Step 1: Activate the Team
As soon as it is known that a critically ill or injured patient is coming to the emergency facility, summon all of the needed personnel. Critical care transport may also be activated.
In most rural settings, a physician is available 24 hours a day. If not present at the hospital, the physician is usually available on call. In a remote (or wilderness) setting, however, the most experienced health care professional available must function as team leader. Under such circumstances, a physician's assistant or nurse practitioner with emergency experience and training may fulfill this role. Team membership may include prehospital personnel, laboratory and x-ray technologists, respiratory therapists, clerical personnel, physicians, and other allied health care givers (such as physician assistants, nurse practitioners, nurses, and nurse anesthetists).
Early notification of all team members is essential. Provide prehospital personnel with protocols regarding the early notification of ground or air inter-facility transport providers. In most rural areas, delivery of the patient to the rural ED for immediate stabilization is the most practical approach (as opposed to scene response), even when transfer to another facility will be necessary. Local geography and weather may dictate which approach to use. In a wilderness setting, an intercept point between the local prehospital personnel and an inter-facility critical care transport team may be arranged to good advantage.
Inter-facility transport by air or critical care transport should not delay the immediate resuscitation of a critically ill or injured patient. The rural ED team must initiate and continue the resuscitation until the patient is in as safe a condition as practical for safe transport.
The Minnesota Trauma Care Taskforce provided model protocols for team activation at trauma stabilization facilities for the Minnesota Department of Health in July of 1995. These are listed here with additional suggestions for non-trauma emergencies:
Indications for Team Activation
-
Mobilize the hospital emergency care team if scene personnel note
the following traumatic conditions:
- Unconsciousness
- Airway compromise that cannot be resolved by foreign body removal, airway adjuncts, or ventilatory support
- Systolic BP < 90
- Tachycardia and tachypnea in conjunction with decreased LOC and delayed capillary refill, especially when associated with evidence of injury
- Uncontrolled hemorrhage
- Penetrating injury of the head, neck, chest, abdomen, or groin
- Fracture of 2 or more proximal long bones
- Amputation proximal to the wrist or ankle
- Second- or third-degree burns of 15% or more of the total body surface area (TBSA) or in combination with other injuries
In addition, scene personnel should strongly consider notification of inter-facility transfer vehicles (ground ALS, airplane, or helicopter).
-
Be suspicious that critical injury may have occurred and that the
emergency care team may need to be activated for the following:
- Motor vehicle crashes (MVC) where one of the following factors has occurred:
a. Ejection from the vehicle
b. Death in the same passenger compartment
c. Extrication time > 20 minutes
d. Major deformity of the vehicle > 20 inches
e. Intrusion > 12 inches into the passenger compartment
f. A pedestrian or a bicyclist struck (at more than 5 mph), thrown, or
run over
- Falls of > 20 feet
- Strongly consider activating the emergency care team by prehospital or hospital personnel if one of the following non-trauma situations exists:
- Newborn infant:
a.
With any signs of weak breathing or crying, limp or weak extremities,
or cyanosis that does not improve with oxygen or 30 seconds of
bag-valve-mask (BVM) oxygen ventilatory support
b. With a fetal heart rate (FHR) < 80 and any baby requiring
chest compressions
c. Rhythmic activity that could be seizure activity
- Obstetrical patients who exhibit:
a. Significant second or third trimester vaginal bleeding
b. FHR < 120 beats per minute (bpm)
c. Tetanic uterine contractions
d. Seizures
e. Hypotension or hypertension
f. Prolapsed umbilical cord or footling presentation
g. Shoulder dystocia manifested by the turtle sign
- Pediatric patients who exhibit:
a. Unconscious or stuporous state
b.
Marked respiratory distress or apnea from any cause including status
asthmaticus, croup, foreign body aspiration, or unknown causes
c. Hypotension from any cause
d. Status epilepticus
e. Anaphylactic reaction and/or angioneurotic edema
- Adult patients who exhibit:
a. Depressed LOC (unless cause is apparent and easily treated)
b.
Marked respiratory distress or apnea from any cause, including tracheal
foreign body, status asthmaticus, pulmonary edema, respiratory failure,
or pulmonary embolus
c. Chest pain with any indication of probable myocardial infarction
d. Anaphylactic reaction and/or angioneurotic edema
e. Cardiac arrest
f. Unstable cardiac arrhythmias
g. Shock state or severe hypertension from any cause
h. Pulmonary edema
i. Severe hypothermia or hyperthermia
j. Evidence for cardiac tamponade
k. Evidence for tension pneumothorax
l. Evidence for leaking abdominal aortic aneurysm
m. Evidence for dissection of the thoracic aorta
n. Gastrointestinal bleed with unstable vital signs
o. Near drowning patient