Trauma Resuscitation - part 2 pdf

As with the primary survey, a well-coordinated team effort is required. Procedures by individual team members are followed according to a precise protocol and tasks are performed simultaneously rather than sequentially. The common error of being distracted before the whole body has been inspected must be avoided as potentially serious injuries can be missed, especially in the unconscious patient. During the secondary survey the airway nurse maintains verbal contact with the patient while the recording nurse continues to measure the vital signs regularly and monitors fluid balance. Unless already obtained in the primary survey, all blunt trauma victims should now have a chest, pelvis and lateral cervical spine x-ray performed. Providing all seven cervical vertebrae as well as the C7–T1 junction can be seen on the x-ray, up to 85% of cervical spine abnormalities will be shown. The easiest way of ensuring an adequate film is obtained on the first attempt is for one of the team members to pull the patient’s arms towards their feet as the radiograph is taken (Figure 1.4) to remove the shoulders from the x- ray field. Alternative views (e.g. oblique and ‘Swimmer’s’ view) or investigations (e.g. computerized tomography (CT)) can be used if this fails to give an adequate view. Further cervical spine views will be required before all injuries to the cervical spine can be excluded. Neurological state This comprises of an assessment of the conscious level using the Glasgow Coma Scale (GCS), the pupillary response and the presence of any lateralizing signs (see Section 6.5.3). One of the circulation nurses should then continue to monitor these parameters. If there is any deterioration, hypoxia or hypovolaemia must be ruled out before an intracranial injury is considered. Examination of the peripheral nervous system should be performed. Abnormalities of motor and sensory function can help indicate the level and extent of spinal injury. In male patients the presence of priapism may be the first indication of spinal injury. If the spinal cord has been transected at or above the mid-thoracic level, there is loss of sympathetic outflow, a reduction in vasomotor tone and peripheral vasodilatation causing hypotension. The degree of vasodilatation depends on how much vasomotor tone is lost. Transection of the spinal cord in the cervical region removes all vasomotor tone and causes profound hypotension. This will not be associated with a Figure 1.4 Pulling the arms down for a cervical radiograph RESUSCITATION AND STABILIZATION OF THE SEVERELY INJURED PATIENT 13 tachycardia because the sympathetic innervation of the heart (T1–T4) has also been lost, a condition referred to as ‘neurogenic shock’ (see Section 7.3.2). Scalp This must be examined for lacerations, swellings or depressions. Its entire surface needs to be inspected but the occiput will have to wait until the patient is turned or the cervical spine ‘cleared’ both clinically and radiologically. Visual inspection may discover fractures in the base of the lacerations. Wounds should not be blindly probed as further damage to underlying structures can result. If there is major bleeding from the scalp, digital pressure or a self-retaining retractor should be used. Although not common, scalp lacerations can bleed sufficiently to cause hypovolaemia; consequently haemostasis is crucial. Base of skull Fractures to this structure will produce signs along a diagonal line demonstrated in Figure 1.5. Bruising over the mastoid process (Battle’s sign) usually takes 12–36 h to appear, it is therefore of limited use in the resuscitation room. A cerebrospinal fluid (CSF) leak via the ears or nose may be missed as it is invariably mixed with blood. Fortunately its presence in this bloody discharge can be detected by noting the delay in clotting of the blood and the double ring pattern when it is dropped onto an absorbent sheet. In this situation nothing, including an auroscope, should be inserted into the external auditory canal because of the risk of introducing infection and hence causing meningitis. As there is a small chance of a nasogastric tube passing into the cranium through an anterior base of skull fracture, these tubes should be passed orally when this type of injury is suspected. Eyes The eyes should be inspected before significant orbital swelling makes examination too difficult. Look for haemorrhages, both inside and outside the globe, for foreign bodies under the lids (including contact lenses) and penetrating injuries. Pupil size and response to light, directly and consensually, should be recorded. If Figure 1.5 Diagonal line demonstrating the level of the base of the skull 14 TRAUMA RESUSCITATION the patient is conscious, having them read a name badge or fluid label can be used as a simple test of visual acuity. If the patient is unconscious the corneal reflexes should be tested. Face This should be palpated symmetrically for deformities and tenderness. Check for loose, lost or damaged teeth and stability of the maxilla (the mid third of the face), by pulling the latter forward (see Section 8.3). Middle third fractures can be associated with both airway obstruction and base of skull fractures. Only injuries causing airway obstruction need to be treated immediately. Mandibular fractures can also cause airway obstruction because of the loss of stability of the tongue. Neck The immobilization devices must be removed for the team leader to examine the neck, therefore the airway nurse will need to reapply manual inline stabilization. The neck should be inspected for any deformity (rare), bruising and lacerations. The spinous processes of the cervical vertebrae can then be palpated for tenderness or a ‘step off’ deformity. The posterior cervical muscles should also be palpated for tenderness or spasm. The conscious patient can assist by indicating if there is pain or tenderness in the neck and locating the site. A laceration should only be inspected and never probed with metal instruments or fingers. If a laceration penetrates platysma, definitive radiological or surgical management will be needed. The choice depends on the clinical state of the patient (see Section 8.3.1). Thorax The priority at this stage is to identify those thoracic conditions which are potentially life threatening, along with any other chest injuries (see Section 3.4). The chest wall must be re-inspected for bruising, signs of obstruction, asymmetry of movement and wounds. Acceleration and deceleration forces invariably leave marks on the chest wall, which should lead the team to consider particular types of injury. Good pre- hospital information is vital to determine the mechanism of injury. The assessor should then palpate the sternum and along each rib, starting in the axillae and proceeding caudally and anteriorly. The presence of any crepitus, tenderness or subcutaneous emphysema must be noted. Auscultation and percussion of the whole chest can then be carried out to determine if there is any asymmetry between the right and left sides of the chest. Potentially life-threatening injuries that need to be excluded include: pulmonary and cardiac contusions—particularly after blunt trauma; a ruptured diaphragm or perforated oesophagus—can follow both blunt and penetrating trauma; tear of the thoracic aorta—after a rapid deceleration; a simple pneumothorax or haemothorax. Penetrating chest wounds can injure any of the structures within the thorax. Wounds that appear to cross the mediastinum pose a high risk of damaging the heart, bronchial tree or upper gastrointestinal tract. A high index of suspicion must be maintained and immediate surgical consultation is mandatory. RESUSCITATION AND STABILIZATION OF THE SEVERELY INJURED PATIENT 15 Abdomen In the secondary survey, the aim is simply to determine if the patient requires a laparotomy—a precise diagnosis of which particular viscus has been injured is both time consuming and of little relevance. A thorough examination of the whole abdomen is required, including both the perineum and stability of the pelvis. All bruising, abnormal movement and wounds must be noted and lacerations should be inspected but not probed blindly as further damage can result. Any exposed bowel should be covered with warm saline- soaked swabs. If underlying muscle has been penetrated, it is not possible to determine the actual depth of the wound; consequently these cases will require further investigations (see Section 5.4.4). The abdomen needs to be palpated in a systematic manner so that areas of tenderness can be detected. An intra-abdominal bleed should be suspected if the ribs overlying the liver and spleen (5–11) are fractured, the patient is haemodynamically unstable or if there are seat belt marks, tyre marks or bruises over the abdominal surface. Further investigation of possible abdominal injury can be achieved with ultrasound, CT scanning or DPL, according to local protocols. This should not delay the treatment of the haemodynamically unstable patient who should proceed directly to theatre. Early liaison with the general surgeons is vital. The detection of abdominal tenderness is unreliable if there is a sensory defect due to neurological damage or drugs, or if there are fractures of the lower ribs or pelvis Marked gastric distension is frequently found in crying children, adults with head or abdominal injuries and patients who have been ventilated with a bag and mask technique. The insertion of a gastric tube facilitates the abdominal examination of these patients and reduces the risks of aspiration. A rectal examination should always be carried out. This provides five pieces of information: sphincter tone—this can be lost after spinal injuries; direct anal or rectal trauma; pelvic fractures; prostatic position—this can be disrupted after posterior urethral injury; blood in the lower alimentary canal. The rate of urine output is an important indicator in assessing the shocked patient (see Section 4.6). Therefore it should be measured in all trauma patients and in most cases this will require catheterization. If there is no evidence of urethral injury, the catheter is passed transurethrally. If urethral trauma is suspected (Box 1.6), and the patient is unable to urinate, a suprapubic catheter may be necessary. The urine that is voided initially should be tested for blood and a sample saved for microscopy and subsequent possible drug analysis. BOX 1.6 SIGNS OF URETHRAL INJURY IN A MALE PATIENT Bruising around the scrotum Blood at the end of the urethral meatus High riding prostate 16 TRAUMA RESUSCITATION Fractured pubic rami Inability to pass urine Extremities The limbs are examined by inspection, palpation and movement. All the long bones must also be rotated and, if the patient is conscious, he should be asked actively to move each limb. Any wounds associated with open fractures must be swabbed and covered with a nonadherent dressing. As different surgeons will need to examine the limb, a digital photograph of the wound before it is covered will reduce the number of times the dressings have to be removed. All limb fractures should be splinted to reduce fracture movement, pain, bleeding, formation of fat emboli and secondary soft tissue swelling and damage. A detailed inspection of the whole of the patient is needed to determine the number and extent of any soft tissue injuries. Each breach in the skin needs to be inspected to determine its site, depth and the presence of any underlying structural damage that will subsequently require surgical repair. Superficial wounds can be cleaned, thoroughly irrigated and dressed in patients who are clinically stable. Upon completion of the examination, the presence of any bruising, wounds and deformities must be noted along with any crepitus, instability, neurovascular abnormalities or soft tissue damage. As time delays can result in tissue loss, gross limb deformities need to be corrected and the pulses and sensation rechecked before any radiographs are taken (see Section 9.3). Back If a spinal injury is suspected the patient should only be moved by a well-coordinated log rolling technique (Figure 1.6). The patient is turned away from the examiner who takes this opportunity to clear away all the debris from under the patient. The whole of the back is assessed, from occiput to heels, looking for bruising and open wounds. The back of the chest must be auscultated, the area between the buttocks inspected and the vertebral column palpated for bogginess, malalignment and deformities in contour. The examination RESUSCITATION AND STABILIZATION OF THE SEVERELY INJURED PATIENT 17 finishes with palpation of the longitudinal spinal muscles for spasm and tenderness. The patient is then log rolled back into the supine position, after the long spine board has been removed. At the same time, the nursing team leader will need to make an initial assessment of the risk of pressure sores developing using a scoring system (Box 1.7). Meticulous attention to prevention must be made from the outset, particularly for patients with spinal injuries and the elderly because they have a high risk of developing decubitus BOX 1.7 PRESSURE SORE RISK ASSESSMENT Figure 1.6 Patient being ‘log rolled’ 18 TRAUMA RESUSCITATION ulcers. Remember the patient may have already spent a considerable time in one position before being rescued and, if he requires surgery, he may have to remain in the same position for several more hours. Lying on a hard spinal board can exacerbate these problems. It is therefore important to note how long the trauma victim remains in one position and to move whatever can be moved, every 30 min using hip lifts for example. The spinal board should be removed at the earliest opportunity. This needs to be taken into consideration when compiling the nursing plans. Medical history By the end of the secondary survey, the medical team leader must have assembled the patient’s medical history. Some information will have already been acquired from the ambulance personnel or relatives. Further sources of information are the patient’s general practitioner (GP) and hospital records. A comprehensive medical history may help clarify clinical findings that do not appear to relate to the history of the incident, which led to the victim’s condition. The important elements of the medical history can be remembered by the mnemonic AMPLE: A—Allergies M—Medicines RESUSCITATION AND STABILIZATION OF THE SEVERELY INJURED PATIENT 19 P—Past medical history L—Last meal E—Events leading to the incident 1.6.3 Assimilation of information As the condition of the patient can change quickly, repeated examinations and constant monitoring of the vital signs is essential. The recording nurse, responsible for recording the latter at 5-min intervals, must be vigilant and bring any deterioration in the respiratory rate, pulse, blood pressure, conscious level and urine output to the immediate attention of the team leaders. By the end of the secondary survey, the answers to the following questions must be known: Is the patient’s respiratory function satisfactory? If it is not adequate then the cause must be sought and corrected as a priority. Is the patient’s circulatory status satisfactory? With less than 20% of the blood volume lost, vital signs usually return to normal after less than 2 l of fluid. If they then remain stable then it implies that the patient is not actively bleeding. Patients whose vital signs initially improve but then decline are either actively bleeding or recommenced bleeding during the resuscitation. They have usually lost over 30% of their blood volume and require an infusion with typed blood and invariably require surgery. The total lack of response to a fluid challenge suggests two possibilities. Either the patient has lost over 40% of their blood volume and is bleeding faster than the rate of the fluid infusion or shock is not due to hypovolaemia. In the case of major haemorrhage, an operation is urgently required, the latter will need invasive techniques to monitor the central venous and pulmonary artery pressures to help guide resuscitation. Are any further radiological investigations required? Any hypoxic or haemodynamically problems must be addressed first. Once his condition stabilizes, radiographs can be performed of particular sites of injury or those areas suggested by the mechanism of injury, along with any other specialized investigations. It is an important part of the team leaders’ responsibilities to determine the priorities of these investigations. What is the extent and priorities of the injuries? The ABC system is used to categorizes injuries so that the most dangerous is treated first. For example, problems with the airway (A) must be corrected before those of the circulation (C). 20 TRAUMA RESUSCITATION Have any injuries being overlooked? The mechanism of injury and the injury pattern must be considered to avoid overlooking sites of damage. Trauma rarely ‘skips’ areas, for example if an injury has been found in the thorax and femur, but not in the abdomen, then it probably has been missed. Is tetanus toxoid, human antitetanus immunoglobulin (Humotet) or antibiotics required? This will depend on both local and national policies that should be known by the team leaders. Is analgesia required? Severely injured patients need analgesia. Entonox can be given until the baseline observations are recorded unless there are any contraindications (i.e. pneumothorax and head and abdominal injuries). Intravenous morphine can then be titrated against the patient’s pain level. 1.6.4 Definitive care This can only start once the patient has been adequately assessed and resuscitated. In many cases this will require transfer to either the operating theatre and/or intensive care. It is therefore very important that the transfer from the resuscitation room to these areas is done as smoothly as possible. While the move is being planned, the medical team leader must complete the medical notes. At the same time the charts, vital signs, fluid balance, drug administration and preliminary nursing care documentation need to be collated. A purpose designed single trauma sheet can facilitate this process (Figure 1.7). The relative’s nurse can then brief the team leaders about the condition of any relatives or friends who are in the department on the patient’s behalf. The medical team leader should accompany her back to the relative’s room, to talk to them. If this doctor has had to accompany the patient another clinician, fully versed with the situation, should speak with the relatives. If the patient is unconscious, his clothing and belongings may provide essential information to help establish his identity. Whether the patient’s name is known or not, some system of identification is required, in order that drugs and blood can be administered safely. This becomes more important when there are several patients in the resuscitation room. If identity bracelets are impractical, then indelible markers can be used to write a number on the patient’s skin. The rescue personnel must hand over any possessions brought in with the patient to the nursing staff. These must be kept safely, along with the patient’s clothing and property. At the end of the secondary survey, or during it if there are hands to spare, all these articles must be searched. A check is needed for any medical alert card or disc, a suicide note and any medicine bottles or tablets. No patient must be allowed to leave the department without identification Jewellery, and when appropriate dentures, need to be removed with permission if conscious and stored in a labelled valuables bag or envelope. As soft tissue can swell, constrictive jewellery must be removed and if this is not possible, it should be cut off. At an appropriate moment, the patient’s property is collected, preferably by nurses outside the trauma team, checked, recorded, signed for and locked away. Whatever the RESUSCITATION AND STABILIZATION OF THE SEVERELY INJURED PATIENT 21 outcome of the resuscitation, relatives take a dim view of items of property being misplaced. Nurses are legally responsible for this property and prolonged problems can result from disregarding the patient’s Figure 1.7 Trauma sheet 22 TRAUMA RESUSCITATION [...]... results in an FiO2=0.85 (85%) (Figure 2. 2) THE MANAGEMENT OF THE AIRWAY AND CERVICAL SPINE CONTROL 31 Figure 2. 5 Two person bag-valve-mask ventilation with reservoir bag and oxygen source 2. 5 .2 Artificial ventilation If the patient is apnoeic or breathing inadequately: Ventilate using a bag-valve-face mask, preferably a ‘two-man’ technique, at a rate of 10– 12 breaths per min (Figure 2. 5) Attach oxygen... Doctors American College of Surgeons, Chicago, IL 2. Driscoll P & Vincent C (19 92) Variation in trauma resuscitation and its effects on outcome Injury 23 :11 3.Driscoll P & Vincent C (19 92) Organizing an efficient trauma team Injury 23 :107 4.Sheehy S, Marvin J & Jimmerson C (eds) (19 92) Emergency Nursing, Principles and Practice, 3rd Edn CV Mosby, St Louis 2 The management of the airway and cervical spine... inspiration Increased respiratory rate ( >29 /min) Agitation Combative, sweating, tachycardia Impaired ventilation Reduced rate, depth Partial obstruction at larynx Airway obstruction Intrathoracic injuries Hypovolaemia Hypoxia Hypercarbia Pre-existing medical problem Hypercarbia Hypoxia Reduced conscious level Airway obstruction 28 TRAUMA RESUSCITATION Figure 2. 2 Nurse stabilizing the cervical spine All... with a facemask and thereby reduce the chance of aspiration (see Section 2. 6.6) 2. 6 Advanced airway control If it is inappropriate or impossible to maintain a patent airway and achieve adequate ventilation using basic techniques (Box 2. 2), one of the following advanced techniques should be used: tracheal intubation; 32 TRAUMA RESUSCITATION laryngeal mask airway (LMA) or Combitube; surgical airway The... adequately ventilated with a bag-valve-mask device, 42 TRAUMA RESUSCITATION then it is appropriate to administer an intravenous anaesthetic agent followed by a muscle relaxant, to provide optimal conditions for intubation (see below) In a patient where there is any predicted difficulty with intubation (see Box 2. 4), the airway is compromised or ventilation impaired (e.g severe facial trauma, laryngeal oedema),... BOX 2. 5 CHECKLIST BEFORE RSI Equipment: Monitors: Drugs: Patient: As for endotracheal intubation Bag-valve-facemask system+reservoir bag Oxygen delivery apparatus Ventilator BP, ECG, Pulse oximeter, end-tidal CO2 Etomidate or Propofol Suxamethonium, Atropine Atracurium or Rocuronium Midazolam On a tipping trolley Airway in place Oxygenated Vital signs being monitored IV access in place 46 TRAUMA RESUSCITATION. .. l/min, to increase the FiO2 to 0.5 Adding a reservoir bag increases the FiO2 to approximately 0.9 Watch for bilateral chest movement, auscultate bilaterally to ensure ventilation of both lungs Note: 1 The use of the reservoir ensures that the bag refills with a greater proportion of oxygen than room air With a tight-fitting mask this method allows an FiO2 of up to 0.9 2 The one-way valve prevents expired... depending upon age, weight, cardiovascular status and the concurrent administration of other drugs, particularly opioids A purpose designed syringe pump (‘Diprifusor’) is available Recovery is rapid on discontinuation of administration Midazolam Presentation: 5-ml ampoule, 2 mg/ml; 2- ml ampoule, 5 mg/ml Dose: 0.1–0 .2 mg/kg, this may be dramatically reduced in the critically ill and elderly The time to loss... of oxygen (i) Use a self-inflating bag with a reservoir and oxygen attached at 15 l/min Ventilate so that the chest is seen to rise and at a rate of 12 15 breaths/min (ii) Use a mechanical ventilator if trained in its function; (a) set a tidal volume of 7–10 ml/kg at a rate of 12 breaths/min; (b) set the pressure limit initially to 25 mmHg (3 kPa, 30 cmH2O); (c) set the FiO2 to 1.0 (100%, no air mix);... immediately life-threatening conditions Following this, a detailed head to toe assessment can be completed The team leaders can then list the patient’s injuries and their priorities for both further investigations and definitive treatment RESUSCITATION AND STABILIZATION OF THE SEVERELY INJURED PATIENT 25 Further reading 1.American College of Surgeons Committee on Trauma (1997) Advanced Trauma Life Support . FiO 2 =0.85 (85%) (Figure 2. 2). 30 TRAUMA RESUSCITATION 2. 5 .2 Artificial ventilation If the patient is apnoeic or breathing inadequately: Ventilate using a bag-valve-face mask, preferably a ‘two-man’. Vincent C. (19 92) Variation in trauma resuscitation and its effects on outcome. Injury 23 :11. 3.Driscoll P & Vincent C. (19 92) Organizing an efficient trauma team. Injury 23 :107. 4.Sheehy. manoeuvres is assessed using the ‘look, listen and feel’ method. Figure 2. 2 Nurse stabilizing the cervical spine 28 TRAUMA RESUSCITATION 2. 4.1 Simple airway devices In the unconscious patient, pulling