What is a Level 1 trauma patient?

A level 1 trauma patient is a patient who has sustained serious, life-threatening injuries and requires the highest level of trauma care. Level 1 trauma centers are specially equipped and staffed to provide round-the-clock surgical coverage, emergency interventions, and intensive care for the most critically injured patients.

Table of Contents

What are the criteria for a level 1 trauma patient?

There are specific criteria that categorize a patient as a level 1 trauma. These include:

Respiratory compromise or intubation
Gunshot wounds to the head, neck, chest, abdomen or extremities proximal to the elbow/knee
Glasgow Coma Scale score of less than 9 with a trauma mechanism attributed

Fall from height >20 feet (1 story = 10 feet)
High-risk auto crash
- Ejection from vehicle
- Death of same car occupant
- Pedestrian hit by car
- Rollover
- High-speed crash >40 mph
Motorcycle crash >20 mph
Amputation proximal to wrist or ankle

Crushed, degloved, or mangled extremity
Pelvic fractures
Open or depressed skull fracture

Paralysis

Any patient meeting one or more of these criteria requires the specialized resources of a level 1 trauma center to give them the best chance of survival and recovery.

What types of injuries may a level 1 trauma patient have?

Some examples of severe, life-threatening traumatic injuries that would lead to a level 1 trauma designation include:

Traumatic brain injury (TBI) – Bleeding, bruising or physical damage to the brain tissue that can impair cognitive abilities, result in coma or death. Caused by blows to the head, whiplash, foreign objects penetrated into brain.
Spinal cord injury – Severing or damage to the spinal cord from vertebral fractures, dislocations, lacerations, contusions. Can cause paralysis.
Internal bleeding – Hemorrhage from lacerations to internal organs like the liver, spleen, kidneys, intestines, and major blood vessel injuries.

Cardiac tamponade – Bleeding into the sac surrounding the heart impairs its ability to pump blood effectively.
Tension pneumothorax – Accumulation of air pressure in the chest cavity that compresses the lung tissue.
Vascular injuries – Dissection, transection, or lacerations of major blood vessels.

Amputations – Traumatic amputation of a limb or body part.
Burns – Severe third-degree and electrical burns over large surface areas.
Crush injuries – Severe crushing damage to body parts from high-impact trauma.

These types of catastrophic injuries require rapid surgical control, resuscitation, and specialty critical care only available at level 1 trauma centers.

What are the initial assessment and treatment priorities?

When a level 1 trauma patient first arrives at the emergency department, the initial assessment and management focuses on the ABCs – airway, breathing, and circulation. The priorities are:

Airway – Assess airway patency and protect airway through intubation if compromised. Suction secretions.

Breathing – Evaluate rate, depth, effort of breathing. Give high-flow oxygen. Treat pneumothorax with chest tube.
Circulation – Assess pulse, skin signs, mentation for perfusion. Initiate IV/IO access. Give blood products for hemorrhagic shock. Identify sources of major bleeding.

Other important initial steps include:

Attach ECG, oxygen saturation monitors
Keep patient warm to prevent hypothermia
Log roll patient to assess back/spine for injuries

Cover open wounds, splint fractures, apply pelvic binder
Obtain radiographs, CT scans
Sample labs (CBC, basic metabolic panel, coagulation studies, toxicology screen)

Foley catheter
Nasogastric tube

Once initial stabilization is achieved, the patient will go for further imaging studies and urgent surgery if needed to stop bleeding, repair organ damage, orthopedic fixation, etc.

What specialists are involved in level 1 trauma care?

It takes a multidisciplinary team of specially trained medical experts to care for the most critically injured trauma patients. At level 1 trauma centers, the following specialists are involved:

Emergency medicine physicians – Initial trauma resuscitation and stabilization in the ER.
Trauma surgeons – Manage complex injuries in the OR.

Neurosurgeons – Treat traumatic brain injuries, spinal cord injuries, intracranial hemorrhage.
Orthopedic surgeons – Manage fractures, amputations, fixations.
Anesthesiologists – Airway management, sedation, pain control.

Surgical specialty teams – Cardiothoracic, vascular, plastics, ENT, maxillofacial, obstetrics, gynecology.
Critical care medicine – Treat respiratory failure, shock, sepsis in the ICU.
Diagnostic radiologists – Interpret complex imaging studies like CT, MRI, angiogram.

Transfusion medicine – Manage massive blood loss and transfusion.
Rehabilitation medicine – Help recovery of function in SCI, TBI, amputations.

This kind of coordinated, protocol-driven trauma care has been proven to save lives and minimize disability following nearly fatal injuries.

What equipment and capabilities make level 1 trauma centers unique?

Level 1 trauma centers are equipped with specialized resources to manage incredibly complex, resource-intensive injuries around the clock. Some examples include:

In-house general surgeons, orthopedic surgeons, neurosurgeons at all times
OR teams available 24/7 for emergency surgeries

Blood bank with massive transfusion protocols and ability to transfuse more than 5 units of blood in 4 hours
Top tier imaging – CT, angiography, MRI, ultrasound
ICU care with advanced ventilatory support, hemodynamic monitoring capabilities

Burn care resources including hydrotherapy tubs
Hyperbaric oxygen therapy
Acute dialysis – CRRT, plasmapheresis

MICU/SICU with highly trained trauma nursing staff
Social work and discharge planning services
Rehab medicine including physical, occupational, speech therapy

It takes both advanced clinical capabilities and system processes to achieve optimal outcomes. Level 1 trauma centers have continuous performance improvement programs and collect registry data to inform new quality protocols.

How does transfer to a level 1 trauma center benefit outcomes?

When a severely injured patient presents to a smaller community hospital not qualified as a level 1 trauma center, they have a significantly higher chance of disability and death. Ideally, major trauma patients should be transported directly to level 1 centers by emergency medical services (EMS).

If a patient does arrive at lower level hospital, prompt transfer to a level 1 center for definitive care is critical. Studies show:

25% higher mortality if injured patients are not treated at level 1 center
Transfer to level 1 center associated with a 15% reduction in mortality
Significantly lower post-injury disability if treated at level 1 center

Therefore, regional trauma coordination is essential to get severely injured patients to the resources they need as fast as possible. Community hospitals and EMS play a key role in recognizing major trauma and activating transfer protocols.

What is the role of rehab and recovery services for trauma patients?

After the acute life-threatening injury has been stabilized, there is still a long road to recovery ahead. Rehabilitation services are a crucial part of trauma care and optimizing long-term function.

Common deficits trauma patients contend with include:

Physical impairments – weakness, balance deficits, loss of mobility from fractures, amputations, spinal cord injury
Communication problems – speech-language deficits from TBI
Cognitive deficits – attention, memory, decision-making from TBI

Difficulty performing self-care – dressing, bathing, toileting due to weakness
Emotional/psychological issues – PTSD, depression
Pain syndromes

Rehab services like physical, occupational, and speech therapy improve strength, function, mobility, communication, and independence with daily living. The trauma team works closely with physiatry rehab doctors to help each patient make the best possible recovery.

What is the typical recovery process and timeline?

The recovery timeline for trauma patients varies widely depending on factors like:

Mechanism and severity of injury

Age and pre-existing health status of patient
Development of complications – infections, bleeding, thromboses

However, a general continuum may be:

Acute hospitalization – Stabilize injuries in ICU, days to weeks
Inpatient rehab – After ICU for continued nursing, 3+ hours of rehab daily, 2-4 weeks
Outpatient rehab – After hospital discharge, PT, OT, speech therapy, months

Home health – Nursing and rehab at home for some patients
Return to work or school – Light duty restrictions initially, then full duty, months
Long term follow up – Monitor TBI recovery, mental health, medications, years

The trauma team remains involved throughout this continuum to optimize each patient’s recovery to the fullest potential.

What are the long term impacts of major trauma?

Survival after major trauma comes at both physical and emotional cost. Some common long term impacts include:

Physical disability – Amputations, weakness from nerve/muscle damage, loss of mobility from fractures or SCI

Chronic pain – Phantom limb pain, back pain, headache, neuropathic pain
Cognitive deficits – Impaired memory, concentration, executive function after TBI
Psychological issues – Depression, anxiety, PTSD, behavioral problems

Lower quality of life – Relationship strain, inability to work, financial hardship
Higher healthcare utilization – More medications, rehospitalizations, chronic disease

For this reason, trauma centers aim to not just save lives, but enable patients to eventually regain productive and meaningful lives despite permanent disability from injury. This requires an integrated system promoting long term wellbeing.

Conclusion

Level 1 trauma patients suffer the most severe, catastrophic traumatic injuries with high risk of mortality if not treated at specialized centers. Multidisciplinary trauma teams aggressively resuscitate, stabilize, and repair damage from nearly fatal mechanisms. The capabilities to manage massive bleeding, complex surgery, ICU care, and seamless handoffs is uniquely characteristic of level 1 trauma centers. Though recovery is long and disability is often permanent, excellent clinical care and rehabilitation services give trauma patients the best odds of returning to their lives. Regional coordination for direct transport and prompt transfer to level 1 centers is critical to improve outcomes for the most severely hurt patients.