The Trauma Bay
Guidebook
A work product by the staff of
the Vanderbilt Adult
Emergency Department
Kevin High/Editor
This guidebook is intended to act as a resource for any and everyone that
functions as a practitioner in the trauma bays of the Vanderbilt Adult
Emergency Department.
This guidebook contains policies, procedures and BMP’s (best management
practices). It is thorough but not all inclusive and should not supersede sound
clinical judgment.
The guidebook is a work in progress and will be amended as needed by the
Trauma Program Manager, Emergency Department management and staff.
This document is a work product of the leadership/administration of Vanderbilt’s Adult
Emergency Department and TWIG (the Trauma Working Interest Group)
Authored/Approved 2011
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Core Requisites for Staff Assigned to the Trauma Bays in the Vanderbilt Adult
Emergency Department
Introduction
The purpose of this document is to clarify and outline the core requisites for being assigned as a PCT, Primary
Nurse or Secondary Nurse or Paramedic to the Trauma Bay assignment within the Adult Emergency
Department (ED).
Vanderbilt Adult ED is a Level I Trauma Center and sees ~2400 Level I trauma patients per year. Each Level I
patient receives a templated response from a team of 10+ individuals within the Vanderbilt system. This team
is composed of physicians, nurses, respiratory techs, paramedics, PCT’s, radiology techs, service center
personnel and social workers.
The following pertains to individuals functioning as a PCT, Primary Nurse and Secondary Nurse/Paramedic.
Discussion
The staff assigned to the aforementioned roles are done so by the charge nurse on duty. Staff have completed an
orientation to the trauma bays and each of the respective roles prior to being assigned.
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Each staff member has a specific role and duties during a trauma including a position at the bedside (see above
image)
Introduction/Initial Orientation
Each role has a different set of requirements and orientation standards; each of these will be covered.
Patient Care Tech (PCT)
Each PCT must successfully complete their respective core ED orientation before working in the Trauma Bays.
The requirements to work as a PCT within the Adult ED is to successfully complete the ED PCT orientation;
special attention focusing blood/lab specimen collection, handling of belongings and chest tube set up.
Paramedics
Individuals working in the paramedic role within the Adult ED work in the secondary role; they must complete
their core ED orientation prior to being independently assigned to work in the trauma bays. The requirements
to work as a paramedic within the Adult ED are one year experience, current ACLS, PALS, ITLS/PHTLS, BLS
and have passed the basic arrhythmia test.
Registered Nurses
Registered Nurses working in the trauma bay may function in the primary or secondary role; they must
complete their core ED orientation and a specific orientation to the trauma bays prior to being independently
assigned to work in the trauma bays. The requirements to work as a nurse within the Adult ED are one year
experience, current ACLS, PALS, TNCC, BLS and have passed the basic arrhythmia (BA) test.
PCT’s
Complete
standard ED
orientation
Graduate
Nurses
Complete standard ED
orientation
ACLS, TNCC, PALS,
CPR, BA current
May orient to Trauma
after 1 year from date of
successful completion of
ED orientation
Must have completed
orientation to Triage!
Experienced
Nurses
Complete standard ED
orientation
ACLS, TNCC, PALS,
CPR, BA current
May orient to Trauma
after 6 months year
from date of successful
completion of ED
orientation
Must have completed
orientation to Triage!
Paramedics
Complete
standard ED
orientation;
(trauma
orientation runs
concurrently)
ACLS, ITLS or
PHTLS, PALS,
CPR, BA current
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Working in the Trauma Bay
RNs and Paramedics must maintain annual competencies, maintain certifications and be oriented to the
triage role.
During the Shift
The primary nurse is responsible for performing the daily room checklists and confirming that the room(s) they
are assigned to are stocked. Checklists are provided for the assigned nurse to utilize in checking the room.
The checklists consist of:
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Large Trauma Bay Cabinet
Basic Mayo Stand Set Up x 2
Overall Room Checklist
Emergency Box Checklist (T2)
Difficult Airway Cart Checklist (T2 and T3)
In addition to checking assigned rooms the nurse shall perform the following tasks as needed during the shift:
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Check utility room for laryngoscopes (require cleaning or soaking) put them in service if possible
Update dry erase board outside bays with staff names and roles
Check utility room for dirty instrument trays; if present; notify and assure they are picked up by service
center
Check warmer; ample supply of blankets? IV fluids?
Check each trauma bay for errant sharps and medications; dispose of properly
Check hall for obstructions (chairs, carts, etc) make sure it is unobstructed
Round on triage and other A pod areas; assist staff as needed.
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Requirements/Components for Orientation to the Trauma Bays in the
Vanderbilt Adult Emergency Department
Introduction
The purpose of this document is to clarify and outline the orientation requirements for the
following disciplines undergoing trauma orientation. These individuals consist of the
following; Patient Care Techs (PCT), Registered Nurses (Primary Nurse or Secondary Nurse)
and Paramedics. This orientation is to be complete prior to assuming a Trauma Bay
assignment within the Adult Emergency Department (ED).
Vanderbilt Adult ED is a Level I Trauma Center and sees ~2400 Level I trauma patients per year.
Each Level I patient receives a templated response from a team of 10+ individuals within the
Vanderbilt system. This team is composed of physicians, nurses, respiratory techs, paramedics,
PCT’s, radiology techs, service center personnel and social workers.
The following pertains to individuals functioning as a PCT, Primary Nurse and Secondary
Nurse/Paramedic.
Patient Care Tech
Complete standard ED orientation and have a minimum of three (3) Level I patient contacts.
Paramedics
Complete standard ED paramedic orientation; must have 12 Level I patient contacts in the
secondary role.
Registered Nurses
Complete standard ED orientation; must have 20 Level I patient contacts as follows: 2 as scribe;
6 as secondary and 12 as primary.
Note: the emphasis is less on hours worked and more on patient contacts. Each orientee
should document patient contacts (patient name/stat name and MR number) in their Trauma
101 checklist/worksheet.
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Orientation Content
•
Spine Immobilization
•
Rapid Sequence Intubation (RSI)
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Blood Products
•
Medication Administration
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Equipment Knowledge/Setup
– Fluid warmer/ rapid infuser
– Bair Hugger
– Thoracotomy Set Up
– Pelvic Binders
– Central Line Placement – subclavians and femorals
– Diagnostic Peritoneal Lavage – DPL
– Burn Sheets
– Pleurovac set up
– Escharotomy Procedure
•
Equipment Knowledge/Setup
– Storz set up
– EZ I/O insertion
– internal paddle trays
These are core orientation points
and each item should be covered
in orientation by the orientee and
the preceptor/supervising
clinician.
– hole in the heart kit
– chest tube set up
– Art line set up
– Tracheostomy set up
– Cricothyrotomy set up
– DPL set up
– Hare Splint
•
Zoll Set Up/Troubleshooting
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Difficult Airway Situations/Equipment
•
Ultrasound
•
Review Foley Catheter: Do/Don’ts
•
Review NG/OG Tubes: Do/Don’ts
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Trauma Bay Nurse’s Five Critical Daily
Actions
Check utility room for laryngoscopes (require
cleaning or soaking) put them in service if possible
Check utility room for dirty instrument trays; if
present; notify and assure they are picked up by
service center
Check warmer; ample supply of blankets? IV
fluids?
Check each trauma bay for errant sharps and
medications; dispose of properly
Check hall for obstructions (chairs, carts, etc)
make sure it is unobstructed
Assigned to the trauma bays?
Are you feeling bored or under
stimulated? Complete each of the
above at least once during your
shift!
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Trauma Bay Staff
Positions/Roles
Respiratory Tech
 Assists with Airway Mgt
 Accompanies Patient
EM Resident
 Performs Airway Mgt
 Controls C-spine
 HEENT Exam
EM Attending
 Supervises Airway Mgt
Primary RN
 Room Prep
 Connect Monitors
 Assist with Procedures
Secondary RN or EMT-P
 Obtain Manual BP
 Assist with Procedures
 Accompany Patient
Trauma Junior
 Performs Secondary
Exam
 Performs Procedures
PCT
 Room Prep
 Labs/Belongings
Trauma Senior/R4
 Acts as Trauma Team
Leader
 Oversees Resuscitation
Trauma Attending
 Assists/Oversees Resuscitation
Scribe RN
 Documents Resuscitation
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Ancillary Personnel
Ancillary personnel are involved in the resuscitation with limited or no direct patient contact.
 Radiology Technician-takes and develops plain films as directed by the trauma team leader (must wear
PPE)
 Medical Student-tasks as assigned by the by the trauma team leader (must wear PPE)
 Service Center Personnel-room prep and equipment management as directed
 Social Worker-gathers information; assists with patient and family needs
 ED Registrar-gathers demographic information
 Environmental Services-room prep and clean up
Trauma Resuscitation Team Personnel: Detailed Description of Responsibilities
Trauma Team-Leader-the senior (PGY-4) Surgical Resident serves as the trauma team leader and directs the
overall resuscitation. The TTL initiates the resuscitation and assumes responsibility for life saving procedures
such as assisting with procedures including surgical airway, emergent chest tube placement, and ED
thoracotomy. The TTL is responsible for the majority of communication during the resuscitation.
Trauma Attending or Fellow-the Trauma Attending or Fellow assumes the overall responsibility for the
resuscitation and for supervising the Trauma Team
Leader. If the Trauma Attending or Fellow is not present, the ED Attending will
assume this role and responsibility. The Trauma Attending/Fellow is the designated trauma triage officer
responsible for directing flow of patients to the OR, CT and ICU. It is imperative that the Trauma
Attending/Fellow be in close communication with the Trauma Unit Charge Nurse for bed allocation and
availability.
Primary EM Resident– an Emergency Medicine Resident will perform the primary
survey and also complete the neurological/HEENT part of the secondary survey. The EM Resident will
perform airway procedures and will be supervised by the EM Attending. The EM resident may also be tasked
with insertion of a gastric tube and controlling bleeding from head/scalp lacerations.
ED Attending– is responsible for the airway and supervising the Primary EM Resident. In the absence of the
Trauma Attending/Fellow the ED Attending will have overall responsibility for supervising the TTL and the
resuscitation as a whole. The EDA is also responsible for all
ED staffing, equipment and triage into the ED. The EDA may also assume the
role of TTL during the resuscitation of multiple patients.
Trauma Junior-a Surgery or Emergency Medicine R2 that performs the secondary survey with the exception of
the airway/HEENT portion. This individual performs the rectal exam and other procedures as directed by the
TTL.
Respiratory Therapist-responsible for placing patient on high flow oxygen via mask/or ventilating the patient
via ambu bag as directed by the Primary EM resident. The RT will accompany the patient to the Trauma Unit
and/or CT scan.
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Primary Nurse-this role is filled by a RN who places monitoring devices (ECG, Sa02, NIPBP on the patient
after the move from the EMS stretcher. The PN will also assure that there is a functioning IV in place and if not
initiate one; the PN may be tasked with blood draw, administering drugs, log rolling the patient and packaging
the patient for transport. The PN is also responsible for room stocking.
Secondary Nurse or Paramedic – The SN or PM will obtain the first manual blood pressure from the left arm
and call it out for the TTL and team to hear.
This person has the responsibility for coordinating transport outside the trauma bay; at times the secondary
person may be accompanied by other ED staff.
Scribe Nurse (Scribe) The scribe nurse is primarily responsible for keeping a written record of the
resuscitation (the trauma flow sheet) and for coordinating the retrieval of equipment and item requested by the
trauma team. (blood products, drugs, etc.) The scribe also initiates videotaping, acts as a conduit for
information to the Trauma Unit, OR and assists in crowd control.
Patient Care Technician/PCT - The PCT’s primary responsibilities are to ensure that blood is sent for
appropriate tests, placing patient on secondary monitor, sorting and performing an inventory of belongings,
assisting with transportation and equipment set up.
Ancillary Personnel
Radiology Technicians (RT) - The RT should be present at all trauma
resuscitations and be prepared to perform the standard chest x-ray and pelvis xray
as directed by the Trauma Team Leader.
ED Social Worker-the ED Social Worker assists as directed by the TTL, Trauma/ED Attending.
Trauma Nurse Practitioner(TNP)- The TNP will be available to assist with
trauma resuscitations at night and occasionally during the day depending on the
acuity and volume of the TNP service.
Medical Student (MS)- The role of the MS is commensurate with their abilities
as determined by the trauma service. The MS will be assigned tasks by either the
TTL.
Service Center Personnel -one staff member should remain in the bay to bring additional supplies
needed for the resuscitation.
ED Registration Personnel- one ED registration person may be present in the bay to gain demographic
information. At no time should the gathering of said information interrupt any part of the resuscitation.
Registration personnel are not allowed at the patient's bedside during the resuscitation
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Highly Successful Habits and Qualities of a Trauma Bay Practitioner
The following outlines a few of the habits and qualities of someone that is an exceptional trauma team
member.
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They are competent: they know their role, the do’s and don’ts and follow them
They communicate well; they are assertive and not aggressive
They have an in-depth knowledge base of the room, the trauma system and process
They pay attention to detail
They have a good work ethic and are adaptable
They work hard at everything; not just taking care of Level I patients
They anticipate the team’s and the patient’s needs and work to be a step ahead
Critical Actions for Primary/Secondary Team Members
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Ensure/call for a prebrief
Have scissors, stethoscope within reach
Observe noise discipline; minimize talking during critical procedures; especially airway interventions
Communicate well with primary or secondary; specifically on drug dosages and administration
Verbally repeat/crosscheck orders for clarification
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The following is a compilation of best management practices (BMP's) put forth by the TWIG group
outlining practices and actions that optimize patient care and flow in the trauma bay.
Primary
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Reduce clutter; both visibly and in cabinets
Have all RSI drugs in room, including "T pack" and Vecuronium (Succinylcholine, Rocuronium,
Etomidate, Lidocaine, Epi, Atropine and anticipated antibiotics
Confirm there are three suction set ups available and ready
Retrieve the Storz Blades (both #3 and 4) from T-3 cabinet
Place monitors
Responsible for completing chart
Right arm IV –is it adequate?
Obtain a temperature on the patient prior to departure from the bay
Verbally repeat orders for clarification
Remove straps from board
Ultrasound machine in room?
Administer drugs as ordered
Ensure blood for labs is drawn and given to PCT
Call out vitals for the room and for the camera, if conditions warrant
OG/NG post-intubation (make sure have it ready always tucked in at bottom of Phillips monitor)
Make sure Foley gets placed for burn patients
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Secondary RN or Paramedic
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Have manual BP cuffs set up and ready; at least one of each size
Remove straps from board
OGT with syringe/lube in reach?
Ultrasound machine in room?
Start IV if needed
Ensure blood for labs is drawn and given to PCT
Have tetanus in room, give if ordered
Obtain blood for labwork
Document well; especially events outside trauma bay (CT scan, OR, etc)
Give drugs as ordered
If meds from Pyxis needed (e.g. Ancef, Gent), get those (if able to leave room)
OG/NG post-intubation
If EMT-P (and staffing permits), transport pt to CT
PCT
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Have glucometer in room
Place Pt ID/Armband-verbally announce with location of armband placement
Blue card and sticker on Zoll
Have stickers ready at "PCT cart"
Warm blankets in room
Remove clothes and jewelry
Place Zoll monitor at end of bed
Attach monitor to patient
Complete property record after patient care is completed
Place blood in tubes and send to lab
Confirm that an O2 tank is on the bed and is full
Assist with equipment set up (chest tube set up, etc)
Expose patient
Remove straps from board
Drop box valuable items
Confirm patient’s clothing is placed under stretcher prior to transport
Assist with splinting extremities
Send labs--including type/screen--and click off labs in Wiz
Get urine from Foley, if already in place
Do property record, , drop valuables
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Scribe
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Confirm that blood administration paperwork is done correctly
Ensure that order sheet is signed by the physician and that the orders are correctly documented
Complete the chart quickly and in a timely manner
Make sure the chart is given to the staff member accompanying the patient to the unit, OR or CT
scanner
Confirm that blood was drawn and sent to lab
Do triage, opening note narrative
Make sure medication times are documented well
Ensure blue card is taped to Zoll monitor
Make sure pre-brief done
Have chart in room before pt arrival
Hit "record" just prior to patient entering room
Assist in getting additional meds (e.g. Ancef, Gent) from Accudose
Get uncrossmatched blood from blood fridge if ordered, or delegate getting from fridge--check off blood
with another licensed staff member
Make sure curtains closed
Sign EMS run ticket
Be assertive; don’t be afraid to speak up; monitor noise discipline
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Safety and Noise Discipline in the
Trauma Bay
The issue of patient safety during the trauma resuscitation process is paramount. Medical error can oftent be
directly related to human factors issues and poor communication. The use of aviation crew resource
management (CRM) techniques are ideal for addressing these issues.
Core CRM actions include but are not limited to:
 Conducting a pre-brief prior to patient arrival that includes team member introduction, summary of
known patient information and plan of care.
 A "time out" prior to procedures; including patient identification, procedure clarity, equipment and staff
available.
 Maintenance of noise discipline; especially during procedures. Minimizing uneccessary talking, pager,
radio and phone tones.
 Constant clarification of patient's condition, plan of care and next steps.
Noise/Crowd Control
The FAA regulations are clear on noise discipline; referred to as the “Sterile Cockpit Concept*”
During critical phases of flight (ground taxi, takeoff, landing and flight below 10K ft) no crew member shall
permit activity that will distract crew from performance of duty; including talking and extraneous noise.
*FAR 121.542 and 135.100/Federal Aviation Administration
Maintaining noise discipline during the resuscitation and especially during critical phases (procedures, etc) is
critical and a concept that we adhere to as a team. This aviation practice has a practical place in healthcare.
Staff/Personal Safety
 Everyone in the "blue square" area must wear PPE. Lead aprons are also available in each room.
 If you use a sharp; you own it. Dispose of your sharps; maintain a high level of situational awareness
with regards to sharps.
 Each patient should receive a "threat assessment" upon entering the bay. Any chemicals, hazardous
materials, weapons, etc should be noted, announced to the group and dealt with.
 Any and everyone involved in the trauma resuscitation process is empowered to speak when and if
there is a ongoing or past issue or event that compromises patient or team safety.
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Special Situations Tips/Tricks and Pearls
Prearrival
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Listen to EMS radio report if possible; it can assist you in preplanning
Confirm ultrasound machine in room
Have party pack/intubation drugs on hand; even if patient is already intubated by EMS
Arrival
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Keep in mind the airway physician coordinates the move; not EMS
Remind EMS to drop rail and not stand between the beds
Airway/Intubation
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If pushing drugs, verbally confirm order with physician
Do not push until you ask and physician confirms that they are ready
DO NOT push drugs in the arm where an NIBP cuff is attached/located
ALWAYS sedative first; then paralytic
Know appropriate doses of each; be careful not to underdose paralytic
Consider half or one third dose of etomidate in hemodynamically unstable patient
Etomidate burns on injection; warn the patient
Make sure the patient is on both cardiac monitor and pulse ox prior to pushing drugs
Do not perform selleck maneuver or cricoid pressure unless ordered by a physician
DO perform "lip traction" (pull out cheek on patient's right) to provide intubator more room
Maintain noise discipline during the procedure; don't announce vital signs or ask unnecessary questions
Monitoring/Obtaining Blood Pressure
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When applying monitor electrodes try not to put them on sites where a chest tube or subclavian line
my need to be placed later
Quickly obtain manual blood pressure; the entire resuscitation momentum hinges on it
If unable to hear/auscultate blood pressure after one attempt state "I'm unable to auscultate a BP; will
attempt to palpate one"
Palpate the blood pressure; if it is measurable announce it to the room
If palpated blood pressure is not measurable state "I'm unable to palpate a blood pressure" state
whether or not there is a radial pulse present
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DO not use any of the following verbiage to describe your attempt
"I can't get one" or "I don't hear anything"
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Announce your findings clearly and loudly to the room
Anticipated Actions/Procedures/Equipment
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Any patient with long bone injuries will require splinting; have the disposable yellow splints and/or
hare splints in the room
With any patient with penetrating thoracoabdominal trauma you should have the thoracotomy set up
out on Mayo stands. (thoracotomy tray, internal paddles, finochetto retractor)
Transport to the OR
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Must be done by both RN and Paramedic-no exceptions
SBAR handoff on blood products to Anesthesia MD
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Trauma Bay Daily/Shift Checklist
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Suction set up
Oxygen tank
IV NS Setup (time, date, blue cap & pressure bag)
Cardiac monitor (leads/electrodes)
Ambu Bag (BVM)
Airway box
o EtC02 detector
o Stylets (peds/adult)
o Blades (peds/adult)
o Handles
IV Carts
Mayo stands (3)
o One (1) Empty
o One (1) with Chest Tube Set-Up
o One (1) with Central Line Set-Up
ED Stretcher (w/ functioning IV pole)
Zoll Monitor (w/ cables & battery)
Storz Device
If you are a nurse assigned to a
Manual BP set ups
bay or bay(s) you are responsible
for checking the equipment and
Thermometer
items on this list and maintaining
IV Pump
an acceptable supply of each
Warm fluids
during your shift.
You may use service center staff
Level I infuser
to augment/supplement stocking
Bair Hugger with blanket
but you are responsible for
assuring that the room is
Oxygen Cylinder
stocked.
Hare Traction Splints Available?
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Mayo Stand Set Up for
Chest Tube
Contents
 Chest tube tray
 Sterile Gloves (assorted sizes)
 #10 blade scalpel
 Suture 2 and 0 silk
 Fluffs (2)
 OR/blue towel pack (2)
 36fr chest tube
 Chlorhexidine
 3" tape
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Mayo Stand Set Up for
Incoming Level I Patient
There should be a minimum of
three (3) Mayo stands in the
room prior to patient arrival.
One should contain a central line
set-up, one a chest tube set-up
and the other should be empty.
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Mayo Stand Set Up for Central Line
Contents
 Central line/Cordis kit
 Sterile Gloves (assorted sizes)
 Suture 0 silk
 Fluffs (1)
 OR/blue towel pack (2)
 Chlorhexidine
 3" tape
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Resources
www.vanderbilttraumabay.com
www.vanderbiltem.com
www.traumaburn.com
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