General Trauma 2022-2023 condensed fuclty of nursing.pdf

section of nursing

1. Nursing management N A
of a Post traumatic I»
Injury Patient

yy
Dr. Hanaa Elfeky
Professor of Critical Care and Emergency Nursing

2. Objectives
At the end of this lecture each student should be
able to:
Discuss types of trauma
*Mention the mechanisms of injury
«Discuss pathophysiology of trauma
*Explain emergency management of post traumatic
injury patients
*Utilize triage principles in management of post trau
matic injury patients

3. Outlines

«Definition and incidence of trauma

«Mechanisms of injury

Classifications of trauma

«Pathophysiology of trauma

«Assessment and management of trauma patients
«Emergency nurses’ role.

4. What is trauma?
Trauma is a wound produced by sudden
physical injury.

“Polytrauma” = Multisystem trauma =
injury of two or more systems.

5. What is injury?

Injury is unintentional or intentional damage
to the body resulting from sudden exposure to
thermal, mechanical, electrical or chemical
or from the absence of such essentials as heat
or oxygen.

6. ¢ Unintentional Injuries such as:
Motor vehicle crashes (MVC), falls, drowning, fires, ...

¢ Intentional Injuries such as:

Suicide attempts, assaults, and homicides (injuries
from poisoning, drowning, cutting, and jumping).

7. Incidence of trauma

¢ It is one of the leading causes of death for
all ages.

° The peak incidence between 15 & 25 years
(the healthy and productive group).

+. Hemorrhage is second-leading cause of
death in trauma.

8. Number of Incidents by Age

Number of Incidents by Age

Number of Incidents

15 22 29 36 43 50 57 64 71 78 85 92 99 106
Age (years)

9. Trimodal Distribution of Trauma

Deaths
Lacerations:
Brain
Brainstem
Aorta
Cord
Heart
£l
A a
al à
Epidural
Subdural 4
Hemopreumothorax E
Pelvec fractures Sepsis
Long bone fractures \ mor
Abdominal injuries
o — __ __ —
o 1 hour 3 hours dwecks 4 wes

Time

10. Classification:

1- According to the type/ cause

1.a-Blunt trauma is commonly caused by

Road traffic accidents
Falls
Sports injuries

11. Blunt trauma
+
Hypotension
+
Altered mental status
_- Diagnostic and Therapeutic — .
Sr Dilemma e

em —

12. 1.b- Penetrating trauma

Injuries to skin, tissues, underlying organs,
viscera, and possibly bone

Gunshot Inlet

4

13. 2- According to the severity of injury:

2.1-Minor trauma:
Single system or limb injuries that do not

pose a threat to life and can be appropriately
treated in a basic emergency facility.

2.2-Major trauma:

Serious multiple system injuries that require
immediate intervention to prevent disability,
loss of limb, or death such as tension pneumotho
rax, open pneumothorax, and Flail chest.

14. Mechanism of Injury

Knowledge of the mechanisms of injury such
as acceleration, deceleration, & other

conditions greatly enhance the management
of trauma patients.

15. Acceleration

Acceleration is the rate of the change of
velocity (speed in a given direction) of any
object.

It refers to an increase or positive change of
speed or velocity.

16. Leceleration

Deceleration always refers to acceleration in the
direction opposite to the direction of the velocity.

Deceleration always reduces speed.

17. Deceleration Injury

y Aortic tear

& Acute subdural brain
hematoma

Kidney avulsion

18. Compression injury

& Frontal brain contusion

tg Pneumothorax

Rupture of Left hemi-
diaphragm

Small bowel rupture

& Unstable Spine fracture

19. Other conditions

Explosions

— Blunt + penetrating + burns
Burns

Crush injuries

Drowning

Hypothermia

20. Trauma Management

Pre-hospital Phase
Begins at the scene of the trauma.

The pre-hospital roles

> Prevention of additional injury
> Rapid transportation

> Advance notification

> Initiation of treatment

> Triage

21. Response to trauma and
metabolic changes:

22. Response to trauma includes various
endocrine, metabolic and immunological
changes. It occurs as a result of activation of the
central nervous system and
hormonal responses against injury. Stress
hormones and cytokines play a role in these
reactions.

The severity of these changes is related to the
amount of exposed stress. More reactions are
induced by greater stress leading to greater
catabolic effects.

23. The characteristic response that occurs in trauma
patients include: protein and fat consumption,

rotection of body fluids and electrolytes because of
hyper-metabolism in the early period (within the first
24 hours)..

Trauma leads to a reduction in:

- Protein synthesis, and so affect metabolic and
nutritional status, as well as defense against infection.

- The normal anabolic effect of insulin, i.e. the
development of insulin resistance.

24. The oxygen and energy requirement increases in
proportion to the severity of trauma.

Free fatty acids are primary sources of energy after
trauma. Triglycerides meet 50 to 80 % of the
consumed energy after trauma and in critical illness.

25. The metabolic response to trauma
has been defined in 3 phases:

1. Ebb phase or decreased metabolic rate in early
shock phase,

2. Flow phase or catabolic phase,

3. Anabolic phase (if the tissue loss can be replaced
by re-synthesis once the metabolic response to trauma
is stopped).

26. The Ebb phase: (within 24-48 hours after injury).

In this phase metabolic response to stress is mediated
by Catabolic hormones such as glucagon,
catecholamines, corticosteroids and by insulin
resistance.

& Cytokines, oxygen radicals € other local mediators
are also involved in this process.

Reconstruction of body’s normal tissue perfusion
and efforts to protect homeostasis.

& Decreased total body energy and urinary nitrogen
excretion.

tg Hemodynamic disturbances (hypotension) due
to the decreased effective circulating volume.

27. The flow phase:

This phase provides compensating response to
the initial trauma and volume replacement.

The metabolic response is directly related to

the supply of energy and protein substrates in order
to protect tissue repair and critical organ functions.

The increased body oxygen consumption and
metabolic rate are among these responses.

28. elf proper resuscitation is done
anabolism will be the outcome in the late
period of flow phase. However, if
inadequate management was done,
catabolism will continue and the
catabolic effects usually develop in
peripheral tissues such as muscles, fat
and skin.

29. The Anabolic phase

The transition from the catabolic state to the
anabolic state depends on injury severity. This
transition occurs approximately 3-8 days after
uncomplicated trauma. However, it takes weeks after
severe trauma and sepsis. This is known as the
corticoid withdrawal phase and is characterized by
reduction of net nitrogen excretion and appropriate
potassium-nitrogen balance.

30. Pre-hospital Trauma
Management

31. Revised Trauma Score

Apply the physiologic injury severity scoring
in the pre-hospital setting as a triage tool.

Revised Trauma Score (RTS) uses 3 specific physiologic p
arameters,

(1) The Glasgow Coma Scale (GCS),
(2) Sytolic blood pressure (SBP), and
(3) The respiratory rate (RR).

32. Revised trauma score

Glasgow. CS. Sys BP RR 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

12 is labeled DELAYED (walking wounded) , 11 is UR
GENT (intervention is required but the patient can wait a
short time) , 10-3 is IMMEDIATE (immediate interventi
on is necessary) , The last possible label is MORGUE .

33. Emergency Department
Trauma Management

34. Assessment and management focus
on:

Preventing death

Minimizing disabilities

A widely adopted trauma management plan t
o minimize morbidity and mortality is advanced
trauma life support (ATLS).

35. Trauma Management

Emergency Department Phase

Principles of ATLS

+ Organized team approach of initial assessment
+ Consider Priorities (Triage)

¢ Treatment before diagnosis

¢ Thorough examination

¢ Frequent reassessment and Monitoring

A well-planned, organized approach to such
patients provides optimal management.

36. Trauma Management

ED Phase Organized Team Approach

Main Responsibilities

& Assessing the patient

Ordering needed procedures and diagnostic studies
& Managing fluid administration

& Monitoring the patient's progress.

tg ControlLing the area

Making therapeutic and the transportation decisions

& Subspecialty consultations and coordinates their
activities

38. The Golden Hour

e The first 60 minutes after the occurrence of multi-
system trauma

e Victim's chances of survival are greatest if they
receive definitive care in the OR within the first
hour after a severe injury.

e The core principle is rapid intervention

39. The Golden Hour

What should we do?

Rapid assessment = ATLS
Resuscitation and stabilization
Definitive management/Transfer

40. Number
of Deaths

Trimodal Death Distribution

Immediate

Deaths

Time After Injury

41. Trauma Management
ED Phase
Priorities in Airway/breathing
Management

Shock/external hemorrhage
& Resuscitation

Impending cerebral herniation
High-Priority Areas Cervical spine
Cardiac

Neurologic

Abdominal

Low-Priority Areas Musculoskeletal

Soft tissue injury

42. Trauma Management

ED Phase
The overall goal of resuscitation procedures

is to improve oxygenation and tissues perfusi
on through:

- Vascular Access
- Choice of Resuscitation Fluid (Start with Crystalloids)
-Transfusion of fully cross matched blood

43. ATLS

tgPrimary Survey
tgAdjuncts
tgSecondary Survey

e Definitive Care/Transfer

44. ATLS

Primary Survey

gA Airway

eB Breathing

gC Circulation

eD (Neurologic) Disability

RE Exposure / Environment

45. A - Airway (with C-spine protection)

Rapid Sequence Intubation (RSI)
% Pre-oxygenation
@ Cricoid pressure
g Sedation
% Oro-tracheal intubation
% Naso-tracheal intubation

@ LMA / intubating LMA

46. B: Breathing

y Examine for:
-Chest excursion & breath sounds
Flail chest
- Pneumothorax
Open
Tension
- Massive Hemothorax

47. C:Circulation

Assess perfusion (Mental status, skin, pulse)
Control bleeding with pressure.

Establish 2 large bore (16G or larger) IV’s in
upper extremity peripheral veins
Resuscitate with Lactated Ringers

— After 4 Liters think about resuscitation with blood

48. D:Disability

« Assess Neurologic status
— Glasgow Coma Scale
» Eye
» Motor-best predictor of long term outcome
+ Verbal
— Anticipate Spinal Cord Injury

49. E:Exposure

« Remove clothes
* Temperature maintenance
— warm blankets
« Maintain full spine precautions

50. Expected Fractures
+ Stabilize Fractures
« Relocate dislocated joints
« Reassess pulses

51. ATLS
Adjuncts

e Urmary catheter
eNG tube
X-rays

52. Secondary Survey

- Obtain a full patient’s history

- Thorough “head to toe” assessment

- CT's, plain radiographs

- Urinary bladder drainage

- NGT insertion

- Blood sampling/monitoring

- Treatment plans based on clinical status and specific
injuries

- Definitive Care/Transfer

53. Triage

[French, from trier, fo sorf

A method of quickly identifying
victims who have immediately

life-threatening injuries and who ~

54. Triage:
- Putting the patient in the right place at the right
time to receive the right level of care ,

- Allocations of appropriate resources to meet the
patient’s medical needs. E à

55. Tagging

TRIAGE TAG TRIAGE TAG

part © 1 part Qt
No. 239352
Rapid AE
er: 9 Move the Walking Wounded A | —
Identification of a |
5 [respirations - Over 30
patient DPortusion - Capary rt

Over 2 seconds.
& Color Coded /Bar re
Coded system

e Plastic “bands” can a LI] RER
substitute tags he ee —

DECEASED DECEASED

56. Noji et al, NEJM |

57. Triage: A rapid approach to prioritizing
a large number of patients

a EN
Incident Site —» Collection —- Triage Unit Leader
Point
Simple Triage Ana Papia Treatment

58. START SYSTEM

& Created in the 1980's by Hoag Hospital and the Newport Beach Fire
Department.

tg Allows rapid assessment of victims.
tg It should not take more than 15 sec/ victim

& Once victim is in treatment area more detailed assessment
should be made.

& Clasification is based on evaluating three items:
Respiratory, Perfusion, and Mental status

59. All Walking Wounded RESPIRATIONS

E A Tes

Position Airway Under 30/min. Over 30/min.

NO respirations Respirations | IMMEDIATE
LS 7 à

PERFUSION
Radial Pulse Absent Radial Pulse Present
OR
Over 2 seconds#— Capillary Refill — Under 2 seconds —%
MENTAL STATUS
Control Bleeding CAN”T Follow CAN Follow
| Simple Commands Simple Commands

60. Description

Moy survive if given immediate simple life
saving measures

2 Should survive if given care within a few
hours
ren 3 Walking wounded: minor injuries that do not
require rapid care
lack 4 Deceased or severely injured patients unlikel

fo survive

61. First priority

Airway and breathing difficulty. (A/B)
Cardiac arrest ( witnessed).
Uncontrolled / sever bleeding. (C)
Cervical spine injury (stabilized).
Decreased level of consciousness.

Sever medical problems: e.g. Acute MI.
Shock.

Joint fracture with no distal pulse.
Fracture femur.

Sever burn.

Red

62. Second priority Yellow

Patient whose treatment and transportation can be temporarily del
ayed e.g:

Burns without airway problems.
Major or multiple bone or joint injury.

Back injury with or without spinal cord damage.

63. Third priority Green (lowest priority)

Patient’s whose treatment & transportation c
an be delayed until last.

Minor fractures
Simple sprains.
Minor soft tissue injury.

64. Fourth priority Black

Patients who are dead or have little chan
ce for survival.

Obvious death.
Sever trunk, open brain trauma.
Cardiac arrest ( over 20 min.).

65. Triage levels

e Level 1: Resuscitative
Level 2: Emergent

& Level 3: Urgent

& Level 4: Less urgent
& Level 5: Non-urgent

66. Level I: Resuscitative

e Conditions that are threats to LIFE or LIMB (or
imminent risk of deterioration) requiring aggressive
interventions.

& Time to MD: Immediate
& Time to Nurse: Immediate

tg Continuous reassessment

67. Level: I

. Usual presentations

@ Cardio / Respiratory Arrest.

@ Major trauma.

- Severe burns--airway compromise .

g Severe respiratory distress.

- Near death asthma (Status asthmatics).
- Tension Pneumothorax.

g Altered mental state.

@ Seizure (Status epileptics).

g Traumatic shock.

@ Overdose.

g Congestive heart failure with low BP.
@ Major head injury-unconscious.

@ Reassessment 15 mins

68. Level II: Emergent

«Conditions that are a potential threat of life,
requiring rapid medical intervention or
delegated acts.

& Time to MD: 15 minutes.

& Time to Nurse: 15minutes

tg Reassessment time: 15 minutes.

69. Level II: Emergent

Usual presentation
- Chest Pain , MI
- Trauma
- Chemical Exposure
- Stroke
- Altered Consciousness
- Acute MI
- Severe Asthma-stridor
- Acute Psychotic Episode with Agitation

tg Reassessment 15 mins

70. Level III: Urgent

Conditions that could potentially progress to a serious
problem requiring emergency intervention.

& May be associated with significant discomfort or
affecting ability to function at work or activities of daily
living.

& Time to MD: 30 minutes.
& Time to Nurse: 30 minutes.

e Reassessment time: 30 minutes

71. Level III: Urgent

& Usual presentations:
@ Renal colic, billary colic
g GI bleed with normal VS
g Previous seizure—alert
gs Dehydration..
@ Vital signs outside normal range.
g Moderate risk of harm to self or others.
@ infant not feeding.
g Behavior change.
Reassessment 30 minutes

72. Level IV: Less Urgent

Conditions that related to patient age, distress, or
pee for deterioration or complications would
enefit from intervention or reassurance within (1-2
hours)

& Time to MD < 60 minutes (1 hr)
& Time to Nurse < 60 minutes (1 hr)

& Reassessment time: 60 minutes (1 hr)

73. Level IV: Less Urgent

Usual presentation:
- Head injury —alert .
- Abdominal pain.
- UTI sign and symptoms.
- Simple laceration requiring sutures.

- Normal VS
- Reassessment: 1 hour

74. Level 5: Non Urgent

& Conditions that may be acute but non-urgent as well as
conditions which may be part of a chronic problem with or
without evidence of deterioration.

& The investigation or interventions could be delayed or even
referred to other area of the hospital or health care system.

tg Time to MD: 120 minutes.
tg Time to Nurse: 120 minutes.

& Reassessment time: 120 minutes

75. Level 5: Non Urgent

& Usual presentation:.
g Sprains
@ Single episode of vomiting.
@ Sore throat.
g Chronic problems with no change.
e Investigation or intervention for these
illnesses or injuries could be delayed

tg Reassessment 2 hours /120 minutes

76. Resuscitation
¢ Restoring organ perfusion

» What are the endpoints of resuscitation?
— Heart rate, blood pressure, urine output
» Trauma may lead to “compensated shock”

— Global indicators of perfusion
« Lactic acid, base deficit
+ Cardiac output, oxygen delivery, oxygen consumption
» Mixed venous O, saturation (SvO,)

77. Best Regards