Planning and Communication

For a trauma team to run effectively there must be an identifiable leader who will direct the resuscitation, assess the priorities and make critical decisions .(20, 21). Clear communication between the trauma team members is vital, as is ensuring that local senior staff are aware and can provide additional support if required.

Once the initial assessment and resuscitation is underway, is it important to plan the next steps in immediate management. Priorities for care must be based on sound clinical judgement, patient presentation and response to therapies. Awareness of limitations in resources as well as training in the emergency field is vital. If escalation of care to senior staff is warranted, then do so early in the patient care episode. Do not wait until the patient deteriorates to ask for assistance.

Frontline clinical staff should initiate contact with ARV early in the patient care pathway or, more importantly as soon as it is identified that the patient meets the inter-hospital trauma transfer criteria or may have sustained injuries beyond the clinical skill set of the emergency department or urgent care service. ARV can be contacted at any time throughout the patient care episode to offer clinical advice and specialist consultation as well as expedite the retrieval process.

ARV coordinators can facilitate a three-way conversation between the referring health service, specialist clinical resources and an ARV consultant to discuss the best, timely management of the patient.

Indications for ARV consultation and / or transfer to a major trauma service

Neurological deficits:

  • Deterioration of neurological status (two points on the GCS), seizures, increasing headache, new central nervous system signs.
  • Persistence of headache, vomiting, confusion, or other neurological disturbance (GCS 9 – 13) > 2 hours post admission; no fracture.
  • GCS < 9 post resuscitation.

Skull fracture:

  • Skull fracture with confusion, decreased conscious state, seizure, focal neurological signs (pupil inequality, change in reactivity such as dilated pupils, pupils unreactive on one side, hemiparesis of the limbs) or any other neurological signs and symptoms.
  • Open skull fracture.
  • Depressed skull fracture.
  • Suspected base of skull fracture, for example, blood and/or clear fluid from the nose/ear, periorbital haematoma, mastoid bruising.

Abnormal CT scan findings:

  • Intracranial haematoma.
  • Cerebral swelling.
  • Aerocele (a cavity or pouch swollen with air).
  • Midline shift.

Patients who are on anticoagulants such as warfarin who sustain a TBI should also be discussed with ARV regarding transfer to a metropolitan neurosurgical service due to their increased bleeding susceptibility.

Isolated neurotrauma in older people

  • Patients over 65 years of age who have sustained their injury in a low (< 1 m) fall, and who present with isolated neurotrauma as described by the above criteria, may be referred via ARV for management at a metropolitan neurosurgical service (as an alternative to a MTS) .(22).
  • Once it has been identified that the patient requires specialist services, arrangements can be made for transfer to a definitive neurosurgical center for evaluation and management. This can occur concurrently with the stabilisation of the patient.
  • Discussions with family should always take place regarding the likelihood of patient outcomes, with clinicians taking all information onboard, so that an informed decision can be made regarding specialist neurosurgical advice. This reflects patient centered care and acknowledges that there are circumstances whereby limitations of care will be required.

The decision of when to transfer an unstable patient should ideally be made by the transferring and receiving clinicians in collaboration with the retrieval service. Clear communication is crucial: the transmission of vital information allows receiving clinicians to mobilise needed resources while the inadvertent omission of such information can delay definitive care. Information should be conveyed in both verbal and written (via the patient record) form and should include the patient’s identifying information, relevant medical history, pre-hospital management and emergency department evaluation and treatment (including procedures performed and imaging obtained).

It is important that additional communication with the ARV coordinator is initiated when there is:

  1. Significant deterioration in:
    • Conscious state.
    • Blood pressure.
    • Heart rate.
    • Respiratory status.
    • Oxygenation.
  2. Major clinical developments such as significantly abnormal diagnostic tests or new clinical signs.
  3. The need for major interventions prior to the retrieval team arriving (for example, intubation or surgery). This will ensure the retrieval team is prepared; the patient receives the appropriate care enroute and is referred to the correct facility.