Step 3: Simultaneous Team Action By Team Members
Immediately after the 10 seconds of silence, the team members work rapidly to obtain exposure, measure vital signs, obtain venous access, and draw blood. They apply monitor leads. They begin fluid resuscitation as directed by the team leader.
The flow of the resuscitation is such that the team leader cannot direct every move of the team. To do so would delay the initial survey and the subsequent pathway. During this phase, the team members work quickly, proceeding from task to task without waiting for orders from the team leader, but asking for direction whenever a choice must be made.
Exposure and
Vital Signs
Expose enough of the patient's body to obtain pulse and BP for
determining circulatory status.
PEDS: A Broselow Pediatric Emergency Tape may be used to quickly estimate the weight of a small child. Relay this information to the team leader. The tape, chart, or dosage book may be used to help select equipment sizes and medication dosages.
Completely undress the patient. In trauma patients, use scissors to cut clothing. Do not roll or lift the trauma patient to remove clothing. Be careful not to cut through bullet or knife holes because they are important as evidence.
Remove jewelry, money, and other personal belongings. Store these in a secure location. Check for bracelets or lockets that contain medical information. Check to see if the patient is wearing contact lenses. If so, inform the team leader. A clerical team member should inspect the patient's wallet for phone numbers and identification.
If a pneumatic anti-shock garment (PASG) is in place, do not remove or deflate unless directed to do so by the team leader. If the patient is wearing a PASG, cut clothing off at the crotch with scissors. Observe for the presence of blood on the underwear and at the tip of the penis. Report the presence or absence of blood to the team leader. Complete exposure is needed in all emergencies. Towels or sheets may be used to provide privacy during most of the resuscitation. Since exposure often contributes to hypothermia, warmth provided by an infrared lamp mounted on the ceiling above the cart can help to prevent hypothermia in adult patients. PEDS: Place all small children under warming lights.
Venous Access
Provide
access for medications and fluids by placing 2 large bore IVs in the
patient's arms. Ideally, insert two 16 or 14 gauge IVs. However, do not
ruin veins by trying to insert needles too large for them. Small IVs
may be dilated up to large size by using guidewire technique. Vol
II—CIRC SKILLS 2 CENTRAL VENOUS ACCESS
If veins are not visible or palpable, inform the team leader, who may need to resort to central venous access, vein cutdown, or intraosseous needle placement. Vol II—CIRC SKILLS 2 CENTRAL VENOUS ACCESS, CIRC SKILLS 5 INTRAOSSEOUS NEEDLE PLACEMENT, CIRC SKILLS 8 SAPHENOUS VEIN CUTDOWN PEDS: In infants and children < 7 years of age, the intraosseous approach may be best to use initially.
Laboratory
Studies
In adults, draw
approximately 40 mL of blood to fill the assorted tubes contained in a
CALS lab bag. The CALS lab bag also contains an armband with removable
stickers printed with an identifying number. Stickers are placed onto
the contained lab tubes, urine container, x-ray slips, and lab slips.
The armband is applied to the patient and serves to positively identify
the patient for lab and x-ray services.
The individual hospital decides which tests are available and useful in its setting. Here are some suggestions:
| Adult Medical | Adult Trauma | Pediatric (small tubes) |
| CBC and Hct | CBC and Hct | CBC and Hct |
| WBC | WBC | WBC |
| Platelet estimate | Platelet estimate | Platelet estimate |
| PT/PTT | PT/PTT | PT/PTT |
| Electrolytes | Electrolytes | Electrolytes |
| Anion gap | Anion gap | Anion gap |
| UA | UA | UA |
| Pregnancy test (if required) |
Pregnancy test (if required) |
|
| Blood glucose | Blood glucose | Blood glucose |
| Extra tubes for optional tests |
Blood alcohol | Extra tubes for optional tests |
| Cardiac enzymes | Type & cross | Calcium and phosphorus |
| Type & cross | Extra tubes for optional tests |
Toxicologies |
| Digitalis level | Fibrinogen | Type & cross |
| Calcium and phosphorus | Drug screen | Carbon monoxide |
| Toxicologies | Carbon monoxide |
Use a glucose monitor to obtain an immediate blood glucose level. Report the results immediately.
Monitor Leads and Oxygen
High-flow
oxygen is applied unless the team leader orders low-flow oxygen. ECG
leads are applied as soon as possible. Place them so they will not
interfere with subsequent central venous access attempts or
defibrillation. Place the monitor so that the team leader can easily
see the tracing.
Oxygen saturation monitors are often unable to
detect oxygenation in shocky patients. Also, carboxyhemoglobin will
register as oxyhemoglobin, giving a false number. If a patient's finger
nail polish interferes with monitoring, remove it with acetone or
polish remover.
Automatic blood pressure cuffs and monitors should
be compared to pressures obtained in the standard way. Many times these
monitors give false numbers when the patient is in shock.
Temperature
probes should be checked to be sure they can measure temperatures down
to 13°C (55°F). Temperatures this low may be seen in severely
hypothermic patients.
Fluid Resuscitation
Unless the team leader
instructs otherwise, begin NS as the initial IV fluid. Too much NS
(several liters in an adult) can result in hyperchloremic acidosis.
Ringer's lactate solution is more physiologically correct. However,
because it contains calcium, it can cause blood clotting in the tubing
when administered with blood. When a patient has suffered blood loss,
it is best to replace it with blood rather than just electrolyte
solution. If too much electrolyte solution is used, the blood becomes
hemodiluted, increasing the bleeding problem. Take great care to avoid
air embolism via IV lines. Also closely monitor the amount of fluid
given.
Another important measure is to administer fluids and blood through a high-flow fluid warmer. Hypothermia decreases the ability of the patient's blood to clot.
Tubes
Ask the team leader about the
advisability of inserting an orogastric or nasogastric tube. Use a
large tube in trauma or ingestion cases.
Ask the team leader about the need for a urinary catheter. In males, anesthetize the urethra by injecting about 5 mL of 2% lidocaine gel into the urethra prior to passing the catheter. Also in males, do not inflate the balloon until the catheter is inserted all the way to its hub and urine appears. This is because urine may appear in the catheter before it has entered the bladder. Do not pass a catheter in traumatized males when there is blood at the tip of the penis (urethral meatus) because this signifies a urethral injury.
In
a head-injured patient with a possible urethral injury, bladder
decompression using a suprapubic cystostomy may be needed. (Vol II—TRAU
SKILLS 4 SUPRAPUBIC CYSTOSTOMY)
Learn how to secure ET tubes in adults and (PEDS) infants. See Vol
II—AIR SKILLS 1 AIDS TO INTUBATION
PEDS: Achieve a high comfort level caring for children by familiarizing yourself with the tools and equipment that they require. Know where to look when questions arise.
X-rays
The trauma series of x-rays
will be ordered for almost all blunt trauma victims. The series
includes a chest x-ray, a lateral cervical spine x-ray, and a pelvic
x-ray. Team members may be asked to assist in obtaining these films.
Larson trauma blocks on the patient cart hold the patient's long board
up, making it easy to place x-ray cassettes under the patient. If your
institution has a CT scanner, make sure that you have a kit of critical
supplies and meds to take along if a CT scan is obtained.
In a rural setting, the roles of team leader and team members may be carried out by different individuals than in an urban setting. For example, a nurse may assume the role of team leader until a physician is available. Specialists may not be available. Nevertheless, the required tasks that must be accomplished for successful emergency care are not significantly different. The difference lies in how the workload is divided.