Level I. Provides a 24-hour, in-house trauma team with the ability to fully resuscitate injured patients and provide definitive surgical care for the most complex injuries. The trauma team is usually led by an attending trauma surgeon, emergency physician or senior-level surgical resident. Level I centers are typically located in population-dense areas. Level I trauma centers also distinguish themselves through research, training, and prevention and outreach programs.

Level II. Clinical capabilities are similar to Level I centers. However, more specialized resources (e.g., cardiac surgery, microvascular surgery) are not required. An in-house trauma surgeon is not required, but must be available to meet the patient on arrival. Level II centers are frequently located in suburban areas.

Level III. These centers typically serve rural areas not easily accessible to Level I or II trauma centers. A surgeon must be available in a timely fashion, but certain subspecialties (e.g., neurosurgery) are not required. Complex patients are routinely transferred to level I or II trauma centers.

Level IV. Provide initial evaluation and assessment of injured patients; typically located in small hospitals or clinics serving the more remote areas. Surgical coverage is not mandatory and most patients will require transfer to higher levels of care.

Non-designated. The majority of hospitals in the United States carry no specific trauma center designation. Each hospital should be aware of the resources available for management of trauma patients with clearly delineated plans for transfer of patients that exceed the “resource threshold.”

Full response (e.g., “trauma code,” “code red”). Highest level of response designed for patients with physiologic instability, severe traumatic brain injury or who present with obvious life-threatening injuries (e.g., abdominal gunshot wound).

Modified response (e.g., “level II trauma,” “trauma alert”). Response typically intended for physiologically stable and neurologically normal patients with the potential for serious injury based on injury mechanism or anatomic findings. Composition of the trauma team will vary with the trauma center; emergency medicine physicians frequently assume the leadership role.

Trauma consultation. In most trauma centers, this response is reserved for low-energy or single system injuries in stable patients. Patients are fully evaluated by an emergency medicine physician prior to consultation with a trauma surgeon.

A dedicated trauma resuscitation area (TRA) is required for any Level I or II trauma center and should be considered in any hospital emergency department that receives a significant volume of injured patients or where an injured patient may arrive without prior notification.

The TRA should be secure, with limited access to non-medical personnel.

Convenient access to the operating room, radiology suite, intensive care unit, and staff call rooms are other important considerations in TRA design.

The TRA must be sufficiently large to accommodate all members of the trauma team (i.e., 5 to 10 people). Ample space must be provided to allow free movement of prehospital providers into and out of the area, complete resuscitation, basic radiographic evaluation, orthopedic stabilization, and required emergency surgical procedures:

Other TRA considerations include:

Any bodily fluid should be considered a potential source of transmissible disease and, thus, barrier precautions should be mandated for all members of the trauma team. Specifically, non-sterile gloves, an impervious gown, surgical mask, protective eyewear, and shoe covers are required for all team members likely to come in contact with a patient.

It is not uncommon for radiographic studies to be performed concomitant with the trauma resuscitation. Appropriate protective gear (e.g., lead vests, lead aprons) should be worn by trauma team members who may be working close to the patient while radiographs are being performed. Having these garments available obviates the need to interrupt the resuscitation during x-rays.

Protective garments should be available in a designated area adjacent to the TRA in full view of those who may enter the area. The trauma team leader or recorder should monitor and enforce compliance with barrier precautions and radiographic protective gear.

Inevitably, patients will arrive without notification. In these cases, guidelines should be developed for relieving personnel who, by necessity, have entered the TRA without barrier precautions. Protected team members should provide rapid relief for those who have not had the opportunity to don protective equipment. The ultimate goal is to minimize the total number of unprotected individuals during a given resuscitation.

Appropriate and visible receptacles available for disposal of used protective gear must be available within the confines of the TRA. Personnel should be discouraged from leaving the TRA with soiled gown, gloves, etc.

Carts or trays may be utilized to store the most frequently used equipment (e.g., airway cart, thoracotomy tray). Equipment trays should contain only those instruments and materials absolutely necessary to perform a given procedure. Trays should be easily accessible, openly displayed, and clearly labeled for easy identification. One logical approach is to stock supplies in a head-to-toe configuration, with airway equipment and cervical collars stored near the head of the stretcher, thoracostomy trays near the midportion of the stretcher, and splinting materials near the foot of the stretcher.

Equipment necessary to manage immediately life-threatening conditions should be stocked close to the stretcher, in proximity to the trauma member most likely to use it (Table 10-1; Fig. 10-1).