Major trauma action cards

Pre-arrival:

• Trauma team activated.
• Team members ‘book in’ with scribe/team leader.
• Protective equipment worn by all key personnel.
• Introductions done and team roles assigned with clearly named badges.
• Nursing pre-arrival checklist done, equipment ready.
• CT aware and ready (and occasionally blood bank, theatres).
• Consider - anaesthetic drugs drawn up/Belmont blood warmer primed.
• Consider - code red activated? - activates MHP and mandates escalation to specialty consultants.
• Paediatric calculations if indicated.
• ATMIST on the board (Age, Time of Injury, Mechanism, Injuries, Vital Signs, Treatments).

On patient arrival:

• Start the clock (delegate to Nurse A).
• All listen for concise 30 second handover from paramedics before transferring patient to trolley unless critically ill.
• Ensure one paramedic immediately attends reception to register patient.
• Command resuscitation, prioritising investigations and treatments of blunt trauma and signs of haemodynamic instability, consider pelvic binder.
• Consider massive transfusion activation if ongoing significant bleeding suspected (2222 – request massive haemorrhage ED resus then contact bloodbank ext 33394 to give patient details.)
• Give tranexamic acid if ongoing bleeding suspected (1g over 10 minutes, then 1g as infusion over 8 hours. Paeds-15mg/kg bolus, then 2mg/kg/hr).
• If meets WBCT criteria (Adult – alert CT radiographer (Ext 35071)), give estimated time to CT. Aim for CT within 30 minutes. Co-ordinate quick, but safe transfer and ongoing resuscitation in scan. Consider CT in lieu of primary survey x-rays in selected cases.
• Speak to relatives.
• Ensure Major Trauma documentation complete and initiate “ready-to-go” checklist.

• On arrival in ED resus bay 1, move to the left side of the trolley as approaching from the foot of the bed.
• Unless patient is critically unstable, stop all movements and give a concise, clear 30 second handover to the team leader/team then transfer patient to ED trolley on scoop stretcher.
• Remove scoop with assistance from trauma team under guidance of trauma team leader.
• Further detail of the history can then be passed directly to the team leader whilst assessment of the patient starts in ED. 

One paramedic should give patient identity details to receptionist ASAP after arrival for patient registration.

• The other team member should ensure scribe has all handover details and update ATMIST whiteboard if relevant.
• Ensure Team Leader has all information required before leaving the department.
• Handover should include the ATMIST content:
  • A - Age
  • T - Time of injury
  • M - Mechanism
  • I - injuries
  • S - Vital Signs
  • T - Treatments commenced

Pre-arrival:

• Check in with team leader/scribe.
• Put on personal protective equipment and designation sticker with first name visible.
• Ensure all airway equipment ready and available, check ventilator.
• Draw up intubation drugs if indicated.

Arrival:

• Unless acute airway compromise, listen to concise 30 second handover from paramedic team before assisting with transfer to resus trolley.
• Communicate airway patency and issues to team leader/scribe.
• Assess respiratory rate and inform team leader/scribe.
• Ensure cervical spine immobilisation, anaesthetist will usually control the log roll if indicated.
• Provide and communicate ongoing assessment of GCS.
• Provide adequate analgesia.
• Obtain AMPLE history.

Pre-arrival:

• Prepare for the trauma call using pre-arrival checklist.
• Put on personal protective equipment and designation sticker with first name visible.

Arrival:

• Listen to 30 second handover, assist transfer.
• Have tuffcut scissors ready, remove enough clothing initially to attach monitoring, Nurse C will continue to remove clothes while you get first set of observations as a priority.

Clearly state first observations to team leader and scribe as soon as available.

• Assist Doctor B with procedures as necessary eg. chest drain, pelvic binder.
• Draw up drugs/administer iv infusions as prescribed.
• Prepare for transfer to CT ASAP (possibly within 10-20 minutes) and/or theatre. This will include:
  • Preparation of monitoring equipment – Phillips X2 transfer monitor.
  • Full Oxygen cylinder with Schraeder valve.
  • Ventilator, propofol infusion and capnography if intubated.
  • Drugs (as directed by anaesthetist).
  • Transfer Bag.
  • Fluid/blood as directed.

Pre-arrival:

• Login with team leader and scribe.
• Put on personal protective equipment and designation sticker with first name visible.
• Check equipment ready - chest drains/pelvic splints.

Arrival:

• Listen to 30 second handover, assist transfer to resus trolley.
• Help to remove chest clothing, and immediately assess chest, neck and effectiveness of ventilation - undertake any necessary “breathing” interventions.
• Utilise chest drain pre-insertion checklist if indicated.
• Communicate findings clearly to team leader and scribe.
• Continue with primary survey, assessing abdomen, pelvis and long bones.

Pre-arrival:

• Prepare for trauma call with Nurse B using pre-arrival checklist.

Arrival:

• Listen to 30 second paramedic handover prior to transfer.
• Have scissors ready - Remove all clothing including underwear and store securely.
• Assist in stemming external haemorrhage with direct pressure.
• Cover with blankets/Bair hugger.
• Help with getting iv access and sending bloods off. If required, set up intraosseus kit (EZ-IO).
• Give iv fluids/blood as directed, manage Belmont blood warmer.
• Help with procedures as necessary eg catheter, chest drain, pelvic/Thomas splints, arterial line.
• Dressings and splints, photographs of open fractures/significant wounds.
• Ensure patient kept warm.

Pre-arrival:

• Login with team leader and scribe.
• Put on personal protective equipment and designation sticker with first name visible.
• Wear personal protective equipment including lead.
• Ready access and blood-taking equipment.
• Familiarise with Typenex system.

Arrival:

• Listen to 30 second handover.
• Assist with transfer of patient.
• Assist in stemming active external haemorrhage with direct compression.
• As soon as possible obtain two large bore peripheral lines taking 20 mls of blood at same time.
• Use designated “trauma set” on ICE and complete hand written Blood Transfusion form to go with BTS sample.
• Ensure bloods sent – porter may be available as runner.
• Order x-rays and CT on ICE in discussion with team leader (trauma order sets).
• Obtain Arterial Blood gas.
• Assess abdomen, pelvis, long bones if doctor B unable to complete primary survey.
• Perform/assist with procedures depending on skill level and training and as guided by team leader.
• Keep patient warm.

• Ensure clock is started by Nurse A/ODP when patient arrives in Bay 1.
• Document team members and arrival times including speciality and grade.
• Document vital signs every 5 minutes in unstable patient and every 15 minutes otherwise.
• Maintain a chronological record of all events e.g. time of venflon, CXR, move to CT etc.
• Ensure patient wrist labels are secured on the patient.
• Inform the team leader if key observations have not been identified e.g. temperature, BM, GCS.
• Inform the team leader every 15 minutes that pass, the aim is to be in CT within 20-30 minutes when appropriate.
• Keep a log of the running total of blood products transfused in a massive haemorrhage situation – this role may be done by Nurse C.
• Prompt the team leader when 4 units of blood have been transfused.

• On receiving major trauma pre-alert, liaise with trauma team leader re ETA.
• Prepare equipment.
• Liaise with team leader if electronic x-ray request is delaying imaging.
• When ready to take x-rays state clearly: “X-rays in Bay 1”.

• Nurse in charge should attend initially and coordinate staff and resources. They may be in a position to initiate the trauma call if deemed necessary.
• Inform ED Consultant of trauma call and give pre-hospital information.
• Provide support for the team and knowledge of the department.
• Co-ordinate with Team Leader early on the plan for disposal of patient from ED.