Trauma Management for Nurses: a -Z!

Dr VAIBHAV BAGARIAMBBS, MS, FCPS

Joint Replacement & Sports Injury SurgeonCARE Hospital, Nagpur, INDIA

www.drbagaria.com

Rules

Be not afraid to ask questions.

The only dumb question is not to ask question.

Two way Interaction

If you donot ask questions, I will!

Goals

Assessment: Assess patient condition rapidly & Accurately

Resuscitate and stabilize the petient depending on priority

Care giving on routine basis

underlying concept

Treat the greatest threat to life first

Lack of definitive diagnosis should never impede the application of indicated treatment

Detailed history is not essential

What you do will vary based on expertise, training and what is available.

SEQUENCE

Primary Survey: ABCDE

Resuscitation

Secondary Survey: AMPLE history

Head to toe

Why a to Z

Because it is not over until its all over.

Nurses - Beyond

It is always nice to go back to School and learn the basics!

Primary Survey

A Airway maintenance with C spine protection

B Breathing and Ventilation

C Circulation with Hemorrhage control

D Disability: Neurologic status

E Exposure / Environment / Extremity

A : Airway with C Spine protection

Does this patient have an adequate airway that they can protect?

Look - facial trauma, foreign body

Listen - stridor

Feel - expanding neck hematoma

Is the patient talking to you?

Management of Airway

Open Airway

chin lift and/or jaw thrust

Clear Airway

suction

Insert Airway

Oral or nasal

AIRWAY Management

Assessment of Breathing

Look - chest excursion, tracheal deviation

Listen - auscultation for absent decreased breath sounds

Feel - subque air, percussion for dullness

Identify

Tension Pneumothorax

Frail chest

Massive hemothorax

Open Pneumothorax

Management of Breathing

Oxygen

Nasal canula of non rebreather

Bag - Valve - Mask

Intubation

Pulse ox

Needle or tube thoracotomy

C : Circulation with Hemorrhage Control

Predominant cause of post injury deaths that are preventable in the hospital setting.

Hypotension is due to hypovolemia blood loss until proven otherwise.

Spinal shock

Assessment of Circulation

Level of consciousness

Skin Color

Pulse

Rate, Quality

Blood Pressure

Identify

External hemorrhage

Apply direct pressure

No tourniquets except for traumatic amputations

OCCULT HEMMORHAGE

Be aware of possible sources of internal bleeding both from blunt and penetrating trauma

Chest

Abdomen

Pericardial Tamponade

Pelvic Fractures

Long Bone Fractures

Management of Circulation

Two large bore IVs

Draw blood for lab studies

CBC, T&C, Chem, ABG, HCG, EtOH, Tox,

Ringer’s Lactate

wide open

Warmed (37 to 40C)

D - Disability

Level of Consciousness

A : Alert

V : responds to Verbal stimuli

P : responds to Painful stimuli

U : Unresponsive to all stimuli

May use Glasgow Coma Scale

Pupils

E : Exposure / Environmental

/ Extremity

No surprises

Maintain temperature

Limb threatening injuries

EXPOSURE

Completely undress

Prevent Hypothermia

You may feel hot

The patient is naked on a metal table

Blankets, Warm IVF

Quick distal neurovascular check

Relocate only if pulseless

F -full vitals & Info

Pts name ,home no ,time ,appearance ,sex ,incident .

Baseline vital signs ,initial medications –dose, route and response . Fluid and rate .

Assessment ,interventions and the outcome .

Accurate and up to date cadrex.

F - Full info

Mivt – mechanic of injury , injuries sustained, vital signs and treatment .

Patient generated information .

AMPLE ;.

A-allergy , M- medications , P – past history , L – last meal , E – events .

G – Give comfort measures

Verbal reassurance .

Tough .

Pharmacologic / non - pharmacologic management of pain .

H – Head To Toe

Head - to – toe assessment ;-

Inspection, auscultation, palpation, percussion and general appearance.

Lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, ecchymosis, oedema .

H – Head to toe

Crackling, subcutaneous emphysema .

Loose teeth, depressions, angulations .

Applied splints – cpd # must be irrigated with water or n/saline .

Motor functions and sensation .

I – Inspect posterior surfaces .

Depressions , bumps .

Deformity .

Anal bleeding .

J - JOB ALLOCATION

Plan ahead

Remember Team work

Distribute work

Ensure responsibility

Remember “ too many cook spoil the broth”

K - KEY NOTES

Mentally go over the case

Make key notes

Specific issues: look for cause of unconsciousness, any specific history, alchol/drug.

L - LIMB EVALUATION

Assess distal neurovascular status.

Expose the parts

Palpate and elicit any boney tenderness.

Ask if it needs evaluation

Donot miss brachial plexus injury.

M - MONITOR

Monitor vitals.

Cradiac monitor

Urine Monitor

Pulse Ox monitor

Family Presence

N - NO

No Complacency

No Assumptions

No Goof ups

No giving Up!

O - OPERATION PLANNING

Inform operating room

Blood cross match

PAC & Part preparation.

Scheduling

Administration of medications - antibiotics , analgesics, sedations etc

P - PLAN AHEAD

Planning Planning Planning

A well thought of and well executed plan is what is required.

Q - QUESTION TEAM LEADER

Refer to rule no #1

Ask for further plans.

Clear any doubts

R - Radiology

FAST Scan

CT Head with Cervical Spine

Any other investigation deemed fit

S - STABILIZATION

Application of traction devices .

Pelvic orthotic device ,

Pelvic sheet wrapping

T - TRANSFER PLANNING

Plan transfer

Prior Intimation

Manpower Arrangment

Consent

U - Remember Your self

You Can make a difference

Every one of us

V - VITALS RE EXAMINE

Continued reevaluation of AVPU and ABCDE

Detailed Head to Toe

Complete Neuro exam

Special Procedures

“Tube or Finger in every hole”

W - WOUND CARE

Take Care of the wounds.

Primary treatment goes long way in preventing infection and systemic complications.

Clean with running water or n/saline then dress

X - X RAYS

X Rays (trauma series portable)

C spine (cross table lateral)

Chest

Pelvis

Obvious long bones

Y - SEARCH WHY?

Specific issues: look for cause of unconsciousness, any specific history, alchol/drug

Z: ZEST For life!

Two Short Videos

Cervical collar Application

Log Rolling

Log Rolling Video

QuickTime™ and a decompressor

are needed to see this picture.

Cervical collar Video

QuickTime™ and a decompressor

are needed to see this picture.

Thank You!

www.carehospital.comwww.drbagaria.com