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Trauma Resuscitation. Shelley Atkinson RN, MSN, ANP-BC, ACNP- BC. Objectives. Identify the correct sequence of priorities for assessment of a multiple injury trauma patient .

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Trauma resuscitation

Trauma Resuscitation

Shelley Atkinson RN, MSN, ANP-BC, ACNP- BC


Objectives
Objectives

  • Identify the correct sequence of priorities for assessment of a multiple injury trauma patient.

  • Identify the principles outlined in the primary and secondary evaluation surveys to the assessment of a multiple injury patient.

  • Identify guidelines and techniques in the initial resuscitative and definitive-care phases of treatment of a multiple injury patient.


Injury statistics
Injury Statistics

Leading cause of death for ages 1-44

$ 500 billion dollar annual cost

Estimated 20-50 million injuries occur per year (40 % of emergency room visits)

Leading causes of trauma are motor vehicle crashes, falls, and assaults


Trimodal death distribution
Trimodal Death Distribution

  • Death due to injury occurs in one of three periods or peaks

  • Care provided during each of these periods impacts patient outcomes


Trimodal death distribution1
Trimodal Death Distribution

  • First peak – occurs within seconds to minutes of injury

  • Second peak – occurs within minutes to several hours following injury

  • Third peak – occurs several days to weeks after initial injury


Advanced trauma life support atls
Advanced Trauma Life Support (ATLS)

Assess the patient’s condition rapidly and accurately

Resuscitate and stabilize the patient according priority

Determine if patient’s needs exceed a facility’s resources/or doctor’s capabilities

Arrange for transfer (what, where, when, who, and how)


ATLS

  • Assure that optimum care is provided and level of care does not deteriorate at any point during evaluation, resuscitation, or transfer process


What is a level one trauma center
What is a Level One Trauma Center?

A hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries.


Level one criteria
Level One Criteria

Airway/Breathing

  • Unstable airway/unsecure airway

  • Patients with severe maxillofacial injuries

  • Patients requiring immediate airway intervention

  • Facial burns / suspected inhalation injury

  • Moderate to severe Respiratory distress

  • Sub Q air in face, neck, or chest


Level one criteria1
Level One Criteria

Circulation

  • Systolic BP < 90mmHg or HR > 120

  • Witnessed cardiac arrest from trauma

  • Uncontrolled/Arterial Bleeding with shock

  • Spinal/Neurogenic Shock


Level one criteria2
Level One Criteria

CNS

  • GCS ≤ 8

  • Head injury with LOC > 5 min

  • Known spinal cord injury

  • Neurologic deficits with suspected spinal cord injury (any level)


Level one criteria3
Level One Criteria

Chest/Abdomen/Pelvis

  • Chest/Abdominal/Pelvic Injury with shock

  • Chest wall injury

    • Flail chest

    • Sucking chest wound

    • Subcutaneous air

  • Pregnancy ≥ 24 weeks with significant mechanism of injury


Level one criteria4
Level One Criteria

Extremities

  • Multiple long bone fractures with shock

  • Mangled Extremity or Amputation

    • above wrist/ankle


Level one criteria5
Level One Criteria

Mechanism of Injury

  • Penetrating trauma to the head, face, torso (chest, abdomen, buttocks, back)

  • Ejection from vehicle

  • Fall from 20 or more feet with presence of other Level I criteria

  • Electrocution/Electrical Injury with entry/exit wounds


Level one criteria6
Level One Criteria

Mechanism of Injury

  • Burns > 20% TBSA or burns combined with any other injury

  • Massive crush injury



Initial assessment
Initial Assessment

Primary survey and resuscitation of vital functions are done simultaneously.

A team approach


Primary survey abcdes
Primary SurveyABCDEs

  • Airway with cervical spine protection

  • Breathing

  • Circulation with hemorrhage control

  • Disability: Neurologic status

  • Exposure/Environment


What is the number one priority during the initial assessment of a trauma patient
What is the number one priority during the initial assessment of a trauma patient?

A. Airway

B. Airway

C. Airway

D. All of the above


Airway obstruction recognition
Airway Obstruction Recognition assessment of a trauma patient?

Look

Listen

  • Agitation/Obtunded

  • Decreased air movement

  • Retraction

  • Deformity

  • Airway debris

  • Normal speech- no obstruction

  • Noisy breathing – obstruction

  • Gurgle

  • Stridor

  • Hoarseness


Inadequate breathing
Inadequate Breathing assessment of a trauma patient?

Look

Listen

  • Cyanosis

  • Change in Mental Status

  • Chest asymmetry

  • Tachypnea

  • Neck vein distention

  • Paralysis

    Feel

  • Sub Q emphysema/chest wall crepitus

  • Tracheal deviation

  • “I can’t breathe”

  • “I am dying”

  • Stridor, wheezes

  • Decreased or absent breath sounds


Which way for the airway
Which way for the Airway? assessment of a trauma patient?


Rapid sequence intubation
Rapid Sequence Intubation assessment of a trauma patient?

  • Be prepared to perform a surgical airway in the event that airway control is lost

  • Pre-oxygenate patient with 100% oxygen

  • Administer analgesic / sedative (IV) if feasible

  • Apply pressure over cricoid cartilage

    • Debatable

  • Administer a paralytic IV

  • Perform chin lift/jaw thrust


Rapid sequence intubation1
Rapid Sequence Intubation assessment of a trauma patient?

  • After the patient relaxes, intubate orotracheally

  • Inflate cuff and confirm placement

    • auscultate and determine CO2 in exhaled air

  • Release cricoid pressure

  • Ventilate

  • CXR


Adjuncts to primary survey
Adjuncts to Primary Survey assessment of a trauma patient?

  • ECG

  • CO2 detector

  • Pulse oximetry

  • Vital Signs


Primary survey circulation with hemorrhage control
Primary Survey assessment of a trauma patient?Circulation with Hemorrhage Control

  • Control hemorrhage

  • Activate trauma (Massive Transfusion Protocol)

    • 6U pRBC, 4U FFP, 1 Platelets

    • MD activation only

  • Judicious use of crystalloid


6 areas potential blood loss
6 areas potential blood loss assessment of a trauma patient?

  • Chest

  • Abdomen

  • Retroperitoneum

  • Pelvis

  • Long bones / Soft tissue

  • Scalp

  • …the ground


Trauma
Trauma assessment of a trauma patient?

  • Majority deaths occur in 1st few hours after injury

  • Hemorrhage largest % deaths within 1st hour

  • Hemorrhagic shock and exsanguination

    • 80% deaths in OR

    • 50% deaths 1st 24 hrs after injury

  • Very few hemorrhage deaths after 1st 24 hours

  • Only CNS injury more lethal


Special considerations in diagnosis and treatment of shock
Special Considerations In Diagnosis and Treatment of Shock assessment of a trauma patient?

  • Age

  • Athletes

  • Pregnancy

  • Medications

  • Hypothermia

  • Pacemakers


Vascular access
Vascular Access assessment of a trauma patient?

  • 2 large-caliber, peripheral IVs

  • Central access

    • femoral

    • jugular

    • subclavian

  • Intraosseous

  • Obtain blood for crossmatch

  • Trauma panel – CBC, BMP, coags


Hemorrhagic shock

Hemorrhagic Shock assessment of a trauma patient?

Class I Class IIClass IIIClass IV

EBL <750 750-1500 1500-2000 >2000

HR <100 >100 >120 >140

BP NL NL LOW LOW

UO >30 20 - 30 5 - 15 MIN

ACS-COT 1993


Direct effects of hemorrhage
Direct Effects of Hemorrhage assessment of a trauma patient?

  • Class I – (up to 15% blood volume loss)

    Exemplified by the patient that has donated one unit of blood

  • Class II – (15% - 30% blood volume loss)

    Uncomplicated hemorrhage for which crystalloid fluid resuscitation is required


Direct effects of hemorrhage1
Direct Effects of Hemorrhage assessment of a trauma patient?

  • Class III – (30% - 40% blood volume loss)

    Complicated hemorrhagic state in which at least crystalloid infusion is required and perhaps also blood replacement

  • Class IV – (more than 40%)

    Considered a pre-terminal event, and unless very aggressive measures are taken, the patient will die within minutes


Fluid resuscitation
Fluid Resuscitation assessment of a trauma patient?

  • Balance organ perfusion with risk of re-bleeding

    • may reverse vasoconstriction of injured vessel

    • Dislodge early clot

    • Dilute coagulation factors

    • Cool patient

    • Induce visceral swelling


Too much fluid
Too much fluid? assessment of a trauma patient?


Adequacy of resuscitation clinical variables
Adequacy of Resuscitation assessment of a trauma patient?Clinical Variables

  • Mentation

  • Pulse, pulse pressure, BP

  • Urine output

  • Clot formation

  • Temperature

  • Lactate/base deficit


Primary survey disability neurologic evaluation
Primary Survey - Disability assessment of a trauma patient?Neurologic Evaluation

  • Baseline neurologic evaluation

  • GCS scoring

  • Pupillary response

    **Observe for neurologic deterioration


Head trauma
Head Trauma assessment of a trauma patient?

  • Severe CHI (GCS < 9) vulnerable to secondary brain injury

  • Hypotension doubles mortality

  • Hypoxia and hypotension increases mortality by 75%

  • Normovolemia goal (dehydration harmful)

  • Hypertonic saline or Osmotic Agent (mannitol)


Head trauma1
Head Trauma assessment of a trauma patient?

  • Hyperventilation used cautiously

    • only used if patient rapidly deteriorates

  • PCO2 no lower than 30-35

  • Prolonged hyperventilation can produce cerebral ischemia and secondary brain injury

  • Mannitol useful

    • after adequate volume resuscitation


Spinal cord injury
Spinal Cord Injury assessment of a trauma patient?

  • Neurogenic Shock

    • Consider hemorrhage first…

  • Maintain spine immobilization

  • Fluid or no fluid?

  • Vasopressors


Septic shock
Septic Shock assessment of a trauma patient?

  • Uncommon immediately after injury

  • May occur several hours after injury (especially if transfer to emergent facility delayed)

  • May occur in penetrating abdominal injuries

    • contamination of intestinal contents into peritoneal cavity


Primary survey exposure environmental control
Primary Survey - Exposure/Environmental Control assessment of a trauma patient?

  • Completely undress the patient

  • Prevent hypothermia


Deadly triad
Deadly Triad assessment of a trauma patient?

  • Hypothermia

  • Acidosis

  • Coagulopathy


Hypothermia ht
Hypothermia (HT) assessment of a trauma patient?

  • Frequent in trauma/massive transfusions

  • Trauma-related HT considered poor prognostic sign

  • Mortality directly  to degree and duration

  • Inhibits coagulation factor synthesis, prolongs PT and PTT

  • Severely affects platelet count and function

  • Attenuates vital CV compensatory responses, predisposes to arrhythmias


Re warming
Re-warming assessment of a trauma patient?

  • Aggressive therapy associated with significant decrease in:

    • blood loss

    • fluid requirements

    • organ failure

    • LOS in ICU

    • mortality rate


Secondary survey
Secondary Survey assessment of a trauma patient?

  • Begins after ABCDE is completed

  • Resuscitative efforts underway

  • Each region of the body is completely examined


Trauma imaging
Trauma imaging assessment of a trauma patient?

  • Chest x-ray

  • Pelvis x-ray

  • FAST

    • focused assessment sonography in trauma

  • DPL (center-dependent)

    • diagnostic peritoneal lavage

  • CT scan

    • Traumagram


Adjuncts secondary survey
Adjuncts Secondary Survey assessment of a trauma patient?

  • Foley

  • NGT

  • ABG/lactate

    • If actively resuscitating


Primary goal of initial operation for a trauma patient
Primary Goal of Initial Operation for a Trauma Patient assessment of a trauma patient?

Damage Control

  • Hemorrhage Control

  • Contamination


Case study 1
Case Study #1 assessment of a trauma patient?

20 year old male, unrestrained driver, in a motor vehicle that collides into a large tree. +LOC at the scene and unresponsive. Starred windshield. Life flight transported to VUMC.

VS: 120/70 mm Hg, HR= 110-115, RR= 15

Receiving oxygen 100% NRB


Question 1
Question #1 assessment of a trauma patient?

What is the number one priority during the initial assessment of this trauma patient?

1-Airway

2-Breathing

3-Circulation

4-Disability


Question 2
Question # assessment of a trauma patient?2

What Level One Criteria does the patient meet?

1- GCS < or = 8

2- Head injury with LOC > 5 min

3- moderate to severe respiratory distress

4- all the above


Question 3
Question #3 assessment of a trauma patient?

True or False.

The patient’s need for airway protection and ventilation is due to unconsciousness.

1- True

2- False


Question 4
Question #4 assessment of a trauma patient?

Which two steps listed below are early steps in the RSI procedure?

1- Pre-oxygenate with 80% oxygen & apply cricoid pressure

2- perform chin lift/jaw thrust to open airway& pre-oxygenate with 100% oxygen

3- administer a paralytic & ventilate


Question 5
Question #5 assessment of a trauma patient?

How do I know the ETT is in the correct position?

1- presence of CO2 in the end tidal CO2 detector only?

2- equal breath sounds bilaterally and gurgling in the epigastrium

3- presence of CO2, equal bilateral breath sounds and CXR


Case study 2
Case Study #2 assessment of a trauma patient?

  • 20 year old male assaulted. GSW to right chest and left lower extremity. Patient is c/o chest pain, SOB, and left lower extremity pain

  • HR= 110; BP=120; RR = 30; SaO2= 90% on 100 % NRB; No BS on Right


Question 11
Question #1 assessment of a trauma patient?

True or False.

This patient does not meet Level One Criteria.

1- True

2- False


Question 21
Question #2 assessment of a trauma patient?

What trauma imaging is needed for this patient?

1- CXR only

2- CT of the chest

3- CXR, CT chest/abd/pelvis, Left femur XR

4- Head CT


What is wrong with this cxr
What is wrong with this CXR? assessment of a trauma patient?


Question 31
Question #3 assessment of a trauma patient?

What do you think is wrong with this patient based on the CXR provided?

1-labored breathing due to pain

2-spleen laceration

3-pneumothorax

4- hemothorax


Question 41
Question #4 assessment of a trauma patient?

What should be assessed in the secondary survey?

1-pulses of right leg only

2-roll the patient for posterior check

3-roll patient over (posterior check) and assess pulses (Fem, DP,PT)

4-secondary survey excluded because the patient states, “I am fine”


Case study 3
Case Study #3 assessment of a trauma patient?

18-20 year old male unrestrained passenger. Car hit a bridge. Driver DOA. Reported by EMS, “Initially awake, not acting right”. Gradually more confused & verbally uncooperative. 2L NS in air craft. BP=110 and decreasing. HR=120. RSI per life flight.


Question 12
Question assessment of a trauma patient?#1

What signs/symptoms are the patient exhibiting that he needs resuscitation?

1- decreased mentation

2- increasing HR and decreasing BP

3- Both


Question 22
Question #2 assessment of a trauma patient?

The patient has increasing HR =130s BP= 84P

What stage of shock is the patient in?

1- Stage 1

2- Stage 2

3- Stage 3

4- Stage 4


Question 32
Question #3 assessment of a trauma patient?

The patient was given 2L of NS during his flight and was unresponsive to this. What is the next step? BP 84P HR=130

1- order a 3rd liter of crystalloid

2- order 2 U PRBCs

3- do nothing

4- give 4 FFP


Question 42
Question #4 assessment of a trauma patient?

What trauma imaging is needed at this time? Secondary survey noted left lower abdominal ecchymosis.

1- CXR

2- CT chest/abd/pelvis

3- FAST exam

4- one and two only


Question 51
Question #5 assessment of a trauma patient?

True or False.

A FAST exam (focused assessment sonography)is used to rapidly identify hemorrhage or potential hollow viscous injury

1-True

2-False


Question 6
Question #6 assessment of a trauma patient?

FAST study positive for a large amount of fluid in the abd. What intervention is needed for the patient at this time?

1- Go to the operating room

2- Activate the trauma exsanguination protocol

3- Go immediately to CT scan

4- Both one and two


Question 7
Question #7 assessment of a trauma patient?

What is the trauma exsanguination protocol or Massive transfusion protocol?

1- 2 L crystalloid

2- 2 U PRBC

3- 2 L crystalloid and 2 U PRBC

4- 6 U PRBC, 4 U FFP, 1 pack plts


References
References assessment of a trauma patient?

  • Acute Trauma Life Support Course – Retrieved from American College of Surgeons Website http://www.facs.org/trauma/atls/information.html on July 1, 2012.

  • Guillamondegui, Oscar MD, MPH, FACS, Associate Professor of Surgery, Medical Director, Trauma ICU, Director of Trauma Education, Vanderbilt University Medical Center.

  • Atkinson, S., Collins, N., Martin, M., Morton, M., Marshall, K. (2012) Outcomes of Adding ACNPs to a Level One Trauma Service with the Goal of Decreased Length of Stay and Improved Patient, Physician and Nursing Satisfaction: A pilot study.


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