Trauma Assessment

1. Trauma Assessment February 2014 Continuing Education Silver Cross Hospital EMS System Erika Ball, RN, BSN

2. Objectives • Review of mechanisms of injury. • Understanding extremity trauma and amputation; prehospital treatment and protocol review. • Care of the patient with chest and abdominal trauma. Review of structures and potential complications associated with injury. • Review of SMO Code 72 for Decompression of Tension Pneumothorax

3. Phases of Trauma • Pre-event • Injury prevention • Not usually accidental • Event • Interact with people, demonstrate professional attributes • Act as mentor, demonstrate good safety practices Aehlert, 2011

4. Phases of Trauma • Post-event • Optimal patient care • Appropriate clinical decisions • Treat patient • Continues until patient delivery to ED, complete report Aehlert, 2011

5. Trauma Systems • Parts • Injury prevention • Prehospital care • Emergency department care • Interfacility transport (if needed) • Definitive care • Trauma critical care • Rehabilitation • Data collection, trauma registry Aehlert, 2011

6. Trauma Systems • Trauma center • Categories • Level I • Regional resource center • Specialized services (Burn ICU) • Level II • Comprehensive trauma care • Not all resources in level I are immediately available • Research not essential component Aehlert, 2011

7. Trauma Systems • Trauma center • Categories • Critical access • Communities without level I or II • Provide evaluation, resuscitation, operative intervention for stabilization • Non-designated • Rural, remote areas • Provides initial stabilization, transfer to level I Aehlert, 2011

8. Trauma Systems • Transport considerations • Time • Single most important factor • Golden period • Do not sacrifice care for speed • Platinum 10 minutes • Most appropriate facility may not be closest Aehlert, 2011

9. Trauma Systems • Transport considerations • Ground transportation • Use if “reasonable” time • Generally within 30 minutes • Protocols may alter time frame Aehlert, 2011

10. Trauma Systems • Transport considerations • Aeromedical transportation • When time critical to patient condition • Scene times extended from extrication • Road, traffic conditions seriously delay access to definitive care • Critical care personnel above ground ambulance training needed Aehlert, 2011

11. Trauma Assessment Process • Scene Size-Up • Primary Survey • Decision for transport, A B C interventions • Reassessment and continued exam ITLS, 2008, 6th ed.

12. Scene Size-Up • PPE • Scene safety • Triage/ number of patients (need for START Triage?) • Help and equipment needs assessment • Determine Mechanism of Injury

13. Mechanism of injury:Common Trauma Injuries • Blunt • MVC • Pedestrian motion injuries • Bicycle • Falls • Penetrating • Firearms, shrapnel, posts • Burns • Remember: these are considered trauma! • Drowning What are the predictive injury patterns associated with these incidents?

14. What are the mechanisms? Look at the impact locations: Front-end Side “quarter panel” = potential for rotational injuries Rear-end Rollover Crush (under a semi) BLUNT TRAUMA • Motor Vehicle Collision • MVC

15. Blunt Trauma: MVC • Machine collision • Body collision • Organ collision ITLS, 2008 (6th ed.)

16. Blunt Trauma: MVC • Vehicle collisions • Frontal (head-on) impact • Down-and-under pathway • Occupant continues forward • Moves downward in seat • Knee – primary impact point • Tibia – Dislocated knee, torn ligaments, knee joint dislocation • Popliteal artery lies behind knee, possible blood clot • Femur impact – Fracture, hip dislocation, pelvic fracture, acetabular fracture, blood clots, vascular injury • Injuries may be subtle

17. Blunt Trauma: MVC • Side Impact: • Head injuries • Cervical spine injury • Pneumothorax/ hemothorax/ tension pneumo • Splenic or liver injury • Pelvic injuries • Extremity injury • Aortic Laceration • Rotational Injury • C-spine injury • Vascular tears

18. Blunt Trauma: MVC This horizontally oriented skull fracture was a result of a side impact when the side of the driver's head impacted a tree as the vehicle slid to a stop against the tree.

19. MVC: What mechanisms of force would injure the spleen?Side, Steering wheel, restrained passenger,unrestrained hitting seat or dashboard Spleen injuryPatient has B/P of 70/palp with no rigid abdomen or distension…

20. Note the AMOUNT of blood that lurks within a spleen injury…(you may need to click play)

21. Blunt Pelvic Injury

22. What else is BLUNT trauma? • Baseball bats, sports injuries • Fall from height • Ejection from moving vehicles (motorcycle, ATV, horses, bicycles, snowmobiles)

23. Blunt Trauma: Pedestrian • Causes fractures of long bones [arms and legs], and causes fractures of spine, pelvis, and vertebrae • Often causes internal injuries that may be severe • Commonly causes head injuries in adults and children • Pneumothorax common in this injury • Two mechanisms of injury: • Vehicle hitting body • Secondary injuries from impact with ground

24. Pedestrian

25. Pedestrian Trauma • Look for the impact locations on the vehicle. • The height of the person can also immensely affect the patient’s injury patterns (for example, children are lower at bumper level). • Be aware if the vehicle stopped, or did it continue in it’s path causing tertiary crush injuries?

26. Bicycle Injuries • Similar to pedestrian versus auto, have several potential impact sites and multiple system injuries • Did they have a helmet on? • Speeds of bicycle? • Were they struck by a vehicle? • Surface of landing? • Did they hit anything during fall? (trees, signposts, other bicyclists)

27. Blunt Trauma: Falls • Vertical deceleration • You must determine the following: • Distance the person fell • What part of the body they landed on (head, feet first, back) • Did they strike anything on the way down? • What surface did they land on? • All of these are determinants for their injury patterns ITLS, 2008, 6th ed.

28. Trauma: Penetrating Injuries • High or low velocity • Firearms are high velocity • Determine all wounds involved • NEVER document ballistics as “entry” or “exit” ALWAYS document as “Wound #1” “Wound #2” etc. • You could inadvertently place the location of a murder suspect and cause them to be released…

29. Penetrating Injury: GSW • There are shock waves with a bullet, damages surrounding tissue • Causes more damage to solid organs: kidney, liver, spleen. • Not always a straight line in the body- may hit bone and change direction • Head, thorax, or abdomen should be transported IMMEDIATELY. Focus on ABC’s, trauma assessment, then transport. ITLS, 2008, 6th ed.

30. Where are thepotential injuries? Intestines/ bowel Vena cava and Aorta Mesenteric Artery (the artery that supplies blood to intestines) Solid organs: kidneys, liver, pancreas, spleen Base of lung Pelvis and spine

31. Penetrating Trauma:Impalement • Basic reminders: • Leave object in place with exception to occlusion of the airway • Stabilize object for transport • The severity of the situation is relative to size, force, and location of object.

32. Note the tourniquet…

33. Transport decisions… Is the airway clear?

34. Trauma : A Short Burn Care Review • Remember: burns are a trauma! • Transport to a trauma center • Be aggressive with airway control • Assessment for soot on face, nose, and hands.

35. Burns • Basic review of burn care: • Determine severity • Begin trauma assessment • AIRWAY! AIRWAY! AIRWAY! • Breathing • Circulation • Remove burning source • Cool burn with clean water, (dry if >20% BSA) no longer than two minutes to avoid hypothermia • Patient is at risk for hypothermia, use precautions ITLS, 2008, 6th ed.

36. Trauma:A Short Drowning Review • 150 ml is all it takes to cause profound hypoxia (ITLS, 2008) • Rapid evaluation and management of ABC’s • C-spine considerations • Rapid initiation of CPR • Cold water does not indicate death, remember “warm and dead”

37. Trauma Assessment Review

38. So here we go… head-to-toe

39. Airway/C-spine • While repositioning airway/doing airway assessment, maintain c-cpine. • Delegate someone to do this or hold c-spine so the primary assessor can do the head-to-toe Trauma Nurse Core Curriculum (TNCC), 2011

40. ASSESS AVPU • Alert • Verbal • Pain • Unresponsive

41. Airway: Patent or non-Patent? • Readjust the airway • Do they need suction: teeth, blood, vomit? • Are they maintaining an airway or do you need to get an adjunct or intubate? • Make these decisions then move to… Trauma Nurse Core Curriculum (TNCC), 2011

42. Breathing • Are they breathing? • No? Begin assisted ventilations • Yes? Assess the rate and quality. • Is the rate under 12? ASSIST VENTILATIONS • Is the rate over 30? Suspect shock and make load-and-go decision. • Quality. Are they shallow or abnormal? • Yes? ASSIST VENTILATIONS All of these are within normal limits, place on NRB and move to… Trauma Nurse Core Curriculum (TNCC), 2011

43. CIRCULATION • Do they have a pulse? • No? Begin CPR • Yes? Note rate, skin color, and any hemorrhaging. • Hemorrhaging or bleeding profusely? • Yes? Control bleeding • No? Assess skin and need for fluid bolus • Keep in mind the need to start 2 large-bore IV or IO while enroute to Trauma center • If circulation is addressed, move to… Trauma Nurse Core Curriculum (TNCC), 2011

44. Trauma Assessment • Head injury? • Contusions, lacerations? • Does the patient have facial injury? • If yes, do NOT use nasopharyngeal airway. • Signs of facial fractures, CSF from the nose or ears, blood from the ears Trauma Nurse Core Curriculum (TNCC), 2011

45. Trauma Assessment • Neck wounds? • Stepoff on the posterior cervical spine? Trachea assessment… midline? • Place patient in Cervical collar Trauma Nurse Core Curriculum (TNCC), 2011

46. Trauma Assessment • Chest injury? • Wounds, gunshots, penetrations, bruising (seatbelt?) • Flail chest • Sucking chest wound? • Treatment? • 3 sided occlusive dressing • Muffled heart tones? Tamponade? • Tension pneumothorax? Decompression Trauma Nurse Core Curriculum (TNCC), 2011

47. Sucking chest wound(you may need to click play)

48. Assessment Finding:Beck’s Triad • In cardiac tamponade a narrow pulse pressure is regularly observed. • The cardiologist, Claude Beck, who was a Professor of Cardiovascular Surgery first identified the triad of medical signs which was later termed “Beck’s Triad.” • Beck’s Triad (in basic terms): • 1. Distended Neck Veins; • 2. Muffled Heart Sounds; • 3. Hypotension. http://www.emergencymedicalparamedic.com/what-is-becks-triad/

49. Assessment Finding:Tension Pneumothorax • Created from blunt or penetrating trauma. • “Collapsed” lung that causes an increase in pressure in the chest (intrathoracic pressure) • This pressure pushes on the vena cava, restricting the blood return to the heart. • Also creates pressure on intact lung, making the situation worse ITLS, 2008, 6th ed.

50. Assessment Finding:Tension Pneumothorax • Symptoms of tension pneumothorax: • Dyspnea (difficulty breathing) • Absent lung sounds on affected side • Anxiety (because of decreased O2) • Tachypnea • JVD (distended neck veins) • Respiratory distress and cyanosis • Loss of radial pulse • Tracheal deviation (often a late sign of this condition) ITLS, 2008, 6th ed.