Surgical Critical Care,  Trauma Surgery

The Five Letters on Which Trauma Stands – Part 1

Hope for the best, but prepare for the worst.

Benjamin Disraeli

Preparedness

Gather everything in your backpack!

As every Scout knows, before a great adventure you need preparedness and planning! 

The trauma path is long and full of adversities… Embrace yourself and get ready!

When we speak about trauma we tend to focus on the ABCDE (aka the Primary Survey), the most exciting and adrenaline phase of treatment. But it is only one of the moments you need to focus on. 

The whole path is composed by:

  • Preparedness
  • Primary survey
  • Secondary survey
  • Damage control
  • Definitive treatment

Obviously, we are all focused on the treatment parts, but everything starts with planning, as in your mind as in practice. 

When you receive a Trauma Team Activation Call you have to start thinking about what is about to happen in the trauma bay.

Napoleon and the other great commanders taught us you cannot win a war without preparedness and planning!

Now, we need to stop speaking about epicness and getting back to planet earth.

To explain what we mean in the easiest way, let’s use a case scenario. The sentences in italic refer to a possible real case scenario where ATLS plays a key role.

So then… 

You are a young consultant and you’re facing a night as the surgeon on call. At 3 o’clock in the morning your beeper rings. You take the call and a paramedic on the other side of the phone tells you that they are fetching to your hospital a patient who sustained a motor-vehicle accident (MVA). 

What did this call tell you? Absolutely nothing! You must not end the call at this point. You need to know more information, and the paramedic (or whoever is… doctor, nurse, volunteer…) must give you. But, what kind of information do you need? 

The handover formula is ATMIST (age, time, mechanism of trauma, injuries, signs & symptoms, treatments). You cannot pretend that the poor paramedic gives you all the information, but at least a good overview. 

Analyzing the ATMIST formula:

  • Age: approximal age (young, middle age, old) and sex. They are useful to anticipate possible scenarios (e.g. old man who is on oral anticoagulant agent).
  • Time: time of the incident, expected time and way of arrival. Remember that you need to prepare all the necessary equipment and alert the Trauma Team. Moreover, it is better to know from which “door” the patient is going to enter.
  • Mechanism of trauma: what the patient sustained (e.g. motor-vehicle accident, pedestrian-vehicle accident, stab, gunshot wound, fall from height…), trauma characteristics (e.g. entrapment, ejection, height of the fall…).
  • Injuries: what is visible at first sight (e.g. pelvic fracture, chest wound, traumatic brain injury…).
  • Signs & symptoms: vital signs and state of consciousness (i.e. blood pressure, heart rate, respiratory rate, saturation, Glasgow Coma Scale).
  • Treatment: basically, what was done. Everything is important here: lines, fluids (what kind? how much?), analgesics (which one? dose?), intubation, oxygen through a face mask, pelvic binder, spinal board…

Sometimes, the paramedic may refer to the patient with a color code (e.g. “we are bringing a red code”) or with a T- or P-number code (e.g. “we are bringing a T2 patient”). These are triage codes and we aren’t going to delve into this topic here. Just to have an overview (if you don’t know already):

Color codeT- or P-number codeMeans
Green3Treatment can be delayed
Yellow2Need urgent medical care
Red1Need immediate life-saving emergency care

With all these data, you may now decide what you need to do. Then, ask yourself:

  • Do I need to use the Shock Room? (usually, if the prehospital team calls you, that means the trauma is quite serious and it’s better to use the Shock Room. Remember: better to over-react than under-react).
  • Do I have to activate the Trauma Team? (the Trauma Team, provided there is one in your hospital, is usually composed at least by a general/trauma surgeon, an anesthesiologist or intensive care doctor, an orthopedic, a radiologist, a radiographer, and related nurses).
  • What kind of equipment do I need? (there are three groups of equipment that are useful in a trauma patient evaluation: self-protection devices (e.g. goggles, gloves, masks, waterproof aprons…), devices for medical maneuvers (e.g. endotracheal tube, tube thoracostomy, IV lines…), and drugs (e.g. fluids, blood, rapid sequence intubation drugs, analgesics…). You must know (or have someone knowing for you) where all you may need is located. It’s extremely stressful to ask for an intercostal drain and finding out during the resuscitation where they are stored. This will make you lose a lot of time, focus, and, in the worst-case scenario, the patient).

Now… Let’s go back to our clinical case…

You ask the paramedic for more information, and he tells you that the patient is a middle-aged man who sustained an MVA while he was riding his motorbike. He hit a car coming out from a private road. He was thrown for about 10 meters. He has a femoral fracture on the right, nothing more at first sight. Vitals are stable, with BP 130/75, HR 110, SatO2 96% in room air, and GCS 14/15. They will be there in 10 minutes.

With the information obtained, you decide to prepare the Shock Room and to activate the Trauma Team.

There are some criteria to determine if a patient sustained a major trauma or not, and if you need the Shock Room and the Trauma Team or not (e.g. ejection, death in the same passenger compartment, vehicle speed >30 kph, fall >6 m for adults and >3 m for children…). However, we are not focusing on them in detail now. Basically, you must consider three aspects to decide if a trauma is major or not: injuries (are or could be the injuries sustained by the patient life-threatening?), the mechanism (how much energy was involved in the accident?), patient’s characteristics (is he/she a fragile patient? Has he/she risk factors that can play a major role in the outcome?).

After you’ve given an answer to all these questions, you have all the elements to decide whether you need to activate the Trauma Team and prepare the Shock Room or not. 

While you wait for the patient to arrive, a good habit is to review each step of the resuscitation you’re about to do (what should I do in A, how should I cope with a PNX, how do I put up a pelvic binder, after how many attempts should I use an intraosseous access…). It will help you to be more prepared when facing the patient and will spare you thinking time!

Remember in trauma you must always hope for the best, but prepare for the worst.

References
  1. Advanced Trauma Life Support: Student Course Manual. 10th Ed. Chicago, IL: American College of Surgeons; 2018.
How to Cite This Post

Marrano E, Bellio G. The Five Letters on Which Trauma Stands – Preparedness. Surgical Pizza. Published on June 20, 2020. Accessed on September 23, 2022. Available at [https://surgicalpizza.org/trauma/the-five-letters-on-which-trauma-stands-part-1].

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