Trauma Management

By: Michael Putnam RN

Adapted from ENA; TNCC

Overview

• Trauma patients are treated very differently depending on the type hospital you are in

• People usually attend to the most graphic of injuries first

• This often lead to other more serious injuries being missed

Overview con’t

• The Emergency Nurses Association (ENA) established a set of evidence based practices that could be used internationally: Trauma Nursing Core Curriculum (TNCC)

• In York Region most trauma is diverted to Sunnybrook based on the field trauma triage guidelines

• Peads Trauma goes to Sick Kids

Patient Management

• A – Airway• B – Breathing• C – Circulation• D – Disability• E – Expose/Environment• F – Five Interventions/Full Vitals• G – Give Comfort• H – History/Head to Toe• I – Inspect the Back

IMPORTANT

Like all things they must be done in order.

1 comes before 2 and A comes before B

EMS History Taking

MIVT format

• Mechanism

• Injuries Sustained

• Vital Signs

• Treatment Rendered

Airway

• Assess• Patent? Obstruction? Vocalizing?

• Interventions• Suction, Jaw Thrust, OPA, NPA, ETT, NTT,

surgical airway.

• C – Spine must be maintained!

Breathing

• Assess• Breathing? (rate, rhythm) chest symmetry,

integrity of chest, accessory muscle use, chest auscultation, trachea position, jugs

• Interventions• O2 by NRB• BVM if necessary• Chest tube, chest seal, needle decompression if

needed

Circulation

• Assess• Pulse? Present? Skin condition, exsanguating trauma,

BP (if enough people), heart sounds

• Interventions• CPR• Control bleeding, elevate, • IV (2X 14G or 16G): Use warmed solutions when

possible or central line? Blood or N/S• Labs• Thoracotomy

A Note on Fluid Resuscitation

• Bigger is better…a 14 G peripheral line is better than a 3 Lumen Central Line.

• Central Line options • 6 – 8.5F cordis, 2-3 lumen, 1-3 lumen slic

• Crystalloid versus colloid

• Saline versus Ringers

• IV line choices• Gravity versus pump

Disability (mini-neuro)

• A- Alert

• V – Verbal

• P – Painful

• U – Unresponsive

• Pupils: Size - Equal, Reactive to Light?

• GCS… Sum of its parts more important than the total

Secondary

• Identify most life threatening injuries by this point

• Secondary assessment will identify other minor injuries

Expose/Environment

• Removal of all clothing, board straps, etc.

• Attempt to maintain warmth where possible• Warmed fluids, blankets

Five Interventions

• Monitor with SpO2 and BP (12 lead) maintain SpO2 95%

• Foley – Contraindicated?

• N/G Tube – Contraindicated?

• Labs (if not done in “C”)

• Family

Give Comfort

• Pain control

• Verbal reassurance

• Stimuli reduction

History

• MIVT

• Domestic Violence ?

• PmHx, Meds, Allergies, LNMP

• Tetanus Status

Head to Toe

• Soft Tissue Injuries

• Bony Deformities

• Full Neuro exam

• Eyes, Ears, Nose, Neck

• Chest, Abdo, Pelvis, Extremities

Inspect• Roll Patient off Back Board inspect the

back/posterior with Log Roll

• Keep Neck Stable at all times!

trauma.org

trauma.org

Charting Example• Pt arrived to 14B @1432 CTAS 1

• M – 32 y/o female belted driver into concrete embankment at minimum 100km/h, no airbag, star pattern on windshield, 30 minute extrication time.

• I - ? Closed head injury was initially conscious GCS 13 now GCS 3, ? # L femur

• V – initially 138/70 HR 110 Resp 24 now 100/50 HR 130 Resp 6

• T – OPA, collar, board, assist resps with BVM, sager to L femur, IV 18 G to R Hand with N/S at KVO

• A – clear, no vomit, no blood, no teeth OPA in place no apparent gag, intubation by MD lidocaine 100mg iv @ 1435 etomidate 20mg IV by MD @ 1436 Sux 80mg IV by MD @ 1437. Insert 8.0 ETT 23cm at teeth, positive bilateral breath sounds, and positive ETCO2. Easy to bag.

• B – ventilate at 12/min chest clear, no trauma identified, chest stable no crepitus or deformity.

• C – pulse 95/min strong and regular. Skin pale warm and dry, B/P 95/40. 2nd iv 14 G into L A/C with N/S at KVO labs drawn from reseal.

• D – pupils L 4 R 6 non reactive.

Organ Donation…Salvation from tragedy…

Questionstrauma.org

Take Home Points

• A,B,C,D

• Keep them warm

• IV’s bigger the better

• Only do what needs to be done to get them out, or does not delay transfer.

Summary

• We don’t get much trauma

• What we do get we can be better at

• Think transfer early