Author(s): Tim Maxim, BA, RN, 2011
License: Unless otherwise noted, this material is made available under the
terms of the...
Citation Key
for more information see: http://open.umich.edu/wiki/CitationPolicy

Use + Share + Adapt
{ Content the copyri...
TRAUMA

Joint Base Lewis McChord, flickr
Objectives

 Demonstrate primary and secondary

patient assessment

 Establish priorities in trauma scenarios

 Initiate p...
Trimodal Death Distribution of
Trauma






Trimodal death distribution
–  First peak is instant death (brain, heart, larg...
Treating Trauma

 Treat the greatest threat to life first

 Do not wait for a diagnosis to start

treatment

 A detailed h...
Initial Assessment and
Management

 An effective trauma system needs the

teamwork of emergency medical services,
nurses, ...
Primary Survey

 Patients are assessed and treatment

priorities established based on their
injuries, vital signs, and inj...
Airway
How do we evaluate the airway?
A- Airway

 Airway should be assessed for patency
–  Is the patient able to talk?
–  Inspect for foreign bodies
–  Examine...
Airway Interventions

 Oxygen

 Suction

 Chin lift/jaw thrust

 Oral or nasal airways

 Establish a secure airway
–  Rapi...
Breathing

 What can we look for to assess a patient s

breathing status?
B- Breathing

 Airway patency does not ensure adequate

ventilation

 Look, Listen, and Touch
–  Deviated trachea, crepitu...
Flail Chest

Trauma.org
Simple Pneumothorax

Source Unknown
Hemothorax

Source Unknown
Breathing Interventions

 Ventilate with 100% oxygen

 Needle decompression if tension

pneumothorax suspected

 Chest tub...
Chest Tube

Trauma.org
C- Circulation

 Rapid assessment of hemodynamic status
–  Level of consciousness
–  Skin color
–  Pulses in arms and legs...
C- Circulation

 Shock should be considered on every

Trauma patient

 Types of shock:

–  Hypovolemic – loss of blood or ...
Hypovolemic Shock

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

 This patient will ...
Hypovolemic Shock Interventions

 Monitor pulse and blood pressure

continuously

 Apply pressure to bleeding sites

 Esta...
IV Tips

 Easiest IV sites –

–  Antecubital
–  Wrist, next to thumb
–  Scalp or feet (on infants)

 Keep catheter TIGHT

...
Cardiogenic Shock

 Inadequate contractility of the heart due to
–  MI
–  Blunt trauma to the heart
–  Dysrhythmias
–  Car...
Cardiogenic Shock Interventions

 ECG as soon as possible

 Cardiac Monitor

 Treat the appropriate dysrhythmias
Obstructive Shock

 Physical obstruction or compression of the

heart or vessels around it
–  Cardiac Tamponade
–  Tension...
Tension Pneumothorax
How do you treat this?

Petr Menzel, Wikimedia Commons

Chest Tube

Source Unknown
Obstructive Shock Interventions

 Remove the underlying obstruction:
–  Hemo/pneumothorax – Chest Tube
–  Cardiac Tamponad...
Distributive Shock

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

 Th...
Distributive Shock Interventions

 Septic shock is treated with antibiotics,

which we will save for another lecture

 Neu...
D- Disability

 Abbreviated neurological exam
–  Level of consciousness
–  Pupil size and reactivity
–  Motor function
–  ...
GCS
EYE

VERBAL

Spontaneous Oriented
4
5
Verbal
3 Confused
4
Pain
2 Words
None

1 Sounds
None

MOTOR
Obeys
Localizes
5
3 ...
Disability Interventions

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

 Decreasing ...
E- Exposure

 Complete disrobing of patient

 Logroll to inspect back

 Rectal temperature

 Warm blankets to prevent hypo...
Always Inspect the Back

Trauma.org
Lets do a Case!

Army Medicine, flickr
Case


28 year old man is involved in a high speed motorcycle accident.
He was not wearing a helmet. He is groaning and ut...
ABCDE

 What are the priorities right now?

 What are this patient s possible injuries?

 What are the interventions that ...
Secondary Survey

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

 Physical exam from head to toe, inclu...
Seatbelt Sign

The Trauma Professional's Blog
Diagnostic Aids

 Bloodwork

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

 Pt should only go to r...
Widened Mediastinum
What disease process does this indicate?

Aortic Dissection
Source Unknown
Bilateral Pubic Ramus Fractures and
Sacroiliac Joint Disruption
What should this injury make you worry
about?

Massive Int...
Abdominal Trauma

 Common source of traumatic injury

 Mechanism is important
–  Bike accident over the handlebars
–  Road...
Abdominal Trauma

 Look for distension, tenderness, seatbelt

marks, penetrating trauma, retroperitoneal
ecchymosis (Bruis...
Splenic Injury

 Most commonly injured organ in blunt trauma

 Often associated with other injuries

 Left lower rib pain ...
Liver injury

 Second most common solid organ injury

 Can be difficult to manage surgically

 Often associated with other...
Pregnant Trauma Patients

 Pregnant trauma patients are at risk for:
–  Premature Labor
–  Abruptio Placentae
–  Uterine R...
Pregnant Trauma Patients
Interventions

 Premature Labor –
–  May be hard to spot in unconscious or intubated pts
–  May b...
Pediatric Trauma Patients

 5 months and under, assume they are

obligate nose breathers

 Respiratory and heart rates dif...
Disposition of Trauma Patients

 Dictated by the patient s condition and

available resources
–  OR, admit, or send home

...
Summary

 Trauma is best managed by a team

approach (there s no I in trauma)

 A thorough primary and secondary survey
is...
Additional Source Information
for more information see: http://open.umich.edu/wiki/CitationPolicy
Slide 3, Image 1: Joint ...
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GEMC- Trauma- for Nurses

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This is a lecture by Tim Maxim from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC- Trauma- for Nurses

  1. 1. Author(s): Tim Maxim, BA, RN, 2011 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  2. 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. TRAUMA Joint Base Lewis McChord, flickr
  4. 4. Objectives Demonstrate primary and secondary patient assessment Establish priorities in trauma scenarios Initiate primary and secondary management Arrange disposition of the patient
  5. 5. Trimodal Death Distribution of Trauma Trimodal death distribution –  First peak is instant death (brain, heart, large vessel injury) –  Second peak occurs from minutes to hours after the trauma –  Third peak occurs days to weeks after the trauma (sepsis, Multiple Organ Failure) Emergency Nursing focuses on the second peak…..Deaths from:   Traumatic Brain Injury,   Skull fractures, orbital fractures…   Penetrating neck injuries…   Spinal cord injuries…   Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries …   Pelvic fractures, femur fractures, humerus fractures…   Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuries   Bladder rupture, renal contusion, renal laceration, urethral injury… You get the point
  6. 6. Treating Trauma Treat the greatest threat to life first Do not wait for a diagnosis to start treatment A detailed history of the trauma is not necessary to begin the care Always start with the ABCDE approach
  7. 7. Initial Assessment and Management An effective trauma system needs the teamwork of emergency medical services, nurses, doctors, x-ray technicians, and others Trauma roles –  Trauma captain – Someone runs the trauma –  Interventionalists – anyone who helps out –  Nurses – who do the work  –  Recorder – to document treatment
  8. 8. Primary Survey Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms ABCDEs of trauma care –  A –  B –  C –  D –  E Airway and c-spine protection Breathing and ventilation Circulation with hemorrhage control Disability/Neurologic status Exposure/Environmental control
  9. 9. Airway How do we evaluate the airway?
  10. 10. A- Airway Airway should be assessed for patency –  Is the patient able to talk? –  Inspect for foreign bodies –  Examine for stridor, hoarseness, gurgling, pooled saliva or blood Assume there is a spinal injury in patients with multi-trauma –  C-spine clearance can be both clinical(by the doctor) and/or x-ray –  Spinal protection should remain in place until patient can cooperate with clinical exam
  11. 11. Airway Interventions Oxygen Suction Chin lift/jaw thrust Oral or nasal airways Establish a secure airway –  Rapid intubation for agitated patients with cspine immobilization DiverDave, Wikimedia Commons
  12. 12. Breathing What can we look for to assess a patient s breathing status?
  13. 13. B- Breathing Airway patency does not ensure adequate ventilation Look, Listen, and Touch –  Deviated trachea, crepitus(popcorn chest), flail chest, sucking chest wound, absence of breath sounds Chest Xray if available to evaluate lungs
  14. 14. Flail Chest Trauma.org
  15. 15. Simple Pneumothorax Source Unknown
  16. 16. Hemothorax Source Unknown
  17. 17. Breathing Interventions Ventilate with 100% oxygen Needle decompression if tension pneumothorax suspected Chest tubes for pneumothorax / hemothorax Occlusive dressing to sucking chest wound If intubated, evaluate tube position
  18. 18. Chest Tube Trauma.org
  19. 19. C- Circulation Rapid assessment of hemodynamic status –  Level of consciousness –  Skin color –  Pulses in arms and legs –  Blood pressure
  20. 20. C- Circulation Shock should be considered on every Trauma patient Types of shock: –  Hypovolemic – loss of blood or plasma –  Cardiogenic – The heart is less able to pump blood –  Obstructive – Physical obstruction reduces cardiac output –  Distributive – Disruption to vasomotor tone
  21. 21. Hypovolemic Shock The physical loss of either –  Blood – due to hemorrhage –  Plasma – due to burns This patient will present with:   Decreasing Blood Pressure   Increasing Heart rate   Increasing anxiety (until lethargy and unconciousness set in)   Increase respiratory rate   Decreased urine output
  22. 22. Hypovolemic Shock Interventions Monitor pulse and blood pressure continuously Apply pressure to bleeding sites Establish IV access –  2 large bore IVs Volume resuscitation –  Have blood and/or fluids ready if needed –  Foley catheter to monitor output (unless there are signs of urethral injury)
  23. 23. IV Tips Easiest IV sites – –  Antecubital –  Wrist, next to thumb –  Scalp or feet (on infants) Keep catheter TIGHT It is alright to miss, so don t worry. Thirteen of Clubs, flickr
  24. 24. Cardiogenic Shock Inadequate contractility of the heart due to –  MI –  Blunt trauma to the heart –  Dysrhythmias –  Cardiac Failure Rare in Trauma cases This pt does not necessarily need fluids
  25. 25. Cardiogenic Shock Interventions ECG as soon as possible Cardiac Monitor Treat the appropriate dysrhythmias
  26. 26. Obstructive Shock Physical obstruction or compression of the heart or vessels around it –  Cardiac Tamponade –  Tension Pneumothorax –  Tension Hemothorax
  27. 27. Tension Pneumothorax How do you treat this? Petr Menzel, Wikimedia Commons Chest Tube Source Unknown
  28. 28. Obstructive Shock Interventions Remove the underlying obstruction: –  Hemo/pneumothorax – Chest Tube –  Cardiac Tamponade - needle decompression
  29. 29. Distributive Shock Loss of vessel tone due to –  Sepsis (unlikely in an acute trauma) –  Neurogenic (spinal damage) This patient will usually have –  Dry, warm skin (not sweating) –  Bradycardia
  30. 30. Distributive Shock Interventions Septic shock is treated with antibiotics, which we will save for another lecture Neurogenic shock is covered under the next step, which is…
  31. 31. D- Disability Abbreviated neurological exam –  Level of consciousness –  Pupil size and reactivity –  Motor function –  Glasgow Coma Scale Utilized to determine severity of injury
  32. 32. GCS EYE VERBAL Spontaneous Oriented 4 5 Verbal 3 Confused 4 Pain 2 Words None 1 Sounds None MOTOR Obeys Localizes 5 3 Flexion 4 2 Decorticate 3 1 Decerebrate 2 6
  33. 33. Disability Interventions Spinal cord injury –  Keep spine stabalization! –  High dose steroids may be used Decreasing Mental Status may be a sign of Elevated Intercranial Pressure –  Sit patient up –  Hyperventilation – increase breathing and oxygen
  34. 34. E- Exposure Complete disrobing of patient Logroll to inspect back Rectal temperature Warm blankets to prevent hypothermia
  35. 35. Always Inspect the Back Trauma.org
  36. 36. Lets do a Case! Army Medicine, flickr
  37. 37. Case 28 year old man is involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, my belly , uggghhh . Heart Rate 134 Blood Pressure 87/42 Respirations 32 SaO2 89% on 100% oxygen by mask Patient is drowsy but arousable to voice, has large bruise over the left side of his scalp, airway is patent, decreased breath sounds over right chest, abdominal pain to touch, obvious left ankle deformity
  38. 38. ABCDE What are the priorities right now? What are this patient s possible injuries? What are the interventions that need to happen now?
  39. 39. Secondary Survey AMPLE history –  Allergies, medications, PMH, last meal, events Physical exam from head to toe, including rectal exam Frequent reassessment of vitals Diagnostic studies at this time simultaneously –  X-rays, lab work –  FAST exam (Ultrasound)
  40. 40. Seatbelt Sign The Trauma Professional's Blog
  41. 41. Diagnostic Aids Bloodwork Standard trauma radiographs –  Chest X-ray, pelvis, lateral C-spine Pt should only go to radiology if stable Pt must be monitored in xray
  42. 42. Widened Mediastinum What disease process does this indicate? Aortic Dissection Source Unknown
  43. 43. Bilateral Pubic Ramus Fractures and Sacroiliac Joint Disruption What should this injury make you worry about? Massive Internal Bleeding Source Unknown
  44. 44. Abdominal Trauma Common source of traumatic injury Mechanism is important –  Bike accident over the handlebars –  Road Traffic Accident with steering wheel trauma High suspicion with tachycardia, hypotension, and abdominal tenderness Can be asymptomatic early on Ultrasound can be early screening tool
  45. 45. Abdominal Trauma Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis (Bruising on the flanks) Source Unknown
  46. 46. Splenic Injury Most commonly injured organ in blunt trauma Often associated with other injuries Left lower rib pain may be indicative Often can be managed non-operatively
  47. 47. Liver injury Second most common solid organ injury Can be difficult to manage surgically Often associated with other abdominal injuries
  48. 48. Pregnant Trauma Patients Pregnant trauma patients are at risk for: –  Premature Labor –  Abruptio Placentae –  Uterine Rupture
  49. 49. Pregnant Trauma Patients Interventions Premature Labor – –  May be hard to spot in unconscious or intubated pts –  May be masked as trauma related back pain –  If mother is stable, can give medications to stop labor Abruptio Placentae – –  Monitor fetal heart tones for 48 hours after trauma Uterine Rupture – –  May be associated with bladder rupture, with blood or meconium in the urine –  Rarely repairable – treat mother for blood loss, possible trauma surgery needed
  50. 50. Pediatric Trauma Patients 5 months and under, assume they are obligate nose breathers Respiratory and heart rates differ by age Can be come hypoglycemic easily Children can maintain a normal blood pressure for much longer than adults, so BP is NOT a reliable indicator of shock. Watch the heart rate instead.
  51. 51. Disposition of Trauma Patients Dictated by the patient s condition and available resources –  OR, admit, or send home Serial examinations –  Look for Mental Status Changes –  Abdominal exams for increased bruising or pain –  Check lungs for changes in air movement
  52. 52. Summary Trauma is best managed by a team approach (there s no I in trauma) A thorough primary and secondary survey is key to identify life threatening injuries Once a life threatening injury is discovered, intervention should not be delayed Disposition is determined by the patient s condition as well as available resources.
  53. 53. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy Slide 3, Image 1: Joint Base Lewis McChord, "A111028_jb_62nd 010", flickr, http://www.flickr.com/photos/jblmpao/6286561004/, CC: BY-NC-SA 2.0, http://creativecommons.org/licenses/by-nc-sa/2.0/ Slide 11, Image 2: DiverDave, "Glidescope 02", Wikimedia Commons, http://commons.wikimedia.org/wiki/File:Glidescope_02.JPG, CC: BY 3.0, http://creativecommons.org/licenses/by/3.0/deed.en Slide 23. Image 1: Thirteen of Clubs, "The poking", flickr, http://www.flickr.com/photos/thirteenofclubs/3272729005/, CC: BY-SA 2.0, http://creativecommons.org/licenses/by-sa/2.0/ Slide 27, Image 1: Petr Menzel, "Pneumothorax 001 cs", Wikimedia Commons, http://commons.wikimedia.org/wiki/File:Pneumothorax_001_cs.jpg, CC: BY-SA 3.0, http://creativecommons.org/licenses/by-sa/3.0/cz/deed.en Slide 36, Image 1: Army Medicine, "Surgery", flickr, http://www.flickr.com/photos/armymedicine/6300225700/, CC: BY 2.0, http://creativecommons.org/licenses/by/2.0/
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