Stretcher enters room.
The Trauma Chief announces: “Patient is coming. Everyone quiet in the room. Hello EMS. What was your last BP? Thank you, we will check ABCs and get report in a few moments. We’ll let you know.”
All personnel work to clear the patient and stretcher from attachments.
Phase 1: “Quick ABCs and Move”
Quick ABCs while EMS is untangling (do not delay move to the ER bed)—should take less than 1 minute!
1. Airway:
a. Unintubated—Blue junior asks the patient to say their name, quickly calls out “airway patent” or “airway may not be patent”
b. Intubated—Trauma junior confirms “ETT in place”
2. Breathing
a. Blue junior listens to lung fields and reports “Equal bilateral breath sounds” or “Breath Sounds diminished on the –side.”
3. Circulation
a. Blue Junior feels for a distal pulse or next closest palpable pulse: “Good radial pulse” or “Thready femoral pulse.”
Move over to the ER bed.
1. 1-2-3 called by Blue Junior asking if all clear to move
2. ETT is disconnected from any ambu device
3. Pt moved on the hard backboard
Phase 2: “Repeat Primary Survey”
Reevaluate/Detailed Primary Survey:--should take less than 3 minutes!
1. Airway
a. Intubated pts:
i. RT Connect the free ETT to an Easy Cap Co2 detector immediately then bags the patient reporting “Good color change”
ii. RT then removes the Easy Cap and places an inline Co2 detector for the telemetry
b. Pt needing Intubation
i. Blue Junior assesses need for intubation and may ask the ER resident present to perform the procedure.
ii. The entire room will have silence or clear read-backs during the RSI.
iii. Have a Easy Cap and inline CO2 available.
iv. RN confirm the IV patency for RSI medication delivery
v. RN ensures pulseox and IV contralateral to the BP cuff.
2. Breathing
a. Blue Junior Listening to both lung fields reports “Equal bilateral breath sounds confirmed”
3. Circulation
a. Blue junior reports skin color and condition.
b. Blue junior reports carotid and radial pulse exam.
c. Blue junior reports any obvious bleeding.
d. Assure adequate vascular access (2 large bore for patients with signs of shock).
4. Disability
a. Blue Junior evaluates GCS and pupils and report aloud.
Phase 3: “Xrays/FAST/Report”
The Trauma Chief Resident calls out the next sequence: “Let’s move to Xray/FAST/Report”
EMS Report
1. The Trauma Chief may bypass the need for a manual BP and proceed directly to the EMS report if the patient is obviously stable and talking.
2. The Trauma Chief will direct the room “Everyone quiet. Let’s all listen to the Report.”
3. At the conclusion of the report, the Trauma Chief will ask “Any other questions for EMS?”
CXR
1. The CXR/PXR can be performed while the Report is given again with all quiet in the room.
2. The patient may stay on the backboard for these images.
3. The XRay tech will back the machine away from the patient to the back of the room for physician evaluation of the digital images.
FAST
1. The Trauma Junior may perform the FAST while Report is given again with all quiet in the room.
2. At the end of Report and at the completion of the FAST, the trauma junior will announce findings “FAST negative” or “Positive RUQ”
3. If the FAST is positive during Report, the junior will leave the FAST machine available for chief/attending viewing of the positive windows.
4. The images will be saved to the machine and uploaded
Phase 4: “Secondary Survey: Exam, Roll, Board ”
Secondary Survey:
1. The Trauma Junior performs the head-to-toe exam anteriorly and calls out normal and abnormal findings including limb ROM. See musculoskeletal exam here: http://www.youtube.com/watch?v=3lwHmxgmIGE
2. The Trauma Junior/Chief resident calls out need for future xrays: “Order a Hand and Wrist Xray” for the deformity described above.
3. Turn the patient to the Left with 2-person nurse logroll and 1-person cspine hold
a. The Trauma Junior performs a posterior exam including rectal exam calling out normal and abnormal findings.
b. Patient clothing is pushed under the patient
c. New warm sheets are applied
d. The backboard is removed
4. Turn the patient to the Right without the junior moving and still holding cspine
a. The nurses on the patient’s left evaluate the remainder of the posterior surface and call out normal and abnormal findings including axilla.
b. The patient’s clothing is now pulled out
c. Any foreign debris such as glass is suctioned from the bed
5. Blue Chief summarizes injuries, dictates necessary imaging/ procedures/ consultants
Phase 5: “Blood/Foley/OGT/Procedures”
1. The Trauma nurse obtains blood from a femoral puncture
2. The Trauma nurse places the Foley catheter under sterile conditions
3. The Trauma nurse places an OGT for intubated patients with auscultation confirmation and attachment to suction
4. New Ccollars are placed if necessary
5. The Trauma juniors perform extremity splinting, wound wrapping, scalp stapling if necessary
Phase 6: “Trauma Scan”
The patient is placed on a Zoll monitor vs Telemetry “brick” for transport to CT scan
The CT scan is held for Trauma Reds
The Trauma Chief confirms the orders for scans (+/- CTA head/neck)
The Trauma Nurse confirms IV patency in the CT room with the CT tech
The Trauma Team debriefs about the Trauma Red in the viewing room
The Trauma Junior places admission orders and calls stat consults in the viewing room
The Trauma Junior takes the “pinks” from the recording intern.
Phase 7: “Xrays”
The patient is moved from the CT scan bed to the Xray bed in the CT room
The patient is transported across the hall
All xrays are performed unless: the patient is unstable or proceeding to the OR.
Phase 8: “Transfer to ICU Bed”
The appropriate bed is obtained for the patient while in CT or Xray: traction vs acute care bed
The patient is placed on the appropriate bed after Xrays then moved to the designated trauma bed as confirmed with the Trauma Chief resident and Trauma Charge Nurse.
A trauma junior or higher must accompany the Trauma Red to the ICU or OR.
A trauma junior or higher must accompany the Trauma Red throughout Phase 1-8.
Any deteriorations in patient condition should be reported to the Trauma Attending/Chief immediately if not present.
Caveats:
If the chief needs to perform an urgernt procedure during phases 1-5, the chief needs to find a new “Trauma Team Leader” to take over resuscitation.
The chief may need to deviate from the above outline for unstable penetrating injuries for example and will advise the team of any changes.
We would like all traumas (Red or Alert) to function the same with Phases 1-5. For the Reds and Codes, the Blue Residents will resuscitate as above. For the Alerts, the ER Residents will resuscitate as above.
