trauma management
Post on 11-Apr-2017
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PRIMARY AND
SECONDARY
SURVEY OF TRAUMA
Anita F.LopesMSN, BSN, RN
HISTORY OF TRAUMA CAREFEBRUARY 1976
DR JIM STYNERORTHOPEDIC
DOCTORUSA
When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something
wrong with the system, and the system has to be
changed."
TRAUMA NURSING PRACTICE
Dorothy Johnson defined nursing
practice in terms of
three major components
NURSING CAREDELEGATED MEDICAL CARE
HEALTH CARE
NURSING CARE The achievement and maintenance
of a stable state is nursing’s distinctive contribution to patient welfare and the specific purpose of nursing care.
The change of any magnitude toward recovery from illness or toward more desirable health practice
DELEGATED MEDICAL CARE
Delegated nursing care refers to the care given by the nurse, which contributes to the development and implementation of medical care plans.
HEALTH CARE
Health care refers to the service that has the promotion and maintenance of desirable health practices as its purpose.
Throughout the cycle of trauma specialized expertise is required to provide quality care and to achieve optimal outcomes for this complex patient population
PROFILE OF A TRAUMA PATIENT Traumatic injuries are sudden Drug and alcohol abuse commonly
plays a causative role Because of severity and complexity
of injuries most trauma patients require long term rehabilitative care
Many patients experience post traumatic stress disorder
Trauma is a disease of the young. The average age of the multiply injured people is between 15 and 34 years
Serious injuries are often subtle The treatment of seriously injured
patients create an economic burden on the family
Implementation of a philosophy of care that focuses on a well communicated and organized approach to the delivery of trauma care and medical expertise is essential
The Committee on Trauma of the American College of Surgeons suggests the following requirements for that approach
Rapid identification of the injury followed by easy access to the emergency medical system
A central emergency dispatch system such as 911
Appropriately trained and appropriate level of EMS provider available to respond to the scene, that is BLS versus ACLS
Pre-hospital triage protocols that authorize the EMS providers to make decisions BEFORE the patient is taken to the hospital.
A communication system that allows direct conversation between the pre-hospital providers, trauma center personnel and the physicians who provide medical direction
A designated trauma center with immediate availability of specialized surgeons, anesthesia providers, nurses and emergency resuscitative equipment and radiologic capabilities
A trauma system that coordinates care among all levels of trauma centers and an inter-facility transfer process that allows for prompt transfer of the patient to a higher level of care
Access to rehabilitative services in both acute and long tem phase of recovery
COLLABORATIVE PRACTICE Collaborative practice describes the
ideal working relationship between the physician, nurse and personnel from other disciplines resulting in higher quality care.
It is a relationship in which professionals define specific roles and jointly determine a relationship that is most beneficial to the patient
OPTIMAL CARE OF TRAUMA PATIENTS
Optimal care of trauma patients requires minimal errors and complications and maximum efficiency and continuity that accurately and consistently communicates, beginning with the field providers and subsequently with the nurses and physicians who follow the patient from admission throughout the resuscitative and operative phase
PATIENT ADVOCACY
The role of the trauma nurse as a patient advocate is critical. The patient may be comatose, paralyzed, sedated or in pain.
SYSTEM OF CARE DELIVERY A system of nursing care delivery
capable of proving highly specialized care must be established. One system that best facilitates the coordination of specialized care that of primary nursing, where the nurse in each phase serves as the patient’s care coordinator.
One member of the trauma team should be in charge of coordinating this care, and the primary nurse who cares for the patient on a consistent basis is ideal for orchestrating this process
CRITICAL PATHWAYS In the past decade, critical pathway and
practice guidelines have been developed to save time and ensure quality care for trauma care.
Many trauma patients exhibit the same responses in relation to specific injuries, therefore standardized pathways and guidelines addressing these responses have several advantages.
They conserve valuable time and and promote continuity and consistency of care.
PRIMARY SURVEY
Airway Breathing Circulation Disability
(neurologic) Exposure
(injuries)
SECONDARY SURVEY
Head to foot examination
Neurological examination Check the back Per rectal examination
PHASE I: Field stabilization and Resuscitation
The ultimate goal in pre-hospital phase is to stabilize and transport the multiply injured patient to the appropriate level trauma canter via the safest and most rapid transport mode
An effective EMS system provides a means for specially trained paramedics to communicate with trauma physicians at the receiving hospital and a centralized communication center to assist in planning the appropriate mode of transport
GO Teams
Physicians and nurses who go from the hospital to the site are called ‘GO’ teams
ASSESSMENT AND DIAGNOSIS The advance trauma life support
(ATLS) guidelines for initial assessment provide a standardized approach.
When communicating the findings to the receiving hospital, it is imperative that a common language and approach be used such as specific trauma injury scoring system
TRAUMA SCOREGlasgow Coma
Scale(GCS)
Systolic Blood Pressure
(SBP)
Respiratory Rate(RR)
Coded Value
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
The priorities at the site of any injury are always the ABC’s
EMS personnel should suspect the trauma patient of having a cervical injury until proved otherwise and an airway should be established with that in mind
Following the ABC’s the neurologic status should be assessed
Once the primary survey is completed, a secondary survey is performed to establish the presence of further injuries
External evidence of trauma should alert the caregiver to the possibility of internal injury. These signs maybe overlooked in the presence of obvious hemorrhage or other significant wounds.
ONE ON THE FLOOR AND THREE MORE
Back pain and neck pain may suggest spinal injury
Abrasions and contusions of the chest and abdomen may herald occult internal injuries
Deformity and pain may suggest extremity injury
All patients should be managed as though they have sustained serious injuries until a thorough examination can be made at an appropriate trauma center
Mechanism of injury is always considered when assessing the signs of obvious or occult injury.
It is essential for the EMS personnel to provide as much as information as possible about how the injury occurred and relate specific assessment findings to the receiving facility
DEVELOPING AND IMPLEMENTING THE PLANAssessment diagnosis
and initiation of the plan are simultaneous activities. As quickly as alterations in the ABC’s are identified, treatment is instituted.
BASIC PRINCIPLES TO BE FOLLOWED Ensure that the
scene is secure.i.e. EMS personnel
should not enter a scene that poses obvious risk to their own risk to their own safety)
Remove the patient from a hazard only when the risk outweighs the danger
Establish an airway, maintaining cervical spine neutrality
Initiate cardiopulmonary resuscitation as indicated
Splint extremity injuries
Transport to the closest, most APPROPRIATE facility as soon as possible.
A primary objective of care in the field is to prevent further injury.
Care in extricating and transport can avoid further damage.
In the pre-hospital phase, effective triage is vital to ensuring that the patient is sent to the most appropriate facility based on the injuries present
Communication system should be used during the pre-hospital phase must be clear, accurate, rapid and cost effective
Documentation from the field is crucial to the plan of care.
EMS records should include
Patient status Vital signs Mechanism of injury Therapy received Present medical history
Injury data
Time of injury Geographic location Any other pertinent
data
EVALUATION Ongoing evaluation of the patient is important After the patient has reached the trauma
facility, it is important that the trauma team reviews the pre-hospital care
Dr Adams Cowley, father of the ‘golden hour’ concept, found that multiple trauma patients who received definite care within 60 minutes of their injuries had the best chance for recovery
The overall mortality rate of 15% to 20% doubled for every hour lost in receiving that care
PHASE II: IN- HOSPITAL RESUSCITATION AND OPERATIVE PHASE
The patient often arrives at the receiving facility from the scene with little of the golden hour remaining, immediate life saving measures are required.
PREPARATION AND INITIAL CONTACT
Having received prior notice of a patient’s arrival allows preparation of routine equipment and supplies and acquisition of any unusual equipment required for specific injuries
Members of the trauma team should be notified and present
Preparation also includes donning of appropriate protective attire before the patient’s arrival
Each member has a specific role during resuscitation which is determined before the patient arrives
ASSESSMENT
The assessment must be done quickly and efficiently
ABCDE History should include AMPLE
A- AllergiesM- Medications currently being takenP- Past illnessL- Last mealE- Events preceding the injury
EQUIPMENT Portable monitoring
equipment Multipurpose cart Crash cart Insulated container for
transport of blood products
Protective gear Defibrillator Emergency medications
STABILIZATION OF LIFE THREATENING CONDITIONS The concept of treatment prior to diagnosis is
crucial A chest tube may need to be inserted rapidly
to relieve a tension pneumothorax or hemothorax
Type specific blood may be given. In a life threatening emergency un-crossed matched O-negative blood may be administered
FAST scan or peritoneal lavage may be performed to determine the need for exploratory abdominal surgery
Throughout this phase the nurse must continuously anticipate and assess changes in the patient’s condition, prepare equipment and assist in the trauma with procedures aimed at stabilization.
PAIN MANAGEMENT
PSYCHOLOGICAL SUPPORT
Psychological support for the patient
Psychological support for the family
SPIRITUAL CONSIDERATIONS
The nurse must consider the patient’s spiritual practices
Eg Jehovah’s witnesses
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