent to the laboratory
  • Perform procedures based on initial assessment findings and interventional priorities as delegated by the Medical Team Leader, for example, insertion of intercostal chest tube, indwelling urinary catheter, gastric tube

Procedure Nurse

  • Introduces self to Procedures Doctor
  • Assists in removal of patient clothing on patient arrival
  • Covers the patient with warm blankets to prevent hypothermia
  • Attaches all monitoring equipment
  • Clearly communicates a baseline set of vital signs to the Nurse Leader for documentation
  • Assists Procedure Doctor with external Haemorrhage Control
  • Assists Procedure Doctor with intravenousaccess
  • Prepares and administers all intravenous fluid (warmed) as prescribed by the Procedure Doctor
  • Provides Haemorrhage Control of active bleedingsites asdirected by Procedure Doctor
  • Is familiar with and assists in all procedures undertaken by the Procedure Doctor, for example, prepares equipment for the following procedures: intercostal tube insertion, indwellingurinary catheter insertion, gastric tube insertion
  • Assesses level of patient’s pain and administers prescribed pain relief as required
  • Assists in splinting of limbs as required
  • Assesses, cleans and apply dressing to wounds

 

 

Figure 3. The Alfred Trauma Call Out Criteria