A glimpse into the inner workings of a trauma activation
The radio crackles and the paramedic's voice cuts through the din of the emergency department. “Doctor to the radio”. The clock already started and time isn’t on our side. “30s-year-old male, a gunshot wound to the right arm and left back. GCS 7. Highest heart rate 110, lowest blood pressure 80 systolic. 5 minutes out.”
The management of trauma starts at the time of injury, with bystanders and dispatched first responders. Immediate interventions can be performed on the scene, which is followed by rapid transport to the hospital. En route, care continues to be delivered as needed (starting IV, giving fluids/ blood, maintain an open airway, etc). The hospital is contacted to prepare them for an incoming patient. Key details dictate the resources that are mobilized in response. There are no universal criteria for what constitutes each level of trauma activation, and different hospitals have unique designations for the highest activation (Trauma Red, Level 1, Code 1, etc). However, triage is designed to rapidly transport the patient to the most appropriate facility.
An adult trauma code 1 is paged out to the trauma team. As the team arrives, the minutes before the patient arrives are spent relaying key patient details shared from the pre-hospital team. For a hypotensive patient or report of massive bleeding, massive transfusion is initiated. Chest trauma? Chest tubes, possibly open thoracotomy tray. Extremity wounds? Check that the tourniquets are ready. Team roles are assigned, and a plan is discussed.
When the patient arrives, the pre-hospital team presents key data to the entire team. At one of the facilities I trained, there was a standardized presentation. It was organized, succinct, and appropriately relevant; the trauma team and the pre-hospital team both knew what information was to be shared.
Pre-hospital team report
Age (or approximate age), gender, mechanism, time of injury, significant event details (prolonged extrication, death on the scene, etc). Significant pre-hospital interventions and events (tourniquet time and location, intubation, change in mental status). Presence of IV access (size and location) and administration of pre-hospital fluids or medications. Highest heart rate, lowest blood pressure.
Trauma Evaluation/ ATLS
After the report, the patient is transferred to the bed and the primary and secondary surveys are performed. Primary survey- assess airway patency, adequacy of breathing (bilateral breath sounds, chest rise and fall), circulation (control active hemorrhage, assess pulses), disability (rapid neurologic assessment with GCS and pupil exam), and exposure (remove clothing to facilitate exam, make sure they get covered with blankets to minimize hypothermia). Concurrent with the primary survey, IV access is obtained, blood is drawn, and interventions are performed based on the findings of the survey. If there are no immediate life-threatening injuries on the primary survey, the secondary survey is performed, which is a comprehensive head to toe exam (see below), including log rolling the patient to examine their back. Common diagnostic testing includes commonly, patients undergo FAST (see vignette "Blast Injury"), chest x-ray, and pelvis x-ray. Based on hemodynamic stability and injuries, patients are then dispositioned to the operating room, radiology for further imaging, admitted to the ICU or floor for ongoing resuscitation, observation, consults, serial exams, etc.
Secondary Survey
Head/ ears/ nose/ throat- facial abrasions/ ecchymosis/ tenderness, periorbital edema/ ecchymosis, crepitus, open wounds, blood from nares/ ears. Tympanic membrane. Jaw occlusion.
Neck- c-collar in place, obvious ecchymosis, abrasions, open wounds, tenderness.
Chest- wounds, ecchymosis, tenderness, crepitus.
Axilla- wounds.
Abdomen- wounds, ecchymosis, tenderness
Pelvis- stability, pain.
Back- midline spinal tenderness/ step-off, ecchymosis, abrasions, wounds.
Rectal- tone, blood on rectal exam.
Extremities- sensation/ motor strength. Abrasions, wounds, gross deformities
Vascular- carotid, femoral, DP/PT, radial pulses bilaterally.
GU- perineal ecchymosis or wounds, blood at meatus.