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A method of quickly identifying
victims who have immediately
life-threatening injuries and who
have the best chance of surviving.
Triage](https://image.slidesharecdn.com/generaltrauma2022-2023condensed-240605191528-a69b95ed/75/General-Trauma-2022-2023-condensed-fuclty-of-nursing-pdf-53-2048.jpg)
General Trauma 2022-2023 condensed fuclty of nursing.pdf
- 1. By Dr. Hanaa Elfeky Professorof Critical Care and Emergency Nursing Nursing management of a Post traumatic Injury Patient
- 2. At the endof this lecture each student should be able to: •Discuss types of trauma •Mention the mechanisms of injury •Discuss pathophysiology of trauma •Explain emergency management of post traumatic injury patients •Utilize triage principles in management of post trau matic injury patients Objectives
- 3. •Definition and incidenceof trauma •Mechanisms of injury •Classifications of trauma •Pathophysiology of trauma •Assessment and management of trauma patients •Emergency nurses’ role. Outlines
- 4. What is trauma? Traumais a wound produced by sudden physical injury. “Polytrauma” = Multisystem trauma = injury of two or more systems.
- 5. Injury is unintentionalor intentional damage to the body resulting from sudden exposure to thermal, mechanical, electrical or chemical or from the absence of such essentials as heat or oxygen. What is injury?
- 6. • Unintentional Injuriessuch as: Motor vehicle crashes (MVC), falls, drowning, fires, … ….. • Intentional Injuries such as: Suicide attempts, assaults, and homicides (injuries from poisoning, drowning, cutting, and jumping).
- 7. • It isone of the leading causes of death for all ages. • The peak incidence between 15 & 25 years (the healthy and productive group). • Hemorrhage is second-leading cause of death in trauma. Incidence of trauma
- 8. Number of Incidentsby Age Number of Incidents by Age 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106 Age (years) Number of Incidents
- 9. Critical care andrehabilitatio n
- 10. Classification: 1- According tothe type/ cause 1.a-Blunt trauma is commonly caused by Road traffic accidents Falls Sports injuries
- 11. Blunt trauma + Hypotension + Altered mentalstatus = Diagnostic and Therapeutic Dilemma
- 12. Injuries to skin,tissues, underlying organs, viscera, and possibly bone 1.b- Penetrating trauma Gunshot Inlet
- 13. 2.1-Minor trauma: Single systemor limb injuries that do not pose a threat to life and can be appropriately treated in a basic emergency facility. 2.2-Major trauma: Serious multiple system injuries that require immediate intervention to prevent disability, loss of limb, or death such as tension pneumotho rax, open pneumothorax, and Flail chest. 2- According to the severity of injury:
- 14. Mechanism of Injury Knowledgeof the mechanisms of injury such as acceleration, deceleration, & other conditions greatly enhance the management of trauma patients.
- 15. Acceleration Acceleration is therate of the change of velocity (speed in a given direction) of any object. It refers to an increase or positive change of speed or velocity.
- 16. Deceleration Deceleration always refersto acceleration in the direction opposite to the direction of the velocity. Deceleration always reduces speed.
- 17. Deceleration Injury Aortictear Acute subdural brain hematoma Kidney avulsion
- 18. Compression injury Frontalbrain contusion Pneumothorax Rupture of Left hemi- diaphragm Small bowel rupture Unstable Spine fracture
- 19. Other conditions • Explosions –Blunt + penetrating + burns • Burns • Crush injuries • Drowning • Hypothermia
- 20. Pre-hospital Phase Begins atthe scene of the trauma. The pre-hospital roles Prevention of additional injury Rapid transportation Advance notification Initiation of treatment Triage. Trauma Management
- 21. Response to traumaand metabolic changes:
- 22. Response to traumaincludes various endocrine, metabolic and immunological changes. It occurs as a result of activation of the central nervous system and hormonal responses against injury. Stress hormones and cytokines play a role in these reactions. The severity of these changes is related to the amount of exposed stress. More reactions are induced by greater stress leading to greater catabolic effects.
- 23. The characteristic responsethat occurs in trauma patients include: protein and fat consumption, protection of body fluids and electrolytes because of hyper-metabolism in the early period (within the first 24 hours).. Trauma leads to a reduction in: - Protein synthesis, and so affect metabolic and nutritional status, as well as defense against infection. - The normal anabolic effect of insulin, i.e. the development of insulin resistance.
- 24. The oxygen andenergy requirement increases in proportion to the severity of trauma. Free fatty acids are primary sources of energy after trauma. Triglycerides meet 50 to 80 % of the consumed energy after trauma and in critical illness.
- 25. The metabolic responseto trauma has been defined in 3 phases: 1. Ebb phase or decreased metabolic rate in early shock phase, 2. Flow phase or catabolic phase, 3. Anabolic phase (if the tissue loss can be replaced by re-synthesis once the metabolic response to trauma is stopped).
- 26. The Ebb phase:(within 24-48 hours after injury). In this phase metabolic response to stress is mediated by Catabolic hormones such as glucagon, catecholamines, corticosteroids and by insulin resistance. Cytokines, oxygen radicals & other local mediators are also involved in this process. Reconstruction of body’s normal tissue perfusion and efforts to protect homeostasis. Decreased total body energy and urinary nitrogen excretion. Hemodynamic disturbances (hypotension) due to the decreased effective circulating volume.
- 27. The flow phase: Thisphase provides compensating response to the initial trauma and volume replacement. The metabolic response is directly related to the supply of energy and protein substrates in order to protect tissue repair and critical organ functions. The increased body oxygen consumption and metabolic rate are among these responses.
- 28. If properresuscitation is done anabolism will be the outcome in the late period of flow phase. However, if inadequate management was done, catabolism will continue and the catabolic effects usually develop in peripheral tissues such as muscles, fat and skin.
- 29. The Anabolic phase Thetransition from the catabolic state to the anabolic state depends on injury severity. This transition occurs approximately 3-8 days after uncomplicated trauma. However, it takes weeks after severe trauma and sepsis. This is known as the corticoid withdrawal phase and is characterized by reduction of net nitrogen excretion and appropriate potassium-nitrogen balance .
- 30.
- 31. Apply the physiologicinjury severity scoring in the pre-hospital setting as a triage tool. Revised Trauma Score (RTS) uses 3 specific physiologic p arameters, (1) The Glasgow Coma Scale (GCS), (2) Sytolic blood pressure (SBP), and (3) The respiratory rate (RR). Revised Trauma Score
- 32. Revised trauma score Glasgow.CS. Sys BP RR value 13-15 >89 10-29 4 9-12 76-89 >29 3 6-8 50-75 6-9 2 4-5 1-49 1-5 1 3 0 0 0 _________________________________________________________ 12 is labeled DELAYED (walking wounded) , 11 is UR GENT (intervention is required but the patient can wait a short time) , 10-3 is IMMEDIATE (immediate interventi on is necessary) , The last possible label is MORGUE .
- 33.
- 34. Assessment and managementfocus on: Preventing death Minimizing disabilities A widely adopted trauma management plan t o minimize morbidity and mortality is advanced trauma life support (ATLS).
- 35. Principles of ATLS •Organized team approach of initial assessment • Consider Priorities (Triage) • Treatment before diagnosis • Thorough examination • Frequent reassessment and Monitoring Emergency Department Phase A well-planned, organized approach to such patients provides optimal management. Trauma Management
- 36. Main Responsibilities Assessingthe patient Ordering needed procedures and diagnostic studies Managing fluid administration Monitoring the patient's progress. ControlLing the area Making therapeutic and the transportation decisions Subspecialty consultations and coordinates their activities Organized Team Approach ED Phase Trauma Management
- 37. Team L ICU GS RN RT RN AN RN N. Supervisor Monitor ventilator CrushCart Intubation Cart with difficult AW Procedure Tray
- 38. The first 60minutes after the occurrence of multi- system trauma Victim's chances of survival are greatest if they receive definitive care in the OR within the first hour after a severe injury. The core principle is rapid intervention The Golden Hour
- 39. What should wedo? Rapid assessment Resuscitation and stabilization Definitive management/Transfer The Golden Hour ATLS
- 41. High-Priority Areas Airway/breathing Shock/external hemorrhage Impendingcerebral herniation Cervical spine Cardiac Neurologic Low-Priority Areas Abdominal Musculoskeletal Soft tissue injury ED Phase Trauma Management Priorities in Management & Resuscitation
- 42. The overall goalof resuscitation procedures is to improve oxygenation and tissues perfusi on through: - Vascular Access - Choice of Resuscitation Fluid (Start with Crystalloids) -Transfusion of fully cross matched blood Trauma Management ED Phase
- 43. Primary Survey Adjuncts Secondary Survey DefinitiveCare/Transfer ATLS
- 44. Primary Survey AAirway B Breathing C Circulation D (Neurologic) Disability E Exposure / Environment ATLS
- 45. Rapid Sequence Intubation(RSI) Pre-oxygenation Cricoid pressure Sedation Oro-tracheal intubation Naso-tracheal intubation LMA / intubating LMA A - Airway (with C-spine protection)
- 46. B: Breathing Examinefor: -Chest excursion & breath sounds Flail chest - Pneumothorax Open Tension - Massive Hemothorax
- 47. C:Circulation • Assess perfusion(Mental status, skin, pulse) • Control bleeding with pressure. • Establish 2 large bore (16G or larger) IV’s in upper extremity peripheral veins • Resuscitate with Lactated Ringers – After 4 Liters think about resuscitation with blood
- 48. D:Disability • Assess Neurologicstatus –Glasgow Coma Scale • Eye • Motor-best predictor of long term outcome • Verbal –Anticipate Spinal Cord Injury
- 49. E:Exposure • Remove clothes •Temperature maintenance –warm blankets • Maintain full spine precautions
- 50. Expected Fractures • StabilizeFractures • Relocate dislocated joints • Reassess pulses
- 51.
- 52. Secondary Survey • Obtaina full patient’s history • Thorough “head to toe” assessment • CT’s, plain radiographs • Urinary bladder drainage • NGT insertion • Blood sampling/monitoring • Treatment plans based on clinical status and specific injuries • Definitive Care/Transfer
- 53. [French, from trier,to sort] A method of quickly identifying victims who have immediately life-threatening injuries and who have the best chance of surviving. Triage
- 54. Triage: - Putting thepatient in the right place at the right time to receive the right level of care , - Allocations of appropriate resources to meet the patient’s medical needs.
- 55. Tagging Rapid Identification of patient Color Coded / Bar Coded system Plastic “bands” can substitute tags
- 56. Noji et al,NEJM
- 57. Simple Triage AndRapid Treatment Triage: A rapid approach to prioritizing a large number of patients Incident Site Triage Unit Leader Casualty Collection Point
- 58. Created inthe 1980’s by Hoag Hospital and the Newport Beach Fire Department. Allows rapid assessment of victims. It should not take more than 15 sec/ victim Once victim is in treatment area more detailed assessment should be made. Clasification is based on evaluating three items: Respiratory, Perfusion, and Mental status START SYSTEM
- 61. Airway and breathingdifficulty. (A/B) Cardiac arrest ( witnessed). Uncontrolled / sever bleeding. (C) Cervical spine injury (stabilized). Decreased level of consciousness. Sever medical problems: e.g. Acute MI. Shock. Joint fracture with no distal pulse. Fracture femur. Sever burn. First priority Red
- 62. Second priority Yellow Patientwhose treatment and transportation can be temporarily del ayed e.g: Burns without airway problems. Major or multiple bone or joint injury. Back injury with or without spinal cord damage.
- 63. Third priority Green( lowest priority) Patient’s whose treatment & transportation c an be delayed until last. Minor fractures Simple sprains. Minor soft tissue injury.
- 64. Fourth priority Black Patientswho are dead or have little chan ce for survival. Obvious death. Sever trunk, open brain trauma. Cardiac arrest ( over 20 min.).
- 65. Level 1: Resuscitative Level2: Emergent Level 3: Urgent Level 4: Less urgent Level 5: Non-urgent Triage levels
- 66. Conditions thatare threats to LIFE or LIMB (or imminent risk of deterioration) requiring aggressive interventions. Time to MD: Immediate Time to Nurse: Immediate Continuous reassessment Level I: Resuscitative
- 67. Usual presentations Cardio / Respiratory Arrest. Major trauma. - Severe burns--airway compromise . Severe respiratory distress. - Near death asthma (Status asthmatics). - Tension Pneumothorax. Altered mental state. Seizure (Status epileptics). Traumatic shock. Overdose. Congestive heart failure with low BP. Major head injury-unconscious. Reassessment 15 mins Level: I
- 68. Conditions that area potential threat of life, requiring rapid medical intervention or delegated acts. Time to MD: 15 minutes. Time to Nurse: 15minutes Reassessment time: 15 minutes. Level II: Emergent
- 69. Usual presentation • ChestPain , MI • Trauma • Chemical Exposure • Stroke • Altered Consciousness • Acute MI • Severe Asthma-stridor • Acute Psychotic Episode with Agitation Reassessment 15 mins Level II: Emergent
- 70. Conditions thatcould potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living. Time to MD: 30 minutes. Time to Nurse: 30 minutes. Reassessment time: 30 minutes Level III: Urgent
- 71. Usual presentations: Renal colic, billary colic GI bleed with normal VS Previous seizure—alert Dehydration.. Vital signs outside normal range. Moderate risk of harm to self or others. infant not feeding. Behavior change. Reassessment 30 minutes Level III: Urgent
- 72. Conditions thatrelated to patient age, distress, or potential for deterioration or complications would benefit from intervention or reassurance within (1 –2 hours) Time to MD < 60 minutes (1 hr) Time to Nurse < 60 minutes (1 hr) Reassessment time: 60 minutes (1 hr) Level IV: Less Urgent
- 73. Usual presentation: •Head injury—alert . • Abdominal pain. • UTI sign and symptoms. • Simple laceration requiring sutures. • Normal VS • Reassessment : 1 hour Level IV: Less Urgent
- 74. Conditions thatmay be acute but non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration. The investigation or interventions could be delayed or even referred to other area of the hospital or health care system. Time to MD: 120 minutes. Time to Nurse: 120 minutes. Reassessment time: 120 minutes Level 5: Non Urgent
- 75. Usual presentation:. Sprains Single episode of vomiting. Sore throat. Chronic problems with no change. Investigation or intervention for these illnesses or injuries could be delayed Reassessment 2 hours /120 minutes Level 5: Non Urgent
- 76. Resuscitation • Restoring organperfusion • What are the endpoints of resuscitation? – Heart rate, blood pressure, urine output • Trauma may lead to “compensated shock” – Global indicators of perfusion • Lactic acid, base deficit • Cardiac output, oxygen delivery, oxygen consumption • Mixed venous O2 saturation (SvO2)
- 77.