Trauma orientation manual

Participate in bedside procedures 

If the rest of the team is in the OR, work with the Red APP to ensure that the patient care continues to progress for the remainder of the service.  

The Blue attending is the backup attending during the day, and the ICU attending is the backup at night. If a patient has a change in status (new tachycardia, arrhythmia, hypotension, hypoxia, altered mental status, hemorrhage, sepsis, etc), and the rest of the team is in the operating room, it is your responsibility to alert the backup attending immediately. 

If you have a question regarding the existing plan of care that cannot be answered by the Red APP, go to the operating room to ask for help.  

Assist with notes and order on activations 

Help facilitate communication with therapy, case management, and social work 

Assist with discharges. 

Be familiar with all patients on the service, and should hold the pager/PerfectServe and continue to advance care on the entire service when all residents are scrubbed or in education.  

Concise, focused (not rounds), discuss unstable patients in detail 

Entire sign out should take less than 20 minutes 

Laboratory results/trends 

Pull up daily imaging and other data 

Enter orders in real time 

Resident or APP presenting the patient should not be the person entering orders at the computer 

Do tertiary exams – should occur as close to 24 hours after admission as possible  

Do bedside procedures and operations (trauma floor residents operate on trauma ICU patients) 

Review new patients 

Swift and focused updates on stable existing patients 

Address questions from RNs, RTs 

New plans for unstable or deteriorating patient 

APP coverage Tuesday-Thursday 

Resident coverage Friday-Monday  

Attend trauma activations  

Complete items to assist day team: 

Tertiary exams 

Populate the problem list, update the patient list through the Problem List tab 

Review all orders, cancel duplicate orders 

Prior§  Communicator to the patient. Relays key information to patient arrival:and obtains patient feedback.

§  Cervical spine stabilization during patient turning

Participate§ in Assist with secondary assessment of HEENT, neck, etc.

§  Once primary and secondary assessments are complete, may either perform or supervise the performance of procedures or FAST exam as designated by Trauma Team Lead.

o   EM Attending

PreBrief§  Responsible for supervising the ED Resident during Primary Assessment of the airway

§  Supervises or assumes management of the airways (including induction plan & techniques)

§  Assumes the role of supervising the Trauma Team when the Trauma attending is not available or during multiple traumas

§  Supervises doctor delegated to perform FAST exam

§  Collaborates with Trauma attending and rest of trauma team once airway is secured

·       Trauma Primary Provider

o   Starts on the left side of the patient, but is free to move about the patient to perform adequate primary and secondary survey

o   Responsible for C: Circulation and E: Exposure of the patient by removing clothing.  If the Airway Resident unable to complete their portion of the primary survey (ie. B: Breathing), this becomes the responsibility of the Trauma Primary Provider

o   Responsible for secondary survey assessment

o   Performs all procedures as delegated by Trauma Team (IO, CVC, thoracostomy tubes, arterial line) under Trauma Attending Supervision

o   Additional responsibilities as delegated by Trauma Team

o   “Travels” with the patient to CT or the operating room

o   Responsible for keeping the Trauma & ED attending, and Trauma Lead informed of patient’s condition and any diagnostic findings

o   May perform other tasks as delegated by Trauma/ED attending

·       Trauma Secondary Provider

o   Starts on the right side of the patient, near foot of patient (see posterdiagram)

o   wall),Assist iwith E: Exposure of patient as needed- needs to carry trauma shears

o   Assist with secondary survey as needed

ntroduceo   yourselfAssist with procedures as needed.  If multiple procedures are needed to be performed at the same time, the Trauma Secondary Provider will be responsible for procedures the Trauma Primary Provider is not performing which will be assigned and yoursupervised position,by preassignthe roles,Trauma/ED ensureattending. equipment is ready and available 

Patiento   arrives:May perform other tasks as delegated by Trauma Team

·       Trauma Techs

o   One stands to the mid/upper right of the patient

o   Second stands to the upper left of the patient if present

o   Pulls red cart to bedside

o   Obtains first set of vitals (including temp) within 30 minutes

o   Places patient on cardiac monitor

o   Helps remove clothing

o   Pulls supplies as needed (see separate checklist for supplies to be pulled before an Agonal Resuscitation)

o   Set up necessary equipment for procedures (ie: chest tube, splinting, lac repair)

o   Assists with bedside procedures as directed by trauma surgeon, assists nursing staff as called upon, otherwise steps away from bedside once tasks complete

o   Performs CPR if necessary

o   Completes patient belonging list

o   Reconciles supply checklist following trauma resuscitation completion

o   Restocks supplies/supply carts

·       Trauma Bedside Nurse (TNS trained)

o   Initiates the Prebrief before patient’s arrival in the trauma bay

§  If Trauma and EM attendings are not present, the ED Trauma Lead Nurse (or ED Lead) should perform the prebrief, including assignment of defined team member roles

o   Directs care to trauma tech

o   Assists with retrieval of equipment

o   Assists with crowd control

o   Confirms EMS providersIV givepatency and obtains 2^nd IV access, if able

o   Inserts foley/NG/OG if indicated

o   Administers medications as ordered

o   Places patient on the telemetry monitor (shared with tech)

o   Primes tubing for Belmont prior to patient’s arrival, when applicable

o   Administers blood products and fluids as ordered

o   Places patient on defibrillator pads

o   “Travels” with the patient to CT, OR or IR

o   Assists with obtaining laboratory blood vials

o   Performs debrief with team following trauma resuscitation (must be performed with Trauma Attending, at minimum)

o   ***In complex traumas/Code 99s/CPR in progress situations, more than 1 Trauma Bedside Nurse is required.  In these cases, another bedside nurse will assist with tasks listed above under the leadership of the ED Lead Nurse

·       Documenting Nurse

o   Responsible for keeping a written record of the resuscitation events on trauma narrator

o   Maintains closed loop communication with entire team

o   Assists with crowd control

·       Additional Trauma or EM residents, APPs, medical students observing or other learners

o   Starts behind the “red line”

o   Are not immediately involved in the trauma resuscitation unless there is a vacant role

o   Are recruited as needed for the care of the patient

o   May assist with electronic orders, gathering equipment

·       Respiratory Therapist

o   Assist with intubation

o   Provide ETCO2 monitoring post intubation

o   Secure ETT

o   Provide suctioning

o   Assist with vitals and monitoring the patient (SpO2, HR, RR, measured parameters, etc.)

o   Provide transport to CT/MRI (NIV, MV, etc.)

o   Restock/check airway cart

·       Pharmacist

o   Prepares drugs, assures appropriate doses, identifies potential interactions, provides clinical support

o   Serves as timekeeper during codes

o   Operates defibrillator machine upon guidance of Trauma and EM attendings

Additional Information

Who is the Trauma Team Lead?

The Trauma Team Lead is the General Surgery resident when present.  During educational time or when General Surgery resident is not present, it is the ACS APP or Trauma attending.

Who is the Airway Resident?

The Airway Resident is the EM PGY 2 or 3 when present.  During educational time when a senior EM resident is not present, it is the EM attending.  If EM is not available, Anesthesia will manage the airway.

Who is Trauma Primary?

The Trauma Primary is the General Surgery resident, off service resident rotating on the trauma service, or available ED resident when present.  During educational time or when General Surgery resident is not present, it is the ACS APP.  30Residents secondor APPs involved in the care of the trauma patient must be present at the time of prebrief and arrival of the trauma patient and remain until the initial resuscitation efforts are complete.

Who is Trauma Secondary?

The Trauma Secondary is the General Surgery resident, or off service resident rotating on the trauma team, when present. overview/report, duringThis role may also be filled by the ER resident, if present and in PPE at the time of the prebrief.  During educational time or when General Surgery or ER resident is not present, it is the ACS APP.  A medical student rotating on trauma or in the ER may assist in this role.

It seems like the Primary Survey is divided between 2 different providers?

That is correct. The Airway Resident tasked with airway management, which thereis closely tied to the pulmonary exam, will perform A: & B: [ZB1] Trauma Primary, who has access to the extremities to evaluate distal pulses and cap refill, fills the C: component. Disability (D:) is then assessed by the Airway Resident who can easily examine the pupils and talk with the patient to obtain a GCS score. The secondary exam then returns to Trauma Primary and Secondary providers.  ALL findings should be noCALLED talking 

Pt moved to trauma bay bed: ABCDEsOUT with closed loop communication with the Trauma Lead and logED rollNurse Scribe.

ATLS primary exam consists of ABCDE, which should be called out first and reported in that order.  The findings in the secondary survey should not be called out until the primary survey is completed.

What is the role of Trauma Secondary if there are no procedures required on the right?

Do not under-estimate the importance of the physical exam and participation in the work up of a trauma patient. It is imperative that the Trauma Secondary is learning from & collaborating with Cthe spineTrauma precautionsTeam Lead in preparation for them to ultimately assume this role. They are also integral in CT interpretation, and “closing the loop” on the patient disposition after CT scan interpretation.

What if EM attending or trauma attending has to perform a procedure?

If either attending is pulled into a procedure, or is called away from bedside to attend to another patient, the other attending should take over as “in charge”.  Both attendings should remain fully available during the resuscitation to supervise residents and APPs involved in the resuscitation.  If an attending is involved in a procedure and can no longer adequately supervise, then additional attending support (foreither bluntEM or trauma) should be called upon.

Who is “In Charge” of the whole Process?

Trauma bay resuscitations are a joint collaboration between the ED & Trauma attendings and teams.  Patient Management Guidelines are based on medical evidence and/or consensus of medical providers at Nebraska Medicine, and are intended to be a guide for the trauma resuscitation team.  Final management decisions are at the discretion and responsibility of the admitting physician.