Author(s): Tim Maxim, BA, RN, 2011

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TRAUMATRAUMA

Joint Base Lewis McChord, flickr

ObjectivesObjectives

Demonstrate primary and secondary Demonstrate primary and secondary patient assessmentpatient assessment

Establish priorities in trauma scenariosEstablish priorities in trauma scenarios

Initiate primary and secondary Initiate primary and secondary managementmanagement

Arrange disposition of the patientArrange disposition of the patient

Trimodal Death Distribution of Trimodal Death Distribution of TraumaTrauma

Trimodal death distributionTrimodal death distribution– First peak is instant death (brain, heart, large vessel injury)First peak is instant death (brain, heart, large vessel injury)– Second peak occurs from minutes to hours after the traumaSecond peak occurs from minutes to hours after the trauma– Third peak occurs days to weeks after the trauma (sepsis, Multiple Organ Third peak occurs days to weeks after the trauma (sepsis, Multiple Organ

Failure)Failure)Emergency Nursing focuses on the second peak…..Deaths from:Emergency Nursing focuses on the second peak…..Deaths from: Traumatic Brain Injury, Traumatic Brain Injury, Skull fractures, orbital fractures…Skull fractures, orbital fractures… Penetrating neck injuries…Penetrating neck injuries… Spinal cord injuries…Spinal cord injuries… Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal

injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries ……

Pelvic fractures, femur fractures, humerus fractures…Pelvic fractures, femur fractures, humerus fractures… Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal

injuriesinjuries Bladder rupture, renal contusion, renal laceration, urethral injury…Bladder rupture, renal contusion, renal laceration, urethral injury…

You get the pointYou get the point

Treating TraumaTreating Trauma

Treat the greatest threat to life firstTreat the greatest threat to life first

Do not wait for a diagnosis to start Do not wait for a diagnosis to start treatmenttreatment

A detailed history of the trauma is not A detailed history of the trauma is not necessary to begin the carenecessary to begin the care

Always start with the Always start with the ““ABCDEABCDE”” approach approach

Initial Assessment and Initial Assessment and ManagementManagement

An effective trauma system needs the An effective trauma system needs the teamwork of emergency medical services, teamwork of emergency medical services, nurses, doctors, x-ray technicians, and nurses, doctors, x-ray technicians, and others others Trauma rolesTrauma roles– Trauma captain – Someone runs the traumaTrauma captain – Someone runs the trauma– Interventionalists – anyone who helps outInterventionalists – anyone who helps out– Nurses – who do the work Nurses – who do the work – Recorder – to document treatmentRecorder – to document treatment

Primary SurveyPrimary Survey

Patients are assessed and treatment Patients are assessed and treatment priorities established based on their priorities established based on their injuries, vital signs, and injury mechanismsinjuries, vital signs, and injury mechanismsABCDEs of trauma careABCDEs of trauma care– AA Airway and c-spine protectionAirway and c-spine protection– BB Breathing and ventilationBreathing and ventilation– CC Circulation with hemorrhage controlCirculation with hemorrhage control– DD Disability/Neurologic statusDisability/Neurologic status– EE Exposure/Environmental controlExposure/Environmental control

AirwayAirway

How do we evaluate the airway?How do we evaluate the airway?

A- AirwayA- Airway

Airway should be assessed for patencyAirway should be assessed for patency– Is the patient able to talk?Is the patient able to talk?– Inspect for foreign bodiesInspect for foreign bodies– Examine for stridor, hoarseness, gurgling, pooled Examine for stridor, hoarseness, gurgling, pooled

saliva or blood saliva or blood

Assume there is a spinal injury in patients Assume there is a spinal injury in patients with multi-traumawith multi-trauma– C-spine clearance can be both clinical(by the doctor) C-spine clearance can be both clinical(by the doctor)

and/or x-rayand/or x-ray– Spinal protection should remain in place until patient Spinal protection should remain in place until patient

can cooperate with clinical examcan cooperate with clinical exam

Airway InterventionsAirway Interventions

OxygenOxygen

SuctionSuction

Chin lift/jaw thrust Chin lift/jaw thrust

Oral or nasal airwaysOral or nasal airways

Establish a secure airwayEstablish a secure airway– Rapid intubation for agitated patients with c-Rapid intubation for agitated patients with c-

spine immobilizationspine immobilization

DiverDave, Wikimedia Commons

BreathingBreathing

What can we look for to assess a patientWhat can we look for to assess a patient’’s s ‘‘breathingbreathing’’ status? status?

B- BreathingB- Breathing

Airway patency does not ensure adequate Airway patency does not ensure adequate ventilationventilation

Look, Listen, and Touch Look, Listen, and Touch – Deviated trachea, crepitus(popcorn chest), Deviated trachea, crepitus(popcorn chest),

flail chest, sucking chest wound, absence of flail chest, sucking chest wound, absence of breath soundsbreath sounds

Chest Xray if available to evaluate lungsChest Xray if available to evaluate lungs

Flail ChestFlail Chest

Trauma.org

Simple PneumothoraxSimple Pneumothorax

Source Unknown

HemothoraxHemothorax

Source Unknown

Breathing InterventionsBreathing Interventions

Ventilate with 100% oxygenVentilate with 100% oxygen

Needle decompression if tension Needle decompression if tension pneumothorax suspectedpneumothorax suspected

Chest tubes for pneumothorax / Chest tubes for pneumothorax / hemothoraxhemothorax

Occlusive dressing to sucking chest Occlusive dressing to sucking chest woundwound

If intubated, evaluate tube positionIf intubated, evaluate tube position

Chest TubeChest Tube

Trauma.org

C- CirculationC- Circulation

Rapid assessment of hemodynamic statusRapid assessment of hemodynamic status– Level of consciousnessLevel of consciousness– Skin colorSkin color– Pulses in arms and legsPulses in arms and legs– Blood pressureBlood pressure

C- CirculationC- Circulation

Shock should be considered on every Shock should be considered on every Trauma patientTrauma patientTypes of shock:Types of shock:– Hypovolemic – loss of blood or plasmaHypovolemic – loss of blood or plasma– Cardiogenic – The heart is less able to pump Cardiogenic – The heart is less able to pump

bloodblood– Obstructive – Physical obstruction reduces Obstructive – Physical obstruction reduces

cardiac outputcardiac output– Distributive – Disruption to vasomotor toneDistributive – Disruption to vasomotor tone

Hypovolemic ShockHypovolemic Shock

The physical loss of eitherThe physical loss of either– Blood – due to hemorrhage Blood – due to hemorrhage – Plasma – due to burnsPlasma – due to burns

This patient will present with:This patient will present with: Decreasing Blood PressureDecreasing Blood Pressure Increasing Heart rateIncreasing Heart rate Increasing anxiety (until lethargy and unconciousness Increasing anxiety (until lethargy and unconciousness

set in)set in) Increase respiratory rateIncrease respiratory rate Decreased urine outputDecreased urine output

Hypovolemic Shock InterventionsHypovolemic Shock Interventions

Monitor pulse and blood pressure Monitor pulse and blood pressure continuouslycontinuouslyApply pressure to bleeding sitesApply pressure to bleeding sitesEstablish IV accessEstablish IV access– 2 large bore IVs2 large bore IVs

Volume resuscitationVolume resuscitation– Have blood and/or fluids ready if neededHave blood and/or fluids ready if needed– Foley catheter to monitor output (unless there Foley catheter to monitor output (unless there

are signs of urethral injury)are signs of urethral injury)

IV TipsIV Tips

Easiest IV sites – Easiest IV sites – – AntecubitalAntecubital– Wrist, next to thumbWrist, next to thumb– Scalp or feet (on infants)Scalp or feet (on infants)

Keep catheter TIGHTKeep catheter TIGHT

It is alright to miss, so donIt is alright to miss, so don’’t worry.t worry.

Thirteen of Clubs, flickr

Cardiogenic ShockCardiogenic Shock

Inadequate contractility of the heart due toInadequate contractility of the heart due to– MIMI– Blunt trauma to the heartBlunt trauma to the heart– Dysrhythmias Dysrhythmias – Cardiac FailureCardiac Failure

Rare in Trauma casesRare in Trauma cases

This pt does not necessarily need fluidsThis pt does not necessarily need fluids

Cardiogenic Shock InterventionsCardiogenic Shock Interventions

ECG as soon as possibleECG as soon as possible

Cardiac MonitorCardiac Monitor

Treat the appropriate dysrhythmiasTreat the appropriate dysrhythmias

Obstructive ShockObstructive Shock

Physical obstruction or compression of the Physical obstruction or compression of the heart or vessels around itheart or vessels around it– Cardiac TamponadeCardiac Tamponade– Tension PneumothoraxTension Pneumothorax– Tension HemothoraxTension Hemothorax

Tension PneumothoraxTension Pneumothorax

How do you treat this?How do you treat this?

Chest Tube Source Unknown

Petr Menzel, Wikimedia Commons

Obstructive Shock InterventionsObstructive Shock Interventions

Remove the underlying obstruction:Remove the underlying obstruction:

– Hemo/pneumothorax – Chest TubeHemo/pneumothorax – Chest Tube

– Cardiac Tamponade - needle decompressionCardiac Tamponade - needle decompression

Distributive ShockDistributive Shock

Loss of vessel tone due toLoss of vessel tone due to– Sepsis (unlikely in an acute trauma)Sepsis (unlikely in an acute trauma)– Neurogenic (spinal damage)Neurogenic (spinal damage)

This patient will usually haveThis patient will usually have– Dry, warm skin (not sweating)Dry, warm skin (not sweating)– BradycardiaBradycardia

Distributive Shock InterventionsDistributive Shock Interventions

Septic shock is treated with antibiotics, Septic shock is treated with antibiotics, which we will save for another lecturewhich we will save for another lecture

Neurogenic shock is covered under the Neurogenic shock is covered under the next step, which is…next step, which is…

D- Disability D- Disability

Abbreviated neurological exam Abbreviated neurological exam – Level of consciousnessLevel of consciousness– Pupil size and reactivityPupil size and reactivity– Motor functionMotor function– Glasgow Coma Scale Glasgow Coma Scale

Utilized to determine severity of injuryUtilized to determine severity of injury

GCSGCS

EYEEYE VERBALVERBAL MOTORMOTOR

Spontaneous Spontaneous 44

Oriented Oriented 55

Obeys Obeys 6 6

Verbal Verbal 33

Confused Confused 44

Localizes Localizes 55

Pain 2Pain 2 Words Words 33

Flexion Flexion 44

None 1None 1 Sounds 2Sounds 2 Decorticate Decorticate 33

None 1None 1 Decerebrate Decerebrate 22

None 1None 1

Disability InterventionsDisability Interventions

Spinal cord injurySpinal cord injury– Keep spine stabalization!Keep spine stabalization!– High dose steroids may be used High dose steroids may be used

Decreasing Mental Status may be a sign Decreasing Mental Status may be a sign of Elevated Intercranial Pressureof Elevated Intercranial Pressure– Sit patient upSit patient up– Hyperventilation – increase breathing and Hyperventilation – increase breathing and

oxygenoxygen

E- ExposureE- Exposure

Complete disrobing of patientComplete disrobing of patient

Logroll to inspect backLogroll to inspect back

Rectal temperatureRectal temperature

Warm blankets to prevent hypothermiaWarm blankets to prevent hypothermia

Always Inspect the BackAlways Inspect the Back

Trauma.org

Lets do a Case!Lets do a Case!

Army Medicine, flickr

CaseCase

28 year old man is involved in a high speed motorcycle accident. 28 year old man is involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, He was not wearing a helmet. He is groaning and utters, ““my bellymy belly””, , ““uggghhhuggghhh””..

Heart Rate 134 Blood Pressure 87/42 Respirations 32 SaO2 Heart Rate 134 Blood Pressure 87/42 Respirations 32 SaO2 89% on 100% oxygen by mask89% on 100% oxygen by mask

Patient is drowsy but arousable to voice, has large bruise over the Patient is drowsy but arousable to voice, has large bruise over the left side of his scalp, airway is patent, decreased breath sounds left side of his scalp, airway is patent, decreased breath sounds over right chest, abdominal pain to touch, obvious left ankle over right chest, abdominal pain to touch, obvious left ankle deformity deformity

ABCDEABCDE

What are the priorities right now?What are the priorities right now?

What are this patientWhat are this patient’’s possible injuries?s possible injuries?

What are the interventions that need to What are the interventions that need to happen now? happen now?

Secondary SurveySecondary Survey

AMPLE historyAMPLE history– Allergies, medications, PMH, last meal, eventsAllergies, medications, PMH, last meal, events

Physical exam from head to toe, including Physical exam from head to toe, including rectal examrectal exam

Frequent reassessment of vitalsFrequent reassessment of vitals

Diagnostic studies at this time simultaneouslyDiagnostic studies at this time simultaneously– X-rays, lab workX-rays, lab work– FAST exam (Ultrasound)FAST exam (Ultrasound)

Seatbelt SignSeatbelt Sign

The Trauma Professional's Blog

Diagnostic AidsDiagnostic Aids

BloodworkBloodwork

Standard trauma radiographsStandard trauma radiographs– Chest X-ray, pelvis, lateral C-spine Chest X-ray, pelvis, lateral C-spine

Pt should only go to radiology if stablePt should only go to radiology if stable

Pt must be monitored in xrayPt must be monitored in xray

Widened MediastinumWidened Mediastinum What disease process does this indicate?What disease process does this indicate?

Aortic Dissection

Source Unknown

Bilateral Pubic Ramus Fractures and Bilateral Pubic Ramus Fractures and Sacroiliac Joint DisruptionSacroiliac Joint Disruption

What should this injury make you worry What should this injury make you worry about?about?

Massive Internal Bleeding

Source Unknown

Abdominal TraumaAbdominal Trauma

Common source of traumatic injuryCommon source of traumatic injuryMechanism is important Mechanism is important – Bike accident over the handlebars Bike accident over the handlebars – Road Traffic Accident with steering wheel Road Traffic Accident with steering wheel

traumatrauma

High suspicion with tachycardia, High suspicion with tachycardia, hypotension, and abdominal tendernesshypotension, and abdominal tendernessCan be asymptomatic early onCan be asymptomatic early onUltrasound can be early screening tool Ultrasound can be early screening tool

Abdominal TraumaAbdominal Trauma

Look for distension, tenderness, seatbelt Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal marks, penetrating trauma, retroperitoneal ecchymosis (Bruising on the flanks)ecchymosis (Bruising on the flanks)

Source Unknown

Splenic InjurySplenic InjuryMost commonly injured organ in blunt traumaMost commonly injured organ in blunt trauma

Often associated with other injuriesOften associated with other injuries

Left lower rib pain may be indicativeLeft lower rib pain may be indicative

Often can be managed non-operativelyOften can be managed non-operatively

Liver injuryLiver injury

Second most common solid organ injurySecond most common solid organ injury

Can be difficult to manage surgically Can be difficult to manage surgically

Often associated with other abdominal Often associated with other abdominal injuriesinjuries

Pregnant Trauma PatientsPregnant Trauma Patients

Pregnant trauma patients are at risk for:Pregnant trauma patients are at risk for:– Premature LaborPremature Labor– Abruptio PlacentaeAbruptio Placentae– Uterine RuptureUterine Rupture

Pregnant Trauma Patients Pregnant Trauma Patients InterventionsInterventions

Premature Labor – Premature Labor – – May be hard to spot in unconscious or intubated ptsMay be hard to spot in unconscious or intubated pts– May be masked as trauma related back painMay be masked as trauma related back pain– If mother is stable, can give medications to stop labor If mother is stable, can give medications to stop labor

Abruptio Placentae – Abruptio Placentae – – Monitor fetal heart tones for 48 hours after traumaMonitor fetal heart tones for 48 hours after trauma

Uterine Rupture – Uterine Rupture – – May be associated with bladder rupture, with blood or May be associated with bladder rupture, with blood or

meconium in the urinemeconium in the urine– Rarely repairable – treat mother for blood loss, Rarely repairable – treat mother for blood loss,

possible trauma surgery neededpossible trauma surgery needed

Pediatric Trauma PatientsPediatric Trauma Patients

5 months and under, assume they are 5 months and under, assume they are obligate nose breathersobligate nose breathers

Respiratory and heart rates differ by ageRespiratory and heart rates differ by age

Can be come hypoglycemic easilyCan be come hypoglycemic easily

Children can maintain a normal blood Children can maintain a normal blood pressure for much longer than adults, so pressure for much longer than adults, so BP is NOT a reliable indicator of shock. BP is NOT a reliable indicator of shock. Watch the heart rate instead.Watch the heart rate instead.

Disposition of Trauma PatientsDisposition of Trauma Patients

Dictated by the patientDictated by the patient’’s condition and s condition and available resourcesavailable resources– OR, admit, or send homeOR, admit, or send home

Serial examinationsSerial examinations– Look for Mental Status ChangesLook for Mental Status Changes– Abdominal exams for increased bruising or Abdominal exams for increased bruising or

painpain– Check lungs for changes in air movementCheck lungs for changes in air movement

SummarySummary

Trauma is best managed by a team Trauma is best managed by a team approach (thereapproach (there’’s no s no ““II”” in trauma) in trauma)

A thorough primary and secondary survey A thorough primary and secondary survey is key to identify life threatening injuriesis key to identify life threatening injuries

Once a life threatening injury is discovered, Once a life threatening injury is discovered, intervention should not be delayedintervention should not be delayed

Disposition is determined by the patientDisposition is determined by the patient’’s s condition as well as available resources.condition as well as available resources.

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Slide 3, Image 1: Joint Base Lewis McChord, "A111028_jb_62nd 010", flickr, http://www.flickr.com/photos/jblmpao/6286561004/, CC: BY-NC-SA

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