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108
M. A. Vella et al.
aspect of a resuscitation that was done well can be used to
maintain a positive TVR culture. If there is a particularly
challenging case or a case during which a complication or
unexpected event occurs, it is advisable to discuss the case
with the primary clinician prior to group review; TVR should
never surprise those involved on the day of a multidisciplinary conference. Given the high-stakes nature of trauma
resuscitations and the interplay between providers that
occurs, it is unavoidable that TVR will occasionally capture
negative interpersonal interactions. In such circumstances,
we recommend that trauma video review never be used as an
arbitration tool, to settle disputes between individuals, or in
a punitive manner, as surely conict resolution can be
achieved between professionals without co-opting quality
improvement efforts.
Future Directions
Recent evidence suggests that TVR utilization is likely to
increase [12]. Cloud-based storage and online-integrated
review platforms (See Fig.15.2) allow for relatively simple
integration of a TVR program into both in-person and virtual
conferences. The incorporation of articial intelligence (AI)
with video review is an area of emerging interest, with one
recent paper discussing the utilization of these merged tech-
nologies to identify the critical view of safety during laparoscopy cholecystectomy [49]. Continued interest in the eld of
surgical safety and transparency in the operating room has
led to the development of platforms that integrate multiple
audiovisual feeds with patient data to create a robust timeline
of operating room events [50]. This technology is also
equipped with multiple AI algorithms to detect intraoperative thermal injuries and bleeding events [51, 52]. As this
technology becomes increasingly available, it is likely to
reach the trauma resuscitation bay, allowing for important
variables like movement in and out of the trauma room,
sound, and team dynamics to be studied in ways that were
never before possible [6].
Additionally, there is a burgeoning interest in incorporating wearable technology in both the operating and trauma
resuscitation rooms for video-based activity recognition and
for use in evaluating surgeon ergonomics and technique [7,
53]. Video review technology has also emerged as a valuable
tool in the intensive care unit setting, allowing for review of
critical ICU events like cardiopulmonary resuscitation, airway management, bedside procedures, and team dynamics
[54, 55]. We anticipate that video review technology will
have an increasingly important role in the evaluation of nontraumatic yet time-sensitive resuscitations occurring in the
emergency department, such as those related to acute coronary syndrome and stroke.
Fig. 15.2 Example of a cloud-based user interface showing camera views for multiple trauma rooms as well as demonstrating the availability of
time stamp, fast-forward, and re-wind functions
15 Trauma Video Review
109
Conclusion
Video review technology along with video-based trainee
education and assessment will only increase over the next
decade. This technology and its myriad of applications will
undoubtedly improve the quality of care administered to
patients in the trauma resuscitation bay, the operating room,
and beyond. It is crucial for trauma practitioners to be at the
forefront of video review advancement and implementation.
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47. Oakley E, Stocker S, Staubli G, Young S.Using video recording
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Med. 2017;92(7):1035–42.
Creating aCRM Toolkit
Zero point survey
Identify team goals and set mission trajectory
LawrenceMarshall Gillman andPeterG.Brindley
For healthcare professionals who are used to learning facts
and “hard” science, Crisis Resource Management (CRM)
skills training can sometimes seem vague and theoretical if
not presented in a concrete manner. For example, discussing
adult learning concepts without offering clear actionable
ways, these can be applied in a trauma resuscitation may not
be helpful to many learners. For this reason, when teaching
the STARTT (Simulated Trauma and Resuscitative Team
Training) Course, we like to help learners create their own
CRM toolkit with several discrete tools that can be easily
retrieved from memory and utilized during stressful trauma
resuscitations. In this chapter, we hope to offer some examples of such tools such that the reader may create their own
toolkits.
Pre-arrival
While there always will be trauma patients walking in or
dropped off at the door, allowing no time for pre-preparation,
ideally most trauma patients transported by EMS will allow
for a trauma pre-alert based on established trauma team activation criteria, allowing the trauma team members to gather
and prepare prior to patient arrival. Pre-arrival checklists
allow the team to prepare in a standardized manner to ensure
16
Pre-resuscitation
S Self
Physical readiness: I’M SAFE
Cognitive readiness: breathe,talk, see, focus
T
Te am
Leader identified
Roles allocated
Briefing
Repeat as nonclinical situation
changes
Fig. 16.1 Zero-point survey and the STEP-UP mnemonic
nothing is forgotten in the heat of the moment. These checklists can be easily modied to t local practices. One such
checklist is the zero-point survey discussed in Chap. 11
(Fig.16.1 and Table16.1) [1]. Others can help ensure proper
equipment and personnel are present (Fig.16.2).
Environment
E
Danger, space, light, noise, crowd control
Resuscitation commenced
PPatient
Primary sur vey ABCDE
Update
Share mental model of patient status
Priorities
Repeat as clinical
situation changes
L. Marshall Gillman (*)
Department of Surgery, Clinical Learning and Simulation Program,
University of Manitoba, Winnipeg, MB, Canada
e-mail: Lawrence.Gillman@umanitoba.ca
P. G. Brindley
Department of Critical Care Medicine, University of Alberta
Hospital, Edmonton, AB, Canada
e-mail: Peter.Brindley@albertahealthservices.ca
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_16
111
112
Table 16.1 I’M SAFE checklist
I Illness
M Medical
S Stress
A Alcohol
F Fatigue
E Emotion/Eating
Adapted from Ref. Reid etal. [1]
Trauma / Pre-arrival
What we know (mechanism, vitals, AVPU)
Team leader and roles assigned
Anticipation / Priorities
Equipment (US, blood, binder, chest tube)
D
M
I
S
T
L. Marshall Gillman and P. G. Brindley
Demographics
Mechanism of injury
or
Medical Complaint
Injuries
or
Illness
Vital Signs
Treatments Provided
Age, sex, weight (if pertinent)
Medical: OPQRST as
appropriate
Mechanism: Speed, mass,
height of fall, restraints, type
of collision, safety device use,
type of weapon
Injuries: Head it toe, significant
findings
Info: ECG, stroke scale, SAMPLE
GCS, pulse, resp., BP, SpO2,
BSG if applicable
Tx: Tubes, Iines, meds,
electrical therapy, O2, wound
care
Trends: Responses to
treatments
Airway cart, BVM, suctioin
Peds? Broselow tape + bag
Environment (calm, crowd control)
Listen to EMS handover
Fig. 16.2 Pre-arrival checklist. (Retrieved from: https://frozendoc.
com/2021/03/16/trauma- checklists/, June 14, 2023)
Patient Arrival
In the absence of an imminent airway emergency or CPR in
progress, there is generally time for a pause prior to or following patient transfer from the EMS stretcher to receive
EMS handover. A structured handover ensures pertinent
data is communicated in a concise and organized fashion.
D-MIST is a commonly used tool for this purpose
(Fig.16.3). A variation of this is the IMIST-AMBO handover protocol (Table16.2).
Fig. 16.3 D-MIST handover. (Retrieved online from: https://www.
ptsf.org/wp- content/uploads/2020/10/PA_DMIST_Poster.pdf, June 14,
2023)
Table 16.2 IMIST-AMBO handover protocol
I Identication
M Mechanism
I Injuries
S Signs
T Treatment and Trends
A Allergies
M Medications
B Background History
O Other Information
Adapted from – https://www.slhd.nsw.gov.au/BTF/pdfs/Education/
ISBAR/IMIST_AMBO.pdf. June 14, 2023
Resuscitation
During the resuscitation, there are a number of tools that can
help prepare the team for procedures and keep the group on
track. The most discrete example is an airway timeout.
Essential components of an airway time out ensure that medications are prepared, equipment is prepped, and back-up
ADDRESS QUESTIONS OR CONCERNS BEFORE PROCEEDING
16 Creating aCRM Toolkit
113
Fig. 16.4 Example of an
airway timeout
PROTECTED INTUBATION CHECKLIST (BRING THIS INTO ROOM)
PATIENT
Position optimized for intubation
O
source on the patient
2
Monitors On and initial Vital Signs documented
MEDICATIONS
Intravenous functional
Consider pretreatments to support hemodynamics: Fluid bolus, Norepinephrine
infusion at 0.1 mcg/kg/min prior to RSI
Rapid Sequence Induction (RSI) Drugs ready
EQUIPMENT
Confirm PPE on appropriately
Ventilator ON with initial settings
In-line Suction on circuit
Bag Valve Mask with filter attached
Suction (tested)
Video Laryngoscope
Endotracheal tube (appropriate size, cuff tested, syringe ready)
Bougie
Forceps
PEEP valve
End-Tidal CO
Endotracheal tube holder and bite block
Orogastric tube
Additional rescue airway equipment readily available outside patient room – LMA,
cricothyroidotomy kit
PLAN
Reassessment of airway for difficulty
Huddle to review plan for medications and approach to airway and backup
approach to airway
st
1
attempt using Video Laryngoscopy +/– Bougie
nd
2
attempt plan described by Airway MD
Post-intubation management discussed – sedation/analgesia/vasopressors
Detector
2
Airway MD to Read
plans in event of failed airway capture are identied.
Figure16.4 is an example of a comprehensive airway timeout
used in our local center during the COVID-19 pandemic.
A simpler example is the SALTED mnemonic
(Table16.3). Again, these can be easily adapted for local use.
A comprehensive ATLS resuscitation checklist may be
redundant or unnecessary in a tertiary care center but may be
very useful in a smaller center that treats complex trauma
patients on a rare or intermittent basis (Fig. 16.5 and
Table16.4). [2]
Table 16.3 SALTED mnemonic
S Suction
A Airways (oral airways)
L Laryngoscope (Video or Direct
or Both)
T Tube (planned size plus size
below)
E End-tidal
D Drugs and difcult airway needs
(if applicable)
114
L. Marshall Gillman and P. G. Brindley
Pre-arrival Plan
Check or prepare:
Oxygen
Suction
Bag and mask
Intubation tray
Intubation medications
Defibrillator
CPR board
Consider ordering blood
Assign team roles:
Airway
IV/IO access
Primary survey
Team leadership
Brief team on incoming
patient
Estimate weight:______ kg
A
B
C
D
E
RE-
EVALUATE
AIRWAY
MONITOR
VITALS
Primary Survey
Confirm C-spine is immobilized
Confirm airway is protected
mask or connect existing mask to O
Place O
2
Check pulses
Establish IV/IO access
Consider ordering blood
State GCS (eyes, verbal, motor)
State pupil size and response
Completely remove patient’s clothing
Cover patient with warm blanket
Evaluate need for intubation
Report FT tube size and depth (if applicable)
Confirm ETCO2 color change (if applicable)
Confirm heart rate is displayed
Confirm pulse ox waveform is displayed
State and evaluate whether WNL:
Heart rate
Respiratory rate
Blood pressure
Oxygen saturation
Temperature
Secondary Survey
Evaluate and state findings:
Head
Ears
Eyes
2
Facial bones
Nose
Mouth
Neck//C-spine
Chest
Abdomen
Pelvis
Upper extremities
Lower extremities
Log roll and back exam
Determine need for:
Laboratory tests
X-rays
CT scans
OR notification
PICU notification
State patient destination
Prepare patient for travel:
Equipment
Medications
Identify who will travel with patient
Plan of Care
Departure Plan
Ye s
Ye s
Ye s
Ye s
Ye s
No
No
No
No
No
Fig. 16.5 ATLS resuscitation checklist. (Retrieved online: https://www.nicepng.com/ourpic/u2w7r5y3i1t4y3u2_trauma- resuscitation- checklist-
used- in- the- checklist- atls/, June 14, 2023)
Table 16.4
Trauma transfer checklist
Continue to Care
Establish and maintain spinal motion restriction. Remove scoop stretcher if present and logroll as necessary
Document vital signs and neuro signs q15min
All documentation on trauma notes for CTAS 1 and 2
Airway and breathing
Conrm ability to maintain adequate oxygenation/ventilation
Consider need for endotracheal tube (ETT): Declining GCS, GCS < 8, inhalation injury, maxillofacial injury or other airway concern
Consider need for chest tube: Conrm and document chest tube functioning and placement prior to departure; make necessary
adjustments
If intubated
Will require escort for ground transport
Conrm ETT position via: auscultation, end tidal CO2 and chest x-ray
Secure ETT, monitor O2 sats and ETCO
2
Insert gastric tube
Ensure adequate analgesia and sedation to RASS-4
Circulation
Control all active bleeding sites—apply pressure dressing, sutures, staples; consider tourniquet if indicated
Establish two large bore peripheral IVs (extension tubing required for air transfers)
Pregnancy test for all women of child-bearing years (do not delay transfer for results)
Ensure patient and uids are warmed
Bleeding or suspected bleeding (adult and pediatric) consider tranexamic acid bolus and infusion if within 3h from time of injury
(continued)
16 Creating aCRM Toolkit
Table 16.4 (continued)
Consider anticoagulant reversal
Consider blood products
Apply pelvic binder/stabilization, if applicable
Insert Foley catheter with urometer, if applicable
Disability
Review medications proposed for use during transfer with the TCP
Cover open fractures with saline dressing
Reduce and splint extremity fractures (avoid air splints)
Control pain
Prophylaxis
Antibiotics: for all open fractures; consider for all penetrating trauma
Tetanus as required
Check glucose
Expose/Environment
Prevent hypothermia
Document temperature
Assess posterior surfaces; remove from scoop stretcher
Consider Logistics
Team required for transfer: Consider RN, RRT and/or Air Ambulance Crew
RN recommended for analgesia, sedation, blood products, and any transfer when scope of practice exceeds that of transport crew provided
Equipment required for ground transfer:
Airway management/O2 saturation/ETCO2 monitoring
Blood and blood products properly packaged by lab personnel for transfer, if applicable
Orders required for transfer
Resuscitation: airway control/debrillation
Medications: including sedation, analgesia, paralytics and anticonvulsant, if applicable
Blood/blood products and I.V. uid
Conrm targets for O2 sats, ETCO2, RASS, BP, MAP parameters during transfer
Documentation to accompany patient
Photocopies of all ED physician notes, nurses’ notes, and initial ambulance call report
Team leader at sending site to directly contact team leader at receiving site once transfer arrangements are conrmed
Adapted from: TraumaNB Trauma Transfer Checklist https://nbtrauma.ca/wp- content/uploads/2022/02/Trauma- Transfer- Checklist- Nov- 2021- bil.
pdf
115
Pre-departure
Prior to leaving the trauma bay, a pre-departure checklist
can be helpful to ensure all pertinent exams, and investigations are completed in the trauma bay and that all prepara-
tions for transport have been made. This checklist will vary
depending on location, for example if transport is within
hospital to CT scan, or OR, or interfacility transport
(Fig.16.6).
116
Fig. 16.6 WHO trauma care
checklist. (Reproduced from
Trauma Care Checklist,
https://www.who.int/
publications/i/item/traumacare- checklist, retrieved
online November 13, 2023)
L. Marshall Gillman and P. G. Brindley
Trauma Care Checklist
Immediately after primary & secondary surveys:
IS FURTHER AIRWAY INTERVENTION NEEDED?
May be needed if:
• GCS 8 or below
• Hypoxaemia or hypercarbia
• Face, neck, chest or any severe trauma
YES, DONE
NO
IS THERE A TENSION PNEUMO-HAEMOTHORAX?
IS THE PULSE OXIMETER PLACED AND FUNCTIONING?
LARGE-BORE IV PLACED AND FLUIDS STARTED?
FULL SURVEY FOR (AND CONTROL OF EXTERNAL
BLEEDING, INCLUDING:
ASSESSED FOR PELVIC FRACTURE BY:
ASSESSED FOR INTERNAL BLEEDING BY:
IS SPINAL IMMOBILIZATION NEEDED?
NEUROVASCULAR STATUS OF ALL 4 LIMBS CHECKED?
IS THE PATIENT HYPOTHERMIC?
DOES THE PATIENT NEED (IF NO CONTRAINDICATION):
Before team leaves patient:
HAS THE PATIENT BEEN GIVEN:
HAVE ALL TESTS AND IMAGING BEEN REVIEWED?
WHICH SERIAL EXAMINATIONS ARE NEEDED?
PLAN OF CARE DISCUSSED WITH:
YES, CHEST DRAIN PLACED
YES
YES
SCALP PERINEUM
EXAM
EXAM
DIAGNOSTIC PERITONEAL LAVAGE
YES, DONE
YES
YES, WARMING
URINARY CATHETER
CHEST DRAIN
TETANUS VACCINE
ANTIBIOTICS
YES
NEUROLOGICAL
VASCULAR
PATIENT/FAMILY
PRIMARY TEAM
NOT INDICATED
X-RAY
ULTRASOUND CT
NOT INDICATED
NO
NASOGASTRIC TUBE
NONE INDICATED
ANALGESICS
NONE INDICATED
NO, FOLLOW-UP PLAN IN PLACE
ABDOMINAL
NONE
RECEIVING UNIT
OTHER SPECIALISTS
NO
NOT AVAILABLE
NOT AVAILABLE
BACK
CT
RELEVANT TRAUMA CHART OR FORM COMPLETED?
Communication Skills
During crisis, CRM training can help improve communication and teamwork. There are some discrete tools that can
be pulled out in certain circumstances to help facilitate
communication and mitigate confusion. The simplest of
these is the 3-C’s of closed loop communication
(Table16.5).
YES NOT AVAILABLE
When team members wish to bring a concern to leader/
team’s attention, this can sometimes pose a challenge.
There are a number of tools that can give members important verbiage that can convey their message in a way that
doesn’t threaten or undermine the leader’s role but still
makes their concerns heard by focusing on the patient’s
safety. These include the PACE levels of graded assertiveness (Table16.6) and the CUS mnemonic (Table16.7).
16 Creating aCRM Toolkit
117
Table 16.5 3 C’s of closed loop communication
C—Cite names
C—Clarity of communication
C—Close the loop
Table 16.6 PACE levels of graded assertiveness
P PROBE—“Did you know that…?”
“Did you realize the sat probe tracing is poor?”
A ALERT—“Can we re-assess the situation…?”
“Can we re-assess the situation as the patient is no longer
breathing?”
C CHALLENGE—“I don’t think we should…because”
“I don’t think we should paralyze this burn patient because
they may have a difcult airway”
E EMERGENCY—“Stop what you are doing…”
“Stop trying to intubate the patient, the patient is hypoxic, we
need to proceed with a surgical airway now”
Table 16.7 CUS mnemonic
I am Concerned!
I am Uncomfortable!
This is a Safety Issue!
Structured Handovers
Table 16.8 SBAR communication
S Situation—What is the situation?
“This is a 29 year old burn patient with a difcult airway”
B Background—Pertinent background information related to the
situation
“This patient was involved in a house re in an enclosed space.
He has be developing increasing stridor”
A Assessment—What is your assessment of the situation?
“I am concerned that his airway is swelling and he requires
intubation”
R Recommendation—What do you want to see happen?
“I will manage the airway, can you set up for a surgical airway
in case it is necessary”
Conclusions
CRM training gives team members a background in nontechnical skills and stresses the importance of focussed communication, leadership, and followership skills in times of
crisis. However, by offering team members discrete and
actionable tools that they can practice in the sim lab and then
utilize during real life resuscitations, these CRM theories can
then be easily accessed. Thus, all team members can form
their very own CRM toolkits.
As Chap. 9 discusses, the process of handover is a potentially
dangerous time when pertinent information must be communicated in a concise yet comprehensive manner such that
important details are both communicated and received. We
have already discussed EMS handover, but numerous other
handovers exist in hospital during the patient’s care journey.
In the heat of the moment, the SBAR communicaiton tool
represents a tried and proven method of communication
(Table16.8).
References
1. Reid C, Brindley P, Hicks C, etal. Zero point survey: a multidis-
ciplinary idea to STEP UP resuscitation effectiveness. Clin Exp
Emerg Med. 2018;5(3):139–43.
2. Kulp L, Sarcevic A, Cheng M, Burd RS.Towards dynamic check-
lists: understanding contexts of use and deriving requirements
for context-driven adaptation. ACM Trans Comput Hum Interact.
2021;28(2) https://doi.org/10.1145/3444947.