Trauma Flashcards
What is done when a patient first gets to the ED?
Triage
What is the point of triaging a patient?
To rapidly determine the acuity of the patient and to recognize any life threatening conditions and to prioritize which patients are seen first
How do you prioritize which patients are seen first?
It is based on how severe the patient is and if they have a threat to their life, they are treated first
When does triage begin?
Begins with the first interaction with the patient
When a life treatening illness or injury is recognized during triage what should be done?
Early intervention and mobilizing resources
Who preforms triage?
RN
What is ESI?
Emergency severity index - determines how severe a patient is
What is ESI 1? What are some examples?
Requires immediate life saving interventions
Uncontrolled hemorrhage, airway compromise, respiratory arrest/distress
What is ESI 2? What are some examples?
High risk/decreased LOC/severe pain
High risk: suicidal, sexual assault victims, physically aggressive
Decreased LOC: confused, lethargic, disoriented
If the patient does not fall into ESI 1 or ESI 2, how is their severity decided?
By how many resources they need
What is ESI 3?
More than 2 resources
Most common patients in the ED
What is ESI 4?
One resource
What is ESI 5?
No resources
What happens if VS are out of range in triage?
The triage nurse should consider increasing the patient to ESI 2, but it is ultimately up to the nurse
How is triage designations made?
Using severity of illness or injury and resource ultilization.
Patients coming to ED are assessed and given a score by the triage nurse
What are resources?
- Labs - blood or urine
- Imaging. - ECG, Xray, CT, MRI, Ultrasound, angiography
- IV fluids - hydration
- IV, IM, or nebulized medications
- Speciality consultation
- Simple procedure - lac repair with stitches, Foley catheter = 1
- Complex procedure - conscious sedation = 2
What are not considered resources?
- History and physical
- Point of care testing
- IV start that are he-locked or saline locked
- PO medications
- Tetanus immunizations
- Prescription refills
- Phone calls to PCP
- Simple wound care like dressings, recheck, crutches, splints, slings
What is assessed in an emergency assessment?
Life threatening conditions using a primary survey and then preforming a focused assessment based on the patient chief compliant
How do you preform an emergency assessment on a trauma patient?
Assessed more systemically using a primary and secondary survey
Allows caregivers to address any life threatening and any concurrent injuries
What is the goal of a primary survey?
Identify and treat life threatening conditions
When can life threatening condition be identifies during a primary survey? What do you do?
Can be identified at any time
When identified stop and initiate intervention regardless of where you are in the assessment
What does primary survey consist of?
Airway, breathing, circulation, disability, expose and environmental control, full set of vital signs, family presence, get resuscitative adjunct
Do they ABCs need to be reprioritized during the primary survey?
Yes, they might need to be.
The new order is ABC
= catastrophic/uncontrolled hemorrhage that will need to be resolved first
What is AVPU? When is it preformed? What is it used for?
Alert, Verbal, Pain, Unresponsive
Assess when trauma patient arrives to the ED
To assess whether patient can control their own airway and will help caregivers choose the most appropriate airway adjunct
What kind of airway support is an unresponsive patient most likely going to need?
Endotracheal intubation using rapid sequencing which is sedation and paralytic to prevent possible aspiration and airway trauma
When a patient is alert..
They respond normally
When a patient is alert to verbal..
They respond to verbal stimulation
When a patient is alert to pain..
They respond to painful stimuli like a sternal rub
When a patient is unresponsive..
They do not respond to anything including verbal or pain
How do you progress for airway management?
Least to most invasive
How should you open the airway of a trauma patient? What are the concerns?
- Open the airway using jaw maneuver and removes any possible obstructions
- Stabilize the cervical spine during airway management - always assume that a patient with an injury to their neck, head or upper torso has cervical spine injury so maintain spine stabilization throughout the whole assessment
What are injuries that cause a deficit to respiratory status?
- Rib fracture
- Pneumothorax
- Penetrating injury
What are interventions for respiratory status deficits?
- Endotracheal intubation
- Chest tube
- Needle thoracotomy
What should you include in your breathing assessment of a trauma patient?
Rate, depth, symmetry and effort
What kind of oxygen supplementation should be given to your trauma patient?
100% oxygen via a non-rebreather d/t increased metabolic demand
How do you assess for s/s of hemorrhagic shock?
- Check the quality and rate of a central pulse like the carotid
- Weak thready pulse –> sign of shock and bleeding
How do you assess for perfusion deficits?
Assess the skin temperature, color, moisture and capillary refill
Prolonger capillary refill –> s/s of shock
How many IV does a trauma patient need? What kind of IV?
2 large bore IV
Large bore: 14-16 gauge
Trauma often requires ______ for lost blood volume
Blood products
Often requires a massive transfusion
Need good IV access to deliver large volume of blood over a short period of time
Uncrossmatched blood is given in emergency situations when there is not enough time for blood typing
What is uncross matched blood?
Type O negative
How do you assess diaability in a trauma patient?
- Assess LOC using the Glasgow coma scale
2. Assess pupils such as size, shape, equality and reactivity
What does the GCS tell you?
Insight for possible head injury
What GCS rating should you consider intubating?
Below 8 because they likely can’t control their own airway
GCS: eye opening response
- Spontaneously
- To speech
- To pain
- No response
GCS: verbal response (orientation)
- Oriented to time, person and place
- Confused
- Inappropriate words
- Incomprehensible sounds
- No response
GCS: motor response
- Obeys commands
- Moves to localized pain
- Flex to withdraw pain
- Abnormal flexion
- Abnormal extension
- No response
What should you remove from a trauma patient? What shouldn’t you remove?
- Remove all clothing to fully assess for any injuries, clothing usually cut off
- DO NOT remove any impaled objects because it could result in life threatening hemorrhage
What comfort measures should be taken with a trauma patient?
Keep the patient warm!
Warm blankets, warmed blood and fluids if possible, raise temperature of the room
Should the family be present during a trauma situation?
Yes, if they want to be
Especially during resuscitation because being with the patient allows them to have a more active role in the patient care.
Also a member of the trauma team should be with the family for questions at all times
Will diagnostic studies be preformed on a trauma patient right away?
No, they will be delayed until the patient is hemodynamically stable
Should VS be taken on a trauma patient?
YES! Full set of VS with temp
What is LMNOP?
Monitor patient condition continuously
L= labs (blood typing, H&H, ABG) M= cardiac monitoring N = Naso or orogastric tube to decompress the stomach O = pulse oximetry P = pain assessment and management
When should a nasogastric tube not be placed?
When there is known or suspected facial or head trauma
What is a secondary survey?
- Brief systematic process to identify all injuries
2. Begins after all components of the primary survey have been addressed and life saving interventions have been started
What information should you get from the EMS personnel?
- Description of the scene and how the patient got injured
- Mechanism of injury can focus the assessment and interventions by predicting injuries based on the details of the accident
What is SAMPLE?
S - symptoms A - allergies M - medication history P - past health history L - lost oral intake E - events leading to the injury
What is the most important aspect of a secondary survey?
Health history
Trauma head to toe assessment: Head/Neck/Face
Gaze Bleeding Bruising JVD Bruising behind ears and around eyes --> significant fracture
Trauma head to toe assessment: Chest
Symmetry
Paradoxical movements
Palpate for crepitus
Breathe sounds
Trauma head to toe assessment: Abdomen/Flank
Bruising
Bowel sounds
Distension
FAST exam (beside ultrasound to assess for peritoneal bleeding)
Trauma head to toe assessment: Pelvis/Perineum
Palpate for stability and crepitus Bleeding Obvious deformity Priapism (to assess for spinal injury) Rectal tone (to assess for spinal injury)
Trauma head to toe assessment: Extremties
Palpate for crepitus
Deformity
Pulses
Compartment syndrome (suspected with a patient who have suffered a crush injury and trauma)
What is the final step in the trauma assessment?
inspecting the posterior surfaces
How do you inspect the posterior surfaces? What are you looking for?
- Logroll the patient using 3 people. One person maintains inline cervical spine stabilization and the other two help the patient cross their arms and roll them
- Looking for bruising, abrasions, wounds and deformities
Monitoring is ___ and interventions are constantly ____
Monitoring is continuous and interventions are reevaluated constantly.
Start by reevaluating airway, breathing and circulation
Assessment needs to be repeated with any change to evaluate status
LOC reassessed and action take for any change in status
What is the goal for cardiac arrest?
Early defibrillation and chest compressions
When is targeted temperature management indicated?
For post cardiac arrest patients who achieved return of spontaneous circulation (ROSC)
What is targeted temperature management? What are the benefits?
Cooling the core temperature to 30-34 degrees Celsius post resuscitation for 24 hours
Associated with decreased mortality and improve neuro function
What is the RN role with death in the emergency department?
- Provides comfort to the loved ones and deceased
- Call the organ and tissue donation
- Prepare the body for viewing and be available for inquires and questions
What should any healthcare worker take part in after a death?
Debrief the emotions
Geriatric population and trauma
- There is a growing population of elderly
- Always check for advanced directives upon arrival to ER
- High risk for injury and illness
- The most common injury is falls which leads to fractures (always look for the reason for a fall such as a medical condition like stroke heart attack)
What are heat cramps?
Cramps in the large muscle groups
It is usually associated with sports or exercise once athlete rest
What are the s/s of heat cramps?
Occurs during rest
Nausea
Tachycardia
How do you treat heat cramps?
Rest for 12 hours
Sodium and electrolyte replacement with sports drinks
What is heat exhaustion?
Prolonged exposure to the heat over hours to days
Usually due to prolonged outdoor activity
What does heat exhaustion look like?(10)
- Fatigue
- N/V
- Extreme thirst
- Anxiety
- Hypotension
- Tachycardia
- Mild confusion
- Perfuse diaphoresis –> moist clammy skin
- Ashen skin color
- Pupils dilated
How do you treat heat exhaustion?
- Remove patient from environment to a cool area
- Removes constrictive clothing
- NS to correct dehydration and hypotension
- Moist sheet over patient
What is heat stroke?
Failure hypothalamus to thermoregulate
Medical emergency
Rapid fluid loss and electrolyte loss d/t sweating which causes the sweat glands to stop functioning –> body is not able to cool itself down and the core temp increases rapidly
Temp above 105.8
What does heatstroke manifest as? (9)
- Increased sweating
- Vasodilation
- Increased RR
- Depleted fluids and electrolytes (sodium)
- Altered mental status
- Loss of muscles coordination
- Combativeness
- Skin is dry, red, and hot
- Constricted pupils
How do you treat heat stoke?
- Cool with a fan, water bath and cool fluids
- Stabilize ABC
- Reducing core temperature
- While cooling them down you want to prevent the from shivering to avoid increasing the core body temperature
What are patient with heat stroke at risk for?
Direct thermal injury to the brain due to cerebral edema and hemorrhage
What is frostbite?
formation of ice crystals in tissues from exposure to freezing temperature
Peripheral vasoconstriction leading to decreased blood flow
Edema d/t ice crystals forming in the interstitial cell membrane
What does superficial frostbite affect?
Skin and subcutaneous tissue like the fingers and toes
Superficial frostbite manifests as
Skin is waxy Skin is pale yellow to blue mottled crunchy Frozen tingling Numbness Burning Frozen to touch Blister
What does deep frostbite affect? What does it look like?
invokes the bones, muscle tissue, and tendon
Mottling to gangrene
How do you treat superficial frostbite?
- Remove wet clothing
- NEVER rub or massage, always handle tissue gently
- Immerse in warm circulating bath
- Blisters - debride and sterile dressing
How to treat deep frostbite?
- Remove wet clothing
- Circulating bath
- After rewarmed, elevate extremities to decrease edema
- Extremity may need to be amputated if tissue damage is too severe
Is rewarming a patient with frostbite painful?
yes, may need analgesic
What is hypothermia?
Heat cause by the body is not enough to compensate for heat loss
Core temp is below 95
Severe hypothermia core temp is below 89.6
What does mild hypothermia manifest as?
- Shivering
- Lethargy
- Confusion
What does moderate hypothermia manifest as?
- Body rigidity
- Slowed RR and HR
- Hypotension/hypovolemia
- Shivering diminishes
What does severe hypothermia manifest as?
Person appears dead
How do you treat moderate to severe hypothermia?
- Remove wet clothing
- Humidified oxygen
- Warm fluids
- Rewarm core first
What is happening with the VS readings with hypothermia?
It can be difficult to get VS
When can a patient with hypothermia be pronounced dead? What is usually the cause of death with hypothermia?
- When the body is warmed at least to 86
- Heart is irritable d/t decrease in temp so it is prone to dysrhythmias
- Cause of death is usually recurrent ventricular fibrillation
Drowning is? How are most commonly the victims?
- Respiratory difficulty after submersion in water
2. Most victims are less than 5 or males between 15-25
Is aspiration common with drowning? What happens if water is aspirated?
It is often prevented by laryngospasms
Pulmonary edema occurs if water is aspirated
What is the treatment fro drowning?
Focuses on correcting hypoxia with aggressive airway control and sometimes can require endotracheal intubation
Always assume that there is a cervical spine injury present
Bites and strings severity is based on
Direct tissue damage or toxins
Wasp, bee, hornet stings s/s and treatment
- Localized pain or life threatening anaphylaxis
2. Treat by removing any stinger from the body and remove any restrictive clothing
Ticks complications and treatment
- Ticks attach themselves to the host and inject a neurotoxin that causes a disease
- Causes Lyme disease which is very serious and can lead to ascending paralysis and respiratory arrest
- Treat by removing ticks with forceps
- Muscle fucnction is restored within 42-72 hours after tick removal
What is poisoning? What is the severity based on? What is the goal of treatment?
- Any chemical that harms the body
- Based on type of chemical and what route to was ingested
- Goal is to decrease absorption, enhance elimination, and administer any toxin specific care
How can poisons get into the body?
Ingested
Inhaled
Absorbed through skin
Splashed in eye
Accidental or incidental
When should poison control be used? How do they help?
Can be used from home or at hospital
When call from hospital, connect with an expert that provides chemical specific treatment
What is the gastric lavage process? What considerations should be taken into account for decreased LOC or absent gag reflex? When does it need to be preformed?
Decreases absorption by removing the substance form stomach
- Large tube is inserted into the stomach and irrigated with copious amount of sterile saline and contents are drawn out using a large syringe
Those with decrease LOC or absent gag reflex need to be intubated prior to gastric lavage to prevent aspiration of substances into lungs
Less than 1 hour from ingestion
How does activated charcoal work? How is it given? When does it need to be given?
Binds to ingested toxin and prevents absorption
Given PO or gastric tube
Within 1 hour of toxin/substance
When is hemodialysis required for poisoning?
If patient becomes too acidotic
What should every patient be screened for with every ED visit?
What is their screening is positive?
- Screened for intimate partner and family violence
2. Positive: nurse advocates for patient by providing resources and notifying appropriate personnel
What does a SANE nurse do?
collect and document evidence in sexual assault cares, provide emergency care and advocates for victims
Is workplace violence is the ED common?
- high risk
- Patients on drugs/alcohol, mental disorders and become violent w/o warning
- In ED must remain aware of surroundings and safety for self and others
- Utilize security and law enforcement and remove yourself from any unsafe situations
What is a mass causality incident
- an emergency event that overwhelms the community to respond with existing resources
- Man-made like terrorism or natural like hurricane, tornadoes, and floods
- Large number of victims
- Multiple agencies responded
Triaging for mass casualty incident
Responsibility of first responders
Different from the ED triage, triaged in 15 seconds
Color tags determine the order that patient should be treated and transported to the hospital
Black tag
Deceased
Patients who aren’t breathing or with injuries that will die before getting to hospital
Red tag
Immediate
Need immediate life threatening interventions and requires next ambulance leaving the scene
Yellow tag
Delayed
Patent is urgent but does not need the next ambulance leaving the scene
Green tag
Minor
Ambulating with minor injuries
Walk from the scene to a safe place
