The presence of significant thoracic trauma needs to be assumed in a multi-trauma patient, particularly when the mechanism of injury is due to a high-energy blunt trauma. Emergency medical services should notify the receiving hospital that a trauma patient with thoracic injuries is on the way. This information may be crucial to how a severely injured patient is managed and can allow for communication to vital members of the response team as well as time to prepare the department for the patient’s arrival. Notification to the on-call surgeon is recommended for all hypotensive patients, who are either not responding to volume resuscitation, or who have sustained a penetrating chest injury.
The following sequence of actions should take place upon initial notification:
Gather vital information from the notifier using the MIST mnemonic:10
Mechanism of injury Injuries found or suspected Signs: respiratory rate, pulse, blood pressure, SpO2, GCS or AVPU Treatment given
Ensure all staff involved in patient care are wearing gloves, aprons and eye protection. Personal protective equipment is vital in the care of trauma patients.
Activate the trauma team and available support departments (medical imaging, pathology). In small health service settings this may only consist of a clinician and a nurse. Additional staff may be gathered from wards or on call. It may be necessary to utilise the skills of all available resources including emergency response personnel in the initial trauma management.
Set up the trauma bay to receive the patient, including equipment checks, documentation, medications and resuscitation equipment. Ensure you have chest trauma equipment at the ready. If sufficient staff are available, a clinician should be prepped and gowned, with equipment open and ready to proceed to rapid chest decompression (finger thoracostomy) if required. Theatres need to be activated early in the event of surgical intervention.
If the patient is hypotensive the massive transfusion protocol should be activated. Hypotension should be considered due to blood loss until proven otherwise. Large-volume blood loss is best managed with blood component resuscitation, and early definitive control of bleeding.
Designate roles and specific tasks to staff and maintain an approach based on teamwork. Ensure good communication between all parties involved in managing the trauma. Use closed-loop communication, which ensures accuracy in information shared between response staff. Repeat instructions, make eye contact and provide feedback. Misinterpreted information may lead to adverse events.
If there is no prior notification of the patient, then rapid activation of the trauma team request must take place and any additional resources notified. If it is anticipated that transfer to an MTS will be required, early retrieval activation is essential (phone ARV on 1300 368 661). Early retrieval activation ensures access to critical care advice and a more effective retrieval response. Early activation and timely critical care transfer improves clinical outcomes for the patient. Even if you are unsure, call the ARV coordinator, who can provide expert guidance and advice over the phone or via tele - or videoconference, and link to an MTS for early notification and further advice.