Clinical Observation of Major Trauma Patient

Major trauma patients may present significant challenges and induce substantial stress on staff, with a loss of situational awareness resulting in key indications for escalation being missed. Studies have shown that multi-tasking and task switching can lead to missed indicators of patient deterioration and that clear charting methods, using easily identifiable thresholds for escalation, can reduce adverse events in patient care.

Alongside this, patients in the ED are at increased risk of unrecognised, unreported and/or undertreated clinical deterioration. Many factors come together to increase the likelihood of this such as time pressures, uncontrolled workloads and limited resources. Add to this the relative unknown history of the patient with non-specific complaints that carry a wide range of differential diagnosis.

Recognising and responding to clinical deterioration

The initial clinical management of a major trauma presentation needs to rely on both the collection of concise data and on astute observations gained from clinical examination of the patient to relay to consulting team members.
Close monitoring is vital in the early stages of care

Clinical criteria for escalation of care provides decision support for clinical staff to ensure there are clear guidelines on when to intensify and increase frequency of communication and observation. Respiratory rate changes, specifically tachypnoea is the most sensitive and specific indicator of clinical deterioration so should be measured frequently and accurately.

Staff should also be aware of acute changes in the patient over time such as fluctuations in pupillary response, confusion, agitation or delirium or an acutely cold, clammy, cyanotic or pulseless extremity.

Additionally, clinicians need to be aware of changes in frequent observations that are documented routinely during the patient’s initial assessment and early management.

The following tables indicate key criteria requiring further assistance with patient assessment and management.
Early warning signs of patient deterioration8Late warning signs of patient deterioration9
Partial airway obstruction (excluding snoring)Airway obstruction or stridor
SpO2 90–95%Sp02 < 90%
Respiratory rate 5–9 bpm or 30–40 bpmRespiratory rate < 5 bpm or > 40 bpm
Pulse rate 40–50 or 120–140Pulse rate < 40 or > 140
Systolic BP 80–100 mmHg or 180–240 mmHgSystolic BP < 80 or > 240 mmHg
Urine output < 200 mL over eight hoursUrine output < 200 mL in 24 hours or anuria
Greater than expected drainage fluid lossExcess blood loss not controlled by ward staff
A drop in GCS of 2 points or GCS < 12 or any seizureUnresponsive to verbal command or
GCS < 8
ABGs Pa02 50–60, PCO2 50–60, pH 7.2–7.3, BE –5 to –8 mmol/LABGs Pa02 < 50, PCO2 > 60, pH < 7.2, BE < –7
BSL 1–3 mmol/LBSL < 1 mmol/L
Poor peripheral circulation 
New or uncontrolled pain (including chest pain) 

Used with permission from: Clinical Excellence Commission - Between the Flags

The ACQSHC National Consensus Statement: Essential elements for recognising and responding to clinical deterioration require eight important clinical processes to be in place at all healthcare services:

  1. Measurement and documentation of observations: establishing the need for the assessment of measureable physiological abnormalities that occur prior to adverse events.
  2. Escalation of care: where an escalation protocol sets out the organisational response to dealing with different levels of physiological abnormality, including modifications to nursing care, increased monitoring, review by attending staff, review by senior medical and nursing staff, or calling for emergency assistance from intensive care or specialist teams.
  3. Rapid response systems: where severe deterioration occurs, it is important that the capacity exists to obtain appropriate emergency assistance or advice prior to the occurrence of an adverse event. In some facilities this may be a combination of on-site and external clinicians or resources.
  4. Clinical communication: effective communication and teamwork among clinicians is an essential element for recognising and responding to clinical deterioration. Poor communication has been identified as a contributing factor to incidents where clinical deterioration is not identified or properly managed.
  5. Organisational support: without strong organisational support for implementation, the system will fail. There needs to be acceptance from senior management to help drive the health care facility to ensure that their systems for recognising and responding to clinical deterioration are operational and effective.
  6. Education: It is essential to provide education to the clinical and nonclinical workforce in support of this standard in order to ensure familiarisation and usage in practice.
  7. Evaluation:  of new systems is important in order to establish their efficacy and determine if any changes are required to optimise performance
  8. Technological systems and solutions: it is important to consider the use of technological systems and solutions which may aid in the delivery and accessibility of implementing new systems.

In managing a deteriorating patient in all health services, the Consensus Statement provides clear guidelines on the development and governance of rapid response systems.

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