Theda Clark Medical Center
Trauma Guidelines
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OPERATIONAL GUIDELINES: RESUSCITATION ROLE ASSIGNMENTS
OBJECTIVES:
1.
2.
To define the roles of the members of the Trauma Team during a trauma resuscitation.
To provide optimal patient care by defining specific responsibilities for each member of the Trauma Team.
GUIDELINES:
To provide optimal patient care by defining the roles/job specific responsibilities for each member of the trauma team.
Each team member should understand his/her responsibilities so that when the patient arrives, the evaluation,
stabilization, and treatment can be done in an efficient and timely manner. Multiple tasks may need to be completed on
the trauma patient simultaneously. Flexibility and communication are very important.
1.
TRAUMA BLUE
a.
Trauma Surgeon/Team Captain
i.
Responsibilities
1)
Has ultimate responsibility and directs resuscitation and management of the injured patient
throughout entire hospital stay or until transfer of responsibility is effected.
2)
Ensures the appropriate and complete participation of all trauma team members, according to
defined roles and established guidelines.
3)
Documents resuscitative events occurring under his/her direction on the chart or the resuscitation
form for physicians and on the death certificate as appropriate.
4)
Participates in the instruction and education of all trauma team members.
5)
Ensures that the patient is expeditiously moved from the Emergency Department to Surgery for
definitive care or to the appropriate inpatient location for further consults, diagnostic procedures
and stabilization.
6)
Coordinates call in of back-up surgeon in the event he is in surgery when another trauma patient
arrives.
7)
Ensures the anesthesiologist on call has been made aware of injuries and need for surgery.
ii.
Management upon arrival
1)
Receives verbal report directly from ambulance or helicopter personnel.
2)
Performs primary and secondary survey:
(a) Primary assessment of airway, breathing and circulation
(b) Performs surgical airway as needed.
(c) Directs diagnostic and treatment priorities.
(d) Assesses the status and techniques of fluid resuscitation and directs volume resuscitation.
(e) Directs cardiopulmonary resuscitation in the event of a patient in full arrest.
(f)
Ensures stabilization of the cervical spine as indicated.
(g) Designates team composition and roles in the event of simultaneous multiple victim arrival.
Determines the need to activate back-up trauma surgeon.
(h) Performs surgical procedures such as cricothyrotomy, open thoracotomy,
pericardiocentesis, tube thoracostomy, central line placement, arterial line placement, etc.
as needed.
(i)
FAST exam as needed.
(j)
Obtains blood specimens as necessary and orders lab tests according to established
protocols.
(k) Decides on the amount of blood and kind (O negative, type specific, etc.) needed.
(l)
Orders NG tube according to established protocols.
(m) Orders foley catheter according to established protocols.
(n) Orders and examines x-rays according to patient needs. Decides on need for further xrays.
(o) Orientates patient to environment and procedures on an ongoing basis.
(p) Records all pertinent information in patient’s chart.
(q) Categorizes the injuries.
(r)
Orders emergent consults and other consults as needed.
(s) Decides on disposition of the patient.
(t)
Talks with the family.
(u) Discusses patient needs with OR and anesthesia if going for an operative procedure.
3)
Supervises:
(a) Tamponade of external hemorrhage by designated team member.
(b) Intravenous access procedures, including peripheral and central lines.
(c) Appropriate exposure of patient.
(d) Operation of equipment used.
4)
Assists other team members, as needed, to perform their designated tasks.
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b.
c.
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Emergency Department Physician
i.
Responsibilities
1)
May take initial phone call from referring hospital physician and initiate Trauma Blue protocols,
dispatch EMS/Theda Star.
2)
Assists Trauma surgeon in procedures and is accountable to Trauma Surgeon/Team Captain.
3)
Makes himself/herself immediately available when the trauma patient arrives in the Emergency
Department.
4)
Supervises care of the trauma patient until patient care is turned over to the Trauma
Surgeon/Team Captain.
5)
Assigns on-call Emergency Physician as necessary.
6)
Anesthesia – appraises of situation and need.
7)
Gives complete verbal report, including assessment and completed and/or ordered procedures to
the Trauma Surgeon/Team Captain or other consultants on arrival.
8)
Runs ACLS codes.
ii.
Patient Management Objectives at the discretion of Trauma Surgeon/Team Captain
1)
Assesses, protects, and secures airway, including intubation or cricothyrotomy while maintaining
neck from injury. Recommends medications for rapid sequence intubation (RSI).
If not already done:
2)
Establishes vascular access as necessary and orders IV fluids.
3)
Obtains blood specimens as necessary and orders lab tests according to established protocols.
4)
Determines need for uncrossmatched blood and signs forms.
5)
Performs needle and/or tube thoracostomy as necesary.
6)
Performs thoracotomy only as indicated.
7)
Performs pericardiocentesis as necessary.
8)
Orders NG tube according to established protocols.
9)
Orders foley catheter according to established protocols.
10) Orders and examines x-rays according to patient needs. Decides on need for further x-rays.
11) Orientates patient to environment and procedures on an outgoing basis.
12) Assists Trauma Surgeon/Team Captain in performance of procedures as requested.
13) Records all pertinent information in patient’s chart.
iii.
Exceptions to the Above Criteria
1)
Other critically ill patients needing attention at the same time will become the responsibility of
the Emergency Department physician.
2)
Direct other critical patient treatment. If circumstances dictate, the Emergency Department
physician will request the resource RN to call in the back-up Emergency Department Physician.
3)
If the assigned Emergency Department Physician for trauma care directly signs out to the On-Call
Emergency Department Physician, this physician will then assume care of the trauma patient.
Emergency Department Nurse Recorder
i.
Patient Management Objectives
1)
Coordinates utilization of trauma packet and assists the registrar with collection of patient data.
2)
Communicates with pre-hospital providers to obtain patient information and prior field treatment
and patient response.
3)
Relays pertinent information to Trauma Captain about patient condition.
4)
Requests Emergency Resource Nurse to place STAT page for absent team members.
5)
Ensures completion of trauma flow sheet and other necessary documentation to include but not
limited to:
(a) Patient’s physiological scores on arrival (obtains additional information as needed to figure
score) and upon discharge from the Emergency Department.
(b) Initial and continues assessment including monitoring VS.
(c) All treatments and procedures rendered and the outcomes of such, including times and
personnel involved.
(d) All fluids and/or medication given and the results.
(e) All diagnostic tests ordered and completed.
(f)
Obtains allergy, tetanus immunization status, current medications and medical history.
6)
Coordinates lab, x-ray, CT, etc.
7)
Releases extra staff from bedside ASAP.
8)
Accepts all blood products from Blood Bank and checks all blood products with Fluid Nurse.
9)
Receives calls and results as required.
10) Maintains communication by providing continuing updates to appropriate personnel, i.e.,
Resource Nurse, Social Worker, etc.
11) Accompanies patient to CT, OR, etc.
12) Assures completion of all procedures. Delegates tasks as required.
13) Obtains room for patient when admitted, if not already done by Resource Nurse. Relays
information to Emergency Department Secretaries for admission papers.
14) Gives report to receiving unit.
15) Reviews all records for completion. Attaches duplicate of trauma chart to remaining ED record,
completed ED charges and then directs completed record to admitting unit.
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d.
e.
f.
g.
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Emergency Department Procedure Nurse/Staff
i.
Patient Management Objectives
1)
Provide care for the trauma patient until the patient is discharged from the Emergency
Department. May need to accompany patient for procedures outside the department.
(a) Orients patient to situation
(b) Directs clothing removal
(c) Assists Trauma Surgeon/Team Captian with primary and secondary assessment as needed.
(d) Initiates/monitors right IV site
(e) Rectal Temperature
(f)
Foley placement after rectal exam and obtain specimen and hemastix
(g) Reports output(s)
(h) Hooks patient to monitors: EKG, NIBP, etc.
(i)
Assists MD with performance of procedures, i.e., chest tubes, peritoneal lavage, line
placement.
(j)
Inserts NG/OB tube. Places/connects OG/NG to suction
(k) Continues ongoing physical assessment and reports findings or changes to MD and
Recorder Nurse/Team leader.
2)
Communicates to Recorder Nurse/Team Leader the completion of all assigned tasks.
3)
Restocks trauma area ASAP.
Emergency Department Fluids Nurse
i.
Responsibilities
1)
Accountable to Team Leader/Recorder
2)
Set up of room to receive Trauma Blue patient
3)
Collaboration with Recorder Nurse/Team Leader to ensure completion of documentation
ii.
Patient Management Objectives
1)
Provide care for the trauma patient until the patient is discharged from the Emergency
Department. May need to accompany patient for procedures outside of the department.
(a) Initiates/monitors left IV site
(b) Monitors fluid status – rate, volume and intake
(c) Administer all medications, including tetanus immunization
(d) Administer all blood products
(e) Check all blood products with Recorder Nurse/Team Leader
(f)
Crash cart responsibilities
(g) Monitors vital signs
(h) Assists procedure nurse as needed
iii.
Communicates to Recorder Nurse/Team Leader the completion of all assigned tasks.
iv.
Restocks trauma area ASAP.
Respiratory Therapist
i.
Responsibilities
1)
Accountable to Trauma Surgeon/Team Captain
2)
Upon patient arrival in the trauma resuscitation area, the RT will:
(a) Assess patient’s respiratory status and assist as needed, i.e., manual bag ventilation of
patient, continue oxygen through NRM, etc.
(b) Listen to patient’s breath sounds initially and repeat in 15 minutes or after a procedure.
(c) Assists with endotrachial intubation
(d) If intubated, will check lip level of tube placement and call to recorder.
(e) Calls initial pulse oximetry and ETCO2 to recorder, 15 minutes after patient arrival.
(f)
Suction as needed.
(g) Draws ABGs if needed.
ii.
Coordinate patient’s care regarding airway and ventilatory management reports.
iii.
Is available to assist with transport of patients requiring ventilatory assistance to CCU or CT, etc.
iv.
Patient Management Objectives
1)
Assist in the initial care of the trauma patient.
2)
Maintains patient airway (maintaining C-spine precautions until C-Spine cleared).
3)
Provides artificial ventilation per ATLS guidelines.
4)
Set up ventilators with appropriate settings when determined by Trauma Surgeon/Team Captain.
NOTE: No trauma patient shall be immediately placed on the ventilator unless cleared by
the Trauma Surgeon/Team Captain.
Laboratory Technician
i.
Responsibilities
1)
Accountable to Nurse Recorder
2)
Assigned on daily basis per shift.
3)
The Lab Tech will draw enough blood on all trauma patients for:
(a) Hgb and hct
(b) Na
(c) K
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h.
i.
j.
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(d) Glucose
(e) BUN
(f)
Creatinine
(g) Amylase
(h) Type/screen or Type/crossmatch for 4 units
(i)
PT
(j)
Urine dip U/A if positive for blood
4)
Additional tests:
(a) Pregnancy – urine on all women of child bearing age
(b) Drug screening
(c) U/A
(d) ABG for intubated patient
(e) Blood alcohol for medical purposes
(f)
Cardiac enzymes with isos if elevated at Trauma Surgeon/Team Captain’s discretion
5)
The phlebotomist is responsible for assuring that the blood specimens get to the lab, labeling
blood tubes, placing Blood Bank armband on patient.
6)
It is the Lab Tech’s responsibility to notify the Lab of the “STAT” status of the blood.
7)
Lab results will be recorded or printed in the Emergency Department or called to the Nurse
Recorder.
Blood Bank Laboratory Technician
Any units issues uncrossmatched will be crossmatched. The Emergency Department Physician will be notified
immediately if any incompatibility is found. Blood Bank will notify the Emergency Department by phone when
crossmatched blood is ready.
i.
Responsibilities
1)
Accountable to lab
2)
Assigned on daily basis per shift
3)
Upon notification by trauma beeper page, the blood bank technologist will ensure that “4” units
of O-negative blood are available. Keep four units on hold at all times for Theda Star and
traumas.
4)
The tech will then await a call from the Emergency Department Resource Nurse, who will inform
them that the blood is needed. The Resource Nurse will give the technologist the patient’s
identification, including BB number and medical record number.
5)
If O-negative/positive blood is needed, the processing will be completed immediately and blood
units placed in designated cooler for transport to trauma resuscitation area.
6)
Blood bank will bring blood to trauma room in a cooler. Emergency Department MD or Trauma
Surgeon/Team Captain will need to sign request/release form.
7)
The trauma physician in charge assumes responsibility for transfusing uncrossmatched blood.
The ordering physician as soon as reasonably possible must sign the Emergency
blood/component request/release form.
8)
Type-specific or type and crossmatched blood will be processed as soon as the blood sample
reaches the blood bank.
9)
Follow massive transfusion protocol. Initiate call to Emergency Department to determine need
for additional blood components as needed, i.e., FFP, plts., cyroprecipitate.
Radiology Technologist
i.
Responsibilities
1)
Accountable to the Recorder Nurse/Team Leader
2)
The technologist will respond to the Emergency Department
3)
Performs X-rays as ordered by the Trauma Surgeon/Team Captain, Emergency Room Physician
and directed by the Trauma Nurse Recorder.
4)
See patient care algorithm
5)
If a contract media is to be used, the radiology technologist will inject the media only if there is a
radiologist present in the department. If there is no radiologist present, the Trauma
Surgeon/Team Captain or Emergency Room Physician will inject the contract media.
ii.
Patient Management Objectives
1)
Notifies Trauma Team prior to shooting each x-ray.
2)
Will maintain the patient in C-spine precautions until Trauma Surgeon/Team Captain has cleared
C-spine.
3)
Movement of trauma patient will be kept to a minimum at all times.
4)
Develops x-rays immediately.
5)
Will immediately hand to Trauma Surgeon/Team Captain all x-rays and will remove x-rays only
upon Trauma Surgeon/Team Captain’s approval.
6)
Assures that all x-rays ordered are completed according to the Trauma Surgeon’s orders. Some
x-rays may be completed in the OR, ICU or floor.
Social Services/Chaplain
i.
Responsibilities
1)
Assists with identifying patient
2)
Contacts patient family
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3)
4)
5)
6)
7)
k.
l.
m.
n.
Keeps appropriate family members informed of patient status.
Coordinates family visits to the bedside with the Nurse Recorder.
Facilitates psychosocial care of patient, family, and visitors.
Supports the grieving process.
Written documentation of time spent with the family, including names and family preesnt and
any important information related in trauma events.
8)
Assists Trauma Recorder by obtaining from family:
(a) Medical history
(b) Last patient meal
(c) Allergies
(d) Current medications
(e) Notification information (next of kin)
(f)
Consent for treatment
(g) Additional pertinent information.
Physiologic Monitor Tech (PMT) – weekends and weeknights only!
i.
Responsibilities
1)
Ensures set up of monitoring equipment
2)
Assist with patient unloading from the helicopter
3)
Sets up necessary monitoring equipment to include monitors, pressure lines, transducers and
catheters.
4)
Assists surgeon with line insertion
5)
Assist with CPR
6)
Assist with transport to other department, i.e., CT Scan, OR.
Pharmacist
i.
Responsibilities
1)
Brings along tackle box with emergency medications
2)
Prepares all medications as ordered by the trauma surgeons and other physicians, including
antibiotics, pressors, and methylprednisolone.
3)
Assists with crash cart during a traumatic arrest
4)
Serves as a source of information for drug interactions, side effects, dosages, etc.
Operating Room Nurse
i.
Patient Management Objectives
1)
The nurse will obtain the following initial information to prepare the surgery suite
(a) Surgeon’s name
(b) Anesthesiologist’s name
(c) Type and extent of injuries
2)
The circulating nurse responsible for the case will receive the patient at the Surgery doors and
obtain the following information from ER:
(a) Total fluids given to patient
(b) Amount and type of blood given
(c) Amount of blood ordered
(d) Any medications given
(e) Pertinent lab results
(f)
Most recent vital signs
(g) C-spine status
Switchboard
i.
Responsibilities (back up to Emergency Paging protocol)
1)
Will dial through the overhead paging system and announce “Trauma Blue ETA _____.”
2)
Call 2114 (Theda Star) to alert flight nurses, if not transported via Theda Star.
3)
Log in code book.
4)
Call security to alert of impending Trauma Blue if arriving via Theda Star.
NOTE: This is just for trauma patients; all previously set protocols stand as is.
2.
Trauma Consult
a.
Emergency Room Physician
i.
Initially evaluates patient according to Advanced Trauma Life Support (ATLS) protocols and TC trauma
protocols.
ii.
Begins diagnostic procedures, including lab, x-rays, CT scan, etc.
iii.
Supervises fluid administration and medication administration
iv.
Consults trauma surgeon to evaluate patient.
b.
Trauma Surgeon
i.
Reviews assessment done by emergency room physician. Completes primary and secondary
assessment as needed.
ii.
Performs procedures dictated by patient condition.
iii.
Admits patients to the hospital
iv.
Ensures all other consulting physicians are notified.
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c.
All other hospital personnel are called as needed including: X-ray, CT Scan, lab, PMT, RT, etc. Each
individual will perform his/her duties as noted in the Trauma Blue section.
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