Trauma Teams and the Approach to Trauma Care

1. Trauma Teams and the Approach to Trauma Care Mr John Ryan (Consultant in Emergency Medicine)

2. Objectives • History • Current Situation • Trauma Team Composition • Trauma Team Protocols • The Future

3. Trauma • Commonest cause of death between 1-40 years • Prevention strategies effective • Treatment effectiveness varies (ref: TARN) • Every Major injury costs about £80,000

4. The Past • Poor pre-hospital care • No advanced warning • Junior medical staff • Difficult access to advanced diagnostic facilities • Fragmented approach to early care

5. There were nine road deaths over the past week, including two teenage boys…. Nov 11th 2001

6. “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”

7. 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

8. 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

9. Developments in Trauma Care • ATLS • Trauma Systems • Trauma Centres • Trauma Audit • Trauma Teams

10. 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

11. Options • Status Quo • Trauma Team (Low Threshold Trauma Calls) • Trauma Team (High Threshold Trauma Calls) • 2 Tier-Trauma Team

12. 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%

13. Major Trauma Team • A&E senior doctor (Team Leader) • Surgical registrar • Orthopaedic registrar • Anaesthetic registrar • Radiology registrar • A&E Nurses • Radiographer • Porter • Chaplain

14. 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

15. Stable Trauma Team • E.D. Senior (Team Leader) • E.D. SHO • 2 E.D. Nurses • Radiographer • E.D. Porter

16. 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

17. 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

18. 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

19. Roles - Anaesthetist • Airway Control • Cervical Spine Control • Ventilation • Monitoring of vital signs • Monitoring of fluid and drug administration • Analgesia • Provide anaesthesia for surgical procedures

20. Roles - Surgical Registrar • Pimary Survey • Assessment of thorax and abdomen, head and facial injuries • Log roll • Thoracostomy or thoracotomy • Diagnostic peritoneal lavage • Urinary Catheter

21. Roles - Orthopaedic registrar • Intravenous access • Assessment of spine, pelvis • Application of external fixator • Assessment of limb injury • Dressing of wounds and stabilization of fractures

22. 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

23. 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

24. Trauma Audit • Assess Trauma call Appropriateness by ISS Admission to ICU Cavity Surgery within 24 hours Deaths

25. Other Trauma Resources • Level 1 rapid infuser • Tabards for Trauma team • Trauma Resuscitation chart • Bair Hugger • ATLS • FAST

26. Any Questions ?