SPECIAL ARTICLE J Trauma Inj 2020;33(2):63-73 https://doi.org/10.20408/jti.2020.0020 JOURNAL OF TRAUMA AND INJURY Part 2. Clinical Practice Guideline for Trauma Team Composition and Trauma Cardiopulmonary Resuscitation from the Korean Society of Traumatology Oh Hyun Kim, M.D., Ph.D.1, Seung Je Go, M.D.2, Oh Sang Kwon, M.D.3, Chan-Yong Park, M.D., Ph.D.4, Byungchul Yu, M.D.5, Sung Wook Chang, M.D.6, Pil Young Jung, M.D., Ph.D.7, Gil Jae Lee, M.D., Ph.D.5, KST (Korean Society of Traumatology) Clinical Research Group Received: June 17, 2020 1Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Accepted: June 23, 2020 Wonju, Korea 2Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea 3Department of Trauma Surgery, Cheju Halla General Hospital, Jeju, Korea 4Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea 5Department of Traumatology, College of Medicine, Gachon University, Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea 6Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea 7Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea Correspondence to Gil Jae Lee, M.D., Ph.D. Department of Traumatology, College of Medicine, Gachon University, Department of Trauma Surgery, Gachon University Gil Medical Center, 783 Namdong-daero, Namdong-gu, Incheon 21556, Korea Tel: +82-32-460-3010 Based on the revised recommendations, the final recommendations were confirmed Fax: +82-32-460-2372 after collecting opinions from trauma experts, experts from the Korean Society of E-mail: [email protected] Traumatology, and research method experts using the Delphi technique (Table 1). SHOULD A TRAUMA UNIT BE ESTABLISHED IN ORDER TO TREAT TRAUMA PATIENTS? Recommendation A. A trauma unit must be established in order to treat severe trauma patients (1C). B. The‌ trauma unit should be activated to respond within an appropriate time rela- tive to the scale of the medical institution (1C). http://www.jtraumainj.org Copyright © 2020 The Korean Society of Trauma This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License eISSN 2287-1683 (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and pISSN 1738-8767 reproduction in any medium, provided the original work is properly cited. Journal of Trauma and Injury Volume 33, Number 2, June 2020 Evidence summary studies have reported that only two doctors are needed to effectively treat trauma patients [12,13], other studies 1. Configuration of trauma units have reported the need to have more than two doctors in It is internationally understood and established that the trauma unit depending on the severity of the patient. different medical specialists and personnel must work The interpretation, experience, and education of each together to treat polytrauma patients. In many developed trauma unit differ according to local circumstances. It is countries with trauma units, the completion of a profes- stated in South Korea’s administrative guideline for trau- sional trauma program such as Advanced Trauma Life ma centers that a trauma unit must be able to respond Support, the Japan Advanced Trauma Evaluation and within 10 minutes and must consist of general surgeons, Care, or the European Trauma Course is required to join thoracic surgeons, neurosurgeons, and emergency med- a trauma unit. Multiple studies have reported that the icine physicians. However, only 16 trauma centers meet establishment of specialized trauma units has many ad- these criteria, and most emergency departments in South vantages [1-4]. However, no study has evaluated the most Korea do not satisfy these criteria. appropriate configuration of the trauma unit. The mem- bership of a trauma unit depends on the location and 2. The role and qualifications of the team leader institution-specific circumstances [5-11]. Although some The role of the team leader is to assess patients’ data, con- Table 1. Scores from the Delphi technique (Likert scale 1-9) Key question Recommendation Mean SD 1 Should a trauma unit be estab- A A trauma unit should be established in order to treat severe trauma patients (1C). 8.1 1.5 lished in order to treat trauma B The trauma unit should be activated to respond within an appropriate time 8.3 1.6 patients? relative to the scale of the medical institution (1C). 2 Should activation of the trauma A A stratified response system maximizes medical resources and thus should be 7.5 1.2 unit be stratified depending on considered (2B). the severity of the trauma injury? 3 What are appropriate physiological A The physiological criteria for trauma unit activation are the following (1B): 6.4 2.3 criteria for trauma unit activation? A. Respiratory rate <10 or >30 breaths per minute B. Systolic blood pressure <90 mmHg C. Heart rate >100 bpm D. GCS <13 4 What deceased should be made A Cardiac resuscitation must follow the standard cardiac resuscitation guideline 8.0 2.0 when CPR is being performed in (1A). trauma patients? B When CPR is being performed, the correction of reversible causes of cardiac 8.6 0.5 arrest should be performed regularly (1B). 5 What indicators should be used A When a trauma patient is being treated with cardiac resuscitation, end-tidal CO2 7.2 2.3 to monitor trauma patients with is recommended to be used as an indicator to decide whether to terminate cardiac arrest? resuscitation treatment and to predict the patient’s death (1B). B Although arterial cannulation can objectively measure the efficiency of the 7.1 1.6 CPR being performed and help diagnose cardiac arrest, cannulation must not delay or stop the process of CPR (2C). 6 What situations require CPR to A Termination of CPR must be considered when resuscitation is not successful 7.5 1.9 be initiated and terminated for after the reversible cause of the cardiac arrest is corrected (1C). trauma patients? B CPR termination must be considered if the patient is determined to have died 7.8 1.8 or exhibits signs and injuries that are unlikely to be survivable (1C). SD: standard deviation, GCS: Glasgow coma scale, CPR: cardiopulmonary resuscitation, MTP: massive transfusion protocol. 64 https://doi.org/10.20408/jti.2020.0020 Oh Hyun Kim, et al. Guideline for Trauma Team and CPR sider multiple treatment options, and swiftly decide on a al. [22] reported that when a trauma doctor resides in treatment plan. Leadership requires the ability to facilitate the hospital, the diagnosis was quicker and the operation communication among members and to work out an was also faster. However, in cases of severe thoracic and interdisciplinary agreement. Hoff et al. [14] reported that head trauma, the time to intensive care treatment was not the implementation of a team leader led to improvements affected [1,2,10]. Wyatt et al. [23] reported that when an in the treatment process of a trauma patient. Further- experienced doctor treated severe trauma patients (1,427 more, Alberts et al. [15] reported that after the implemen- patients, injury severity score [ISS] >15), the survival rate tation of a “trauma unit leader”, the outcomes of trauma was higher than when doctors without much experience patients improved. The team leader must have superb treated these patients. It is also recommended that acute knowledge regarding the treatment of polytrauma pa- trauma patients be reevaluated within 24 hours of their tients and experience in interdisciplinary treatment, which initial treatment in order to prevent additional complica- consists of being able to assess the patient depending on tions. the situation, treat and monitor, consult with other med- Although trauma centers in South Korea are not grad- ical specialties, adjust the medical team, and explain the ed, the 16 trauma centers that exist function as level I decision process in the trauma unit to the patient’s legal centers. Therefore, it was determined that this clinical guardian. It is important that the interdisciplinary meth- practical guideline was acceptable and applicable within od of treatment does not cause a lag in the treatment pro- South Korea. cess, which underscores the importance of establishing a treatment guideline [14,16,17]. According to a nationwide survey of trauma centers conducted by the American Col- SHOULD ACTIVATION OF THE TRAUMA lege of Surgeons Committee on Trauma (ACSCOT), one- UNIT BE STRATIFIED DEPENDING ON fourth of team leaders were trauma surgeons and one-half THE SEVERITY OF THE TRAUMA INJURY? were general surgeons [17]. Although it was reported that the time to surgery was faster when the team leader was Recommendation a trauma surgeon, there was no significant difference in A stratified response system maximizes medical resources survival outcomes [18]. The main role of the team leader and thus should be considered (2B). is to manage the trauma unit. The management of a team involves recording the team members’ competencies, and Evidence summary researching and making decisions at every step of diagno- sis and treatment through discussion and agreement. In 1. Activation of the trauma unit trauma, a team leader must possess the ability and qualifi- In an effective trauma system, the patient’s status and cations to follow standard guidelines through an interdis- severity must be determined and the patient must be ciplinary approach to medicine [19]. transported prior to activating the trauma unit. Not only does the matrix triage system provide a more efficient 3. Response time way to treat severe trauma patients, but it also reduces The response time is defined as the time from the pa- transportation costs. The American Trauma Society states tient’s arrival to the initiation of treatment by the trauma that 25% to 35% patients are overtriaged, whereas 5% are team doctor [20].