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