Initial Management Of Trauma PDF

INTIAL MANAGEMENT OF TRAUMA FOR NURSES TRAUMA NURSING Dr. Garry Johnson, DHSc, MSN, RN SAN JOSE CALIFORNIA EPIDEMIOLOGY One of Leading Cause of death globally #1 Cause of death in 18-29 year olds Worldwide 1.25 million deaths related to road accidents alone worldwide Over 45 million people annually...

INTIAL MANAGEMENT OF TRAUMA FOR NURSES TRAUMA NURSING Dr. Garry Johnson, DHSc, MSN, RN SAN JOSE CALIFORNIA EPIDEMIOLOGY One of Leading Cause of death globally #1 Cause of death in 18-29 year olds Worldwide 1.25 million deaths related to road accidents alone worldwide Over 45 million people annually sustain disability related to trauma worldwide In USA, accounts for 10% of deaths SA, more than 50 million hospital visits and 30% of ICU admissions Accident deaths are steadily increasing and are now 4th leading cause of death in some cities World Health Organization, 2023 MORTALITY AND MORBIDITY Risk Factors: Advanced Age, Co-morbidities, Obesity, Low GCS Risk Factor: Mortality is increased if patient is not treated at Trauma Center Risk Factor: Coumadin Therapy CAUSES OF DEATH IN TRAUMAUNPREVENTABLE Hemorrhage MODS Cardio-Pulmonary Arrest PREVENTABLE Unitended Extubation Technical or Surgical Failures Missed Injuries Catheter Related Complications GOLDEN HOUR Early Studies looked at getting patients to care within 60 mins. More recent studies found that certain patients benefit even beyond Golden Hour Few Patients die after 1st 24 hours following injury. Most die at scene or within 4 hours. MECHANISM OF INJURY Increased Mortality and Morbidity associated with MVA especially Pedestrian vs. Auto Motorcycle Accidents Falls greater than 20 feet Caption BEFORE ARRIVAL TO ER EMS notify ER that Trauma patient en route SBAR report should include: Patient, Age, Sex, Mechanism of Injury, VS, Apparent Injuries, IV’s, Medications and other essential treatments ER Charge or Triage RN notify additional staff: surgery, obstetrics, ortho, radiology, interpreter Prepare Equipment: Intubation, Chest Tubes, Blood Transfusion, Warm Fluids TRAUMA TEAM RN’S In smaller or rural areas, may be RN and ER MD In large Trauma Centers, will include many others ie Social work, PA, RT etc Communication and Roles must be clear Staff training essential to recognize shock Clear Leader INITIAL ASSESSMENT Use ATLS approach : Prioritize injuries that pose immediate threat to life A: Airway including Cervical Spine Stabilization B: Breathing and Ventilation: May include Intubation C: Circulation Assessment: Control Bleeding and Maintain Perfusion D: Disability Assessment: Basic Neurologic Evaluation E: Exposure: Undress Patients and search for other injuries AIRWAY CONSIDERATIONS Nurses may assist in Intubation Nurses may manage other O2 devices if no RT present Prepare equipment including Suction, Bag-valve mask to high flow O2, oral and nasal airways, Cricothyrotomy kit, ET tubes, Laryngoscopes Many ER’s have an Intubation Cart or Kit or they are in the Trauma Bay Flail chest indicates Rib Fractures HEMORRHAGE Most common preventable case of mortality Alert for signs of bleeding including hypotension (requires 30% blood loss to impact BP) Usual locations: external, intrathoracic, intraperitoneal, retroperitoneal, pelvic or long bones CIRCULATION MANAGEMENT Place two large bore (16 gauge IV’s) in Antecubital Blood draws for labs done immediately and cross matching: CBC, Chemistry, Coags, Pregnancy test (urine in child bearing women), CK (if patient found down for long time) May use intraosseous if no IV’s accessible Nurse will administer IV fluids (20ml/kg isotonic saline) and Type O blood for severe blood loss Give reversal agents for anticoagulation DISABILITY AND NEUROLOGICAL EVALUATION GCS Spine immobilization Complete Neuro checks including movement and sensation EXPOSURE AND ENVIRONMENT Examine entire body : Use scissors to remove clothing if necessary Pay attention to scalp, axillary, perineum, abdominal folds Prevent Hypothermia: Remove wet clothing and use warm blankets and warmed fluids. DIAGNOSTICS Mechanism of injury factors into decisions for imaging Xray usually portable or in OR: look for fractures and foreign objects All penetrating chest injury patients receive CXR FAST exam: Type of Ultrasound used to detect pericardial and intraperitoneal blood CT: Used to detect internal bleeding (may or may not be used depending on stability of patient and clinical pathway), Use Canadian CT Head Rule ECG: All patients SECONDARY EVALUATION Head to Toe done in all trauma patients after focus on hemodynamic stability Includes detailed history, physical exam, diagnostic studies and essential to avoiding missed injuries including: Blunt abdominal trauma, penetrating abdominal (rectal and urethral), thoracic trauma (temponade, esophageal perforation), Extremity trauma (fractures, compartment syndrome) Mechanism of injury information can increase suspicion of certain injuries: blunt trauma, seat belt use, steering wheel deformation, airbag deployment, direct impact, distance ejected, height of fall, body part landed on, penetrating trauma, type of firearm, distance from firearm, number of gunshots heard, type of blade, length of blade etc Ask about medications, allergies and medical surgical history, and use of anti-coagulants , drug and alcohol use HEAD AND FACE AND NECK Inspect and Palpate looking for tenderness, deformity, bleeding Battle’s Sign (bruising behind ears)= Basilar Skull Fractures Raccoon Eyes (usually appear 24 hours later) = Basilar Skull Fracture Eye exam and Ear exam: Look for clear fluid and vision issues Assume injury to Neck and use Canadian C-Spine Rule CHEST AND ABDOMEN Inspect and palpate entire chest with attention to sternum and Clavicle looking for fractures NEXUS Chest Criteria used to determine if chest imaging is needed due to blunt trauma Inspect Abdomen for lacerations, contusions (seat belt sign), palpate for tenderness and rigidity: All may indicate intra-abdominal injury RECTUM AND GI Inspect Perineum for injury (straddle injury) Digital Rectal exam not done routinely - only in cases where urethral or penetrating rectal injury is known or suspected: Check for gross blood, high prostate (urethral injury), abdominal sphincter tone (spinal cord injury), bone fragments (pelvic fracture) Vaginal examination for all patients at risk for vaginal injury ie lower abdominal pain, pelvic fracture or peritoneal laceration MUSCULOSKELETAL Inspect and palpate all 4 extremities for tenderness, deformity or decreased ROM Assess Neurovascular status of each extremity Manipulate all joints both passively and actively if patient can follow directions Irrigate and debridement and wound care for all open wounds may be expected. Anticipate ABX and wound instructions Compartment syndrome: pain, tense compartments, pain on stretch: Keep measuring! Inspect and palpate pelvis checking for pelvic ring disruption: ecchymosis, tenderness NEURLOGICAL AND SKIN Can change over time: Use assessments over time especially if subdural hematoma suspected Skin: look for lacerations, abrasions, ecchymosis, hematomas, serums. BE THOROUGH! Penetrating wounds can be anywhere. PAIN MANAGEMENT Injured patients are in pain! Usually combined pain medication with anti-anxiety medications: IV vs PO? Common meds: Fentanyl, Morphine, Midazolam Monitor RR, Oxygen Saturation, Pain level COMMON MISTAKES IN TRAUMA NURSING Displaced ET tubes-up to 6% Hemorrhagic Shock: Remember 30% rule Cardiac Tamponade: JVD primary sign Penetrating Wounds involve both Thoracic and Abdominal Cavity Open Book Pelvic Fractures: Do not move pelvis Eye Injuries: Not fully assessed Geriatric Patients: Medications mask symptoms ie beta blockers HOW TO BECOME A TRAUMA NURSE 1. Become a Nurse-Bachelors preferred usually 2. Get a job in ER as RN 3. After 2 years - get Trauma Certified