The ATLS is designed such that the lone doctor can safely look
after a multiply injured patient. Tasks are performed in sequence,
one after the other. This 'vertical organization' is the least efficient
method of proceeding, and where more than one member of staff is
available, a team approach is usually employed. This 'horizontal
organization' has been shown to lead to significant reductions in
The trauma team is ideally made up of a group of doctors, nurses,
operating department assistants, radiographers and other support
personnel who have no o ther commitment that day than to receive
and treat trauma patients. Obviously this is a very expensive arrangement,
and most hospitals cannot afford this level of cover. If the doctors
involved are residents, senior consulting staff should be immediately
available if necessary. Many centres now have their trauma teams
led by consultants.
The Core Trauma Team is that group of professionals that receives
and treats the patient. This includes :
Additional staff outside of this group need to be mobilized to provide
- Team Leader
- Anaesthetic Assistant
- General Surgeon
- Orthopaedic Surgeon
- Emergency Room Physician
- Two Nurses. (Three if no anaesthetic assistant)
- Scribe (Nurse or doctor)
Other staff, while not necessarily involved in every trauma call,
need to be available to the trauma team immediately :
- Porters - to run samples to the lab, collect blood etc.
- Haematologist and Biochemist to receive and process samples.
- Blood Bank
Certain areas need early notification of the trauma victim.
- Thoracic Surgeon
- Plastic Surgeon
The core trauma team comprises 10 people working around a single patient.
It is vital that everyone knows their place and their tasks, and has
the skills, equipment and support to accomplish these. The trauma
room should be quiet so that the voice of the team leader can be heard
and assessments from team members can be relayed back to him. Vital
signs should be called out every five minutes and these must be heard
- CT Scanner
- Intensive Care
With practice and exposure the trauma team becomes an efficient
machine that is exciting and compelling to watch or be part of.
Trauma Team Tasks.
The Team Leader
The Team Leader should not touch the patient. Instead he acts
as conductor of the orchestra. Responsibilities of the team leader
The trauma team leader should be the most experienced team member
present before the patient arrives in hospital. The leader's role
should not be superseded by late arriving members or passing senior
staff. This avoids confusion for the team members of who to take direction
from and who to report to.
- Obtain history from paramedics.
- Direct team members in their actions.
- Establish priorities for investigation and management.
- Order or authorize investigations and procedures.
- Keep track of whole state of the patient.
- Receive and interpret all results of investigations
- Order fluid or blood administration.
- Supervise spinal manoeuvres.
- Consult with other specialities.
- Decide on appropriate disposition.
- Talk to relatives.
- Write in the notes.
- Record audit information.
- Dismiss and debrief team members.
- Educate trauma team.
The anaesthetist has a central role in the trauma team. Responsibilities
- Airway Control
- Cervical Spine Control
- Monitoring of vital signs.
- Monitoring of fluid and drug administration.
- Provide anaesthesia for surgical procedures.
The general surgeon focusses on assessment of the thorax, abdomen
and head if no neurosurgeon is on the core trauma team. Responsibilities
- Pimary Survey
- Assessment of thorax and abdomen, head and facial injuries.
- Thoracostomy or thoracotomy.
- Diagnostic peritoneal lavage.
- Urinary Catheter
Emergency Room Physician
- Intravenous access.
- Assessment of spine, pelvis.
- Application of external fixator.
- Assessment of limb injury.
- Dressing of wounds and stabilization of fractures.
- Urinary Catheter.
Some overlap is necessary between the general surgeon, orthopaedic
surgeon and emergency department physician to ensure that tasks continue
simultaneously and no time is lost and no hands wasted.
- Intravenous access.
- Venous and arterial blood samples.
- Urinary Catheter.
- Assist with diagnostic peritoneal lavage.
If their is no anaesthetic assistant on the trauma team, one nurse
should be solely dedicated to the anaesthetist. Otherwise nurses
should attach themselves individually to each hands-on surgeon or
ED physician and assist in their tasks. The nurses should not have
to leave the resuscitation room to fetch equipment or run samples
to the labs. Ancillary staff should be outside the main resus area
to provide this.
The radiographer should immediately start with the trauma series
of X-rays, in the order Cervical Spine, Chest and Pelvis, unless
directed otherwise by the team leader. Once these have been processed,
other views may be required by evidence of other injuries. The radiographer
should also act as liaison to the CT scanning department.
The scribe is responsible for the full record of the trauma call.
A separate individual, either doctor or nurse should be allocated
to the roll. They should be situated near the team leader so that
all information passing through the leader is then passed to the
scribe. Records must include :
- Time of arrival.
- Mechanism of injury.
- Personnel present at call
- Physical findings
- Vital signs. Urine output. Glasgow Coma Scale.
- Results of X-rays and other investigations.
- Fluids administered.
- Drugs administered.
- Previous Medical History.
- Summary of injuries.
- Disposal of patient.
The aim of the trauma team is to provide a safe and efficient
evaluation of the patient. Identify all injuries and instigate definitive
management of such injuries. The golden hour starts at the time
of injury. So most trauma teams will have about 30 minutes to accomplish
this and should work towards achieving this goal.