After reviewing many recordings of major trauma resuscitations, I have come to the conclusion that we are not training our learners on how to perform as a Trauma Team Leader (TTL). They are forced to extrapolate from ATLS, a course never designed for a team at a Level I trauma center. Trauma resuscitations as opposed to medical are a bounded reality. Both the time in the bay and the menu of options are limited–the complete list could be delineated and therefore available for novice TTLs. For a few weeks, I set out to do exactly that. I then sent it out to Chris Hicks (@humanfact0rz) for peer review. His feedback was so good, that I asked him to co-author this project with me. If the response to this project is positive, we will work on the penetrating edition as well.
Blue=cognitive tasks for the TTL
Red=TTL must assign to a subteam (operational)
Solid=always happens in every trauma
Dotted=May happen based on patient injuries or severity
- Zero Point Survey
- Team Leadership with Cliff Reid
- EMCrit #230 – Resuscitation Communication
- COMM CHECK: More On Resuscitation Communication
Revised Assessment of Bleeding and Transfusion (RABT)
- Penetrating Trauma
- Shock Index > 1.0
- Pelvic Fracture
- Positive Abdominal FAST
=2 had sensitivity of 84% and a specificity of 77%
World J Surg 2018;42:3560
5 Sites of Bleeding
- Chest
- Intra-Peritoneal
- Retro-Peritoneal/Pelvis
- Thigh
- Street
- EMCrit RACC Podcast 216 The Hemodynamically Neutral Intubation
- Podcast 176 Updated EMCrit Rapid Sequence Intubation Checklist
Podcast 170 the ER REBOA Catheter with Joe DuBose
and remember the most important marker for when you are performing well as a trauma team leader:
Trauma Should be Fun!!!!
Please leave your comments on this below…
Additional Stuff
- ATACC Course Manual [link currently broken]
- Change C-ABC to XABC
You Need an EMCrit Membership to see this content. Login here if you already have one.
Fantastic Px But without logroll and spinal exam ,how can you send pt for imaging ,won’t it lead to missed injuries and resending pt
They are all getting CT Chest/Abd/Pelv and Cervical/Thoracic/Lumbar anyway.
very timely, trying to implement something similar in my EMS service before I dip. never understood why I “needed” to do a spinal exam in someone with a GCS of negative 15, also the spinal exam never rules out a spinal injury in massive trauma but somehow squeezing the pelvis rules out a fx with involved bleeding, binder for all massive blunt trauma has been my MO for years, residents think I’m a weirdo.
Hi Scott,
a very well thought approach to Trauma and so much better than the almost “religious” ATLS, wich like you stated is slowing down an experienced Traumateam.
I recently completed my “European Trauma Course” http://europeantraumacourse.com. Here you either found inspiration for your approach or will find some more.
Thanks for this cast and greetings from Germany
Thomas
Scott, I love this podcast because it fits with how I try to work. Some observations from what I know about this conversation which I could summarize into a few buckets: 1) Split vs unified leadership (RN + Doc or Doc only as identified team leader) We have been using a podium nurse for a very long time at our Level 2 Trauma Center, community hospital. I agree that splitting leadership is important, allowing management of the room/team/tasks and management of the clinical thinking to be different jobs. I do not believe this is the only way to manage a… Read more »
Sorry – job title didn’t work
Wow … what a nice post. I think i speak for everyone on this, YES we want part 2 🙂 A lot of questions Arrival of the patient Could you describe exactly how you move the patient from the paramedics stretcher to yours ? In my ED we tend to transfert the patient with the paramedic stretcher and then log roll the patient to put them on a plastic board that we can use for CT scan. No sure i understand how you are able to move your patient without any log roll Diagnostic Peritoneal Lavage. You talked very briefly… Read more »
Hey Fred, Transfer All our patients come in on a backboard or a scoop stretcher. If on backboard, we just slide them off. If on a scoop, we just break it. If you need that plastic board, by all means, do as much of a logroll as you need–the point is to avoid unnecessary movement. DPL the cards do not list DPL, they list DP aspiration. Entirely different procedure. DPA only occurs when the ultrasound views are inconclusive. Ultrasound Fred, you will not have a vast amount of FF and no signs of shock. Fluid Resus Based on your scenario,… Read more »
Wonderful ! Thank you so much for taking the time for a such detailed answer. You make, as always, excellent points that are hard to argue 😉 DPA Don’t you think that the same principle apply for DPA ? If ultrasound is inconclusive, meaning no certainty of free fluid, how a blind DPA is going to help if you are not even able to locate free fluid on ultrasound ? The only logical scenario to me is to differentiate between blood or ascites on a positive fast ? Fluid Resus You cleared a lot of confusion on this, thanks. Do… Read more »
Ultrasound becomes inconclusive b/c of lack of windows–most common cause is subQ air from large pneumos. DPA is entirely reliable for intra-p bleed sufficient to cause the pt’s hemodynamic instability. It is a binary result, either pos or neg.
If their MAP is good, I am holding the blood. Don’t worry, it will drop again and then you can give more.
Great stuff – good to compartmentalize as you have. You know what I’m gonna say – I have some issues with your REBOA box. I would say in the appropriately skilled hands, you should not wait to use it until they arrest – this is the key procedure to do BEFORE they arrest to minimize the risk of neurologic ischemic injury. In the indicated patient get your CFA access (also make sure the catheter gauge is enough to allow the passage of an 0.035 inch wire so at least 4-5Fr or 18G) and if the patient’s injury pattern is amenable… Read more »
yes, of course that is what we all think. Problem is no evidence to support even this role.
Hey Scott,
You guys have a lot of fans here in Brazil!
Looking forward to a podcast about Rottem/TEG! How about that?
Congrats on your REALLY nice work!
love this, definitely need to see the penetrating version!