There are over 2000 trauma calls per year at The Royal London Hospital. After a trauma call is declared a team comprising of the following personnel will be group called to the Emergency Department.
- Team Leader (ED Consultant or SpR)
- ACCU SpR (Anaesthetist or senior ICM trainee)
- General surgical SpR or SHO
- Orthopaedic SpR or SHO
- Neurosurgical SHO – scribe
- ED Nurse 1
- ED Nurse 2
During office hours, trauma calls will also be attended by a Consultant Anaesthetist from the Royal London Trauma Anaesthesia Group (TAG). Their role is to advise on the running of the trauma call, provide guidance, teaching and an extra pair of hands, and to help you do your job. They will expect you to carry out your role as outlined below, but to use them as a resource to help you.
All “advanced” and “code red” trauma calls must be attended promptly by one of the Senior ICM or anaesthetic SpRs. You do not need to attend a simple “adult trauma call”, or any paediatric emergency calls. All of the following anaesthetic bleeps receive trauma calls.
- Bleep 1113
- Bleep 1480
- Bleep 1220
- Bleep 0814
- Bleep 1119
If, at any point, you are unsure or feel that you need help, call an ACCU consultant.
Role of the ACCU doctor:
- In everything you do, work as part of the whole team. Communicate your actions clearly (e.g. “I am giving 50 mcg fentanyl now.”) so that the shared mental model remains accurate.
- Assess breathing and provide ventilatory support as necessary; approximately 30% of patients will already be intubated and ventilated.
- In conjunction with the team leader assess circulation and co-ordinate fluid, blood and blood product replacement.
- Gain large bore peripheral or central venous access.
- Establish intra-arterial blood pressure and central venous pressure monitoring.
- Provide anaesthesia and analgesia.
- Co-ordinate patient transfer in conjunction with team leader.
- Ensure that spinal immobilisation is maintained.
- Inform scribe of all therapeutic interventions undertaken and encourage documentation of vital signs, blood results and other relevant information.
- Discuss need for critical care post resuscitation and advise accordingly.
If the patient is awake
- Take an AMPLE history – Allergies; Medications; PMH; Last ate; Events Leading to…
- Ensure that cervical spine immobilisation is maintained during intubation in all trauma patients at risk of cervical spine injury.
- You may remove the cervical hard collar to allow adequate mouth opening but a suitable assistant must apply manual in-line immobilisation.
- A second assistant will be required to maintain cricoid pressure if this is required.
If the patient is anaesthetised
- Administer 100% oxygen on 10 litres/min via the Bain circuit and ventilate manually until you have quickly examined the chest.
- Then place the patient onto the ventilator after checking the oxygen concentration, inspiratory and expiratory times and the flow rate per second.
- A ventilator alarm should be used. Please check peak airway pressures regularly.
After attaching all appropriate monitoring, including end-tidal CO2 you should consider instituting some form of anaesthesia. There may be volatile agents available if you require.
Most patients will arrive in a cervical collar taped to sandbags. You will usually be asked to assist with a log roll onto a scoop so that the patient can be moved from the vacumat. You will then have to log roll the patient off the scoop to allow for x-rays etc. to be taken. It is the responsibility of the anaesthetist to co-ordinate this move unless you are administering life saving intervention.
If the patient is hypotensive or severely shocked you should insert a large bore 8 French trauma line via a Seldinger technique into a central vein before the situation gets critical. Internal jugular access is not usually possible as a cervical collar will often be in place and the spine must be maintained in alignment. If using a subclavian line, insert it on the side of the chest injury if it is likely that the patient will need a chest drain on that side, as this may prevent the development of bilateral pneumothoraces! However, beware if a major vascular injury is suspected at this site. The femoral route should be avoided in those with suspected severe pelvic trauma.
You should discuss fluid replacement with the team leader and advise or coordinate this as you see fit. Please bear in mind the team leader may be a very experienced consultant or a relatively junior SpR, so use your discretion accordingly.
Beyond the initial assessment:
After initial evaluation and resuscitation you must co-ordinate fluid resuscitation. Type O blood is often administered in an emergency in a severely shocked patient. However group specific blood is usually available within 10 minutes of the sample being taken and this should be used instead of type O blood as soon as this is available. You must co-ordinate the fluid resuscitation in conjunction with the team leader, ODP and Nurse 1 as indicated.
All fluids should be warmed; a Level 1 or Belmont rapid infusion device may be used in unstable patients (ED staff will set this up). Please beware as very large volumes of fluid can be given very quickly.
If there is a suspected head injury it is wise to assess the ABCs followed by a mini neurological examination, paying particularly attention to pupillary size and reaction. In addition you must review the arterial blood gas results and maintain the PaCO2 in a neuro-protective range, that is approximately 4 .5 – 5.0 kPa. You will need quite a high minute volume to prevent the re-breathing of CO2 and you must pay particular attention to this. Change tight ET tube ties to a secure tape if severe head injury suspected/confirmed. In adults you should aim to maintain the mean blood pressure at 80-90 mmHg until significant head injury is excluded. In patients with haemorrhagic shock who are likely to have a head injury it is best to aim for a MAP of 70 mmHg until haemorrhage has been controlled, as over resuscitation may exacerbate bleeding.
Insert a temperature probe and take measures to maintain normothermia. This includes the warming of all fluids and using a Bair hugger as soon as it is available.
Trauma patients normally spend 40 – 60 minutes in the resuscitation area prior to transfer for further investigations, surgery or intensive care. All patients will have a routine chest x-ray and pelvic x-ray and frequently abdominal, pelvic, limited focused cardiac and chest ultrasound (extended FAST scan). When the FAST scan is being done you should ask the radiologist to rule out pericardial collection in patients who are shocked or if there is any possibility of cardiac tamponade.
Most patients will go on to have extensive CT imaging, including head, spine, chest, abdomen and pelvis, where appropriate. A preliminary report will be provided by radiologists as soon as possible with a more detailed report available subsequently on PACS and CRS.
Please pay particular attention to the results of these investigations as this will save a lot of time and effort on the Intensive Care Unit at a later stage. Please encourage the appropriate personnel to document all results in the patient’s notes. Following completion of the primary survey, the orthopaedic SpR will usually complete a secondary survey if the patient is stable. Otherwise the patient may be sent for urgent scanning or surgery and this will need to be completed at a later stage. Where possible patients should be stabilised prior to transfer to the CT scanner or other diagnostic areas within the radiology department. You must liaise with the Team Leader and advise accordingly, depending on the status of the patient. However, the team leader’s decision may be to transfer an unstable patient to CT scan. If this is the case, the patient should be accompanied by the FULL TRAUMA team with resuscitation ongoing. If in any doubt call the ACCU consultant.
The scribe will usually document vital signs, drugs and fluids administered, urine output and initial results while the patient is still in the ED resuscitation room. However, you must liaise with the ED nurse accompanying the patient to the CT scanner to continue this process. You must ensure a full record is available.
Prior to the transfer of the patient to the CT scanner etc. you must secure all lines and tubes and commence a propofol infusion, maintain analgesia and fluid resuscitation and change the patient over to a portable ventilator. The patient should be placed on a scoop prior to transfer. Alternatively a “patient slide” can be used. You may use the portable ventilator while the patient is in the CT scanner. Please ensure that the patient is stable prior to initiating scanning and that all lines, tubes etc are safely positioned. You must place the monitor and the ventilator in a position that can be viewed from the control room while the scan is being performed. You may of course interrupt the scanning process at any stage if there is a problem with the patient.
Please pay attention to all investigations performed and the results as they become available.
To avoid delays please liaise with the Intensive Care Unit at an early stage if it is obvious that the patient will need an intensive care bed. If it is likely that the patient will need to go to the operating theatre please liaise with your colleague on bleep 1220 to plan this process well in advance.
YOU MUST ENSURE THAT ALL APPROPRIATE INFORMATION IS FULLY DOCUMENTED ON CRS. Vital signs must be recorded in all unconscious patients. Ensure they are being entered into CRS by the ED staff, or write them on an anaesthetic chart (especially if the patient is going to theatre or IR).
Please read the BH guidelines for all of the following:
- Clearance of the Spine in the unconscious patient
- Management of severe head injury (RLH ACCU guidelines)
- Massive transfusion guidelines/ use of Activated Factor VIIa