By: Michael Putnam RN Adapted from ENA; TNCC Trauma Management By: Michael Putnam RN Adapted from ENA; TNCC Info from TNCC

Overview Trauma patients are treated very differently depending on the type hospital you are in People usually attend to the most graphic of injuries first This often lead to other more serious injuries being missed

Overview con’t The Emergency Nurses Association (ENA) established a set of evidence based practices that could be used internationally: Trauma Nursing Core Curriculum (TNCC) In York Region most trauma is diverted to Sunnybrook based on the field trauma triage guidelines Peads Trauma goes to Sick Kids Trauma Triage guidelines Blunt or penetrating trauma with signs of hemodynamic instability defined by bp less than 90 mmHg or hypovolemia +/- crush injuries 3rd degree burns >10% bsa or over joints, chest, and face or neck 4 over 16 y/o or showing secondary sex characteristics CONTRAINDICATIONS Unsecured airway except pentrating trauma Travel time >30min from transport decision ACP vs PCP If pcp is unable to control airway then no transfer Paeds…. Decision of Base Hospital Program the must patch for order

Patient Management A – Airway B – Breathing C – Circulation D – Disability E – Expose/Environment F – Five Interventions/Full Vitals G – Give Comfort H – History/Head to Toe I – Inspect the Back This is the RN approach to Trauma… the MD ATLS is slightly different, but the concepts are the same….

IMPORTANT Like all things they must be done in order. 1 comes before 2 and A comes before B

EMS History Taking MIVT format Mechanism Injuries Sustained Vital Signs Treatment Rendered Have the crew remain until you are certain you have all the information *** photo’s

Airway Assess Interventions C – Spine must be maintained! Patent? Obstruction? Vocalizing? Interventions Suction, Jaw Thrust, OPA, NPA, ETT, NTT, surgical airway. C – Spine must be maintained! R/T will be invaluable in controlling airway, however you should be able to manage it in the interim.

Breathing Assess Interventions Breathing? (rate, rhythm) chest symmetry, integrity of chest, accessory muscle use, chest auscultation, trachea position, jugs Interventions O2 by NRB BVM if necessary Chest tube, chest seal, needle decompression if needed

Circulation Assess Interventions Pulse? Present? Skin condition, exsanguating trauma, BP (if enough people), heart sounds Interventions CPR Control bleeding, elevate, IV (2X 14G or 16G): Use warmed solutions when possible or central line? Blood or N/S Labs Thoracotomy Pneumatic Anti-shock garments – very rarely used but can be very effective Thoracotomy – very rarely done at YCH pt will require immediate transfer to tertiary care

A Note on Fluid Resuscitation Bigger is better…a 14 G peripheral line is better than a 3 Lumen Central Line. Central Line options 6 – 8.5F cordis, 2-3 lumen, 1-3 lumen slic Crystalloid versus colloid Saline versus Ringers IV line choices Gravity versus pump Colloid infusions… 3-5 units prbc’s = ffp In relatively healthy adult start with 2 L fluid challenge For central line… subclavian is primary choice, but take what you can get.

Disability (mini-neuro) A- Alert V – Verbal P – Painful U – Unresponsive Pupils: Size - Equal, Reactive to Light? GCS… Sum of its parts more important than the total GCS is more important as the sum of its parts versus the total number E 1-4 V 1-5 M 1-6

Secondary Identify most life threatening injuries by this point Secondary assessment will identify other minor injuries

Expose/Environment Removal of all clothing, board straps, etc. Attempt to maintain warmth where possible Warmed fluids, blankets

Five Interventions Monitor with SpO2 and BP (12 lead) maintain SpO2  95% Foley – Contraindicated? N/G Tube – Contraindicated? Labs (if not done in “C”) Family

Give Comfort Pain control Verbal reassurance Stimuli reduction Advocate for your patient…. Fentanyl is a good choice… potent narcotic.. Rapid on.. Rapid off

History MIVT Domestic Violence ? PmHx, Meds, Allergies, LNMP Tetanus Status

Head to Toe Soft Tissue Injuries Bony Deformities Full Neuro exam Eyes, Ears, Nose, Neck Chest, Abdo, Pelvis, Extremities

Inspect Roll Patient off Back Board inspect the back/posterior with Log Roll Keep Neck Stable at all times!

trauma.org

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Charting Example Pt arrived to 14B @1432 CTAS 1 M – 32 y/o female belted driver into concrete embankment at minimum 100km/h, no airbag, star pattern on windshield, 30 minute extrication time. I - ? Closed head injury was initially conscious GCS 13 now GCS 3, ? # L femur V – initially 138/70 HR 110 Resp 24 now 100/50 HR 130 Resp 6 T – OPA, collar, board, assist resps with BVM, sager to L femur, IV 18 G to R Hand with N/S at KVO A – clear, no vomit, no blood, no teeth OPA in place no apparent gag, intubation by MD lidocaine 100mg iv @ 1435 etomidate 20mg IV by MD @ 1436 Sux 80mg IV by MD @ 1437. Insert 8.0 ETT 23cm at teeth, positive bilateral breath sounds, and positive ETCO2. Easy to bag. B – ventilate at 12/min chest clear, no trauma identified, chest stable no crepitus or deformity. C – pulse 95/min strong and regular. Skin pale warm and dry, B/P 95/40. 2nd iv 14 G into L A/C with N/S at KVO labs drawn from reseal. D – pupils L 4 R 6 non reactive.

Salvation from tragedy… Organ Donation… Salvation from tragedy…

Questions trauma.org

Take Home Points A,B,C,D Keep them warm IV’s bigger the better Only do what needs to be done to get them out, or does not delay transfer.

Summary We don’t get much trauma What we do get we can be better at Think transfer early