Trauma and Triage Flashcards
Blunt Trauma Definition and associated forces
Can be less-obvious than penetrating
* Forces Associated:
* Shearing
* Acceleration and deceleration forces
* Compression force
The most common organs injured in penetrating trauma:
the small bowel (50%), large bowel (40%), liver (30%), and intra-abdominal vascular (25%).
When a penetrating trauma is in close range, there is more __________ than those injuries sustained from a distance
kinetic energy
Trimodal Distribution of Trauma Deaths
- 1st peak: within minutes of injury (on site)
- 2nd peak: within 2 hours of injury (in the ER)
- 3rd peak: within days to weeks after injury (in the IC/ward)
7 Points of the Trauma Nursing Process
- Preparation and triage
- General impression
- Primary survey (A–G) with the corresponding intervention as necessary
- Reevaluation (consideration of transfer/need for higher level of care)
- Secondary survey (H–I)
- Reevaluation (J) and post-resuscitation care
- Definitive care, transfer, or discharge
1st step of trauma nursing process:
Preparation and Triage
* Activate the trauma team
* Prepare for patient arrival
* PPE and safety
2nd step of trauma nursing process:
General impression - assessing for
1. Uncontrolled external hemorrhage?
2. Unresponsive
3. apnic?
3rd step of trauma nursing process:
Primary Survey + Corresponding Interventions
Finding the Biggest Issues: the A-G assessment
A: alertness and airway
B: breathing/ventilation
C: circulation/hemorrhage control
D: disability
E: exposure/environment
F: full set of vitals and family
G: get adjuncts and give comfort
If life-threatening conditions are identified during primary survey:
interventions are started immediately and before proceeding to the next step of the survey.
Primary Survey: A
Alertness and Airway
How do you assess alertness in primary survey?
AVPU
Alert
Verbal
Pain
Unresponsive
How do you assess airway in primary survey?
Vocalization
Also look for:
* Bony deformity
* Burns
* Edema
* Fluids (blood, vomit, or secretions)
* Foreign objects
* Inhalation injury (burns, singed facial hair, soot)
* Loose or missing teeth
* Sounds (snoring, gurgling, stridor)
* Tongue obstruction
Airway interventions
Repositioning
* Jaw-thrust maneuver or Head Life/Chin Tilt
Adjuncts Following Positioning:
* Oropharyngeal Airway (OPA)
* Nasopharyngeal Airway (NPA)
* Endotracheal tube (ETT)
How do you verify ETT placement
CO2 detector - yellow to purple
observe chest rise & fall
auscultate epigastrium (should not hear air)
bilat breath sounds (unilateral if entry into right stem)
What is capnography?
CO2 detector following ETT placement; allows for placement verification
B in primary survey
Breathing and ventilation
How do you assess breathing in primary survey
- Breath sounds (decreased, absent)
- Depth, pattern, rate
- Increased work of breathing
- Dyspnea
- Open wounds or deformities
- Skin color (pallor, cyanosis)
- Spontaneous breathing
- Subcutaneous emphysema
- Symmetrical chest rise and fall
- Tracheal deviation or JVD
If you can’t get past A and B in primary survey:
Intubate
C in primary survey
Circulation and Control of Hemorrhage
How to assess C in primary survey
- Inspect and palpate
* Color
* Temperature
* Moisture - Palpate a central pulse
- Control hemorrhage
Why palpate for a central pulse in primary survey
peripheral pulses may be absent because of injury or vasoconstriction
Central pulse examples
Carotid, femoral, brachial
D in primary survey
Disability/Neuro Status
What 4 things are assessed with disability in primary survey?
- GCS (eye, verbal motor)
- AVPU (alert, verbal, pain, unresponsive)
- Pupils
- Glucose
E in primary survey
Exposure and Environment Control
How do you assess E in primary survey?
Remove all clothing
* Inspect for injuries
Warming measures
* Blankets
* Increase room temperature
* Warmed IV fluids
* Warming lights
F in primary survey
- Obtain a full set of vital signs
- Facilitate family presence
G in Primary Survey
Get adjuncts and Give Comfort
Assessments/Interventions for G in primary survey
LMNOP
- L: Laboratory analysis
- M: Cardiac monitor; consider 12-lead ECG
- N: Consider naso- or orogastric tube for stomach decompression/decrease aspiration risk
- O: Oxygenation and capnography; consider weaning oxygen
- P: Assess pain using appropriate scale
- Consider analgesia
- Nonpharmacologic comfort
4th step of trauma nursing process
Reevaluation (consideration of transfer/need for higher level of care)
5th step of trauma nursing process
Secondary Survey
3 Components of Secondary Survey
- history
- head to toe
- inspect posterior and anticipate interventions
First component of secondary survey
History
S- signs and symptoms
A- allergies
M- medications
P- past medical history
L- last oral intake/menstrual period
E - event leading up
Second component of secondary survey
Head to toe assessment
* Focus:
* Manage the injuries
* Optimize respiratory and cardiac function
Third component of secondary survey
Inspect Posterior
* Unless contraindicated by known or suspected spine or pelvic injury
* Turn, inspect and palpate
* Remove backboard
and Anticipate Interventions
6th step of trauma nursing process
Keep re-evaluating VIPP
V - vitals
I - injuries and interventions
P - primary survey
P - pain
What is the Trauma Triad of Death?
- hypothermia
- coagulopathy
- acidosis
Treating _____ is key in the presence of hypovolemia in trauma
Hypothermia
Why is the treatment of hypothermia key in the presence of fluid loss?
Hypothermia:
* Inhibits platelet function
* Slows coagulation factor activation
* Body temp low, blood will flow
* Blood clots best at 37 degrees
Triage assigns priorities based on:
Resources
What is MEWS?
Modified Early warning system (MEWS)
A screening and scoring tool to identify hospitalized patients at risk for deterioration
What 6 things does MEWS assess?
- RR
- HR
- SBP
- LOC (AVPU)
- Temp
- Hourly urine for 2 hours
Best MEWS score
0
What actions do you take for a 1-2 MEWS?
q2h observations and inform charge nurse
What actions do you take for a 3 MEWS?
q1-2h observations and inform charge nurse
What actions do you take for a 4 or greater MEWS?
q30min observations, ensure medical advice is sought + contact outreach team
RR Mews Scoring
2 - < 8
0 - 9-14
1 - 15-20
2 - 21-29
3 - > 30
HR Mews Scoring
2 - < 40
1 - 40-50
0 -51-100
1 - 101-110
2 - 111-129
3 - > 129
SBP Mews Scoring
3 - < 70
2 - 71-80
1 - 81-100
0 - 101 - 199
2 - > 200
LOC Mews Scoring
3 - unresponsiveness
2- responds to pain
1- responds to voice
0 - alert
1 - new agitation/confusion
Temp Mews Scoring
2 - < 35
1 - 35.1 -36
0 - 36.1 - 38
1 - 38.1 - 38.5
2 - > 38.6
Hourly Urine Output Mews Scoring
3 - < 10
2 - < 30
1 - < 45
Level 1 CTAS (Canadian Triage Acuity Scale)
Resuscitation
Conditions that are considered threats to life/limb requiring immediate aggressive interventions
Level 2 CTAS (Canadian Triage Acuity Scale)
Emergent
Conditions that are a potential threat to life/life or function requiring rapid medical interventions
Level 3 CTAS (Canadian Triage Acuity Scale)
Urgent
Conditions that could potentially progress to a serious problem requiring emergency interventions
Level 4 CTAS (Canadian Triage Acuity Scale)
Less urgent
Conditions that related to a potential for deterioration that would benefit from intervention
Level 5 CTAS (Canadian Triage Acuity Scale)
Non urgent
Conditions that may be acute but non urgent and intervention can be safely delayed
CTAS Level 1 Condition, time to assessment and re-evaluation
Threat to life/limb
Immediate assessment
Continuous re-evaluation
CTAS Level 2 Condition, time to assessment and re-evaluation
Potential threat to life/limb/function
15 min assessment
q15 re-evaluation
CTAS Level 3 Condition, time to assessment and re-evaluation
Potential to progress to serious problem
30 min assessment
q30 re-evaluation
CTAS Level 4 Condition, time to assessment and re-evaluation
may progress to urgent status
60 min assessment
q60 re-evaluation
CTAS Level 5 Condition, time to assessment and re-evaluation
acute/chronic but not urgent
120 min assessment
q120 re-evaluation
Four Phases of Disaster Management
- Preparedness
- Response
- Recovery
- Mitigation/Prevention
What is the Mass Casualty Triage System?
RPM 30, 2, Can Do
Assess resps (<30), perfusion (<2), and mental status (can do commands)
According to RPM, if a patient is walking around they are categorized as:
Minor
According to RPM, if a patient is not walking around and not breathing after airway reposition they are categorized as:
Expectant
According to RPM, if a patient is not walking around, breathing, but have one or more RPM features, they are categorized as:
Immediate
According to RPM, if a patient is not walking around, breathing, and have no RPM features, they are categorized as
Delayed
Minor Triage Category
Able to walk
Delayed Triage Category
Not able to walk, spontaneous breathing, RR < 30, radial pulse present/cap refill < 2, obeys commands
Immediate Triage Category
Not able to walk, then either:
- breaths after airway reposition
- RR > 30
- radial pulse absent/cap refill > 2
- doesn’t obey commands
Expectant Triage Category
Not able to walk, apneic after airway reposition
How does pediatric triage differ from adult?
Following airway reposition, if apneic still assess pulse and attempt 5 rescue breaths
RR values 15-45
Information on triage tag
Basic info: injuries, vitals, meds, decontamination, parent/child connection
Once triaged: bottom torn off (triage is lowest category)
Code Red
Fire
Code orange
Incoming mass casualty
Code green
evacuation
Code black
bomb threat
Code purple
hostage situation
Code white
violent act
code silver
active assailant with weapon
code yellow
missing patient/resident
Code blue
cardio-respiratory arrest
code brown
hazardous materal/spill
code t-alert
tornado
What intervention occurs alongside airway and alertness assessment in primary survey and why?
cervical spine stabilization (holding c-spine) or immobilization occurs with airway because…
* High c-spine injury can compromise airway/cut off drive to breath
* Already assessing neck, so makes sense to lump here
What 3 things show need for c-spine stabilization?
- mechanism of injury
- indication of head injury
- change in LOC
What airway interventions can/can not be done on indication of c-spine compromise?
Jaw thrust = any
head tilt = not done on suspection
OPA Considerations
- shorter than ETT
- nurses can place
- not done on conscious (gag reflex)
NPA Considerations
- when OPA (mouth) isn’t best option
- cannot be placed with head injury/suspected cranial vault fracture
- used in conscious or unconscious patient
- nurses can place
Intervention for B in primary survey
Bag Valve Mask - maximize oxygen
Intubation
What is C-ABC mean?
If patient presents with uncontrolled hemorrhage, it is managed before airway
Why assess glucose in primary survey?
Trauma patients have increased metabolic rate. Low sugars cannot facilitate high metabolic need
Low blood sugar can cause lower LOC; differentiate low GCS from injury/sugars
Common traumatic chest injuries
- rib fractures
- flail chest
- pulmonary contusion
- tension pneumothorax
- Open pneumothorax
- Massive pneumothorax
Flail Chest
type of rib fracture requiring intervention – breaking away of lateral ribs so frontal ribs are not attached, not responding to inhalation/exhalation
When they move during breathing or other movement, these fractured ends can cause damage to the surrounding muscles, blood vessels, or even to your lungs and heart. This can cause internal bleeding, which can be life-threatening.
Pulmonary contusion
bruising of lungs
Tension pneumothorax definition and care
increased air pocket causing mediastinal shifting
Emergent Care: Needle decompression (14G) penetrates lung and cath left in for air release (2 ICS MCL)
Definitive care: chest tub
Cardiac tamponade
fluid buildup in pericardial sac squishing heart so that it cannot appropriately contract and fill
Intervention for abdominal injuries
Damage control surgery: usually unknown what is going on
Goal is hemostasis – stop the bleeding; temporary closure; prevention of contamination
* Proper closure in days following
Risk with pelvic injuries and symptoms
iliac artery lacerations
- Perianal ecchymosis
- Pain on palpation of iliac crests
- Hematuria
- Lower extremity rotation or paresis
3 Types of Level 1 CTAS Patients
- major trauma
- serious car accident
- heart stopped
5 Types of Level 2 CTAS Patients
- severe trauma
- suspected heart attack
- suspected stroke
- large broken bone
- trouble breathing
6 Types of Level 3 CTAS Patients
- moderate trauma
- fainting
- head injury
- asthma attack
- temperature > 40
- seizure
4 Types of Level 4 CTAS Patients
- minor trauma
- cut requiring stitches
- small broken bone
- sore ear eye or throat
5 Types of Level 5 CTAS Patients
- minor trauma
- removal of stitches
- renewing prescription
- vomiting/diarrhea without dehydration
- coughing/congestion
