Olen Bogert BSN RN CEN CPEN TCRN CCRN This abbreviated document has been prepared for speaker presentation purposes only and can not be substituted for AT 3 course content. Rights to all images, content, and concepts presented here are retained and may not be reproduced without the expressed written consent of the author(s), and may not be used or otherwise implemented for commercial or other institutional use. v. 041820
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Transcript
Olen Bogert
BSN RN CEN CPEN TCRN CCRN
This abbreviated document has been prepared for speaker presentation purposes only and can not be substituted for AT 3 course
content. Rights to all images, content, and concepts presented here are retained and may not be reproduced without the expressed
written consent of the author(s), and may not be used or otherwise implemented for commercial or other institutional use.
v. 041820
Welcome to the AT 3 course - [PART-1]! This course is intended to prepare the experienced emergency provider to care for critically ill and injured patients in a
dynamic team environment. The content presented will expose the learner to the core components of the ideal trauma
team, highlight anticipated challenges, and discuss techniques used to maximize the safety, efficiency, and streamlined
outcomes common in highly effective trauma resuscitations. To maximize learning potential, each learner is required to
prepare themselves for the course with the resources provided and arrive to the course ready to participate in a number
of simulated roles and situations outside of their typical job parameters. Please pick up your copy of the Student Packet
from the ED administrative office at least seven (7) days prior to class.
STUDENT PACKET CONTENT
● AT 3 skills validation form
● Team role cards
● Presentation worksheets
● Scavenger hunt worksheet
● Trauma nomenclature form
● Procedure/tray guidelines
● Trauma criteria form
● TNP flowsheet
● Trauma charting flowsheet
● Course completion instructions
PRE-COURSE PREPARATION
1. Review & Read: Student Packet contents
2. Complete “Self Assessment Code” column of AT 3 Skills Validation form
3. View all online skill review videos - follow the following link:
• Visceral hemorrhage20. Managing Trauma in Pregnancy
• Placental abruption
• Uterine rupture
• Premature labor
• Maternal positioning
• Fetal monitoring (FHT or EFM)21. Penetrating Injury Management
• Gunshot wounds
• Stab/slashing wounds
• Impalements
4
22. Pediatric Trauma Considerations
• Circulatory assessment
• Fluid/blood resuscitation
• Lund & Browder chart
• Non-accidental trauma
• Broselow tape
23. Other Trauma Concepts
• Electrocution
• Evidence preservation
• Log-roll vs. team lift for posterior assessment [V]
• Drowning/near drowning
Critical Skills Evaluation SAC VO Date Initials
ED NURSE ONLY1. Utilizes Trauma Activation Criteria to initiate alert and response
teams2. Complete activation, PMH, and prehospital documentation on
flowsheet3. Complete GCS assessment; records Height/Weight4. Complete Primary and Secondary Survey on flowsheet5. Identify appropriate interventional and reassessment
● Place patient on monitor and set frequency q. 5-10 minutes as indicated
● Assist with tasks on Designated Side:○ IV/IO access x2○ Obtain blood sampling○ Central venous access○ Arterial access & monitoring○ Chest tube insertion & drainage
● Ensure Type & Cross band is correct and placed to pt wrist
● Assist with splinting and immobilization● Collect and bag patient belongings, provide to
security as indicated● Maintain chain of custody if forensic evidence if
suspected or found
● Announce name and role to Trauma RN-1● Supervise initial trauma resuscitation and
interventions● Prioritize care planning and communication with
radiology, blood bank, and OR● Combined trauma care with Emergency
Provider
● Announce name and role to Trauma RN-1● Lead initial stabilization of patient and complete
primary interventions as indicated● Complete and call out Primary and Secondary
assessment findings to Trauma RN-1● Combined trauma care with Trauma Surgeon● Ensure trauma protocols and additional orders
are placed for progression of care● Communicate with other specialty providers
immediate needs and plan of definitive care
● Announce name and role to Trauma RN-1● Maintain presence at head of bed● Place initial oxygen and basic airway adjunct as
indicated● Initiate capnography monitoring● Manage airway and breathing within scope of
practice● Assist with basic and advanced airway
management as indicated● Manage mechanical ventilation● Draw and send ABG if ordered● Assist and accompany during patient transport
MATCH TASKS & ROLES (select all that apply) 1. Places monitoring devices during ini�al pa�ent contact. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 2. Announces name and role to recording lead upon arrival to resus room. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 3. Obtains blood sampling. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 4. Places NRB at 15 Lpm to adult pa�ents upon arrival to resus room. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 5. Removes pa�ent clothing and places warming measures. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 6. Places orders for interven�on, imaging, and treatment during resus. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 7. Obtains IV or IO access. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 8. Manages massive transfusion of blood and serum products during resus. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 9. Obtains manual BP upon pa�ent arrival and reports to team leaders. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 10. Places rigid cervical collar if indicated or ordered by provider. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 11. Assists staff with donning of PPE. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 12. Assists ED or trauma providers with Primary/Secondary survey. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 13. Reports medica�on administra�on to team lead for recording. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 14. Assists with wound care, splin�ng, and other interven�ons as assigned. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon 15. Places core temperature monitoring devices during ini�al resuscita�on. ▢ Nurse-1 ▢ Nurse-2 ▢ ED Technician ▢ Resp Therapy ▢ ED Provider ▢ Trauma Surgeon
Give an example of using the Shared Mental Model [SMM]: _________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Give an example of a 3-Step-Summary [3SS]: _____________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Give an example of Task-Switching: _____________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
EFFECTIVE TEAMS vs SOURCES OF CONFLICT Place a star next to each item associated with effec�ve teams - Circle each poten�al cause of team conflict.
LABEL EACH POSITION WITH THE APPROPRIATE TEAM ROLE - ADULT & INFANT:
Dynamic teams are made of individuals of variable training that may not be familiar with their assigned role, may not be
familiar with the standards of communication during the resus, and may share the same goals of the team but have
variable understandings of the process.
How do we Manage Dynamic Teams?
▫ Model team leadership
▫ Review allocation of roles
▫ Review role expectations
▫ Practice closed-loop communication
▫ Emphasize the Shared Mental Model [SMM]
▫ Tasking checklists
▫ 3-Step-Summary [3SS]
Key Characteristics of Leadership:
Situational Awareness
▫ A big picture view of the process and anticipation of error or complication
▫ Avoids fixation on tasks or distracting elements that are not the current priority
Mindfulness
▫ Adopting a leadership mentality will all associated responsibilities
▫ Awareness of team dynamics and the leader’s role in shaping the mood of the resus environment
A Common Problem...
Team leaders are often expert providers and may become distracted trying to assist or participate in hands-on care. This
“task-switching” prevents the leader from participating completely in either task, leads to error & delay, and imparts
confusion on other team members in the absence of a clear leadership role.
Expectations of the Team Lead:
▫ Clearly identified to other team members
▫ Positioned in an area of clear vision
▫ Reaffirms roles and expectations
▫ Clearly and calmly spoken
▫ Positive in communication
▫ Assertive in demeanor
▫ Effectively summarizes and reorients as indicated
Team Member Expectations
▫ Identify name and role to Trauma RN-1
▫ Don appropriate PPE while in resus room
▫ Wear role sticker and badge for identification
▫ Speak only to report interventions, findings, voice concerns, or seek clarification
▫ Interact in a mutually respective and professional manner
▫ Depart the trauma room when excused by Team Lead or tasking is no longer needed
Team Briefing
Team leads will address the assembled team members and use known information to summarize priorities, an
anticipated course of care, and destination planning. Preparations are reviewed and an opportunity to ask questions or
voice concerns is provided prior to the patient’s arrival.
Team Briefing - first 30 seconds:
▫ Type of patient
▫ Type of trauma/injury
▫ Causative mechanism
▫ Severity/stability
▫ Provider’s level of concern
▫ Known/potential injuries
▫ Priorities and anticipated course of care
Effective Teams…
Allocate Tasks to Individuals:
Naming individuals with tasks reinforces roles, provides efficiency in tasking, and cements personal responsibility for
completion of duties assigned.
Provide Concrete Time Frames:
Setting timed goals focuses the team dynamic, reduces idle conversation, and minimizes distraction as each member
keeps the clock in mind.
Effective Teams…
Closed Loop Communication:
Instructions given will be read back; findings reported will be read back; care planning will be summarized.
This minimizes error and contributes to the SMM
Other Elements of Success:
Mutual trust
Mutual performance monitoring
Backup behaviors
Adaptability
Sources of Conflict
Too much help:
▫ Excess staff “helping” in the resus room is often more distracting and leads to breakdown in the organized
approach to care.
▫ Problems include intrusiveness, distraction, incorrect prioritization, opinion conflicts, and incorrect interventions
Sources of Conflict
Cognitive Emergency Reaction:
▫ When faced with stressors, people may revert to ingrained, dogmatic, or reactionary habits
▫ Examples: aggressiveness, non-constructive criticality, task focusing, tunnel-vision, loss of situational awareness
Sources of Conflict
Distraction:
▫ Staff members or consults not part of the initial team briefing may repeat questions already addressed, call out
findings already noted, and frequently fail to adhere to the expectations and decorum of communication put
forth by the team leader
Sources of Conflict
Conflicting opinions:
▫ Trauma and ED providers may not agree on the best course of care or intervention for an abnormal or
emergency finding.
▫ Specialty providers may request imaging prior to surgery while another may request direct OR admit
Sources of Conflict
Inappropriate Intrusiveness:
▫ Senior or more assertive staff may micromanage others of dictate interventions outside their role
▫ Opinions may be offered that are not appropriate and may result in power struggles or intimidation
The majority of conflict during any trauma resus will arise from…
** POOR COMMUNICATION **
Sources of Conflict
Individual factors:
▫ Fatigue, individual stressors, time on shift, and prior experiences all contribute to interpersonal conflict
▫ These factors slow cognition, shorten tempers, retard critical thinking, and reduce the individual's ability to cope
with stress
Sources of Conflict
Hierarchy:
▫ Senior providers and team members may dominate others less experienced or new to the team
▫ Newer or less experienced members of the team may be less like to report errors, challenge wrong decisions, or
interrupt flawed thinking pathways
Sources of Conflict
Knowledge factors:
▫ Knowledge deficits can precede stress and anxiety
▫ Lack of familiarity with policy, procedure, or other team members can cause interpersonal frustration
▫ Prioritization may differ between individuals with varying knowledge focuses
Sources of Conflict
Toxic personalities:
▫ Egotism, narcissism, and sociopathy may be seen in any team member, regardless of specialty
▫ Excessively passive, introverted, or avoidant personalities may cause issue as well, as they may be less apt to
speak up or act independently when warranted
Resolution Techniques…
Be Nice:
Extend niceties to force the urge to reciprocate.
Nice people are harder to be mean to and peer pressure will reinforce the imbalance
Be Authoritative:
Being overly collaborative and accommodating may undermine progress - be directive and tell rather than ask.
Stay Objective:
Redirect subjective arguments by focusing on the facts, the current priorities of care, and the patient as the victim of
disagreement.
Resolution Techniques
Ask for Help:
Asking shows a willingness to include individuals in the team process.
Keep the request narrow to avoid a runaway power shift.
Physical Gestures:
Not that kind of gesture…
A simple handshake or welcoming gesture when team members arrive creates and inclusive environment.
Power of the Group:
Deindividualization of disagreements or arguments helps put focus back of the best interests of the patient - reinforces
each team member as part of the group.
Resolution Techniques
Review the SMM:
Reviewing the goals of care, using the 3SS if needed, reinforces mission trajectory and reinforces the need for a cohesive
team approach.
Change the Context:
Summarize or restate the issue in question - it could be a simple misunderstanding or error made during
communication.
Pre-supposition:
Restate any issues in question as fact to imply inherent truth to the idea.
Ideas stated as truth, versus opinion, are harder to argue against.
Resolution Techniques
Ask for Clarification:
Pausing to request clarification can expose errors in judgement, help redirect the care process, or otherwise defuse a
growing conflict.
Seek Another Opinion:
If there is disagreement between providers, a third outside opinion is warranted and may provide justification in either
direction.
Refer to Policy:
Referencing protocol or policy can solidify arguments when there is a question of process or procedure.
When all else fails, have policy on your side.
TRAUMA NOMENCLATURE STANDARDIZATION Acknowledge “Acknowledge 100 mcg Fentanyl IV Push, now.”
“Acknowledge absent breath sounds on right and prepare chest tube tray.” “Manual blood pressure 84/56, please acknowledge. Affirma�ve, start MTP.”
Affirma�ve (yes) “Confirm posi�ve FAST exam of right upper quadrant. Affirma�ve”
Nega�ve (no) “Bleeding controlled with tourniquet? Nega�ve.” “Confirm menta�on unchanged from last assessment. Nega�ve, pt now unresponsive to pain.”
Read Back “Read back primary assessment findings please.” “Read back verbal medica�on order please.”
Say Again “I say again, collect 2 units PRBC in a trauma cooler from lab.” “Say again �me of fentanyl administra�on.” “Say again ET tube size and depth.” “Say again etomidate and sux dosage.” “I say again, quiet in the room please.”
Stand By “Can you confirm ET tube placement? Stand by…” “Confirm eFAST findings. Stand by…”
That is Correct “Con�nue C-spine immobiliza�on? That is correct.” “Confirm palpable step-off of mid thoracic spine. That is correct”
Unable “Unable to establish IV access, IO will be placed.” “Unable to establish a response to painful s�muli.”
Abort “Abort intuba�on a�empt, resume bag mask oxygena�on and prepare for cricothyrotomy.”
Cancel “Cancel normal saline bolus, ini�ate MTP.” “Cancel CT scan and contact OR for immediate transfer.”
Correc�on “End �dal reading 31… correc�on end �dal reading 28.” “ET tube depth 23cm at the lips… correc�on 22cm at the gums.”
Confirm “Confirm: radial pulses are absent in le� extremity.” “Confirm number and type of blood units administered thus far, please.” “Confirm OR ready to receive pa�ent.” “Confirm IV placed to le� AC 16 gauge. Affirma�ve” “Confirm wound loca�on, size, and depth please.”
Request “Request current oxygena�on satura�on.” “Request current �me to OR ready.” “Request ready of chest tube tray and two collec�on kits, please.”
Resume “Resume intuba�on, second a�empt.” “Resume primary assessment please.” “Resume trac�on and prepare to splint with posterior long leg.”
Time “Time since last analgesia?” “Time to OR ready?”
Con�nue “Con�nue MTP un�l further advised.” “Con�nue wound packing and pressure, prepare for OR transfer.”
Go Ahead “Request for task clarifica�on. Go ahead…” “Request to review assessment findings and plan of care. Go ahead…”
Maintain “Team lead, maintain hemodynamic stabiliza�on and prepare for OR admit.” “RT, maintain mild hyperven�la�on on vent.”
(Yankauer, Big-Tip)● Bedside US machine with probe
cover● Cautery pen
1. Assist in positioning patient for anterior chest procedure; place trash can on provider’s working side; have bedside US available if requested
2. Assist with airway/breathing, chest tubing, and infusion monitoring as indicated
3. Administer generous analgesia/anesthesia PRN
4. Respond to provider instruction as directed
NOTE: RED TIP
STAPLER
● Stryker box with manometer and needles
● Sterile gloves/gown/face shield● Chlorhexidine Swabs (1)● Local anesthesia as ordered
1. Assist provider with patient positioning as directed
2. Provide patient with reassurance and comfort during procedure
3. Clean and return items to proper storage
Physiological Indicators (Adult) Systolic BP <90 Respiratory rate <10 or >29 sustained GCS ≤ 12 Unable to adequately ventilate a patient Respiratory arrest or intubation Traumatic Paralysis Traumatic Arrest Requiring blood transfusion or
vasopressors to maintain blood pressure
Physiological Indicators (PEDS <15) Tachycardia for age plus poor perfusion
(cap refill > 2 seconds) Systolic BP not appropriate for age
(70+[2 x age]) Respiratory rate not appropriate for age GCS motor score < 5
Anatomic Indicators:
Penetrating injuries to:
• Head, neck, torso
• Extremities proximal to elbow or knee
Amputation proximal to wrist or ankle
Fractures:
• Bilateral femur fractures
• Unstable pelvis
Motor Vehicle Crash (MVC) With ejection High speed (>55mph) Unrestrained with rollover Death in the same compartment Major vehicle damage (>12” of intrusion
into the passenger compartment, or extrication and patient with injuries)
Falls (Falls measured from the patient’s feet) ≥ 15 feet ≥ 2 x height if a child age ≤ 6 years
Motorcycle Crash (MCC/ATV) Crash speed > 35 mph
Geriatric Patients (≥ 65 years of age) with 2 out of 3 of the following: SBP < 110 Anticoagulation Therapy (Anti-platelets not included)
Head injury with LOC
Other: Non-Accidental Trauma (NAT) in
pediatric patients Pedestrian or bicyclist struck by a car at
speed >20 mph Ejection from an animal Blast or explosion
Other Considerations: Consider Trauma Consult
Age < 5 or > 65 Co-Morbid conditions Anticoagulation Presence of intoxicants Pregnancy > 20 weeks Three or more rib fractures Bicycle, skateboard, or rollerblade injuries Burns: 2nd or 3rd degree and/or to face, hands, feet, groin, or inhalation
Full Trauma Team Activation (FTTA) Criteia Limited Trauma Team Activation (LTTA) Criteria
Limited Trauma Team Activation (LTTA)
If the injury is >12 hours old, do not initiate a
Trauma Activation unless patient is unstable;
instead consider “Trauma Consult”
*May activate a LTTA/FTTA at any time per physician discretion.
*Any field activation will be honored.
TRAUMA NURSING PROCESS [TNP]
INITIAL CONSIDERATIONS Activate the trauma team, PPE, Consider Decontamination, Special Equipment? 60 Seconds of Silence [SSS] for EMS Report or HPI Uncontrolled Hemorrhage? → C-ABC Initial LOC – Alertness