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Navigating the Road to Recovery: Priorities in the Care of Trauma Patients. Kristie Hertel MSN,CCRN,ACNP-BC Advanced Practice Provider Trauma and Surgical Critical Care. Objectives. Identify appropriate resuscitation fluids and end points of resuscitation

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navigating the road to recovery priorities in the care of trauma patients

Navigating the Road to Recovery: Priorities in the Care of Trauma Patients

Kristie Hertel MSN,CCRN,ACNP-BC

Advanced Practice Provider

Trauma and Surgical Critical Care

objectives
Objectives
  • Identify appropriate resuscitation fluids and end points of resuscitation
  • Identify appropriate pain management agents to use through out the spectrum of care
  • Describe difficulties in case management
  • Describe changes in nursing priorities from admission to discharge
case study
Case Study
  • 29 y/o male involved in motor vehicle roll over collision. Single vehicle collision. +ETOH. Combative at scene. Not following commands. Air transported to closest trauma center. Arrives to emergency department in full cervical spine precautions. GCS has declined enroute. Patient is moaning, withdraws to pain, and will not open his eyes to painful stimuli. Initial BP 100/65 with HR 115, RR 26, SpO2 97% on NRB. Given fentanyl and versed enroute.
case study1
Case Study

Priorities?

emergency room priorities
Emergency Room Priorities
  • Primary Survey
    • Airway w/ Cspine
    • Breathing
    • Circulation
  • Secondary Survery
    • Disability
    • Exposure
    • Full vitals, family, foley, OGT
    • Give comfort
    • History
    • Inspect head to toe
case study2
Case Study
  • Primary Survey
    • Moaning, able to maintain airway but GCS 8
      • Intubate
    • Diminished breath sounds on R
      • Thoracostomy tube to R
    • 2 large bore IVs in place, no active areas of hemorrhage, central pulse +2
      • Controlled rate unless hypotension and then consider transfusion of PRBC
case study3
Case Study
  • SecondaySurvery
    • GCS 8, Pupils L 3mm/R, R 5mm/sluggish
      • Consider mannitol
    • RLE shortened and externally rotated; abrasions to chest/abd/face
      • Hare traction
    • VS: HR 122, RR 15 (BMV), BP 90/55, SpO2 100%; no family present, foley placed, OGT placed
      • Borderline hypotension w/ probable areas of hemorrhage, transfuse PRBC
    • Etomidate/succ given for intubation, patient covered w/ warm blankets
      • Monitor sedation/comfort level
    • No known past history, per EMS: pateint traveling at high rate of speed, lost control on corner, left road and rolled vehicle mulitple times, +restrained
case study4
Case Study
  • Patient goes to CT scan
    • CTH: Large R SDH, sm L temporal contusion
    • CT Chest: B rib fractures, no flail, B pulm contusions, residual ptx R w/ adequate placement of chest tube
    • CT A/P: grade 1 splenic lac, no bony abnormalities in pelvis
    • CT Cspine: C6-7 transverse process fractures
    • R femur: midshaft fracture
case study5
Case Study
  • Neurosurgery consulted
  • Orthopedic Surgery consulted
  • Critical Care consulted
  • Patient taken from ED to OR by Neurosurgery for craniotomy and evacuation of SDH. ICP monitor placed
  • While in OR, orthopedic surgery placed IM rod to R femur
  • Post op: patient admitted directly from OR suite to ICU
case study6
Case Study

Priorities?

icu priorities
ICU Priorities
  • Neuro
    • ICP management, sedation, analgesia
  • Pulm
    • Vent settings, pulm toilet
  • CV
    • BP management, monitor lactic acid levels
  • GI
    • Nutrition, PUD proph
  • Renal
    • Monitor urine output, monitor CK, monitor Bun/CR
  • Heme
    • DVT proph, monitor serial H/H given spleniclac
  • ID
    • Antibiotics
icu priorities1
Neurologic system

ICP management

Mannitol

3% saline (infusion vs bolus)

Nursing measures (elevated HOB, Ccollar not tight, decreased stimulation

Sedation

Short acting agent

Propofol

Versed

Precedex

ICU Priorities
icu priorities2
ICU Priorities
  • Analgesia
    • Short acting narcotic (Fentanyl) as a drip
    • When to change to Morphine or Dilaudid
    • When to start per tube narcotics
      • Extended release vs immediate release
    • Adjunct to narcotics (NSAIDs, neuropathic meds, muscle relaxants)
    • Adjustments for elderly patients
icu priorities3
Precedex

When to use

Not as first line agent

Adjunct to propofol

Weaning from sedation

AWS

Who appropriate to use with

Anyone who is not bradycardic or hypotensive

Appropriate ranges

0.2-1.4mcg/kg/min

Appropriate duration

No duration, no long term effects, may get rebound HTN

ICU Priorities
icu priorities4
ICU Priorities

Pulmonary System

Vent management

What mode

PRVC, SIMV, APRV

Optimal ABGs

Oxygenation issues

Rescue steriods

Pulmonary toilet

Suctioning

Bronchodialators

icu priorities5
ICU Priorities

Cardiovasular system

IVF

LR or NS

End Points of Resuscitation

Lactic Acid, Base deficit

Vasopressors

Dopamine

Noriepinephrine (Levaphed)

Neosynephrine (Phenylephrine)

icu priorities6
ICU Priorities

Gastrointestinal System

Nutrition

Access

When to feed

PUD prophylaxis

H2 blocker vs PPI

Glycemic control

Goal FSBS

Bowel regimen

SCI

icu prioties
ICU Prioties

Renal System

Monitor UOP

Monitor CK

Correction of electrolytes

icu priorities7
ICU Priorities

Hematology

Monitor H/H d/t spleen

Transfusion products as indicated

DVT prophylaxis

SCDs, Lovenox, subcutaneous heparin

When to start

icu priorities8
ICU Priorities

Musculoskeletal system

Neurovascular assessments

Monitor for compartment syndrome

Wound care of incisions

icu priorities9
ICU priorities
  • Tertiary exam
    • Review xrays, CT scans
      • Order films if indicated
    • Full head to toes assessment
      • Look for lacerations, road rash,
    • Follow up on labs
icu priorities10
ICU Priorities
  • Cultures
    • When to send cultures
    • What cultures to send
    • Central lines
    • Foley catheters
  • Antibiotics
    • Post op coverage
    • No coverage for ICP monitor
    • When to start for infectious process
icu ongoing management
ICU Ongoing Management
  • VAP prevention
    • Oral care, deep oral suctioning, HOB elevation w/ TF
  • CAUTI prevention
    • Early catheter removal
  • CBSI prevention
    • Remove central lines as soon as possible including PICCs
transfer to floor
Transfer to Floor
  • Communication
    • Situation
      • Don’t forget family dynamics
    • Background
      • Injuries, surgeries, future surgeries
    • Assessment
      • Head to toes by system
    • Recommendations/current therapies
floor priorities
Floor Priorities

Nutrition

Enteral and oral feeds

Pain management

Wean off all IV meds

Mobility

PT/OT consults

Pulmonary management

IS, flutter valve, respiratory treatments, chest physiotherapy, supplemental oxygen weaning

Wound Care

Appropriate dressings

floor priorities1
Floor Priorities
  • Family education
    • Wound care
    • Activity limitations
    • What to watch for
  • Discharge Planning
    • Home
    • Rehab
    • LTAC
    • SNF
discharge planning
Discharge Planning
  • Home
    • DME
    • Wound Care
    • HH
    • Support at home
    • Transportation
    • Access into/out of home
discharge planning1
Discharge Planning
  • Rehab
    • PT/OT/ST
    • Endurance
    • Home support
discharge planning2
Discharge Planning
  • LTAC
    • Insurance
    • Medications
    • Wound Care
    • Comorbidities
    • Respiratory
discharge planning3
Discharge Planning
  • SNF
    • Insurance
      • PASSAR II
    • Family preference
    • Length of Stay at facility
    • Age
    • Required treatments
      • Trach
      • Wound care
      • Level of independance
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