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