All posts by TheTraumaPro

Who’s On Your Trauma Activation Team?

Yesterday’s video highlighted members of the trauma team at a medium size teaching hospital. Today, I will discuss who actually needs to be on the team.

The decisions leading to the composition of your trauma activation team are complex ones. The key is to look at your needs during a typical trauma resuscitation, and look at the resources available within the ED and the hospital as a whole.

The trauma resuscitation team can consist of as few as 4 to as many as 15 or more people! The first item to consider is who is available to go to a trauma activation? If your ED staff is small, the team will be small, or you will have to draw personnel from other areas of the hospital.

The absolute minimum personnel are:

  • 1 Physician
  • 1 Nurse
  • 1 Scribe
  • 1 Assistant (can be physician, nurse, or other)

Using the minimum contingent will force the use of ATLS the way it is classically taught, with the physician sequentially going through the entire process. Additional physicians and nurses allow overlapping portions of the evaluation and treatment and will also speed up the resuscitation process.

An ideal team for a non-teaching hospital is:

  • 2 Physicians
  • 2 Nurses
  • 1 Scribe
  • 2 Assistants

This allows for the physicians and nurses to split their responsibilities (airway, exam, IV access, monitoring) and assures adequate help with patient safety, evaluation and restraint.

Additional personnel can be added from outside the ED to provide a better interface with other hospital services. Examples include:

  • OR representative – communicates with the OR charge nurse to enable rapid access to an OR if needed
  • Lab representative – interfaces with blood bank to provide access to blood products
  • ED nurse – acts as an interface between the resuscitation room and services in the rest of the ED (supplies, calls to consultants, etc.)
  • Anesthesiologist or CRNA – to provide support of the difficult airway
  • ICU nurse – can provide additional nursing support or take other roles
  • Ultrasound tech – may perform FAST if the resuscitation physicians do not have this skill
  • Pediatric intensivist / pediatrician – assists with management of small children

Tomorrow: trauma teams in the teaching hospital

Evaluation After Head Injury in Adolescents

Traumatic brain injury (TBI) is the most common cause of death in children. Even mild concussions can cause some degree of functional impairment. Many clinicians believe that the degree of impairment correlates with the initial Glasgow Coma Scale score (GCS), although this has only been shown in adults. This has led many hospitals to perform cognitive screening selectively, usually on adolescents with lower GCS scores.

A recent study by Goold and Vane at the Cardinal Glennon Children’s Medical Center in St. Louis, and the University of Vermont College of Medicine in Burlington looked at the correlation between GCS and level of impairment, and ways to determine which groups of adolescents need more sophisticated cognitive testing to evaluate deficits.

A total of 609 young adults age 13-21 with brain injuries were identified, and a cognitive screening test was performed (Occupational Therapy Head Injury Mini Screen [OT HIMS]). There was no correlation between GCS and the components of the OT HIMS. Interestingly, the GCS did not predict which patients were discharged to rehab centers either.

The Bottom Line: Adolescents can develop significant cognitive deficits or behavior issues after any degree of head injury. Because of this, it is not possible to selectively screen for cognitive deficits. All adolescents age 13-21 should undergo screening with an instrument like the OT HIMS after head injury.

At our Level I Pediatric Trauma Center, we consider a child to have a TBI if:

  • the mechanism involves head impact and
  • any of the following apply:
    • known or suspected loss of consciousness
    • cannot remember the event
    • parents detect any change in behavior

All of these children undergo a TBI screen performed by Gillette Children’s Specialty Hospital physiatry, occupational and physical therapy services. If needed, they receive followup in the Gillette Minor Neurotrauma Clinic.

Reference: Goold D, Vane DW. Evaluation of Functionality After Head Injury in Adolescents. Journal of Trauma 2009;67:71-74.

Forensic Nursing

Forensic Nursing combines nursing science with the investigation of injuries or deaths that involve accidents, abuse, violence or criminal activity. Sexual Assault Nurse Examiners (SANE nurses) are one of the most recognized types of forensic nurses, but they have special training in one type of injury. Forensic nursing programs typically involve a broader set of skills, encompassing some or all of the following:

  • Interpersonal violence, including domestic violence, child and elder abuse/neglect, psychological abuse
  • Forensic mental health
  • Correctional nursing
  • Legal nurse consulting
  • Emergency/trauma services, including auto and pedestrian accidents, traumatic injuries, suicide attempts, work-related injuries, disasters
  • Patient care facility issues, including accidents/injuries/neglect, inappropriate treatments & meds
  • Public health and safety, including environmental hazards, alcohol and drug abuse, food and drug tampering, illegal abortion practices, epidemiology, and organ donation
  • Death investigation, including homicides, suicides, suspicious or accidental deaths, and mass disasters

Forensic nurses find that their additional training improves their basic nursing skills, and allows them to derive greater career satisfaction from helping patient in another rather unique way.

Approximately 37 training programs exist, ranging from certificate programs that require a specific number of hours of training, to degree programs (typically Masters level programs). Many of the certificate programs are available as online training. 

Source: International Association of Forensic Nurses (http://www.iafn.org/)