Triage / Trauma

Most miss cervical trauma fractures?

"All Trauma surgeons Occasionally Miss Cervical Fractures" Airway obstruction Tension pneumothorax Open pneumothorax Massive hemothorax Cardiac tamponade Flail chest

PQRST mnemonic

*P*rovokes *Q*uality *R*adiation *S*everity *T*ime

Secondary Survey

A brief, systematic process that aims to identify all injuries History and Head-to-Toe Physical assessment: more detailed exam of the patient's chief complaint and clinical status Diagnosis: information collected is analyzed to determine acuity need and formulate diagnoses an initial data base is established identify outcomes for each patient Planning: determine a course of action for identified needs to meet expected outcomes identify urgency of problems prioritize care designate an appropriate treatment are communicate findings and pertinent information to other team members identify appropriate interventions

Cushing's Response

A compensatory response that attempts to provide adequate CPP with an elevation of ICP: º rising systolic pressure º widening pulse pressure º bradycardia Cushing's triad: a late presentation of brain stem dysfunction º presents as HTN º bradycardia º abnormal respiratory patterns

Primary Survey: C

Circulation Includes the heart, intact blood vessels, and adequate blood volume Check carotid or femoral pulse Palpate pulse for quality and rate Assess skin color, temperature, and moisture Check capillary refill Altered mental status and delayed cap refill are common signs of shock If absent pulse, initiate cardiopulmonary resuscitation and advanced life support measures If shock symptoms or hypotensive, start two large-bore (14- to 16-gauge) IVs and start infusions of normal saline or lactated Ringer's solution Consider intraosseous or central venous access if IV access cannot be rapidly obtained Administer blood products if ordered Consider autotransfusion if isolated chest trauma Consider use of pelvic splint or belt in the presence of pelvic fracture with hypotension Per powerpoint tx: º two large bore IV º warm fluids º look for the source

Primary Survey

Focuses on airway, breathing, circulation (ABC), disability, exposure, facilitation of adjuncts and family, and other resuscitation aids. The primary survey aims to identify life-threatening conditions so that appropriate interventions can be started. * <C> stands for catastrophic hemorrhage and, if present, must be controlled first <C>ABC

How to report trauma

M.I.S.T. Mechanism of injury Injuries found and suspected Signs (RR, O2, PR, BP) Treatment given

Trauma Triad of Death

Hypothermia Acidosis Coagulopathy Coagulopathy noted in hypothermic caused by either enzyme inhibition, platelet alteration or fibrinolytic processes All three processes may simultaneously contribute to coagulopathy, but are perhaps triggered at different levels of hypothermia Coagulopathy correction - blood transfusion Spontaneous hypothermia along with coagulation and acidosis are widely recognized as a lethal triad that correlates with poor outcome

Purpose of Triage Interview

Is the basis for gathering data and making clinical decisions Is a rapid systematic collection of data Begins with the chief complaint followed by collecting subjective and objective information *Clinical judgment for a triage severity rating* Assess: º type of illness (chronic or new onset) º mechanism of injury (how did it happen, what forces were involved) º STAT vital signs º think - will they die on me º will the problem get worse

Define components of the primary and secondary survey.

Primary Survey: Quickly identify life threatening injuries *A*lertness and airway (voice, air exchange) *B*reathing (breath sounds, chest wall, neck veins) *C*irculation (mentation, skin color, pulse, bleeding) *D*isability (pupils, extremities, AVPU) *E*xposure and environmental control *F*acilitate adjuncts and family *G*et resuscitation adjuncts Secondary Survey: *H*istory and head-to-toe assessment *I*nspect posterior surfaces

Triage

Process works on the premise that the patients who have a threat to life must be treated before other patients Most important assessment skills needed by emergency nurses Purpose is to provide the best care for each individual patient

Level 1 Trauma Center

Pulse <60 or >100/min Resp <10 or >30 SBP <90 GCS <15 Penetrating injuries to head, torso or extremities proximal to elbow or knee Flail chest Pelvic fx Paralysis Amputation Burns >15%, face or airway

Discuss the epidemiology and classification of trauma.

SAMMC is a trauma Center in SA Penetrating trauma: º handguns º stab wounds º AR-15 º shrapnel º AK-47 Blast trauma: º shotgun º mines / mortars º RPG Blunt trauma: º MVC º traumatic amputations º military vehicles º parachuting º behind body armor

ESI Level 4

Stable ABCs No life threat or organ threat Could be delaying seeing the doctor Low resource intensity, one simple diagnostic study or simple procedure Examples: Closed extremity trauma, simple laceration, cystitis º healthy 19 year old with a sore throat and fever º healthy 29 year old with a UTI, denies vaginal discharge º healthy 43 year old with a stubbed toe "I think I broke it" º healthy 12 year old with a minor thumb laceration

When pulses are lost?

Thoracotomy

Chest Tube

Tracheal shift Large bore 14 or 16 gauge IV cath for the decompression 36 Fr chest tube Scalpel 10 blade Large curved clamp Large straight clamp Scissors and 00 silk suture Analgesia

Discussion of patient demographics accessing services and US emergency care

*African American person* Hispanic/Latino Asians < white person *65 years & older* 50-64 years 22-49 years _________________________________________ In-patient beds are full due to hospital closures and downsizing Nursing staff shortage limits open beds Aging population, the largest group that uses ED Limited access to health care for many populations (uninsured patients are displaced with only ED available for care), inability to see an HCP The challenges of high demand and decreasing capacity, shower hospital stay resulting in frequent readmissions Acute health crisis

Order to Assess

1 - Assess the patient for any threats to life (ESI 1) or presence of a high risk situation (ESI 2) 2 - Evaluate patients who do not meet the criteria for ESI 1 or ESI 2 for the number of anticipated resources that they may need Normal vital signs are *required* for patients assigned to ESI 3 3 - After the initial focused assessment to determine the presence of actual or potential threats to life, proceed with a primary and secondary survey (the approach for all trauma patients)

Pediatric Fever Criteria

1 to 28 days of age: assign at least ESI 2 if temp >100.4 F 1 to 3 months of age: consider assigning ESI 2 if temp >100.4F 3 months to 3 yrs of age: consider assigning ESI 3 if temp > 102.2 F, or incomplete immunizations, or no obvious source of fever

What skills does a Triage Nurse need?

A questioning mind High index of suspicion Understand A&P (disease process) Interpersonal communication skills Public relations skills Medico legal aspects An across-the-room assessment that continues in the privacy of the triage room Know what to look for using eyes, ears, nose, fingers, and hands to assess At any time if life-threatening s/s are identified: interventions are initiated and the patient is transferred to a care area

Emergency Severity Index (ESI)

A triage system that identifies and categorizes patients so that the most critical are treated first A five-level system that incorporates concepts of illness severity and resource utilization (ECG, lab test, radiology, IV fluids) to determine who should be treated first

Discuss the principals and techniques employed by the nurse in the triage process

A way to evaluate all of the patients arriving to the ED A priority for the healthcare organization at all levels Uses a five level system to categorizes patients by acuity and expected resource needs Triage is often conducted in an environment: º that has limited privacy º patients clamoring for priority in the treatment queue The purpose is to provide the best care for each individual patient The objectives are: º *for all patients to be assessed within 5-10 min of arrival to the ED* º identifying those requiring *immediate care* vs. those who can wait for a period before being evaluated and treated º determine appropriate area and resources for treatment º facilitate patient flow º provide information and referrals º alleviate fear and anxiety Requires an experienced *emergency department nurse* who is trained and competent to triage, recognition of life-threatening illness or injury is one of the most important goals A fortified formal triage is key

ESI Algorithm

A: patient dying → yes → 1 ↓ no ↓ B: shouldn't wait → yes → 2 ↓ no ↓ C: how many resources ↓ ↓ ↓ none one many ↓ ↓ ↓ 5 4 D: vital signs ↓ ↓ no consider ↓ ↓ 3 2

Primary Survey: A

Alertness and Airway Determine LOC by assessing the patient's response to verbal and painful stimuli A=alert V=responsive to voice P=responsive to pain U=unresponsive Assess for catastrophic external bleeding Control bleeding with direct pressure and pressure dressings __________________________________________ Primary s/s in a patient with a compromised airway include: dyspnea, inability to speak, gasping breaths, foreign body in the airway, and trauma to the face or neck Assess for respiratory distress Assess airway for patency Check for loose teeth or foreign bodies Assess for bleeding, vomitus, or edema Airway mgmt show progress rapidly from least to most inverse method Open airway Use jaw-thrust maneuver Remove or suction any foreign bodies Insert oropharyngeal or nasopharyngeal airway, cricothyroidotomy Rapid sequence intubation Immobilize cervical spine using rigid cervical collar and cervical immobilization device. Secure forehead to backboard Per powerpoint tx: º supplemental O2 º suction º chin life º oral airway/nasopharyngeal º ET tube º surgical airway 2-10% of unconscious patients with injuries above the clavicle will have a concurrent C-spine injury

Primary Survey: B

Breathing Assess ventilation Scan chest for signs of breathing Look for paradoxic movement of the chest wall during inspiration and expiration Note use of accessory muscles or abdominal muscles Observe and count respiratory rate Note color of nail beds, mucous membranes, skin Auscultate lungs Assess for jugular venous distention and position of trachea s/s of inadequate ventilation: dyspnea, paradoxic chest wall movement, decreased or absent breath sounds on the affected side, visible wound to the chest wall, cyanosis, tachycardia, and hypotension Give supplemental O2 via appropriate delivery system (non-rebreather mask) Ventilate with bag-valve-mask with 100% O2 if respirations are inadequate or absent Prepare to intubate if severe respiratory distress (agonal breaths) or arrest Have suction available If absent breath sounds, prepare for needle thoracostomy and chest tube insertion Per powerpoint tx: º ET tube º needle decompression º chest tubes º thoracotomy º analgesia

Primary Survey: D

Disability Use the Glasgow Coma Scale to determine LOC Assess the pupils for size, shape, equality and reactivity Periodically reassess level of consciousness, mental status, and pupil size and reactivity

Identify the triage models primarily used in the Emergency Departments (ED) throughout the U.S

Emergency Severity Index (ESI) Uses a five level system to categorizes patients by acuity and expected resource needs Treatment goals based on Nurse triage: º 1 - immediate - resuscitation º 2 - <15 min - emergent º 3 - 15-60 min - urgent º 4 - 1-2 hr - semi urgent º 5 - 2-24 hr - non urgent Triage Assessment: º *A*irway º *B*reathing º *C*irculation º *D*isability º *P*ain

Primary Survey: E

Exposure and Environmental Control Remove all trauma patients' clothing to perform a thorough physical assessment, *do not* remove any impaled objects Assess full body for determination of additional or related injuries Assess environment Once exposed, use waring blankets, overhead warmers and warmed IV fluids to limit heat lost, prevent hypothermia and maintain privacy

Primary Survey: F

Facilitate Adjuncts and Family Facilitate family presence, as "patient helpers" and "staff helpers" Determine caregiver's desire to be present during invasive procedures and/or cardiopulmonary resuscitation It is essential to assign a member of the interprofessional care team to explain care delivered and answer questions should a caregiver request FP during resuscitation or invasive procedures.

Primary Survey: G

Get Resuscitation Adjuncts Determine need for additional adjunct measures for monitoring the patient's condition L=lab test M=monitor N=nasogastric tube O=oxygenation and ventilation assessment P=pain assessment and management Provide emotional support to patient and caregiver Provide additional comfort measures as appropriate

ESI Algorithm Decision Point C

How many resources? Determined by the experienced ED RN at triage, based on the standard of care, independent of type of hospital, physician on duty or acuity of the department Examples: º fracture ankle º abdominal pain º most migraines If yes to any of the examples, the patient ESI 3

Nursing Dx for trauma patients

Ineffective airway clearance Impaired gas exchange Altered tissue perfusion Fluid volume deficit Decreased cardiac output Risk for aspiration Hypothermia Pain Anxiety and fear Powerlessness

Nursing DX for trauma patients

Ineffective airway clearance Impaired gas exchange Altered tissue perfusion Fluid volume deficit Decreased cardiac output Risk for aspiration Hypothermia Pain Anxiety and fear Powerlessness

ESI Algorithm Decision Point B

Is this a high risk situation? Determination is based in a brief patient interview, gross observations Do not require a full set of vital signs Unsafe for the patient to wait Suggestive of a condition; easily deteriorate S/S of a condition that's treatment is time sensitive Potential major life or organ threat Is the patient confused, lethargic or disoriented? Is there an acute change in LOC, is this a situation where the brain is structurally or chemically compromised Examples: º episode of chest pain, known cardiac history º r/o pe º newborn with fever º r/o ectopic pregnancy º neutropenia with a fever º suicidal/homicidal º needle stick in a healthcare worker Is this patient in severe pain or distress? Is this patient currently in pain? Examples: º patient with severe flank pain, vomiting with a hx of renal colic º patient with burns to both arms º patient with a dislocated shoulder, pain rated as a 10+, diaphoretic, tearful º psychiatric patient who is screaming obscenities If yes to any of the examples, the patient is ESI 2

ESI Algorithm Decision Point A

Is this patient dying? Does this patient require immediate lifesaving interventions? Examples: º obstructed or partially obstructed º unable to protect their own airway º apnea º intubated prehospital º severe respiratory distress º SpO2 less than 90% º pulseless or concerned about rate, rhythm or quality º hemodynamic interventions º immediate IV meds to correct hemodynamic instability º hypoglycemia, need glucose º heroin OD, need narcan º subarachnoid bleed º P or U on AVPU scale If yes to any of the examples, the patient is ESI level 1

Describe nursing responsibilities related to initial resuscitation and stabilization of the trauma patient

Ongoing monitoring and evaluation of interventions are critical The evaluation of airway patency and effectiveness of breathing will always be the highest priority Rapid assessment, coordination and action Prepare the trauma room based on the initial call of injuries reported, prepare yourself mentally Initial Evaluation: quick primary survey, ventilation, perfusion, mental status Treat immediately life threatening injuries as they are identified Look at the neck 6 times in the primary survey Watch for subtle changes: GCS Revised trauma score Watch for s/s of Cushing's Reflex When able do the secondary assessment, then redo primary assessment

Causes of Death from Trauma

Prehospital: º hemorrhage º head injury º pneumothorax Hospital: º hemorrhage º head injury º sepsis

Goals of Resuscitation

Restore hemodynamics Correct metabolic abnormalities Restore tissue microcirculation

ESI Level 5

Stable ABCs No life threat or organ threat Could be delaying seeing the doctor Low resource intensity, examination only Examples: Cold symptoms, minor burn, recheck, prescription refill º healthy 10 year old with poison ivy º healthy 52 year old who ran out of his blood pressure med yesterday º 22 year old, involved in a car accident 2 days ago, wants to be checked, "nothing hurts" º 46 year old with a cold

ESI Level 3

Stable ABCs Unlikely but possible life threat or organ threat Should be seen up to 1 hr Medium to high resource intensity, multiple diagnostic studies, complex procedure Examples: Abdominal pain or gynecologic disorders unless in severe distress, hip fracture in older patient

What do you need to Intubate?

Suction (tested and connected) Bag valve mask (attached to a high flow O2) Oral airway 10ml syringe (to test ET and is attached) Endotracheal tube Blades and handles (sizes, checked, compatible) Prepare RSI pharmacological agents If ET placement didn't work = cricothyrotomy Need: Scalpel (#11) Tracheal hook Small curved dilator Tracheostomy tube or ET Good lighting

Manifestations of Shock

Tachycardia Hypotension Tachypnea Cutaneous vasoconstriction Decreased urine output Narrowed pulse pressure Decreased mental status Untreated shock compromises body systems, shock state ultimately becomes irreversible: Vasomotor failure Hepatic failure Cardiac failure

ESI Level 2

Threatened ABCs Likely but not obvious life threat or organ threat Should be seen within 10 min High resource intensity, multiple often complex diagnostic studies, frequent consultation, continuous monitoring Examples: Chest pain resulting from ischemia, multiple trauma unless responsive

Discuss the objectives and components of a trauma system

Trauma Centers meet specific criteria, vary in their specific capabilities and are identified by "Level" designation: Level 1 - highest Level 2 Level 3 - lowest

Identify populations at risk, economic/societal considerations, and resource/ethical considerations of traumatic injury.

Trauma is the leading cause of death in individuals younger than 45 Alcohol: º plays a role in almost all types of injury º problem remains with 15-24 age group, risk takers and tired people Violence: º homicide º assaults º firearms º intimate partner violence

ESI Level 1

Unstable ABCs Obvious life threat or organ threat Should be seen immediately High resource intensity, staff at bedside continuously, often mobilization of team response Examples: Cardiac arrest, intubated trauma, overdose with bradypnea, severe respiratory distress

Irreversible Shock

Untreated shock compromises body systems Shock state ultimately becomes irreversible Vasomotor failure Hepatic failure Cardiac failure

ESI Algorithm Decision Point D

What are the patient's vital signs? Consider the vital signs Are they outside the acceptable parameters for age? If unacceptable consider up-triage to ESI Level 2