Title: ED Management of Trauma Patient Protocol Document Category: Clinical Document Type: Protocol Department/Committee Owner: Emergency Department Original Date: August 2009 Approver(s) last review: Approval Date: February 2013 Director of Emergency Services, February 2013 (Complete history at end of document.) Medical Director Emergency Services, February 2013 PURPOSE: Injured patients differ in severity. It is essential to classify patients based on objective data in order to maximize resources with injury severity. Patients that are more severely injured will require greater resource utilization as compared to those that is less likely to have significant injuries. LEVEL: Interdependent (*) indicates a dependent action. Enter order per protocol GENERAL GUIDELINES: Assessment: Initial assessment and classification is based upon EMS report if arriving via ambulance. If patient is not evaluated in the field the triage nurse will evaluate the patient initially and classify patient according to Lawrence Memorial Hospital criteria. EMS classifies trauma patients based the criteria outlined by the American College of Surgeons. Although this may serve as a guide for.lmh, we should classify patients based on our criteria as outlined below. This will decrease over utilization of resources. Class I GCS <8 with mechanism attributed to trauma (unconscious) Systolic BP <90 Respiratory Rate <10 or >29 Airway compromise, inhalation injury, or need for intubation All gunshot wounds to head, neck, chest or abdomen Amputation (including partial) proximal to wrist and ankle ERP discretion Class II (with absence of any Class I criteria) GCS <13 with mechanism attributed to trauma Paralysis or signs of spinal cord injury MVC with speed >40 mph with obvious injuries or altered mental status MVC Rollover Major auto deformity >20 inches Prolonged extrication >20 minutes Pedestrian/bicyclist/motorcycle hit at speed of >5 mph Pedestrian thrown or run over ED Management of Trauma Patient Protocol, Page 1 of 6
Motorcycle or ATV crash >20 mph with obvious injuries or altered mental status or with separation of rider from vehicle Falls > twice patient s height with obvious injuries (excluding isolated orthopedic injuries) All deep penetrating injuries of the neck, chest, abdomen, or proximal to the knee or elbow All open long bone fractures Death of same car occupant ED Physician (EDP) discretion Communication (Activation): Upon receiving report by EMS, or initial triage and evaluation by ED nurse, the Trauma Activation will be initiated in conjunction with ED Physician and Charge Nurse*. This will be an overhead page during day and evening hours. Included will be Trauma Code and ED room location. Upon responding to the ED, trauma team members will also be provided with available patient information. Response Times: In house hospital staff will respond to ED prior to patient arrival. Trauma Team Composition Class I Trauma In Trauma Room: Emergency Department Physician Primary RN Trauma Nurse 1 (TN 1) ED RN, TNCC certified Trauma Nurse 2 (TN 2) ED or ICU RN, TNCC certified ED Tech Respiratory Therapy Phlebotomist (& notification of blood bank) Radiology Tech Outside Trauma Room: House supervisor ED Charge Nurse CT Tech Security Notification only Pastoral Care OR nurse Blood bank Class II Trauma: In Trauma Room: Emergency Department Physician ED Management of Trauma Patient Protocol, Page 2 of 6
Primary RN Trauma Nurse 1 ED RN, TNCC certified ED Tech Respiratory Therapy Phlebotomist Radiology Tech Outside Trauma Room: Trauma Coordinator (if available) or ED Charge Nurse Trauma Team Member Responsibilities: ER Physician Team Leader: 1. Primary assessment. Calls out their assessment to the documenter 2. Coordinates all team activities. 3. Performs procedures. 4. Secondary Assessment. 5. Airway support Establishes clear airway Intubates as indicated 6. Central line placement/io Primary RN DOCUMENTATION NURSE, ED RN, TNCC certified: 1. Coordinates and delegates care of patient. 2. Receives report from EMS 3. Documents utilizing trauma flowsheet in First Net for Class I and II 4. Assumes responsibilities of TN 1 or TN 2 once they are released. 5. Releases team members as acuity dictates. Attempts to release TN 2 within 15 minutes or as acuity indicates ED Tech to be released ad lib Trauma Nurse 1 to be released ad lib Trauma Nurse 1 ED RN On right side of patient: 1. Assists with primary assessment. Airway Breathing Circulation Disability 2. Starts large bore IV with lock or fluids as indicated by patient condition. 3. Controls any bleeding on right side. 4. Places foley catheter. 5. Places OG tube unless contraindicated. 6. Gives CT contrast if indicated 7. Assists with secondary assessment. Trauma Nurse 2 ED or ICU RN, TNCC certified On left side of patient: 1. Obtains initial blood pressure MANUALLY 2. Connects to monitor and obtains initial vital signs. 3. Starts large bore IV and collects blood for lab. ED Management of Trauma Patient Protocol, Page 3 of 6
4. Blood sample to include: 3ml pink top for T&C 1.5ml lavender tops (2) 2-3ml blue top (up to black line) 2ml red 5. Initiates fluid resuscitation via the Level 1 warmer. 6. Assists with procedures 7. Obtains and administers medications. 8. Administers blood products. 9. Controls any bleeding or left side. Respiratory Therapy: 1. Assists with management of airway and ventilator support. 2. Suction as needed. 3. Collects and runs ABG s. Radiology Tech: 1. Obtains X-rays Phlebotomy: 1. Collects blood samples from RN with IV start or performs phlebotomy in absence of IV blood draw. 2. Places blood bank ID bracelet. 3. Takes serum and urine samples to lab. ED Tech: 1. Removes clothing. 2. Rectal temp 3. Places identification bracelet 4. Provides warm blankets and/or bear hugger 5. Obtains additional supplies as needed 6. Obtains ECG. 7. Collects any clothing and valuables and gives to family or security 8. Assists in transporting patient. 9. Assists with procedures as directed by Primary Nurse Blood Bank Tech: 1. Transport 2 units of O negative blood to trauma room ED Charge Nurse/House Supervisor: 1. Family, media, and law enforcement liaison 2. Coordinates any transfers to other facilities Completes transfer forms Assures that copies radiological studies, chart, and patient demographics are ready at time of transfer Provides family with directional information to receiving facility, if needed 3. Coordinates/facilitate transfers to floor, ICU, or OR 4. Ensures quality of care and documentation 5. Monitors need for security with crowd control CT Tech: 1. Clears CT table when done with current patient ED Management of Trauma Patient Protocol, Page 4 of 6
Pastoral Care: 1. Provides emotional and spiritual support to patient and family Security: 1. Assists in crowd control and to maintain order 2. Locks down ED at ED physician, or ED charge nurse s discretion Interventions: 1. The focus of treatment for Class I traumas will be to stabilize for transport to a trauma center, if injuries cannot be treated at LMH. Class I patients will, upon arrival, have the following orders entered into Cerner and implemented according to protocol upon discretion of the ED physician*. *CBC *Chem Comp *PT/PTT/INR *Type and Cross 2 units PRBC *Urine HCG for females *ECG *AP chest *Two large bore IV s *Foley catheter with temp probe (unless contraindicated) These orders will be initiated at physician discretion as indicated by a check box* *Urine Drug Screen *Serum ETOH *AP pelvis 2. Class II patients will be first evaluated by Emergency Department Physician prior to any orders carried forth. 3. In addition to protocol orders other nursing interventions will also be utilized. Level I fluid warmer on all fluids and blood products Universal Precautions including gown, mask with face shield, and gloves Vital signs upon arrival and every 5 minutes until stable. Initial blood pressure will be done manually. GCS upon arrival, discharge, and at least hourly while in ED. Warming efforts such as warmed blankets, and fluids will be utilized. ED Management of Trauma Patient Protocol, Page 5 of 6
DOCUMENTATION: Documentation will be initiated upon arrival Clinical reassessment of the patient s status should be done at regular intervals (depending on the severity of patient s status), as well as after every intervention initiated. This will include primary assessment, focused secondary assessment, pain assessment, VS, cardiac rhythm, monitoring of lines, and tubes. Notification of ED Physician of any changes in patients status REFERENCE: American College of Surgeons Committee on Trauma. (1998). Resources for Optimal Care of the Injured Patient: 1999 American College of Surgeons Committee on Trauma. (1997). Advanced Trauma Life Support for Doctors (6 th ed.). Chicago, IL Dries, David J., MSE, MD, FACS, FCCP, FCCM. (Nov. 2004). Initial Evaluation of the Trauma Patient. emedicine. Retrieved May 18, 2005 from http://www.emedicine.com/med/topic3221.htm Emergency Nurses Association. (2000). Trauma Nursing Core Course (5 th ed.). Bedford Park, IL Revision History: ORIGINAL DATE: August 2009 REVIEWED: August 2011 REVIEWED: Director of Emergency Services, February 2013 Medical Director Emergency Services, February 2013 ED Management of Trauma Patient Protocol, Page 6 of 6