GCC Nursing Guide — Trauma Team & ATLS

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Trauma Team Activation Criteria

Mechanism

Physiology

GCS< 14

SBP< 90 mmHg

Respiratory Rate<10 or >29

Anatomy (High-Risk Injuries)

Flail chest (paradoxical chest movement)
Open or depressed skull fracture
Open fracture of femur
Unstable pelvic fracture
Paralysis or spinal cord injury
Amputation proximal to wrist/ankle

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Trauma Team Composition

Trauma LeaderED Consultant / Trauma Surgeon

Airway DoctorAnaesthesiologist / RSI-trained ED

Primary NurseAirway assist, C-spine, obs

Secondary NurseIV access, catheter, bloods

Documentation NurseTimestamps, drug chart, AMPLE

RadiographerPortable CXR, pelvis X-ray

RunnerLab specimens, blood bank

Blood Bank AlertO-negative uncrossmatched ready

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Documentation is a legal requirement. Timestamp every intervention, drug, and clinical finding. Use 24-hour clock. If it is not documented, it did not happen.

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ATMIST Handover from Pre-Hospital

A — Age

Patient age and relevant pre-existing conditions if known.

T — Time of Injury

Exact time injury occurred. Relevant for TXA window (within 3 hours) and ischaemia timing.

M — Mechanism

How the injury happened. High-speed RTA, fall height, type of penetrating object.

I — Injuries Found/Suspected

Confirmed injuries on scene. "Suspected" if not confirmed. Do not anchor — reassess everything on arrival.

S — Signs (Vitals on Scene)

GCS, SBP, HR, RR, SpO2 at scene. Trend is important — improving or deteriorating?

T — Treatment Given

Fluids administered, drugs given, tourniquet applied and time, chest seal placed.

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Pre-Arrival Resus Bay Preparation

Equipment to Check

Airway trolley — laryngoscope, ETT (range 7.0–8.5), bougie, LMA, surgical airway kit
Level 1 fluid warmer primed and ready
Defibrillator on and pads attached
Thoracostomy tray (chest drain kit, Heimlich valve)
Pelvic binder at foot of trolley
Tourniquet ×2 at head of trolley
Warming blanket active, room temperature raised to 26–28°C

Blood & Medications

O-negative blood: 4 units RBC + 2 units FFP in blood fridge
Massive transfusion protocol pack labelled and accessible
Tranexamic acid 1g in 100 mL NaCl drawn up and labelled
RSI drugs prepared: ketamine/thiopentone + suxamethonium/rocuronium
Adrenaline 1:10,000 drawn up
Calcium gluconate 10% available (for massive transfusion)

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Nursing Roles During Patient Reception

Primary Nurse

Positioned at head of trolley
Manual inline C-spine immobilisation during transfer
Assist airway doctor — suction, BVM, ETT confirmation
Attach continuous SpO2, ETCO2
Call out patient's own breathing effort

Secondary Nurse

Two large-bore IV cannulae (14–16G antecubital)
Draw blood: FBC, U&E, coag, cross-match, VBG, BM
Attach ECG, BP cuff, temperature probe
Insert urinary catheter once haemodynamically stable
Manage fluid and blood product administration

Documentation Nurse

Activate trauma documentation form on arrival
Record all vitals with exact timestamps
Document every drug, dose, route, and time
Record ATMIST handover details
Collect AMPLE history from relatives/paramedics

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cABCDE order is mandatory. Catastrophic haemorrhage control BEFORE airway. Each step must be completed and life threats treated before moving to the next. Call for help — do not work alone.

c — Catastrophic Haemorrhage Control

External life-threatening haemorrhage must be controlled before airway management. Visible exsanguinating haemorrhage kills in minutes.

Haemorrhage Control Methods (in order of escalation)

Direct pressure: firm continuous pressure with haemostatic gauze or dressing. Do not remove packing to check — continue pressure for minimum 3 minutes.
Tourniquet (limb wounds): apply 5–7 cm proximal to wound. Tighten until bleeding stops. Record application time on patient's forehead and tourniquet.
Wound packing: for junctional or truncal wounds not amenable to tourniquet. Pack tightly with haemostatic gauze (QuikClot/Combat Gauze). Apply firm manual pressure for 3–5 minutes.
Junctional pressure devices: groin, axilla, neck — SAM junctional tourniquet or manual pressure.

Nursing Key Points

Never use tourniquet on neck, torso, or pelvis
Tourniquets can remain in place for up to 2 hours with acceptable risk
Document tourniquet time — record in bold on body chart
Junctional haemorrhage (groin, axilla, neck junction) requires specialist haemorrhage control — call vascular or trauma surgery immediately

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Do NOT remove pelvic binder once applied — even for secondary survey. Binder reduces pelvic volume and allows clot formation.

A — Airway with C-Spine Protection

Airway Assessment

Can patient speak? (best assessment of patent airway)
Stridor, gurgling, or absent sounds
Look for blood, vomit, secretions, foreign body
Facial fractures — high risk of airway compromise

Airway Opening — Trauma Modification

Jaw thrust ONLY — never head-tilt/chin-lift in trauma (C-spine not cleared)
Yankauer suction — under direct vision, limit 15 seconds
OPA (Guedel): size 2–4 — only in unconscious patient (absent gag reflex)
NPA: size 6–8 mm — tolerated in conscious patients. Contraindicated in base of skull fracture

Definitive Airway Indications (RSI)

GCS ≤8 (inability to protect airway)
Burns to face/oropharynx — impending obstruction
Penetrating neck trauma with haematoma
Unconsciousness + active haemorrhage
Anticipated clinical deterioration

C-Spine Immobilisation

Manual inline stabilisation until hard collar applied
Hard collar + head blocks + straps for pre-hospital transfer
Log roll requires 4 people + lead (5 total)
C-spine clearance only by senior clinician after imaging

B — Breathing & Ventilation

Assessment

Expose chest fully — inspect, palpate, percuss, auscultate
Rate, depth, symmetry, accessory muscle use
Tracheal position (deviation = late, emergency sign)
SpO2 target: ≥95% (do not over-oxygenate in TBI)

Immediate Life Threats (ATOM FC)

Airway obstructionCleared in A step

Tension pneumothoraxNeedle decompression 2nd ICS MCL

Open pneumothorax3-sided occlusive dressing

Massive haemothoraxChest drain, fluid replacement

Flail chestAnalgesia, CPAP, may need ventilation

Cardiac tamponadePericardiocentesis / thoracotomy

Tension Pneumothorax — Recognise & Act

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Signs: absent breath sounds one side, hypotension, tachycardia, raised JVP, tracheal deviation (late). SpO2 plummeting. Do not wait for CXR — treat clinically.

Needle decompression: 14G cannula, 2nd intercostal space, midclavicular line, upper border of rib (avoids NVB). Hear hiss of air — confirms diagnosis.
Follow immediately with chest drain insertion (5th ICS anterior axillary line)
Reassess — if no improvement, repeat on opposite side

Open Pneumothorax Dressing

Apply three-sided occlusive dressing (Asherman or improvised)
One side open allows air out but not in on inspiration
Monitor for development of tension pneumothorax

C — Circulation & Haemorrhage Control

Vascular Access

Two large-bore IVs (14–16G) antecubital fossa — first choice
If IV fails after 2 attempts → IO access (proximal tibia, humeral head, sternal IO device)
Central venous access if required for vasopressors (not primary resuscitation route due to speed)

Haemodynamic Targets

Blunt traumaSBP 80–90 mmHg until haemostasis

Penetrating (no TBI)SBP 50–60 mmHg — minimal resuscitation

TBI presentMAP ≥80 mmHg (CPP protection)

eFAST Scan — Bedside Ultrasound

Pericardial effusion (cardiac view)
Haemoperitoneum (Morrison's pouch, splenorenal)
Haemothorax (bilateral pleural)
Pneumothorax (absence of lung sliding)

Tranexamic Acid (TXA) — CRASH-2 Protocol

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Dose 1: 1g IV over 10 minutes

Dose 2: 1g IV over 8 hours

Time window: within 3 hours of injury. After 3 hours — harmful, do NOT give.

Shock Classification (Class I–IV)

Class	Blood Loss	HR	SBP	GCS
I	<750 mL (<15%)	<100	Normal	Normal
II	750–1500 mL (15–30%)	100–120	Normal/↓	Anxious
III	1500–2000 mL (30–40%)	120–140	↓↓	Confused
IV	>2000 mL (>40%)	>140	Critical	Lethargy

D — Disability (Neurological)

GCSEyes + Verbal + Motor — record individual scores

PupilsPEARL — size, equality, reactivity

BM (blood glucose)Hypoglycaemia mimics head injury

Focal deficitLimb power, sensation, reflexes

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Unilateral fixed dilated pupil: ipsilateral uncal herniation until proven otherwise. Urgent neurosurgical review.

Maintain spinal precautions until imaging clears C-spine
Avoid hypotension and hypoxia — both worsen TBI outcome
Serial GCS — deterioration by 2 points = urgent CT head

E — Exposure & Environmental Control

Full exposureCut off all clothing, remove jewellery

Log roll5-person technique, PR exam, spine palpation

PR examinationSpinal injury, pelvic fracture, penetrating trauma

TemperatureCore temp — hypothermia <36°C worsens coagulopathy

Hypothermia Prevention (Lethal Triad Component)

Warm IV fluids and blood products via fluid warmer
Forced-air warming blanket (Bair Hugger)
Raise resus room temperature to 26–28°C
Minimise exposure time — cover immediately after examination
Remove wet clothing before covering

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Lethal Triad: Hypothermia + Acidosis + Coagulopathy. Recognition and targeted reversal of all three components simultaneously is the cornerstone of trauma resuscitation. Each potentiates the others.

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Massive Transfusion Protocol (MTP)

MTP Triggers

Ongoing haemorrhage with haemodynamic instability
Likely to require ≥10 units PRBC in 24 hours
ABC Score ≥2 (penetrating, SBP ≤90, HR ≥120, positive FAST)
Activation by trauma leader — nurse initiates blood bank call

1:1:1 Ratio Transfusion

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RBC : FFP : Platelets = 1 : 1 : 1

Prevents dilutional coagulopathy. Mirrors whole blood resuscitation.

Fibrinogen: target >1.5 g/L — give cryoprecipitate or fibrinogen concentrate early.

Nursing MTP Responsibilities

Call blood bank: MTP activation, patient ID, trauma bay location
Send runner to blood bank with labelled samples (G&S, crossmatch)
O-negative blood until crossmatched blood available
Document all units transfused — time, batch number, bedside check
Monitor for transfusion reactions — TACO, TRALI, allergic
Give calcium gluconate 10% 10 mL after every 4 units (citrate toxicity)
Recheck coag (fibrinogen, PT, APTT, TEG/ROTEM) every 30–60 min

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Permissive Hypotension Strategy

Rationale

Aggressive fluid resuscitation raises BP and dislodges clot — "popping the clot." Permissive hypotension maintains minimum perfusion while preserving haemostasis until surgical control is achieved.

Target SBP by Injury Pattern

Blunt trauma (no TBI)SBP 80–90 mmHg

Penetrating (no TBI)SBP 50–60 mmHg — minimal resus

TBI present (any mechanism)MAP ≥80 mmHg — CPP priority

DurationUntil surgical haemostasis achieved

Fluid Choice in Trauma

First lineWarmed blood products (1:1:1)

CrystalloidRestricted — NaCl 0.9% max 1–2L total

AvoidHartmann's in TBI (slightly hypotonic)

AvoidLarge volume crystalloid — dilutes clotting factors

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Hypotonic or glucose-containing fluids are contraindicated in TBI — worsen cerebral oedema.

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Damage Control Resuscitation vs Surgery

Damage Control Resuscitation (DCR)

Prioritise correcting coagulopathy before definitive surgery
1:1:1 MTP + TXA + correction of hypothermia and acidosis
Permissive hypotension during active haemorrhage phase

Damage Control Surgery (DCS)

Phase 1: haemorrhage control + contamination control (abbreviated laparotomy)
Phase 2: ICU resuscitation — warm, correct coagulopathy, restore physiology
Phase 3: return to theatre for definitive repair once physiology normalised

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Resuscitate while preparing for theatre — these are not sequential. Activate theatre while primary survey ongoing if major haemorrhage is confirmed.

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Blood Gas Targets During Resuscitation

pH target> 7.2

LactateClearance >10% per hour = improving

Base excessTarget BE > -6

Bicarbonate≥18 mmol/L target

Ionised Ca2+≥1.1 mmol/L (replete with Ca gluconate)

Fibrinogen≥1.5 g/L — give cryo if below

Temperature≥36°C core

Lethal Triad — Targeted Treatment

HypothermiaWarm fluids, blankets, warm room

AcidosisRestore perfusion, treat haemorrhage

CoagulopathyMTP 1:1:1, TXA, fibrinogen

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Secondary survey begins ONLY after primary survey is complete and life threats are addressed. Resuscitation must be underway. If patient re-deteriorates, return to primary survey (cABCDE) immediately.

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AMPLE History

A — Allergies

Drug allergies, contrast allergies (important for CT angiography). NSAID/aspirin intolerance.

M — Medications

Anticoagulants (warfarin, NOAC, heparin), antiplatelets, beta-blockers (mask tachycardia), steroids.

P — Past Medical History

Bleeding disorders, liver disease, cardiac conditions, previous surgery.

L — Last Meal

Fasting status — critical for RSI/GA. Risk of aspiration. Note for anaesthetics team.

E — Events Leading to Injury

Was there a medical cause of the trauma? (Collapse, seizure, MI causing RTA). "Medical cause of trauma" must be excluded.

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Head-to-Toe Assessment

Head & Face ▼

Scalp lacerations: can lose 1–2 litres — control with staples or sutures early
Palpate skull for depressions, step deformities, crepitus
Facial bones: Le Fort fractures, mandible, zygoma — assess for airway risk
Serial GCS — note and trend changes
Pupils — PEARL, anisocoria, Horner syndrome
Battle's sign (mastoid bruising) — base of skull fracture (delayed, 24–48h)
Raccoon eyes (periorbital bruising) — base of skull fracture
CSF from nose or ear — base of skull fracture

Neck ▼

C-spine immobilisation maintained until cleared
Penetrating neck injury: Zone I (below cricoid), Zone II (cricoid to angle of jaw), Zone III (above angle of jaw)
Tracheal position — deviation is a late and emergency sign
Haematoma — expanding haematoma is surgical emergency
JVP assessment — elevated in cardiac tamponade, tension pneumothorax; absent in haemorrhage
Tracheal crepitus — subcutaneous emphysema suggests pneumothorax or tracheobronchial injury

Chest ▼

Rib fractures: ≥3 consecutive = flail segment if paradoxical movement
CXR: widened mediastinum suggests aortic injury
Haemothorax: dull percussion, decreased air entry — chest drain (5th ICS, anterior axillary line)

Chest Drain Nursing

Document output hourly — >200 mL/h for 2h = thoracic surgery
Ensure underwater seal integrity at all times
Swinging and bubbling — check on drain not clamped
Cardiac tamponade: Beck's triad (muffled sounds, raised JVP, hypotension) — emergency pericardiocentesis

Abdomen & Pelvis ▼

eFAST: haemoperitoneum in Morrison's pouch, perisplenic, pouch of Douglas
Absent bowel sounds — normal early in trauma (do not reassure)
Peritoneal signs: guarding, rigidity, rebound = laparotomy
Seat belt sign — bruising across abdomen: small bowel/mesenteric injury
Flank bruising — retroperitoneal haematoma (renal, aortic)
Distension — haemoperitoneum (can hold 3–4 litres silently)

Pelvic Fracture

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Pelvic binder at the level of the greater trochanters — NOT the iliac crests. Reduces pelvic volume. Do NOT remove once applied. Haemodynamic instability + pelvic fracture = angioembolisation referral.

Do NOT spring the pelvis in primary survey — risk of clot disruption
Log roll: examine posterior pelvis for lacerations, perineum
Urethral injury: blood at meatus → urological review before catheter

Extremities ▼

Fracture Assessment

Distal neurovascular status: pulse, sensation, motor function, capillary refill
Femur fracture: 1–2 litres blood loss per fracture — apply traction splint
Open fractures: culture swab, wound dressing, early IV antibiotics (co-amoxiclav), orthopaedic review

Compartment Syndrome

6 Ps: Pain (out of proportion), Pressure, Paralysis, Paraesthesia, Pallor, Pulselessness (late)
Measure compartment pressure if suspected: >30 mmHg or within 30 mmHg of diastolic BP = fasciotomy
Remove all circumferential dressings and splints if compartment syndrome suspected
Hourly neurovascular observations mandatory post-fracture

Neurological — Full Assessment ▼

GCS: record E+V+M individually, document trend
Spinal cord injury — ASIA Impairment Scale: A (complete) to E (normal)
Dermatomal sensory level: locate highest level of injury
Priapism in male patient — sign of spinal cord injury until proven otherwise
Log roll: palpate entire spine for midline tenderness, step deformity
PR: anal tone — absent tone suggests cauda equina or cord injury at sacral level

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Traumatic Brain Injury (TBI)

Nursing Priorities

Avoid hypotension (SBP <90 mmHg doubles mortality)
Avoid hypoxia (SpO2 <95% independently worsens outcome)
Head of bed 30° — reduces ICP, maintains venous drainage
Avoid neck rotation — impairs jugular venous drainage
Normocapnia: ETCO2 35–40 mmHg on ventilated patient
Avoid hyperthermia (target normothermia 36–37°C)

ICP Management

ICP target< 20 mmHg

CPP target60–70 mmHg (MAP - ICP)

Mannitol 20%0.5–1 g/kg IV bolus — osmotic diuretic

NaCl 3%Hypertonic saline — preferred in haemodynamic instability

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Bilateral pupils fixed and dilated = immediate neurosurgery. Mannitol 1g/kg stat, intubate, transfer.

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Spinal Cord Injury

Immobilisation Protocol

Manual inline stabilisation at all times until imaging
Hard collar + head blocks + tape for transfer
Log roll: 4 people minimum (5 including leader)
Pressure area care from outset — no sensation = no feedback
Urinary catheter early — neurogenic bladder

Methylprednisolone

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No longer routinely recommended (NASCIS III). May be considered by spinal surgeon within 8 hours of acute injury — consultant decision only.

Neurogenic Shock — Recognise

HRBradycardia (sympathetic loss)

BPHypotension (vasodilation)

SkinWarm, flushed (below injury level)

DistinguishingNo tachycardia — key difference from haemorrhagic shock

Treatment

IV fluids (cautious — risk of pulmonary oedema)
Vasopressors: noradrenaline to maintain MAP ≥85 mmHg for 7 days (spinal perfusion)
Atropine or temporary pacing for severe bradycardia
Transfer to spinal injury unit as soon as stabilised

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Penetrating Chest Trauma

Haemopneumothorax: chest drain 5th ICS — up to 1.5L of blood possible
Cardiac injury: stab wound mediastinum — eFAST cardiac view, Beck's triad
Emergency thoracotomy: ED resuscitative thoracotomy for penetrating trauma with witnessed cardiac arrest (<10 min CPR)
Oesophageal injury: subcutaneous emphysema, mediastinitis, pleural effusion — CT oesophagram required
Aortic injury: widened mediastinum on CXR, haemothorax — CT angiography urgently

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Paediatric Trauma

Broselow tape: weight-based drug dosing for all ages — mandatory in paediatric trauma
Higher surface area to volume ratio — hypothermia risk is greater
Fontanelle assessment in infants — bulging = raised ICP
Non-accidental injury (NAI): multiple bruising in different stages, inconsistent history, delay in presentation — safeguarding referral mandatory
IO access: proximal tibia preferred in children <6 years
Tachycardia is the primary shock response in children — BP maintained until late decompensation

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Elderly Trauma

Higher mortality from same mechanism of injury — less physiological reserve
Anticoagulated patients: warfarin (reverse with vitamin K + PCC), NOAC (idarucizumab for dabigatran, andexanet alfa for Xa inhibitors)
Beta-blockers mask tachycardia — normal HR does not exclude significant haemorrhage
Pre-existing osteoporosis: fragility fractures from lower-energy mechanisms
Subdural haematoma: relatively more frequent after minor head trauma (cerebral atrophy, bridging veins under tension)
Lower threshold for CT head, chest, and pelvis imaging

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GCC Trauma Context

Road traffic accidents: GCC countries have among the highest RTA mortality rates globally. High-speed motorway collisions and non-seatbelt use are major factors.
Construction & occupational trauma: large migrant worker population in UAE, Saudi Arabia, Qatar — falls from height, crush injuries, machinery trauma
Penetrating injuries: workplace tools, machinery — less common than in Western urban trauma but present
Language barriers: use trained interpreters — do not use family for medical interpretation in trauma
Cultural considerations: female patients — ensure female chaperone present for exposure and intimate examination where possible
Ramadan: delayed presentation if injury during fasting hours — increased time from injury to treatment

Category	Criterion	Action
Mechanism	RTA >60 km/h, fall >3m, penetrating torso/head, pedestrian vs vehicle	Full trauma team activation
Physiology	GCS <14	Trauma team + CT head
Physiology	SBP <90 mmHg	MTP pre-alert, blood bank activate
Physiology	RR <10 or >29	Anaesthetics to bedside
Anatomy	Flail chest, open femur, pelvic fracture, spinal injury	Full activation + orthopaedics