Trauma Resuscitation
Shelley Atkinson RN, MSN, ANP-BC, ACNP- BC
Objectives• Identify the correct sequence of priorities for
assessment of a multiple injury trauma patient.
• Identify the principles outlined in the primary and secondary evaluation surveys to the assessment of a multiple injury patient.
• Identify guidelines and techniques in the initial resuscitative and definitive-care phases of treatment of a multiple injury patient.
Injury Statistics• Leading cause of death for ages 1-44• $ 500 billion dollar annual cost• Estimated 20-50 million injuries occur per year
(40 % of emergency room visits)• Leading causes of trauma are motor vehicle
crashes, falls, and assaults
Trimodal Death Distribution
• Death due to injury occurs in one of three periods or peaks
• Care provided during each of these periods impacts patient outcomes
Trimodal Death Distribution• First peak – occurs within seconds to minutes
of injury• Second peak – occurs within minutes to
several hours following injury• Third peak – occurs several days to weeks
after initial injury
Advanced Trauma Life Support (ATLS)Assess the patient’s condition rapidly and
accuratelyResuscitate and stabilize the patient according
priorityDetermine if patient’s needs exceed a facility’s
resources/or doctor’s capabilitiesArrange for transfer (what, where, when, who,
and how)
ATLS
• Assure that optimum care is provided and level of care does not deteriorate at any point during evaluation, resuscitation, or transfer process
What is a Level One Trauma Center?
A hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries.
Level One CriteriaAirway/Breathing• Unstable airway/unsecure airway• Patients with severe maxillofacial injuries• Patients requiring immediate airway
intervention• Facial burns or burns with significant suspicion
of inhalation injury• Moderate to severe Respiratory distress• Sub Q air in face, neck, or chest
Level One CriteriaCirculation• Systolic BP < 90mmHg or HR > 120• Witnessed cardiac arrest from trauma• Uncontrolled/Arterial Bleeding with shock• Spinal/Neurogenic Shock
Level One CriteriaCNS• GCS ≤ 8• Head injury with LOC > 5 min • Known spinal cord injury• Neurologic deficits with suspected spinal cord
injury (any level)
Level One CriteriaChest/Abdomen/Pelvis• Chest/Abdominal/Pelvic Injury with shock• Chest wall injury– Flail chest– Sucking chest wound– Subcutaneous air
• Pregnancy ≥ 24 weeks with significant mechanism of injury
Level One Criteria
Extremities• Multiple long bone fractures with shock• Mangled Extremity or Amputation– above wrist/ankle
Level One CriteriaMechanism of Injury• Penetrating trauma to the head, face, torso
(chest, abdomen, buttocks, back)• Ejection from vehicle • Fall from 20 or more feet with presence of
other Level I criteria• Electrocution/Electrical Injury with entry/exit
wounds
Level One Criteria
Mechanism of Injury• Burns > 20% TBSA or burns combined with any
other injury• Massive crush injury
Pre-hospital care
Initial AssessmentPrimary survey and
resuscitation of vital functions are done simultaneously.
A team approach
Primary SurveyABCDEs
• Airway with cervical spine protection• Breathing• Circulation with hemorrhage control• Disability: Neurologic status• Exposure/Environment
What is the number one priority during the initial assessment of a
trauma patient?A. AirwayB. AirwayC. AirwayD. All of the above
Airway Obstruction RecognitionLook
• Agitation/Obtunded• Decreased air movement• Retraction• Deformity• Airway debris
Listen
• Normal speech- no obstruction
• Noisy breathing – obstruction
• Gurgle• Stridor• Hoarseness
Inadequate BreathingLook• Cyanosis• Change in Mental Status• Chest asymmetry• Tachypnea• Neck vein distention• ParalysisFeel• Sub Q emphysema/chest wall crepitus• Tracheal deviation
Listen• “I can’t breathe”• “I am dying”• Stridor, wheezes• Decreased or absent breath
sounds
Which way for the Airway?
Rapid Sequence Intubation• Be prepared to perform a surgical airway in
the event that airway control is lost• Pre-oxygenate patient with 100% oxygen• Administer analgesic / sedative (IV) if feasible• Apply pressure over cricoid cartilage – Debatable
• Administer a paralytic IV• Perform chin lift/jaw thrust
Rapid Sequence Intubation
• After the patient relaxes, intubate orotracheally
• Inflate cuff and confirm placement – auscultate and determine CO2 in exhaled air
• Release cricoid pressure• Ventilate• CXR
Adjuncts to Primary Survey • ECG• CO2 detector• Pulse oximetry• Vital Signs
Primary SurveyCirculation with Hemorrhage Control
• Control hemorrhage• Activate trauma (Massive Transfusion Protocol)– 6U pRBC, 4U FFP, 1 Platelets– MD activation only
• Judicious use of crystalloid
6 areas potential blood loss
• Chest• Abdomen• Retroperitoneum• Pelvis• Long bones / Soft tissue• Scalp• …the ground
Trauma • Majority deaths occur in 1st few hours after
injury• Hemorrhage largest % deaths within 1st hour• Hemorrhagic shock and exsanguination– 80% deaths in OR– 50% deaths 1st 24 hrs after injury
• Very few hemorrhage deaths after 1st 24 hours• Only CNS injury more lethal
Special Considerations In Diagnosis and Treatment of Shock
• Age• Athletes• Pregnancy• Medications• Hypothermia• Pacemakers
Vascular Access
• 2 large-caliber, peripheral IVs• Central access– femoral– jugular– subclavian
• Intraosseous• Obtain blood for crossmatch• Trauma panel – CBC, BMP, coags
Hemorrhagic ShockClass I Class II Class IIIClass IV
EBL <750 750-1500 1500-2000 >2000
HR <100 >100 >120 >140
BP NL NL LOW LOW
UO >30 20 - 30 5 - 15 MIN
ACS-COT 1993
Direct Effects of Hemorrhage• Class I – (up to 15% blood volume loss)Exemplified by the patient that has donated one unit of blood• Class II – (15% - 30% blood volume loss)Uncomplicated hemorrhage for which crystalloid fluid resuscitation is required
Direct Effects of Hemorrhage• Class III – (30% - 40% blood volume loss)Complicated hemorrhagic state in which at least crystalloid infusion is required and perhaps also blood replacement• Class IV – (more than 40%)Considered a pre-terminal event, and unless very aggressive measures are taken, the patient will die within minutes
Fluid Resuscitation• Balance organ perfusion with risk of re-bleeding– may reverse vasoconstriction of injured vessel– Dislodge early clot– Dilute coagulation factors– Cool patient– Induce visceral swelling
Too much fluid?
Adequacy of ResuscitationClinical Variables
• Mentation• Pulse, pulse pressure, BP• Urine output• Clot formation• Temperature• Lactate/base deficit
Primary Survey - DisabilityNeurologic Evaluation
• Baseline neurologic evaluation• GCS scoring• Pupillary response
**Observe for neurologic deterioration
Head Trauma
• Severe CHI (GCS < 9) vulnerable to secondary brain injury
• Hypotension doubles mortality• Hypoxia and hypotension increases mortality
by 75%• Normovolemia goal (dehydration harmful)• Hypertonic saline or Osmotic Agent (mannitol)
Head Trauma• Hyperventilation used cautiously– only used if patient rapidly deteriorates
• PCO2 no lower than 30-35 • Prolonged hyperventilation can produce
cerebral ischemia and secondary brain injury• Mannitol useful– after adequate volume resuscitation
Spinal Cord Injury
• Neurogenic Shock– Consider hemorrhage first…
• Maintain spine immobilization • Fluid or no fluid?• Vasopressors
Septic Shock
• Uncommon immediately after injury• May occur several hours after injury
(especially if transfer to emergent facility delayed)
• May occur in penetrating abdominal injuries– contamination of intestinal contents into
peritoneal cavity
Primary Survey - Exposure/Environmental Control
• Completely undress the patient• Prevent hypothermia
Deadly Triad
• Hypothermia• Acidosis• Coagulopathy
Hypothermia (HT)• Frequent in trauma/massive transfusions• Trauma-related HT considered poor prognostic sign• Mortality directly to degree and duration• Inhibits coagulation factor synthesis, prolongs PT and
PTT• Severely affects platelet count and function• Attenuates vital CV compensatory responses,
predisposes to arrhythmias
Re-warming
• Aggressive therapy associated with significant decrease in:– blood loss– fluid requirements– organ failure– LOS in ICU– mortality rate
Secondary Survey
• Begins after ABCDE is completed• Resuscitative efforts underway• Each region of the body is completely
examined
Trauma imaging• Chest x-ray• Pelvis x-ray • FAST– focused assessment sonography in trauma
• DPL (center-dependent)– diagnostic peritoneal lavage
• CT scan– Traumagram
Adjuncts Secondary Survey• Foley• NGT• ABG/lactate– If actively resuscitating
Primary Goal of Initial Operation for a Trauma Patient
Damage Control• Hemorrhage Control• Contamination
Why Trauma NPs??High acuity, high volume with seasonal surges.
Transition area of 17 beds experiencing delayed throughput
Hypothesized that by adding experienced Trauma NPs, we could improve throughput and quality in care.
1 year, compared with 2 years prior
Results:•Increased volume of cases by 14.3%•1.0 reduction in ALOS for entire trauma service•27.8 million reduction in hospital charges. •Increased direct discharges by 21%.
MD/RNs found the addition of ACNPs beneficial, improved patient care, improved workflow, improved communication and throughput.
References• Acute Trauma Life Support Course – Retrieved from American
College of Surgeons Website http://www.facs.org/trauma/atls/information.html on July 1, 2012.
• Guillamondegui, Oscar MD, MPH, FACS, Associate Professor of Surgery, Medical Director, Trauma ICU, Director of Trauma Education, Vanderbilt University Medical Center.
• Atkinson, S., Collins, N., Martin, M., Morton, M., Marshall, K. (2012) Outcomes of Adding ACNPs to a Level One Trauma Service with the Goal of Decreased Length of Stay and Improved Patient, Physician and Nursing Satisfaction: A pilot study.