Trauma Teams and the Approach to Trauma Care Mr John Ryan (Consultant in Emergency Medicine)
Objectives • History • Current Situation • Trauma Team Composition • Trauma Team Protocols • The Future
Trauma • Commonest cause of death between 1-40 years • Prevention strategies effective • Treatment effectiveness varies (ref: TARN) • Every Major injury costs about £80,000
The Past • Poor pre-hospital care • No advanced warning • Junior medical staff • Difficult access to advanced diagnostic facilities • Fragmented approach to early care
There were nine road deaths over the past week, including two teenage boys…. Nov 11th 2001
“And, in Cork, a man was fighting for his life after being stabbed outside a nightclub in the north of the city early yesterday. He required emergency surgery to his face and neck and his condition was described as critical”
Current Trauma Workload at SVUH • 3 Month Period - (July-September 2001) • Retrospective Audit • 2,244 Trauma Patients • 296 Trauma admissions (13%) 61% Orthopaedic 26% General Surgery 10% Plastic • 4 Major Trauma Cases • Estimated % trauma calls = 100 ie: 1/day
Challenges in Trauma Care at SVUH • Defining Major Trauma - ? RTS - ? ISS - ? Based on abnormal vital signs and injury criteria • Provide Institutional Commitment and Multispecialty Expertisein Trauma Resuscitation
Developments in Trauma Care • ATLS • Trauma Systems • Trauma Centres • Trauma Audit • Trauma Teams
Trauma Teams • Match ‘patient need’ with ‘resource utilisation’ • Encourage earlier senior clinical decision making • Provide a co-ordinated approach to early trauma care • Minimise delay in the Emergency department
Options • Status Quo • Trauma Team (Low Threshold Trauma Calls) • Trauma Team (High Threshold Trauma Calls) • 2 Tier-Trauma Team
2 Tier-Trauma Team • Major Trauma Team (Vital Signs & Injury Criteria) • Stable Trauma Team (Blunt mechanism) Implementation of a two-tier trauma response Ryan JM, Gaudry PL, McDougall P, McGrath PJ Injury 1998 29:9;677-683 • Under-triage 8%, Over-triage 10%
Major Trauma Team • A&E senior doctor (Team Leader) • Surgical registrar • Orthopaedic registrar • Anaesthetic registrar • Radiology registrar • A&E Nurses • Radiographer • Porter • Chaplain
Indications for Major Trauma Call • Vital Signs Resp Rate >30 <10, cyanosis, retractive breathing, attempted intubation, Pulse >130 <50, SBP < 90mmHg, GCS <13 • Injury Flail chest, penetrating injury to head, neck, chest, abdomen, pelvis back or groin, major crush injury to torso or upper thigh, limb amputation, paralysis from spinal injury, burns >20% BSA • History Combative patients, >20 weeks pregnant • Multiple Patients >2 patients arriving simultaneously
Stable Trauma Team • E.D. Senior (Team Leader) • E.D. SHO • 2 E.D. Nurses • Radiographer • E.D. Porter
Indications for Stable Trauma Call • History Fall >3 metres, Pedestrian or cyclist struck by a car, RTA > 60 mph, death of other occupant, RTA with rollover, extensive damage to car, extrication > 20 mins, pregnant < 20 weeks, Interhospital transfer < 24hrs from injury • Vital Signs Resps 10-30, PR 50-130, BP > 90mmhg, GCS>12 • Injury 2 or more long bone fractures, penetrating limb injury, potential spinal cord or spinal bony injury
Procedure • Triage Nurse allocates appropriate level of Trauma Response for patient • Patient transferred to Resus Bay 1 • Switch Put out ‘007’ call = Major Trauma Call • Switch put out ‘006’ call = Stable Trauma Call • All members of Major Trauma Team expected to attend for ‘007’calls
Roles - Team Leader • Hands free Role: • Direct team members in their actions • Establish priorities for investigation and management • Order or authorize investigations and procedures • Keep track of whole state of the patient • Receive and interpret all results of investigations • Order fluid or blood administration • Supervise spinal manoeuvres • Consult with other specialities • Decide on appropriate disposition • Talk to relatives
Roles - Anaesthetist • Airway Control • Cervical Spine Control • Ventilation • Monitoring of vital signs • Monitoring of fluid and drug administration • Analgesia • Provide anaesthesia for surgical procedures
Roles - Surgical Registrar • Pimary Survey • Assessment of thorax and abdomen, head and facial injuries • Log roll • Thoracostomy or thoracotomy • Diagnostic peritoneal lavage • Urinary Catheter
Roles - Orthopaedic registrar • Intravenous access • Assessment of spine, pelvis • Application of external fixator • Assessment of limb injury • Dressing of wounds and stabilization of fractures
Procedure - Major Call • E.D. senior acts as Trauma Team Leader • Surgical Registrar acts as Team Leader if second team required • All team members to document assessment • Team to agree plan before any stand down
Procedure - Stable Call • E.D. senior performs primary survey • Relevant specialties called as indicated • Upgrade to Major Trauma if physiology deteriorates • Plan documented and agreed by team before stand down
Trauma Audit • Assess Trauma call Appropriateness by ISS Admission to ICU Cavity Surgery within 24 hours Deaths
Other Trauma Resources • Level 1 rapid infuser • Tabards for Trauma team • Trauma Resuscitation chart • Bair Hugger • ATLS • FAST
Any Questions ?
