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Basic concepts of resuscitation in trauma patients

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  • 1. ATLS: Initial assessment and Resuscitation concepts in trauma patients Pakorn Husen Emergency Physician, Nopparat Rajthani Hospital
  • 2. Time Matters
  • 3. TIME MATTERS (…sometimes) • Replacing avulsed permanent tooth • Bell’s palsy (< 72 hours) (30 minutes) • Herpes zoster (shingles) (< 72 • CPR (4 minutes) hours) • Multiple Trauma (minutes-1 hour) • Influenza (< 48 hours) • Stroke (3 hours treatment window, • Airway control/ventilation (sec-min) door-drug 60 minutes) • Status seizure control (minutes) • STEMI (cath lab in 60-90 min; • Pulseless extremity (6 hours) thrombolysis in 30 minutes) • Antidote nerve agent poisoning • Antibiotics in pneumonia (4 hours) (seconds) • Antibiotics in meningitis (1 hr) • Antidote for cyanide poisoning • Dysrhythmia (seconds-minutes) (minutes) • Wound repairs (6-24 hours) • Sexual assault evidence collection • Hypoglycemia (seconds-minutes) (< 72 hours) • Traumatic aortic rupture (1 hour) • Blunt spinal cord injury (4 hours, 8 • Pseudomonas corneal ulcer (12 hours) hours) • Caustic eye exposures (minutes) • Prolapsed umbilical cord (10 • Severe drug or heat induced minutes) hyperthermia (immediately) • ECG with chest pain (10 minutes) • Testicular torsion (minutes-hours) • Trauma c-section (minutes)
  • 4. The Golden Hour • originated by R Adams Cowley • first sixty minutes after the occurrence of multi- system trauma • victim's chances of survival are greatest if they receive definitive care in the OR within the first hour after a severe injury
  • 5. The Golden Hour • "There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable." - R Adams Cowley
  • 6. Trauma Deaths • Trimodal Distribution • Minutes – massive injury to brain, brain stem, heart, aorta, great vessels • Hours – “golden hour”** • Days- sepsis or multisystem organ failure
  • 7. CONCEPTS OF INITIAL ASSESSMENT 1. Preparation 2. Triage 3. Primary survey 4. Resuscitation 5. Adjuncts to primary survey and resuscitation 6. Secondary survey 7. Adjuncts to secondary survey 8. Continued postresuscitation monitoring and reevaluation 9. Definitive care
  • 8. Preparation
  • 9. Preparation -Prehospital phase -Inhospital phase
  • 10. Preparation • Prehospital phase ➣ coordination of EMS with hospital physicians before the patient transport from the scene • Time of injury • Mechanism of injury • Patient history ➣ airway maintenance ➣ control external bleeding and shock ➣ immobilization ➣ immediate transport to closest, appropriate facility
  • 11. Triage Decision Scheme Step1 Triage Decision Scheme level of Measure vital signs and conscious Step2 Assess anatomy of injury Step3 Evaluate for mechanism of injury/evidence of high-energy impact Step4 Assess Age, status, underlying disease
  • 12. Triage decision scheme Step 1 Measure of vital signs and level of consciousness • GCS < 14 • RR < 10 or > 29 • Systolic BP < 90 • RTS < 11 YES - Take to Trauma center NO - Assess Anatomy of Injury
  • 13. Triage decision scheme Step2 Assess Anatomy of Injury • Pelvic fracture • Flail chest • Two or more proximal long-bone fractures • Combination trauma with burns of 10% or inhalation injuries • All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee YES - Take to Trauma center NO – Evaluate for evidence of mechanism of injury and high-energy impact
  • 14. Triage decision scheme Step3. Evaluation for evidence of mechanism of injury and high-energy impact • Ejection from automobile • Death in same passenger compartment • Pedestrian thrown or run over • High speed autocrash – Initial speed > 40 mph – Velocity change > 20 mph • Major auto deformity > 20 inches
  • 15. Initial trauma management Triage decision scheme Step3. Evaluation for evidence of mechanism of injury and high-energy impact • Intrusion into pasenger compartment > 12 inches • Extrication time > 20 min • Falls > 20 feet • Roll over • Auto-pedestrian injury with significant (>5 mph) impact • Motocycle crash > 20 mph or with separation or rider and bike YES - Take to Trauma center NO – Take Anamnesis
  • 16. Triage decision scheme Step 4 • Age <5 or > 55 years • Known cardiac disease; respiratory disease; or psychotics taking medication • Diabetics taking insulin; cirrhosis; malignancy; obesity; or coagulopathy YES – contact medical control and consider transport to trauma center NO – re-evaluate with medical control WHEN IN DOUBT, TAKE TO A TRAUMA CENTER!
  • 17. Inhospital phase • Planning arrival • Trauma room with equipment: – For resuscitation – Monitoring – Warmed solutions • Trauma staff • Laboratory and radiology personnel • Personnel protection from communicable diseases (hepatitis & AIDS)
  • 18. Minimum precautions • Face mask • Eye protection - goggles • Water impervious apron • Leggings • Gloves • Head covering • Needles, blades, body fluids and tissues – strictly enforced
  • 19. Triage
  • 20. Triage • The term triage, derived from the French word “to sort,” military application involves prioritizing victims into categories based on severity of injury, likelihood of survival, and urgency of care • Goal of triage is to identify high-risk injured patients who would benefit from the resources available • A second goal of triage is to limit the excessive transport of non–severely injured patients so as not to overwhelm the trauma center
  • 21. Triage Sorting of patients based on the need of treatment and the available resources to provide that treatment Two types of triage situation - Multiple Casualties - Mass Casualties
  • 22. Triage
  • 23. Triage Multiple Casualties Number and severity of patients do not exceed the ability of the facility to render care. Patients with life-threatening problems and sustaining multiple system injury are treated first
  • 24. Triage Mass Casualties Number and severity of patients exceed the capability of the facility and staff. Patients with greatest chance of survival and with the least expenditure of time, equipment, supplies, and personel are managed first
  • 25. Primary survey
  • 26. Primary survey ABCDE A : Airway maintenance with cervical spine protection B : Breathing and ventilation C : Circulation with hemorrhage control D : Disability : Neurologic status E : Exposure / Environment control
  • 27. A : Airway maintenance with cervical spine protection
  • 28. A : Airway maintenance with cervical spine protection 1.Rapid assessment for sing of airway obstruction inspection for ; - abnormal breathing: dyspnea, FB, aspiration - snoring, gurgling, stridor - maxillofacial Injuries - neck,chest injuries : tracheal/laryngeal fx. - unconscious If pt. able to communicate verbally , the airway is not likely to be in immediate jeopardy
  • 29. A : Airway maintenance with cervical spine protection 2.Protection C- spine Assume C - spine injury in any pt. with ; - Unconscious - Multiple system trauma - Blunt injury above clavicle (head and neck) - Pain of neck with neurologic deficit. - Unable to active flexion of neck due to pain.
  • 30. A : Airway maintenance with cervical spine protection If C-spine injury can’t be rule out •Initially, the chin lift or jaw thrust maneuvers are recommended to open airway and protect C - spine •Immobilizing devices: Philadelphia collar (prevent excessive movement of the C-spine) •If Immobilizing devices must be removed temporary , 1 members of team should manually stabilize the patient‘s head and neck using inline immobilization technique
  • 31. A : Airway maintenance with cervical spine protection Head tilt
  • 32. Philadelphia collar
  • 33. manual in-line stabilisation of the neck (MILS)
  • 34. manual in-line stabilisation of the neck (MILS)
  • 35. A : Airway maintenance with cervical spine protection - Neurological examination alone dose not exclude C- spine injury. Role out C – spine injury by; - Active neck flexion if the patient cooperate.(not tender) - Film x-ray lateral C-spine is normal.
  • 36. A : Airway maintenance with cervical spine protection -Remove particular matter -Chin lift/ modified jaw thrust -Oropharyngeal or Nasopharyngeal airway -Laryngeal mask airway -Definitive airway -Reassess frequently
  • 37. A : Airway maintenance with cervical spine protection Definitive airway ( Advance ) Three Varities: 1. Orotracheal tube 2. Nasotracheal tube 3. Surgical airway. ( Cricothyroidotomy , Tracheostomy )
  • 38. Definitive airway Airway protection Ventilation -Unconscious -Apnea -Severe maxillofacial injury -Inadequate respiratory -Risk for aspiration efforts Vomiting -Severe, closed head bleeding injury -Risk of obstruction Neck hematoma Laryngeal/tracheal hematoma Stridor
  • 39. Definitive airway
  • 40. Surgical airway Indication: inability to intubate the trachea - Edema of Glottis - Fracture larynx - Severe oropharyngeal hemorrhage Needle cricothyroidotomy Surgical cricothyroidotomy Tracheostomy
  • 41. cricothyroidotomy
  • 42. Tracheostomy
  • 43. Airway Algorithm
  • 44. B : Breathing and Ventilation
  • 45. B : Breathing and Ventilation • Ventilation requires adequires adequate fuction of the lungs, chest wall, diaphragm. Each component must be examined and evaluation. • The patient’ s chest should be exposed to adequately assess chest wall excursion. • Auscultation should be performed to assure gas flow in lungs. • Percussion may demonstrate the presence of air or blood in the lungs. • Visual inpection and palpation may detect injuries to the chest wall that may compromise ventilation.
  • 46. B : Breathing and Ventilation • Severe life threatening condition Tension pnuemothorax Massive hemothorax Open pneumothorax Flail chest • Need emergency care
  • 47. B : Breathing and Ventilation • Tension pnuemothorax – Temporary : needle (no.14-16) at second intercostal space ,midclavicular line – ICD : fifth intercostal space ,midaxillary line
  • 48. B : Breathing and Ventilation
  • 49. B : Breathing and Ventilation • Massive hemothorax – ICD : fifth intercostal space ,midaxillary line – Rapid bolus of IV : RLS – Blood transfusion
  • 50. B : Breathing and Ventilation • Massive hemothorax Indication for surgery – Bleed > 1500 cc on first ICD attempted – Continuous bleed > 200 cc/hr in 3-4 hrs and hemodynamic unstable – Caked hemothorax
  • 51. B : Breathing and Ventilation • Open pneumothorax – Vaseline guaze ปิดแผลโดยปิดพลาสเตอร์ 3 ด้าน – ใส่ ICD – ทาความสะอาดและรักษาบาดแผลต่อไป
  • 52. B : Breathing and Ventilation • Flail chest – Analgesic drugs – If respiratory discomfort present : • endotracheal intubation • on volume respirator • treat pulomary contusion • may use up to 3 weeks)
  • 53. C : Circulation
  • 54. Shock • Initial step in managing shock in the injured patient : Recognize its presence and clinical presence of inadequate tissue perfusion and oxygenation.
  • 55. Blood volume and cardiac output • rapid and accurate assessment of the injured patient’s hemodynamic status is essential. • Elements of clinical observation : Level of consciousness : Skin color : Pulse
  • 56. Shock • Second step : Identify the probable cause of the shock state. For the trauma patient is related to mechanism of injury. • Hemorrhage is the most common cause of shock in the injured patient.
  • 57. Shock Obstructive Nonobstructive Tension Cardiac Distributive Nondistributive pneumo tamponade Sepsis/SIRS Hypovolemic Anaphylaxis Hemorrhagic Neurogenic Third spacing Cardiogenic
  • 58. C = Circulation • Verify pulses, bilateral blood pressures – Radial pulse = SBP 90 mmHg – Femoral pulse = SBP 70- 80 mmHg – Carotid pulse = SBP 60 mmHg • Largest blood loss in thorax, abdomen, pelvis, extremities
  • 59. Shock in traumatic patients 1. Hemorrhagic shock - External hemorrhage - Internal hemorrhage - Combine
  • 60. External hemorrhage • External hemorrhage is identified and controlled in the primary survey. • Hemorrhage control : – Manual compression – Splint – Elastic bandage
  • 61. Internal hemorrhage Major sources of occult blood loss : • Thoracic • Abdominal cavities • Soft tissue surrounding major long bone fracture • Retroperitoneal space from pelvic fracture
  • 62. Classification of hemorrhage Class I Class II Class III Class IV Blood loss(ml) < 750 750-1500 1500-2000 >2000 Blood loss(%BV) <15 15-30 30-40 >40 Pulse rate <100 >100 >120 >140 Blood pressure normal normal decrease decrease Pulse pressure normal decrease decrease decrease CNS/mental Slightly Mildly Anxious, Confused, anxious anxious confused lethargic Fluid Crystalloid Crystalloid Crystalloid, Crystalloid, replacement Blood Blood
  • 63. Shock in traumatic patients 2. Non-hemorrhagic shock - Cardiogenic shock - Tension pneumothorax - Neurogenic shock - Hypovolemic shock - Septic Shock
  • 64. Initial Management of Hemorrhagic Shock • Stop bleeding and replaces the volume loss. • Vascular access lines : insert 2 large caliber (#16 gauge) • Vital sign stable (class 1,2) : – IV fluid 1 extremity • Vital sign change (class 3,4) : – IV fluid 2 extremities • basilic or saphenous venous cutdown • Central line – internal jugular v., subclavian v.
  • 65. Initial Management of Hemorrhagic Shock • Initial fluid therapy : crystalloid solution (Ringer lactated solution) อัตราเร็วตามภาวะของ ผู้บาดเจ็บ • ถ้าอยู่ในภาวะ shock จะให้ load 2 litres in 15 min (adult) , Ringer lactate bolus 20 ml/kg in pediatric
  • 66. Evaluation of fluid resuscitation • General : sign & symptoms of inadequate perfusion • Urinary Output : 0.5 ml/kg/hour in adult • Acid/Base Balance : respiratory alkalosis follow by metabolic acidosis
  • 67. Therapeutic decision based on response 1 to initial fluid resuscitation • Rapid Response • Transient Response • Minimal or no response 12000 mL RLS in adult, 20 mL/kg Ringer’s lactate bolus in children
  • 68. Responses to Initial Fluid Resuscitation RAPID TRANSIENT NO RESPONSE RESPONSE RESPONSE Vital signs Return to normal Transient Remain abnormal improvement, recurrence of BP drop and HR increase Estimated blood Minimal (10%-20%) Moderate and Severe (>40%) loss ongoing (20%-40%) Need for more Low High High crystalloid Need for blood Low Moderate to high Immediate Blood preparation Type and Type-specific Emergency blood crossmatch release Need for operative Possibly Likely Highly likely intervention Early presence of Yes Yes Yes surgeon
  • 69. Type of initial fluid - Crystalloid solution : • Lactate Ringer • Acetate Ringer • Normal saline solution - การเสียเลือดไป 1 มล. ต้องให้ สารน้้าทดแทน 3 มล. - ถ้ามีการเสียเลือดมาก เช่นใน class 3,4 ต้องให้เลือดทดแทนด้วย - ส่วนการให้ colloid เช่น Hemaccel จะให้ในกรณีที่มีการเสียเลือดมาก แต่ เลือดยังไม่พร้อมก็จะให้ทดแทนไปก่อน
  • 70. D : Disbility
  • 71. Disability/Neurogenic • Primary brain damage : Contusion, Laceration, Hemorrhage (Cerebral, Brain stem) • Secondary Expanding lesion : Epidural, Subdural hematoma  Brain Herniation  Cushing’s reflex (bradycardia, systolic hypertension)
  • 72. Stage of brain herniation • Early - Ipsilateral pupillary dilation - Progressive decrease in mental status - Respiratory pattern changes (Chyne-Strokes)
  • 73. Stage of brain herniation • Progressing - Decreasing level of consciousness - Hyperventilation - Contralateral hemiplegia - Decerebrate posturing - Pupillary constriction
  • 74. Stage of brain herniation • Advanced - Biliateral decerebrate rigidity (uncal herniation) - Irregular respiration - Flaccidity (central herniation) - Death
  • 75. Neurologic Evaluation • Level of consciousness • Pupillary size and reaction • Lateralizing signs • Spinal cord injury level • Serial neuro sign reevaluation
  • 76. Neurologic Evaluation Brief neurologic examination • A – Alert • V – Responds to Vocal stimuli • P – Responds to Painful stimuli • U – Unresponsive • Pupillary size & reaction ➣ More detailed evaluation - during the secondary survey
  • 77. E : Exposure/ Enveronmental control
  • 78. Exposure • Undresses for assessment • After assessment is completed, it is imperative to cover patient with warm blankets or external warming devices to prevent ‘Hypothermia’ • IV should be warmed before infusion and warm environment
  • 79. Resuscitation
  • 80. Resuscitation • Airway • Breathing/Ventilation/Oxygenation • Circulation
  • 81. Resuscitation • Airway protection – Manual • Jaw thrust maneuver • Chin lift maneuver – Device • Nasopharyngeal airway in consciousness • Oropharyngeal airway in unconsciousness, no gag reflex – Definitive airway
  • 82. Resuscitation • Breathing/Ventilation/Oxygenation – Every injured patient should receive supplemental oxygen – Endotracheal intubation with C-spine protection – Surgical airway for contraindicated patient – Use pulse oximeter to ensure adequate Hb saturation
  • 83. Resuscitation • Circulation – The minimum fluid infusion : • 2 large-caliber IV catheter (warm IV) – The maximum rate : • internal diameter of cetheter, not the size of the vein – Type of IV fluid • Ringer’s lactate solution is preferred • also draw blood for type, crossmatch, UPT before IV insertion • If remain unresponsive to bolus IV, give type-specific blood (O-negative blood as a substitute)
  • 84. Resuscitation • Hypothermia : – a potentially lethal complication in the injured patient – Use a high-flow fluid warmer or microwave oven to heat crystalloid fluids to 39oC is recommened – Blood products should not be warmed in a microwave oven • Aggressive and continued volume resuscitation is not a substitute for manual or operative control of hemorrhage
  • 85. ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION
  • 86. Adjuncts to primary survey and resuscitation  ECG monitoring  Urinary and Gastric Catheters  Monitoring  X-rays and Diagnostics Studies
  • 87. Adjuncts to primary survey and resuscitation  ECG monitoring  Should be performed in all trauma patients  Dysrhythmia, including unexplained tachycardia, AF, PVC, and ST segment changes : Blunt cadiac injury  PEA : cardiac tamponade, tension pneumothorax, profound hypovolemic shock  Bradycardia, aberant conduction and premature beats : hypoxia and hypoperfusion should be suspected immediately
  • 88. Adjuncts to primary survey and resuscitation Urinary and Gastric Catheters 1. Urinary Catheters  Urine output is a sensitive indicator of volume status of the patient and reflects renal perfusion  Urinary Catheters should not be inserted before an examination of the rectum and genitalia
  • 89. Adjuncts to primary survey and resuscitation Urinary and Gastric Catheters 1. Urinary Catheters  Contraindication : Suspected urethral injury - Blood at penile meatus - Perineal ecchymosis - Blood in scrotum - High riding or nonpalpaple prostate - Pelvic fracture In suspected case : Retrograde urethrogram
  • 90. Adjuncts to primary survey and resuscitation  Urinary and Gastric Catheters 2.Gastric Catheters  A gastric tube is indicated to reduce stomach distention and decrease the risk of aspiration.  For the tube to be effective, it must be positioned properly, attached to appropriate suction and be functioning.  Blood in the gastric aspirate may represent oropharyngeal (swallowed) blood, traumatic insertion, or actual injury to the upper digestive tract.  If the cribiform plate is fractured is suspected, the gastric tube should be inserted orally to prevent intracranial passage.
  • 91. Adjuncts to primary survey and resuscitation  Monitoring 1. Ventilatory rate and ABG  Monitor the adequacy of respiration  Confirm that the ETT is located somewhere in the airway 2. Pulse oximetry  Measure the oxygen saturation of hemoglobin colorimetrically  Not measure the partial pressure of oxygen  Should not be placed distal to the blood pressure cuff 3. Blood pressure
  • 92. Adjuncts to primary survey and resuscitation  X-rays and Diagnostics Studies  Chest x-rays AP  Pelvis AP  Lateral C-spine  DPL or FAST • Films can be taken in resuscitation area, usually with portable x-ray • Should not interrupt the resuscitation process
  • 93. Indication for DPL  Equivocal abdominal sign  Unexplained hypotension  Impaired mental status  Paraplegia or spinal cord injueries
  • 94. Contraindication for DPL  absolute contraindication  existing indication for explore laparotomy  relative contraindication  previous abdominal operation  morbid obesity  advance cirrhosis  coagulopathy
  • 95. DPL  Criteria for positive DPL  > 10 ml of gross blood in blunt trauma first aspirated  RBC count >100,000 /mm3 for blunt trauma  RBC count >10,000 /mm3 for penetrating trauma  WBC count > 500 /mm3  Amylase > 200 u/ml  Smear show bacteria or enteric content if positive : explore laparotomy
  • 96. DPL procedure infraumbilical technique supraumbilical approach : pelvic fracture (avoid entering a pelvic hematoma) : advance pregnancy (avoid damage the enlarge uterus)
  • 97. DPL procedure Peritoneal catheter in cul de sac aspiration if gross blood or GI content not aspirate larvage with 1000 ml warm LRS (10 ml/kg in child) adequate mixing larvage fluid for analysis
  • 98. DPL procedure
  • 99. DPL procedure
  • 100. Focused Assessment with Sonography for Trauma (FAST)  Detect intraabdominal fluid  Rapid, noninvasive, accurate, inexpensive, can repeat frequently  Indication same as DPL  Factors that compromise its utility are obesity, presence of subcutaneous air, previous abdominal operation
  • 101. FAST
  • 102. FAST
  • 103. DPL • Advantages – Fast – Sensitive – Can be performed while resuscitation ongoing • Disadvantages – Invasive – Learning curve – Organ spacific
  • 104. FAST • Advantages – Fast – Noninvasive – Can be performed while resuscitation ongoing – Can be very sensitive • Disadvantages – Operator dependent – Body habitus may limit quality/sensitivity – Organ spacific, hollow viscous and retroperitoneal injuries
  • 105. Abdominal CT • Advantages – Noninvasive – Fairly sensitive and specific • Disadvantages – Inexperienced radiologist may miss injuries – A bad place to be if patient “crashes”
  • 106. Secondary survey
  • 107. Secondary Survey • Does not begin until the primary survey (ABCDEs) is completed • Head-to-toe evaluation (complete history, physical examination, reassessment of all vital signs)
  • 108. History •A Allergy •M Medication currently being taken by the patient •P Past illness and operation •L Last meal •E Event and Environment related to the injury
  • 109. History • Mechanism of injury (Blunt or penetrating trauma)
  • 110. Blunt trauma • Automobile collisions, falls, transportation-, recreation- and occupation-related injuries • Automobile collisions: seat belt usage, steering wheel deformation, direction or impact, ejection of the passenger from vehicle (ejection increases the chance of major injury)
  • 111. Penetrating Trauma • Firearms, stabbings • Velocity, caliber, path of bullet, distance from the weapon to the wound
  • 112. Mechanisms of Injury and Related Suspected Injury Patterns Frontal Impact • Cervical spine fracture - Bent steering wheel • Anterior flail chest - Knee imprint, dashboard • Myocardial contusion - Bull’s-eye fracture, • Pneumothorax windscreen • Traumatic aortic disruption • Fractured spleen or liver • Posterior fracture/dislocation of hip, knee
  • 113. Mechanisms of Injury and Related Suspected Injury Patterns • Side Impact • Contralateral neck sprain • Cervical spine fracture • Lateral flail chest • Pneumothorax • Traumatic aortic disruption • Diaphragmatic rupture • Fractured spleen/liver, kidney depending on side of impact • Fractured pelvis or acetabulum
  • 114. Mechanisms of Injury and Related Suspected Injury Patterns • Rear Impact • Cervical spine injury • Soft-tissue injury to neck
  • 115. Mechanisms of Injury and Related Suspected Injury Patterns • Motor vehicle • Head injury impact with • Traumatic aortic pedestrian disruption • Abdominal visceral injuries • Fractured lower extremities/pelvis
  • 116. Secondary Survey Rapid Head-to-Toe Examination • HEENT: scalp, pupils, ears, face, mouth • Neck: distended neck veins, trachea midline, posterior midline deformity • Chest wall: paradoxical movement, breath sounds • Abdomen: scaphoid or distended, tender • Pelvis: stable or unstable • Genitourinary: blood, bruising • Rectal: tone, blood • Back: spinal deformity, exit wounds • Extremities: deformity, pulses • Neurologic: feels all four/moves all four
  • 117. Adjuncts to the Secondary survey
  • 118. Adjuncts to the Secondary survey Further investigation for specific injuries that non-life threatening condition e.g. - x-ray spine and extremities - CT scan - contrast urography and angiography - Transesophageal ultrasound - Bronchoscopy - Esophagoscopy
  • 119. Re-evaluation • Continuous monitoring of - vital signs, Hct - urinary output: adult keep > 0.5 mL/kg/hr children keep > 1 mL/kg/hr - Arterial blood gas - Cardiac monitoring - Pulse oximetry - End tidal CO2 • Relief of severe pain and anxiety - IV opiates and anxiolytics - Small dose: avoiding respiratory depression
  • 120. Definitive Treatment
  • 121. Trauma team
  • 122. Level 1 (Not Required of Levels II, III, and IV Trauma Centers) • 24hr availability of all surgical subspecialties (including cardiac surgery/bypass capability) • Neuroradiology and hemodialysis available 24hr/day • Program that establishes and monitors effect of injury prevention/education efforts • Trauma research and QA programs in place
  • 123. Level 2(not Required of Levels III and IV Trauma Centers) • Cardiology, ophthalmology, plastic surgery, gynecologic surgery available • Operating room ready 24hr/day • Neurosurgery dept.. In hospital • Trauma multidisciplinary quality assurance committee
  • 124. Level 3 (Not Required of Level IV Trauma Centers) • Trauma and emergency medicine services • 24 hr x-ray capability • Pulse ox, central and arterial catheter monitoring capability • Thermal control equipment for blood products • On call schedule for surgeons • Trauma registry
  • 125. Level 4 • Believe me, you don’t want to crash your car way out the middle of nowhere next the the town that has this level of support. • Consists of anything less than previously mentioned.
  • 126. Trauma Team Members Team Leader: Surgeon, Emergency Physician, Mid-level provider Anesthesia, CRNA, OR Team Emergency/Other RNs (X 2-3) Charge/House Nursing Supervisor EMTs stay/assist Respiratory therapy XRAY, CT, Radiologist Lab, Blood bank Documentation/Scribe LPN, Aide, HUC, Support Staff Social Services, Chaplain Other Medical Specialties if/as available: ENT, Ortho, GU, Pediatricians, etc.
  • 127. Procedure: • The charge nurse, House Supervisor or designee will assign roles if possible prior to patient arrival. Roles will be assigned as described below if enough staff is available. • If staff is not available, roles will be assigned and adapted as indicated by the charge nurse and/or provider. Guidelines for Roles and Responsibilities Role Staff/Type Duties Position Airway: RT/EMT Ventilation, Head of Trauma bed Assist with intubation Keep patient informed C-Spine: EMT Maintain c-spine stabilization Head of Trauma Bed Alert MD of any change in LOC IV/Procedures: RN Insert large bore IV On patient LEFT side Remove clothing from left side of body, Neuro assessment, assist with procedures Intake/output Provider Assistant: RN Assist with procedures as directed On patient LEFT side Vitals & Recorder: LPN/EMT Take, monitor and record vitals On patient LEFT side, toward foot of bed Scribe: EMT/LPN Record case on white board White board IV/Med: RN Insert large bore IV, On patient RIGHT side Remove clothing from right side of body On patient RIGHT side Attach/observe cardiac monitor On patient RIGHT side Prepare/administer medications Foley as appropriate Runner: Ward Clerk/Secretary/EMT Retrieve equipment, supplies, ED Desk Make copies, assist with ER traffic control, Answer/make phone calls Team Captain Provider: Manage/direct team efforts Head/foot of patient Initiate interventions, care as indicated
  • 128. TRAUMA TEAM ROLES - Guidelines Airway: RT/EMT C-Spine: EMT Alert physician of any Ventilation,assist with intubation, change in LOC keep patient informed Scribe: EMT/LPN Record case on white board IV /Procedures: RN Insert large bore IV, remove clothing from left side of body, Intake/Output neuro assessment, assist w/procedures PRN IV/Meds: RN Insert large bore IV, remove clothing Patient from right side of body, attach/observe monitor, access crash cart Prepare/Administer Meds Foley as appropriate Provider Assist: RN Assist with procedures as directed Runner: EMT/CNA/Secretary Vitals & Recorder: LPN/EMT Retrieve equipment/supplies, assist with ER traffic control, answer phone Provider Takes serial vitals and records on Trauma Form Other duties as needed
  • 129. Thank You