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NUR 262 Adult Nursing 2
Scenario 1 (in sequences)
“Tom has an accident”
1a. Louise Adcock
Immediate care and interventions, information on how many units have an
effect on a person and some information on motorcycle crashes.
Farmer Giles should:
On finding Tom should assume he has a cervical spine injury: maintain the
head in the neutral position, with the head, neck and spine aligned. I
If Tom is breathing, he should try to leave him in the position he has been
found and apply direct pressure to control any bleeding from wounds
(D.Bowden et al). The motorbike helmet should not be removed unless it is
absolutely necessary. Farmer Giles should call an ambulance as soon as
possible; the police need to be informed as it is a road traffic accident also. It
is important to remember that in any life threatening situation the emergency
services should be called as soon as breathing or absence of breathing has
been identified (ST. Johns ambulance Service).
The paramedics on arrival should:
Assess the environment for safety and determine the resources needed to
adequately manage the scene. Safety is of paramount concern, always think
of your own safety first (being the paramedic), then the other rescuers, then
bystanders and finally the safety of the casualty. A ‘methane’ format can be
used to deliver a situation report:
Major incident standby or declared
Exact location of incident
Type of incident
Hazards (present and potential)
Access and egress routes
Number, severity and type of casualties
Emergency services present on scene and further resources required
(Trauma emergencies in adults)
A primary survey should be used to identify potentially life threatening injuries
to Tom, when ever possible treatment of a life threatening problem should be
carried out as soon as it is identified. Ideally the primary survey should only
take 1-2 minutes (Greaves et al). If any abnormalities are detected during the
assessment the need for senior clinical support should be considered. The
primary survey follows the system of ABCDE (Airway with cervical spine
control, Breathing with adequate ventilation/oxygenation, Circulation with
control of external haemorrhage, Disability and neurological examination,
Exposure and evaluation)
Establish the level of consciousness: Can you hear me? Is Tom rousable?
The shoulders can be gently shaken without moving the head.
Approximately 5% of trauma patients have a cervical spine injury; anyone who
is unconscious or has evidence of a blunt injury above the clavicle should be
treated as having a cervical spine injury until it is proved otherwise. The
airway has priority over the cervical spine. NICE guidelines state: Full cervical
spine immobilisation if any of these are present (unless other factors prevent
● GCS < 15 on initial assessment by healthcare professional
● Neck pain or tenderness
● Focal neurological deficit
● Paraesthesia in the extremities
● Any other clinical suspicion of cervical spine injury.
Maintain immobilisation until full risk assessment including clinical
assessment (and imaging after arrival to the nearest hospital if necessary)
indicates removal is safe.
Airway: Look for obvious obstruction, listen for air flow and feel for air
movement, depth, pattern
(Trauma emergencies). If the airway is compromised, use jaw thrust to open
it, but try to avoid tilting the head. Jaw thrust is done if suspected cervical
spine injury and is a skill often only acquired by nurses working in such areas
as A&E and anaesthetics (D. Bowden et al).
Breathing Management: All trauma patients should receive high concentration
oxygen irrespective of their respiratory rate to ensure an oxygen saturation of
>95% unless they are known to have COPD. If rate is below 10 or above 30
or oxygenation saturation is <90 assisted ventilation may be required
(Greaves et al). Normal respiratory rates should be 12-18 bpm. Respiratory
rates can be determined by listening for 5 seconds to listen for problems and
counted for 15 seconds and multiplying by 4 to approximate minute rate. In a
secondary survey it will need to be done for a whole minute. Once the airway
has been opened, cleared and secured (possibly with oropharyngeal or
nasopharyngeal airways), a rigid collar is fitted and immobilisation on a long
spinal board maintained for all unconscious trauma patients.
Circulation and Pulse: Assess rate and pulse.Should be at resting 60-100 per
minute, >100 tachycardic due to anxiety, stress, pain, hypovolaemia and
sympathetic stimulation. Or bradycardiac <60 could indicate hypoxia. A rapid,
weak and thready pulse could indicate shock. If there is a pulse, BP should be
measured. If there is a pulse, but not breathing ventilation using a bag and
mask will be needed. A present radial pulse implies a systolic BP of 80 -90
giving adequate perfusion of organs, but can be variable. If radial pulse
absent look for carotid pulse which if present implies a systolic of 60 mmHg
(Trauma emergencies in adults).
Carotid pulse indicates a minimum BP of 60mmHg
Femoral indicates a minimum BP of 70mmHg
Radial indicates a minimum BP of 80mmHG
Disability: Cerebral perfusion: An AVPU is a simple scoring system that can
assess if Tom is alert or responsive to verbal or painful stimulation or is
unresponsive. An AVPU is also used as the baseline for further observations.
Pupillary assessment of pupillary size and reaction to light should be made.
The head should be checked for bruising, lacerations, evidence of tenderness
and other signs of fractures involving the skull or face. The nose and ears
should be specifically inspected for blood and cerebrospinal fluid leakage
(Greaves et al).
Exposure: To allow for clinical examination to exclude any life threatening
conditions of loss of blood concealed by clothes or under the patient, blood
loss can be external, chest, abdomen, pelvis and long bones. Dignity and
protection from extremes of cold need to be used. The neck collar will need to
be loosened to look for any life threatening injuries a format called TWELV
can be used: Tracheal deviation, Wounds, bruising, swelling, Emphysema
(surgical), Laryngeal crepitus, Venous engorgement (jugular) (Trauma
emergencies in adults an overview).
Skin perfusion: Poor skin perfusion is characterised by cool peripheries, skin
mottling, pallor, cyanosis and a delayed capillary refill >2 seconds. If Tom is
cool to the touch this may indicate poor skin perfusion. To assess capillary
perfusion blanch the sternum or forehead for 5 seconds and release. A
delayed capillary refill >2 seconds can indicate circulatory shock.
Include deterioration in conscious level, confusion, agitation and lethargy.
External cues: Looking for medications, medic alert bracelet, anything
appearing suspicious around the scene of the accident or Tom (D. Bowden et
al). AMPLE can be a useful mnemonic to ask if there are any friends, family or
if the patient becomes conscious this stands for Allergies, Medication, Past
illnesses, Last ate, Event.
The ambulance crew should have a record and with a GCS ≤ 8 make a
standby call to the hospital to ensure appropriately experienced professionals
available to treat patient and to prepare for imaging.
Secondary survey may be performed in order to identify non-life threatening
injuries; this may be done in the ambulance on the way to the hospital. It
should begin with reassessing the airway, then re-examining the head, nose
and ears and AVPU score, including pupillary reaction to light. This is followed
by reassessing the neck maintaining stabilisation, chest which can be
auscultated and palpated being in the ambulance may be easier to perform
this because of ambient noise at the scene. The abdomen and pelvis are both
examined; bleeding from the urethra may also be noticed. Upper and lower
limbs are inspected for swelling, deformity and wounds; they can be palpated
for fractures. The limb examination should include motor response (test for
active movements), sensation (response to touch), and circulation (pulse and
skin temperature) Limb injuries should be treated as necessary with dressings
and/or splintage and analgesia should be a high priority using such pain relief
as morphine or nitrous oxide inhalation (Greaves et al)..
Fluids: Should be given with a wide bore cannula, they may raise the BP, cool
the blood and dilute clotting factors, worsening haemorrhage therefore fluids
should only be given when major organ perfusion is impaired. If there is
visible external blood loss greater than 500 mls, fluid replacement should be
given as a bolus of 250 mls of crystalloid. In adults blood loss of 750-1000ml
will produce little evidence of shock; blood loss of 1000-15000ml is required
before more classical signs of shock appear. Further signs need to be
reassessed before further fluid replacement is given (Emergencies in adults
Recognising Shock: Certain groups disguise shock these are children,
pregnant women, people on certain types of medication such as beta blockers
and the physically fit, the signs of shock may appear late for these groups
(Emergencies in adults an overview).
It is known that Tom is leaving a party in the early hours of the morning in high
spirits. He may be suffering from the effects of alcohol. Alcohol intoxication
can lead to reduced consciousness, hypoglycaemia, metabolic acidosis and
vomiting that may cause aspiration. After one or two drinks (1-3 units), people
become talkative and heart rate speeds up a little. ‘The warm feeling', or
flushes, is caused by alcohol in the blood making small blood vessels in the
skin expand, allowing more blood to flow closer to the surface and lowering
blood pressure at the same time. After a couple more drinks (4-6 units) make
people light headed co-ordination and reaction times are impaired. Ability to
make decisions is also slowed down. All of these effects are caused by
alcohol acting on nerve cells all around the body and making them work more
Another few drinks (7-9 units) and most people will show definite outward
signs of alcohol's effects. Reaction times are much slower, vision becomes
blurry and speech is slurred. Drinking more than eight units at a time seriously
overloads the liver.
Drinking more than 10 units has most people staggering about the place.
Accidents are commonplace. This amount of alcohol will be affecting cells all
over the body. In an effort to rid itself of the poison, the body tries to pass the
alcohol out mixed with water in our urine. Alcohol makes people urinate a lot
and is the cause of the dehydration and headaches. Alcohol also attacks the
gut, causing stomach upsets, heartburn, sickness and diarrhoea. Drinking
more than 30 units (that's about twelve pints of strong lager) is enough to
cause unconsciousness. From there, it's a short step to heart failure and
breathing slowing to a stop. Even when people are already unconscious,
alcohol in the stomach can continue to be absorbed and can reach lethal
levels. People can also be sick and suffocate on their vomit.
Info from a study looking at motor bike accidents:
Motorcyclists make up less than 1% of vehicle traffic but their riders suffer
14% of total deaths and serious injuries on Britain’s roads (DETR,2000).
There are two main groups of riders that interventions should be focussed on.
The first is young and inexperienced riders of smaller capacity machines such
as scooters, and the second is older, more experienced riders of higher
capacity machines. Both the skills and attitudes of these riders need to be
According to RoSPA (2001), between 1998 and 1999 the number of
motorcyclists killed or seriously injured on British roads seemed to increase
after a period of general decline, perhaps owing to a recent rise in motorcycle
traffic over the same period. Recent increases in registered two-wheelers of
all kinds and further increases in motorcycle traffic for the period 2001–2002
(DfT statistics, 2003), mean that this problem could get even worse.
D. Bowden, D. Halliwell, R Mc Mahon. (2007) ‘Emergency care and first aid
for nurses.’ Elsevier ltd.
I. Greaves, K.Porter, T. Hodgetts, M. Woollaerd (2006) Emergency Care. A
text book for paramedics. Elsevier ltd, 2nd ed.
B.Foster (2007) Trauma Emergencies In Adults An Overview
The short term effects of Infoscotland.com.
vice=Content.show&#immediate. Accessed 25.09.08
National Institute For Health And Clinical Excellence. Head injury Triage,
assessment, investigation and Early management of head injury in infants,
children and adults. Issue date: September 2007.www.nice.org.uk
St. John’s Ambulance Service-Life Saving Procedures.
D. Clarke, P.Ward, C. Bartle, W. Truman. Road Safety Research Report No.
54, In Depth Study Of Motorcycle Accidents. Department Of Transport