Victim with Severe Injury
An individual can become seriously injured in various ways. Some examples of injury mechanisms are as follows: motor vehicle crashes (as a passenger or pedestrian), falls, being struck by an object, stabbings, and gunshot wounds. Emergency trauma care is needed to save the individual’s life and to prevent or reduce the risk for complications and disabilities.
EMS Dispatch and Pre-Arrival Instructions
The emergency medical services (EMS) system is the essential service that coordinates and provides initial care to the injured patient. Once a bystander calls 911 to seek help for the victim, the emergency medical dispatcher sends EMS care providers to the scene of the injury and gives the bystanders instructions for care until the EMS providers arrive.
EMS Field Triage and Transport
EMS providers assess the injured victim with the aid of field triage protocols and medical direction to determine the severity of injury and the appropriate medical facility destination. A communication system is needed to enable EMS providers to obtain medical direction when the patient care needs exceed protocols and to alert the trauma center that they need to prepare for the patient’s arrival. The goal is to match the victim’s emergency care needs to the medical facility equipped with the right resources to provide the optimal care. This approach may mean bypassing the closest hospital to send the victim to the highest level of care – a trauma center. In some locations, the trauma center is too distant or the patient needs stabilization before going to the trauma center. In this case, the victim is transported to the closest trauma system hospital.
Trauma System Hospital
A trauma system hospital may be a designated trauma center (level III, IV, or V) or a trauma system participating community hospital. The hospital’s trauma response team assesses and treats the victim’s life-threatening injuries. Once the patient is stabilized, preparation for interfacility transfer to the higher level trauma center occurs when appropriate. Physicians and nurses in these participating trauma hospitals receive education so they can identify and stabilize seriously injured patients until the interfacility transfer occurs. The trauma system hospital is often capable of treating victims with mild or moderate injuries. Such patients are admitted to the trauma system hospital, thus reducing the potential for overwhelming the higher level trauma center with too many patients.
Trauma victims needing a higher level of care than the trauma system hospital can provide are sent by ground ambulance or air medical ambulance (helicopter or fixed wing plane, depending upon the distance to the trauma center and services available) to the trauma center. In some states and regions, critical care transport (by ground or air) is available with specially trained health professionals to provide essential care during transfer. In other states and regions, patients transferred by ground ambulance are accompanied by community paramedics, nurses, or physicians to provide essential care during transfer.
Trauma Center and Team Activation
A trauma center is a regional medical center that has the specialized resources and health professionals to care for victims with critical injuries 24 hours a day, 7 days a week. Optimal care and cost-effectiveness is obtained when a large number of injured patients are treated in the trauma center each year, and the volume of patients also enables the health professionals to maintain their skills. Hospitals are expected to meet criteria (either the American College of Surgeons' or the state’s designation criteria) for designation as a trauma center. Criteria for designation include resources such as health professional qualifications, essential equipment, and services, as well as trauma patient data submission to the state trauma registry and quality improvement processes.
The trauma team activation occurs once the trauma center is notified that a trauma victim with severe injuries is coming so that all essential health professionals will be in the trauma resuscitation room of the emergency department prior to the patient's arrival. Essential health professionals include surgeons, emergency physicians, nurses, an anesthesiologist or nurse anesthetist, radiology technicians, and a family support professional (e.g., social worker, chaplain, or nurse). Other important members of the trauma activation team include communication coordinators, laboratory medicine couriers (to bring blood products to the trauma resuscitation room and to send specimens to the laboratory), and security. Once the patient arrives at the trauma center, the trauma team performs continuous assessments and provides care for life threatening injuries until the patient is transferred to the operating room or intensive care unit. In some cases the patient is sent for interventional radiology before transfer to the intensive care unit.
Operating Room and Interventional Radiology
Patients with severe injuries may be sent to the operating room directly from the trauma resuscitation room or after admission to the intensive care unit. Surgery is performed to control bleeding and to repair damage caused by the injury.
The patient may be sent directly from the trauma resuscitation room to interventional radiology where a catheter angiogram can be performed to identify and possibly occlude damaged blood vessels that could cause life-threatening bleeding.
Intensive Care Unit
Patients with severe injuries are cared for in the intensive care unit so they can be carefully monitored for signs of worsening condition and complications of injury. Life sustaining interventions are provided, such as ventilation, medications, fluids, and nutrition. Initial evaluations for rehabilitation often occur in this setting.
General Care Unit and Early Rehabilitation
Once the patients’ condition has stabilized and life-sustaining interventions are no longer needed, the patient is moved to a general care unit in the hospital for nursing care and ongoing monitoring. Rehabilitation begins with physical and occupational therapy support. A case manager begins working with the family to identify the most appropriate next stage of care – inpatient rehabilitation, home with outpatient rehabilitation, or a skilled nursing facility.
Patients with severe injuries need rehabilitation services. Depending upon the type of injury and its severity, rehabilitation may occur in different settings. For example, patients with brain or spinal cord injuries often go to inpatient facilities for an intensive rehabilitation program. Some patients can be managed at home with outpatient rehabilitation services (either in-home or in an office setting).
A patient with a condition that cannot be managed at home or in a rehabilitation facility, e.g., ventilator-dependence, may be sent to a skilled nursing facility.
Home and Follow-Up Care
Patients sent home need community follow-up care with their primary care provider and rehabilitation services.
Injury Epidemiology and Prevention
Data from all injured persons (e.g., mechanism and severity of injuries, mortality rates, morbidity, and functional outcome) are essential for trauma system planning in a state or region, and to determine which injury prevention programs would be most valuable. Injury mortality and morbidity can be measured from data collected by a state (e.g., vital statistics data, hospital discharge data, and the trauma registry). Functional outcome data are often collected by rehabilitation facilities.
Coordinated injury prevention programs that address the most common injuries in a community, region, or state and the population group (e.g., children, elders, teen drivers, specific occupations, etc.) in which they occur are important to reduce the number of injuries in the population. Injury prevention programs may be coordinated by the state, community organizations, or trauma centers. Many injury prevention programs are developed by national organizations or the federal government for implementation within states.