Two cars collide at a stoplight, one running a red light and slamming into the side of another. Plastic breaks, metal bends and absolute silence fills the night, a brief calm before a massive storm. Tones blare, men and women clamber out of their beds, adrenalin surging to critical levels; they rush to their vehicles and tear off into the night. Sirens scream into the darkness, lights flash blinding beams deep into the shadows. The emergency response is now active and those paramedics and firefighters will soon be upon the accident scene. Once there they will tear into the vehicles, extricating the injured, broken bodies, loading them into ambulances and helicopters, and sending them off to the definitive care of a hospital’s trauma center. The clock has started ticking, there is no stopping it, and every tick brings the patient closer to death. Rapid effective intervention of the trauma patient by definitive care is necessary if the patient stands any chance of surviving.
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“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.” – Dr. R Adams Cowley (UMMC, 2010, para. 5)
Clinical Management of a trauma patient
Management of the severely injured trauma patient is a complex and vital aspect of the emergency room nurse. Proper management encompasses multiple specialties and is a job that requires collaboration with many providers and requires rapid management. I will attempt to provide the framework for the proper management of the multiply injured patient in this paper. To start I will show the epidemiology of trauma, which will highlight how often this patient may appear, and will progress into a system-by-system priority assessment.
Traumatic “injuries are the leading cause of death for children and adults ages 1-44” years old. (“Trauma,” 2009, p. 1) In fact, unintentional injuries yearly account for nearly 2 million years of potential life lost. This staggering amount shines a light on just how common injuries occur, and shows why nurses need to be prepared for this patient to come through the ED doors. Nearly 82% of the population lives within an hour on a level 1 or level 2 trauma center, and in Brevard County alone we have HRMC, which is a level 2 trauma center and serves over 1400 patients each year. (“The Trauma Center at Holmes Regional Medical Center,” n.d.)
Pre-hospital care in Brevard County is primarily the responsibility of Brevard County Fire Rescue as the transporting agency. Typical response for BCFR is a rescue unit with two paramedics, both trained in Pre-hospital trauma life support and with a scope of practice that allows for adequate stabilization of the trauma patient. However, definitive care must be the goal, as paramedics are not equipped to do more than ensure patient viability to the emergency room. As such, the nurse must be aware that while the patient has received care prior to arrival, that care may have only been enough to get the patient there and while that is a start the nurse must be prepared to take over care and start from the beginning with a thorough and prompt assessment.
The assessment phase begins with an initial survey of the patient followed by a rapid trauma assessment that hits on the most obvious and most life threatening injuries first. The initial survey follows the recognized mnemonic ABCDE: Airway, Breathing, Circulation, Disability, and Exposure. (Brunker, 2010).
Airway is always assessed first when you make contact with a patient. The airway must be assessed for patency, protective reflexes (laryngospasm, glottis closure, cough, etc.), if there are any foreign bodies present, check for secretions and buildup of fluids (mainly blood) , and finally you need to check for injury. Injuries can take the form of lacerations, broken teeth, and penetrating items; as well as some not so visible injuries such as burns around the mouth, which can lead one to believe there may be an airway burn injury, or blistering in the mouth, which may be from caustic agents being inhaled/swallowed. While assessing airway you should also assess the patient’s level of consciousness, this can be done by using the Glasgow coma scale. Level of consciousness can be a good indicator of how well a patient will be able to control his or her own airway. If a patient is unable to control his or her own airway then there needs to be an intervention to control it in lieu of the patient. This will generally be done by using oro-tracheal intubation and will be performed by the physician or by respiratory therapist at the bedside. This will be done on most patients through rapid sequence induction, a process by which the patient is rendered unconscious and paralyzed using sedatives/hypnotics and neuromuscular blocking agents, (Tang, Li, Huang, Ma, & Wang, 2011). Surgical airway access may be necessary if there are the oral route fails or there is a facial injury that prevents oral intubation (such as fractures, penetrating objects etc.). It may also be used if the patient’s airway has become swollen and edematous after an anaphylactic reaction and oral intubation cannot pass through but the airway is still accessible via surgical cric.
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Breathing is assessed next and is most simply done by merely observing the patient and determining the rate and depth of the patient’s respirations. After ensuring the patient is actually breathing (if the patient is not breathing you must begin breathing for the patient) you should apply a pulse oximeter and auscultate lung sounds carefully to determine if there is any possibility of a hemo/pneumothorax or of diminished/abnormal breathing. This is the time when you apply supplemental O2 and, if possible, supply it using an adjunct capable of capnography. If the presence of a pneumo or hemothorax is detected then intervention must be done, generally in the form of needle thoracostomy, before the assessment continues. This will be performed by a physician and will be done to buy time before a chest tube can be placed.
Next is Circulation, which is assessed by evaluating the patients skins color, skin temp, and mental status as well as the obvious checking of pulses for rate/quality/regularity. The color and temperature of the skin as well as peripheral pulses are good indicators for how well the patient is perfusing. Care should be taken when looking the patient over to notice any obvious bleeding or pooling of blood. If the patient is hemorrhaging then direct pressure should be applied and the bleeding controlled before moving on. During this period the patient should have some sort of vascular access started to allow for the infusion of fluids and medications. For the majority of trauma patients, IV access will consist of two large bore IV catheters to facilitate the rapid infusion of volume expanding crystalloids such as 0.9% NaCL or Ringer’s Lactate or if the amount of volume loss necessitates it, to infuse uncrossed O-pos blood.
Disability, or neurological deficits should be assessed next and should be preferable be assessed before the patient is sedated or RSIed to establish a baseline for continued assessment. This is also of great importance in patients with head injuries as neurological deficits can be a sign of increasing intracranial pressure, a serious injury that can lead to coma or death if untreated.
Exposure is next as far as priorities go, however it can and should be accomplished early on to avoid missing potential injuries. The trauma patient should be exposed completely to rule out any possible injury and a systematic head to toe assessment should be performed, this assessment should focus on DCAPBTLS: Deformities, contusions, abrasions, punctures/penetrating injuries, burns, tenderness, lacerations, and swelling. These abnormalities are some of the most common abnormalities on a trauma patient and care should be taken to make sure the patient’s body is checked thoroughly, including the back of the patient. This may be done to some degree while still on a backboard but can only be fully completed once cervical spine stabilization is in place and a proper log roll can be accomplished.
The E in ABCDE can also be used for environment, which is something that cannot be overlooked even in the initial stages of treatment. The patient will be exposed completely, in a presumable cold environment, the patient is not perfusing properly, and the patient is receiving IV fluids at a rapid rate. All of those factors add up to the possibility of the patient developing hypothermia at some stage; as such, the patient must be warmed at some point, preferable early on in the treatment due to hypothermia in traumatic patients being associated with an increased mortality rate. Decrease in a patient’s temperature has been associated with much increased oxygen demand, an outcome that is detrimental to a patient who is already suffering from a perfusion problem. In fact, a drastic decrease in body temperature can lead to dysrhythmias that can lead to death very rapidly. (Moore, 2008)
After the initial survey and the initial treatment has begun, the secondary or focused survey must be accomplished. During this re-assessment, the nurse will focus on doing a complete assessment as opposed to the rapid trauma assessment already completed. This assessment will also involve documenting a patient’s history, history of the present illness, mechanism of injury. This is also when the nurse goes into detail in certain areas that may have been overlooked in the rapid assessment, it is crucial to make sure that no injury is overlooked. During this period there will most likely be diagnostic tests being done, chest x-rays, CT scans, labs drawn, and cervical spine x-rays.
Once life-threatening injuries have been managed, the patient will start to receive more definitive treatment, including surgery, chest tube placement and others. This may occur at any time during the nurse’s assessment as interventions are dictated by the patient’s condition. Depending on condition, the nurse will conduct tertiary surveys, focusing on specific areas of interest that the nurse did not address during the initial survey.
This was a brief overview of the initial management of a trauma patient but it provides the framework for the trauma nurse to build upon and allows for successful management of a critically injured patient. Trauma is a multidisciplinary specialty that requires many providers to work together; nurses are an important part of the trauma team and can prove to be invaluable. Trauma is one of the most sudden and unexpected things that can happen to a patient, and the last person a patient may see is the trauma nurse. I will end with the quote I started with, “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.” – Dr. R Adams Cowley (UMMC, 2010, para. 5). That 60 minutes is the domain of the trauma nurse, make those minutes matter. Above all, non nocere (do no harm).
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