Introduction
Every year 35 million people visit an emergency department (ED) because of an injury. Trauma is the leading cause of death in the United States for people under the age of 44. Tragically, trauma accounts for a disproportionate percentage of deaths in younger people, causing 31.8% of all deaths for people aged 1 to 9 years, 40.6% for those aged 10 to 24, and 34.6% for those aged 25 to 44. Because the care of trauma patients can be resource-intensive and trauma resuscitation is often a fluid enterprise, it is crucial that trauma care be delivered by a team of providers who are all familiar with their specific roles but are also able to perform any of a core set of skills described in this chapter.
Trauma Activation
The purpose of a trauma activation system is to alert the relevant personnel, gather equipment, and mobilize resources necessary to care for complex trauma patients. Ideally, this activation occurs before the patient arrives, based on emergency medical services (EMS) information from the scene of the trauma. This additional time before patient arrival allows the team to prebrief regarding the impending patient encounter, tailor their preparations to the clinical scenario, and don the appropriate personal protective equipment (PPE).
As prearrival notification does not always occur, it is important for the ED always to have a baseline level of readiness. Critical equipment (e.g., material to start peripheral intravenous [IV] lines, secure the airway, control bleeding) should be kept in the trauma bay or other designated area in a clear and organized fashion. ED staff that will care for trauma patients should be predesignated and their other duties adjusted to allow for the fact that they may need to respond at a moment’s notice.
Because the care of trauma patients is multidisciplinary, trauma activations tend to involve resources and personnel from multiple services in the hospital. Trauma protocols are institution specific, but in general they may include the following:
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General/trauma surgery team to come to the ED to be part of the team assessing the patient
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Anesthesiology to either come to the ED to help manage the patient’s airway or to stand by in the operating room (OR) in case the patient is taken to surgery
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Radiology technicians to come to the ED with a portable x-ray machine to take whatever images are required immediately (a chest x-ray is part of the standard trauma patient evaluation)
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Radiology department to hold a computed tomography (CT) scanner open
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OR team to standby to open an OR as needed
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Blood bank to prepare to send blood products to the ED quickly (some blood products require a period to thaw before use)
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Chaplain services to come to the ED to attend to spiritual needs of the patient and their family
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Security services to come to the ED to ensure a safe environment for staff and patients
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An administrative team member (e.g., nursing administrator, trauma coordinator) to help coordinate the logistical needs of the team
Many trauma centers will have at least two levels of trauma activation to better align the resources expended to the patient severity. Based on patient characteristics and mechanisms of injury the goal is to identify “major” or “level I” traumas who are likely to require any/all of the resources described and “minor” or Level II” traumas who will still require more resources than the average patient, but less than a major trauma. These criteria are institution specific, but some common examples are included in Table 20.1 :
| Level I Trauma activation | Level II Trauma activation |
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Initial Assessment
Initial assessment of the trauma patient is crucial for identification of life-threatening injuries and rapid application of life-saving therapies. Preparation is key. Once a trauma patient is identified, coordinating with prehospital agencies and obtaining necessary equipment ensures a smooth transition from the prehospital to the hospital phase. The ED technician (EDT) assist in the preparation by listening to the prehospital report, noting the patient age, the type of injury, any specific patient history, and any special considerations.
After the prehospital information is received, the role of the EDT is often to prepare the resuscitation room, gather needed equipment, and don the appropriate PPE to await the arrival of the trauma patient.
When the patient arrives, multiple team members have individual assignments that occur simultaneously. These actions include:
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Disrobing the patient, often by cutting off their clothes (nurse or tech)
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Obtaining IV access with one or two large-bore IV catheters (nurse or tech)
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Taking vital signs (nurse or tech)
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Placing the patient on a cardiac monitor (nurse or tech)
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Obtaining a brief history, focusing on underlying medical problems, medications, and allergies (nurse)
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Beginning the primary survey (provider)
The provider begins the primary survey, which is focused on identifying and prioritizing all the patient’s injuries. The team leader makes a visual assessment, noting any areas of trauma or hemorrhage. By looking at the chest, abdomen, pelvis, and the floor, the team leader may reprioritize hemorrhage control prior to continuing with the initial assessment.
If no excessive bleeding is noted in the trauma patient, the team leader will proceed with the initial assessment (ABCDE). These ABCDEs of trauma include the following:
A: Airway maintenance with cervical spine precautions
B: Breathing and ventilation
C: Circulation with hemorrhage control
D: Disability (neurologic evaluation)
E: Exposure and environmental control
If concerns are discovered at any point during the primary survey, the team will pause and try to correct the issue. For example, if the team discovers an airway issue, they may suction the airway, insert an oropharyngeal airway, or even perform rapid-sequence intubation to establish a secure airway. It is important to note that once an intervention is completed, the team will reassess the effectiveness of that intervention before moving to the next stage of the trauma process.
Once the primary survey is complete and any life-threatening injuries are addressed, the team will complete any adjuncts to the primary survey and begin the secondary survey. These include the following:
F – Full set of vital signs
G – Get necessary adjunct measures, and give comfort measures (pharmacologic and nonpharmacologic)
H – Head-to-toe assessment and complete history
I – Inspect posterior surfaces
Adjunct measures may include electrocardiogram monitoring, urinary and nasogastric suction catheters, arterial blood gases, and diagnostic studies such as CT scans or x-rays. The role of the EDT in trauma resuscitation may include direct patient care, patient transport to imaging, and continued communication with the trauma team regarding the patient’s progress. Depending on the institution, at this time the patient may be prepared for transport to a higher level of care.
After the primary and secondary surveys are complete, the trauma patient will require constant reevaluation. Trauma patients can quickly deteriorate, and reassessment of both the primary and secondary surveys, as well as specific findings identified during those surveys, can prevent the trauma patient from decompensating.
Vascular Access
Reliable vascular access is critical, as it allows the trauma team to administer medications, IV fluids, blood products, and to draw blood for diagnostic testing. Because many of these functions are time-sensitive, vascular access should be obtained during the primary survey.
The ideal site for vascular access depends on a number of factors, including patient habitus, injury pattern, and preexisting medical conditions (e.g., dialysis access, prior surgeries that preclude using that limb). Because vascular access in trauma patients is often used for rapid administration of high volumes of resuscitative fluids, it is preferred to obtain large-bore access (18 gauge), usually in the upper extremities. In patients where rapid administration or multiple simultaneous products are anticipated, two IVs are often placed simultaneously, one in each arm. In choosing a site for IV access, you should consider the length and gauge of the intended catheter and select a site where the vein is both large enough and travels in a straight line long enough to accommodate the catheter.
Traditional peripheral IV placement using anatomic landmark and palpation is not always possible, particularly in patients with challenging anatomy, obesity, or a history of IV drug use. In those situations an ultrasound-guided or ultrasound-assisted peripheral IV may be employed (see Chapter 16 ). Because ultrasound allows for direct visualization of the vessel, it enables the user to access deeper vessels that cannot be palpated, identify tortuous or branching vessels, and directly visualize placement of the catheter in the vein. Ultrasound-guided peripheral IVs have also been shown to decrease complication rates and central line utilization, and to have a higher success rate than the traditional approach.
Intraosseous Access
Intraosseous (IO) access is another form of vascular access, which can be used either when traditional IV access cannot be obtained or as a first-line technique in patients where difficulty with vascular access is anticipated (e.g., pediatric patients, morbidly obese patients). IO access involves using a specially designed, commercially available drill to insert a metal catheter through the cortex and into the medullary space of a long bone. Because the medullary space is supported by rigid bone, it does not collapse or become harder to access in hypotensive patients the way peripheral veins do. Studies have shown that IOs can be placed as quickly, but with much higher rates of success, than peripheral IVs in hypotensive patients.
The preferred sites for IO access in adults are the humeral head (2 cm above the surgical neck, into the greater tubercle) and proximal tibia (2 cm inferior and medial to the tibial tuberosity). In pediatric patients, only the tibia should be used (1 cm below the tibial tuberosity), and care must be taken to avoid the epiphyseal plate.
Contraindications to IO placement include prior attempt at IO placement in that bone, fracture of the bone, overlying cellulitis or infection, or adequate venous access having already been established. Once obtained, IO access can be used to infuse any medication that can be given intravenously, and studies have shown that routine laboratory tests run on blood aspirated from an IO will yield similar results to blood drawn from a vein (though formal blood work should be obtained to ensure accuracy).
Blood Products
In resuscitating a trauma patient, four simultaneous objectives are pursued: improve blood pressure to reverse or reduce hypoperfusion of tissues, maintain oxygen delivery to tissues, reduce or halt ongoing blood loss, and avoid coagulopathy. Transfusing blood products with different physiologic properties is the best way to accomplish all of these objectives.
Packed Red Blood Cells
Red blood cells are responsible for oxygen delivery, so transfusing them in traumatic patients is logical. However, as they have no hemostatic properties (will not enhance coagulation) transfusing them alone is insufficient, as they will not prevent further blood loss. Transfusion of packed red blood cells (PRBCs) will also improve the volume status of the patient, raising blood pressure and improving hypoperfusion; however, this increased hydrostatic pressure at the site of injured tissue could increase the rate of blood loss.
There are four major blood types: A, B, AB, and O. When transfusing PRBCs, it is important to administer compatible blood. If incompatible blood is administered, the patient could have a severe transfusion reaction leading to shock and kidney damage. Patients with blood type A, AB, and B must be given either their blood type or type O, which is known as the “universal donor.” It takes the blood bank some time to determine the patient’s blood type and perform a crossmatch, by which the donor blood of the patient’s blood type is mixed with the patient’s blood to confirm their compatibility. In the meantime, the clinician has two alternatives to obtain blood rapidly for unstable patients. The first is to administer type O blood, and the second is to administer type-specific blood without having done the crossmatch.
This process is further complicated by the additional need to determine the presence of the Rh factor, another genetically determined protein located on the outside of red cells that influences the compatibility of blood to be used for transfusion. Rh-negative blood is safe to administer to both Rh-negative and Rh-positive patients, so it should be safe to administer type O, Rh-negative blood to any patient without knowing their blood type in advance.
Fresh Frozen Plasma
Trauma patients who are bleeding will deplete their own plasma proteins that are needed to form clots in damaged blood vessels. Fresh frozen plasma (FFP) is a product that, when administered, will replace the patient’s own procoagulant proteins that are depleted by the trauma. FFP is separated from whole blood and stored frozen in units of 200 to 250 mL. FFP requires time to defrost before use, so providers must notify the blood bank early if they anticipate needing it. Some facilities (particularly trauma centers) will keep a small amount of FFP defrosted and ready for use at all times.
Platelets
Platelets are the cellular components of blood that are responsible for triggering the coagulation cascade by adhering to the lining of damaged blood vessels and clumping together, forming a clot. They are generally pooled from multiple donors and concentrated into a unit of platelets, which will raise the patient’s platelet count by roughly 50,000/μL.
Transfusion Protocols
The ratios of blood products given in trauma resuscitation has been long debated, but currently a 1:1:1 ratio of PRBCs, FFP, and platelets is most commonly used. There is growing interest in the use of whole blood in the resuscitation of trauma patients, as it would seem to be the ideal resuscitative product in terms of addressing physiologic derangements.
Massive transfusion is generally defined as more than 10 units of PRBCs in the first 24 hours, but protocols for how the blood products are released, in what ratios, and under what circumstances are institution specific. It is important to obtain samples for crossmatching prior to initiating massive transfusion, as it will be difficult to perform the test on samples drawn after the patient has received large volumes of donor blood.
Tourniquet
A tourniquet is an external hemorrhage control device that obtains hemostasis by applying circumferential compressive force proximal to the wound. By applying enough force to halt blood flow to the injured area, the tourniquet prevents further blood loss from the wound. Although they are often thought of as prehospital/EMS devices, tourniquets are frequently used in the OR during limb surgeries in order to maintain a bloodless surgical field. Because they can be applied quickly and easily (in some cases with one hand) and can improve the survival of bleeding patients, they are an invaluable tool in the care of trauma patients. Commercially available combat-style tourniquets are now commonly used in urban trauma centers ( Fig. 20.1 ), and instructions for their specific application should be consulted before use.
