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JOURNAL OF E M E R G E N C Y NURSING
can result in abnormal postures and contortions of the eyes, face, neck, or throat. A serious sign of acute dystenic reac- tion occurs when the eyes roll back and up; this phenome- non is called an oculogyric crisis. Cogentin (A) and diphen- hydrarnine (Benadryl) are the drugs of choice. Epinephrine (B), Proventil (C), and Solu-Medrol (D) are not used to treat dystonic reaction.
Tueth, 2 212-6.
3. Correct answer: B The patient recently started taking haloperidol, a neuroleptic agent. The pat ient is having symptoms of neuroleptic malignant syndrome. Risk factors for neuroleptic malignant syndrome are the recent addition of, or change in, the dose of a neuroleptic drug or withdrawal of an antiparkinson agent. The patient would have labile hypertension (not hypotension [A]) with pale vasocon- stricted skin (in contrast to hot dry skin [C]). The pat ient would have tachycardia.
Foley, 3 139-41.
4. Correct answer: C Patients with pulmonary edema have impaired gas exchange as a result of fluid backup into the alveoli. The nurse should address this condition first by placing the pat ient in the high Fowler position and admin- istering high-flow oxygen. Although the other measures are
correct and should be rapidly addressed, these interventions should be taken after initial measures to correct impaired gas exchange.
Phipps et aL, 4 877.
5. Correct answer: C The elbow should be flexed at slightly less than 90 degrees so that the hand and fingers will be higher than the elbow to help prevent dependent edema. The fingers are exposed to assess circulation.
Proehl 5
References
1. Addy JA. Dopamine not effective for treatment of chlorpromazine overdose: first case report. J EMERG Nuns 1995;21:99-101. 2. Tueth M J. Emergencies caused by side effects of psychiatric medications. Am J Emerg Med 1994;12:212 6. 3. Foley JJ. Recognition and treatment of neuroleptic malignant syndrome. J EMERO Nuns 1993;19:139-41. 4. Phipps W J, Cassmeyer VL, Sands Jr, Lehman, eds. Medical- surgical nursing: concepts and clinical practice. 5th ed. St Louis: Mosby-Year Book, 1995:877. 5. Proehl J. Adult emergency nursing procedures. Boston: Jones and Bartlett, 1993:400.
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OURNAL OF S'M~"RGENCT NURSING/Matthews
UNIVERSITY OF UTAH HOSPITAL EMERGENCY DEPARTMENT Trauma Assessment Tool
1. Did prehospital care follow Salt Lake County EMS guide- lines?
2. Were all trauma team members present? v,' Please indicate those absent: __ Trauma physician __ Emergency physician _ _ Respiratory __ Neurosurgeon _ _ Anesthesiology
3. Was trauma directed by an identified Team Leader? 4. Did team leader supervise only? 5. Were ATLS/TNCC guidelines followed?
A. Assessments done in ED: ABCs __ Abdomen (DPL/CT)
,
7. 8. 9.
10.
B. Was airway protected? _ _ Nasal airway __ Oral airway
C. Was C-Spine protected until cleared by radiology? D. Were there at least two peripheral large-bore IVs (->16
gauge)? Was necessary equipment available? Were procedures performed by students? Was patient informed of procedures? Was patient's family dealt with? (Crisis Intervention) Physician Input:
[ ] Yes
[ ] Yes
[ ] Yes [ ] Yes [ ] Yes
[ ] No
[ ] No _ _ Nursing supervisor _ _ Messenger __ X-ray _ _ EKG __ Pulmonary
[ ] No [ ] No [ ] No __ Chest (X-ray/Ausc.) _ _ C-Spine (lateral x-ray
before backboard removal)
_ _ Intubated __ Tracheostomy
[ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] N/A
A
Figure 1 Trauma Assessment Tool developed at the University of Utah Hospital Emergency
(Please see reverse side)
Department. A, The front side of the form consists primarily of a checklist format.
The first pr ior i ty was to dev i se an ob jec t ive tool to eva lua te the cur ren t provis ion of care. Us ing T r a u m a Nurs ing Core Course and A d v a n c e d T r a u m a Life Suppor t gu ide l ines , and concen t r a t i ng on a reas tha t we re of spec i f ic concern , t he " T r a u m a A s s e s s - m e n t Tool" w a s d e v e l o p e d (Figure 1). This tool p rov ides for nu r s ing and p h y s i c i a n inpu t r e g a r d i n g pa t i en t flow and de l ivery of care. It also p rov ides an oppor tun i ty to d o c u m e n t a n d follow up problems.
The Trauma A s s e s s m e n t Tool is completed by the primary e me r ge nc y nurse after a t r auma pa- t ient has been t ranspor ted to a definitive care area.
The forms are collected weekly and reviewed monthly by the ED t r auma commit tee . Staff m e m - bers are encou raged to d i scuss problems with m e m - bers of the in terdisc ipl inary team. Unresolved issues are t hen b rought before the hospital t r auma commit- tee for review.
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Matthews/JOURNAL OF EMERGENCY NURSING
TRAUMA ASSESSMENT TOOL (Continued)
11. Nursing Input:
12. Comments:
13. Follow-up:
Place in Trauma One Committee Drawer, under central monitor, when completed.
Figure 1 continued B, The reverse side of the form includes spaces for more detailed notes. ATLS, Advanced Trauma Life Support; Ausc, auscultation; C-spine, cervical spine; DPL/CT, diagnostic peritoneal
lavage/computed tomography; TNCCI Trauma Nursing Core Course; N/A, not available. Used with permission.
A t the s a m e t ime w e b e g a n use of the T r a u m a A s s e s s m e n t Tool, a s y s t e m a t i c and cons i s t en t room s e t u p w a s deve loped . Two " t r a u m a car t s" are s tocked wi th the supp l i e s tha t are c o m m o n l y u s e d in t r a u m a resusc i t a t ions . The s e c o n d car t is u sed for mult i - p le t r a u m a p a t i e n t s or as a reserve. A l amina t ed copy of d e s i g n a t e d supp l i e s (Table 1) is affixed to the car t s for cons i s t en t res tock ing . The c i rcu la t ing nurse is r e spons ib l e for r e s t ock ing the car t after e ach use , and cha rge nu r se s ensu re t ha t t he car t supp l i e s a re comple t e at e a c h shift change . To d i s cou rage ca- sual u se of suppl ies , the car t s are covered wi th clear p las t i c vent i la tor covers unti l needed . Avai labi l i ty of t h e s e s t o c k e d car t s a t t he b e d s i d e d e c r e a s e s t he n u m b e r of t i m e s t ha t staff a re r equ i red to leave the beds ide .
Add i t i ona l room s e t u p inc ludes the following: (1) arterieJ l ine se tup , (2) IV of l a c t a t ed R inge r ' s solu-
t ion w i th blood tubing, (3) four wall suc t ion s e t u p s (two wi th suc t ion ca the t e r s and two for na soga s t r i c / c h e s t tubes) , (4) blood warmer / in fuse r , and (5) IV pumps .
We d e c i d e d tha t t r a u m a re susc i t a t ion could be a d e q u a t e l y pe r fo rmed wi th two e m e r g e n c y nurses : a p r imary nurse and a c i rcu la t ing nurse. D e s igna t ed roles for nu r s ing staff were d e l i n e a t e d (Table 2). In ad- dit ion, init ial d o c u m e n t a t i o n a n d traffic control are n o w t h e respons ib i l i ty of the t r a u m a recorder . Help ing wi th t h e s e at t i m e s are the t r a u m a coordinator , the ED nurse m a n a g e r , nu r s ing superv isors , and the cl inical nur se spec ia l i s t s .
Our n e w s y s t e m b e g a n in t he sp r ing of 1993. Staff m e m b e r s were i n t roduc e d to i t du r ing month ly staff m e e t i n g s and b i annua l e d u c a t i o n days . New nurs ing staff m e m b e r s s u b s e q u e n t l y l ea rned dur ing formal o r ien ta t ion sess ions .
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JOURNAL OF E M E R G E N C Y NURSING/Matthews
Table 1 T r a u m a cart c h e c k l i s t
Top she l f IV s ta r t supp l ies (in small basin):
Ang ioca the te r s , a s s o r t e d sizes Povidone dedine/a lcohol p r e p s Tourn ique t T r a n s p a r e n t adhes ive d r e s s i ng 2" • 2" gauze d r e s s i n g s
Blood d r a w supp l i e s (in small basin): Large red- top t u b e Blue-top t u b e Grey- top t u b e Arterial syr inge Small red- top t u b e s (• Purple- top t u b e 30 ml syr inge Stopcock
Nasogas t r i c t u b e 24" t r a c h e o s t o m y t ape Stool guaiac card IV labels (numbered) 100 ml b a g normal saline solut ion Piggyback t u b i n g Ches t d ra inage t u b e (Pleur-evac) (empty) Povidone-iodine/4 • 4 gauze 60 ml ca the t e r tip syr inge Lubr icant (• Developer Tape Cefazolin (Ancef) 1 g m vial Medicat ion label 36F ches t t u b e s (•
B o t t o m she l f Foley ca the t e r kit Tube t h o r a c o s t o m y t ray Diagnost ic per i tonea l lavage t ray and lavage b a g s
The d e p a r t m e n t of surgery seems pleased wi th the s t reaml ined system. In fact, it is rev iewing a sug- ges ted role de l inea t ion for the ent i re t r auma t eam tha t was formulated by the respect ive chairs from the hos- pital and ED t r auma commit tees .
Our t r auma resusc i ta t ion revision process has b e e n opera t ing for a year and a half. Initially, we had to overcome some of the staff 's previous "bad" expe- r iences and pe r suade t h e m to "buy into" the n e w system. Inheren t res i s tance to change clouded some of the in terdisc ipl inary t e a m ' s viewpoint , bu t in mos t cases, phys ic ian and nu r s ing staff have b e c o m e
e n t h u s e d and support ive of the change.
Results Our t r auma resusc i ta t ions now run m u c h more smoothly. The average a m o u n t of t ime in the emer- gency d e p a r t m e n t for a pa t i en t receiving t r auma re- susc i ta t ion has dec reased by 22%, and the pe rcen t age
Table 2 T r a u m a n u r s i n g r o l e s
Primary nurse 1. Receive pre l iminary EMS report. 2. Es tab l i sh line of communica t ion w i t h t r a u m a
t e a m leader before pa t ien t arrival: A. Identify n u r s i n g and phys ic ian staff. B. Discuss role a s s i g n m e n t . C. Discuss pa t i en t care objectives. D. Briefly orient physician staff to t r auma carts.
3. Perform direct pa t i en t care: A. IV ini t ia t ion/blood sampling. B. Drug adminis t ra t ion. C. Blood adminis t ra t ion, D. Fo ley /nasogas t r i c t ube as needed .
4. Coordinate and a s s i s t w i t h procedures . 5. A c c o m p a n y pa t i en t to all d iagnost ic
procedures . 6, Nurs ing d o c u m e n t a t i o n af ter leaving
e m e r g e n c y depa r tmen t . 7. Give repor t a n d escor t pa t ien t to unit,
Circulat ing nurse 1. Apply moni to r leads to pat ient , 2, Procedure t ray se tup . 3. Medicat ion acquis i t ion /prepara t ion . 4. Labora tory s p e c i m e n dis t r ibut ion/ label ing. 5. Check and p r epa r e blood products . 6. Support pr imary nurse wi th direct pat ient care. 7. Traffic control, 8. Restock t r a u m a car ts af ter resusci ta t ion.
Table 3 A v e r a g e t i m e s a n d n u m b e r s of i n v a s i v e p r o c e d u r e s for t r a u m a p a t i e n t s *
M o n t h
7/91 7/92 7/93 7/94
Average a m o u n t of 49.5 44.7 40.3 38.8 t ime s p e n t in the e m e r g e n c y d e p a r t m e n t by the t r a u m a level I pa t i en t (minutes) .
Pe rcen tage of 19% 20% 21% 39% t r a u m a resusc i t a t ion pa t i en t s in e m e r g e n c y d e p a r t m e n t 30 m i n u t e s or less.
Ave r age n u m b e r of 3,2 3.9 3.0 3.2 invasive p rocedu re s pe r fo rmed whi le pa t i en t in e m e r g e n c y depa r tmen t .
*New t r a u m a s y s t e m b e g a n in sp r ing 1993.
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of such pat ients who spend 30 minutes or less in the emergency depar tment has increased from 19% to 39%. The average number of invasive procedures per- formed has remained consis tent (Table 3).
The nursing staff feels more confident and com- fortable with the new system. Designated roles, a consis tent room, t rauma cart setups, discussion of t eam roles, and ass ignments with the team leader, and brief orientation of the responding caregivers before pat ient arrival have decreased confusion significantly.
Our t rauma resusci tat ion process is continu- ously assessed and adapted. Education is also ongoing, as each year 's new group of surgical residents begins their rotation. The consistency of the nursing staff's approach to t rauma resuscita- tion seems to also enhance the educat ion of new residents. We have not iced that the changes in our t rauma resusci tat ions have also improved our esprit de corps and pride among our t rauma team members.
| | V ou can give almost all IV push drugs within 30 A , to 60 seconds." "Most of the t ime I dilute the
IV injections, so the pat ients will not complain of burning when I give it to them," "I do not have time to just s tand there, so I inject the drugs up the IV tub- ing and that way they go in slower." Do these com- ments sound familiar? Are these safe ways to admin- ister IV injections?
Many emergency pat ients require IV medica- tions, and emergency nurses often determine the specifics of IV drug administration, including the de- cision to administer the drug by intermit tent infusion (piggyback, rider) or by direct IV injection (bolus, push). The IV push (IVP) t echn ique- -admin i s t e r ing the drug within a brief period of time, usually 1 to 5 m i n u t e s - - i s especially suitable for emergency pa- t ients for a number of reasons:
1. A rapid onset of the medica t ion ' s effects is desirable for pat ients with emergent or urgent condi- tions.
2. Less nursing t ime is required to prepare a sy- ringe with an IV push medicat ion compared with set- t ing up a secondary infusion set for intermit tent infu- sion.
3. Incremental doses are easily controlled; thus
short-acting agents can be t i t rated according to indi- vidual pat ient requirements.
4. IV push medicat ions can be adminis tered se- quentially, and the need to run several intermittent IV p iggyback solutions at once is avoided. Potential drug-drug and drug-solution incompatibil i t ies may be avoided.
Unfortunately there are also several dist inct dis-
advantages to the IV push method, particularly if the drug is adminis tered hurriedly. These include the fol- lowing:
1. Administrat ion by direct IV injection increases the risk of side effects and adverse reactions. Serum drug levels increase rapidly after bolus dosing, and in some ins tances a temporary brief "toxicity" may oc- cur as drug levels peak precipitously.
2. When medicat ion is given over a period of less than 60 seconds, there is little opportunity to slow or discontinue the injection if allergic or other reactions
Reprints not available from author. J EMERG NURS 1995;21:323-6 Copyright �9 1995 by the Emergency Nurses Association. 0099-1767/95 $5.00 + 0 18/62/64947
August 1995 3 2 3
