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What is a major trauma?
- Energy is applied to body tissues in excess of what the tissues are able to absorb
- Kinetic energy is the most common cause of trauma and includes mechanisms such as MVCs, falls, gunshot wounds
- Thermal, electrical, chemical and radiation energy causes burns
- Lack of O2occurs in events such as drownings and hangings
- Major trauma pts are at risk for all types of shock - hypovolemic is most common
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Assessment
- Primary
- Focuses on managing immediate threats
- "What could kill the pt now"
- Goal: Evaluate and treat life threatening injuries
- Secondary
- Complete head-to-toe assessment to identify other serious injuries
- Goal: Identify all the injuries the pt has incurred
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Primary Assessment
- A: Airway (includes protection of spine)
- B: Breathing
- C: Circulation
- D: Disability (neurological status)
- E: Environment/Exposure
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Airway and C-spine assessment
- Is the airway open
- Can pt maintain airway
- Is there potential for airway obstruction or compromise - tongue, blood, vomit, secretions, foreign objects, fx, loss of teeth...
- Inspect face/neck for signs of trauma
- Palpate neck for crepitus
- Watch for dyspnea, low breath sounds, stridor, dysphagia, drooling
- Open and secure airway
- Suction gently PRN - prevent aspirationsLogroll as needed, keeping spine manually stabilized
- Position pt to allow for max air mvmnt
- Intubate as needed
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Breathing assessment
- Respiratory rate, depth
- Chest expansion (symmetry)
- Accessory muscle use
- Auscultate breath sounds bi-laterally
- Palpate for crepitus or sub-q air in chest
- Inspect for tracheal deviation or jugular vein distention
- Assess for pain with breathing or palpation
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Breathing compromise
- Injuries that can impair ventilation:
- Rib fx (flail chest)
- Pneumothorax
- Hemothorax
- Spinal cord injury
- Head trauma
- Ruptured diaphragm
- Aspiration
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Circulation assessment
- Check for obvious bleeding
- Observe skin color
- Palpate pulses (rate, rhythm, strength)
- Check capillary refill
- Palpate skin for temperature
- Auscultate heart sounds and BP
- Risk of shock is high with trauma-observe BP
- Cardiac arrest, myocardial dysfunction, and hemmorhage can all lead to shock
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Rapid assessment of BP
- Presence of radial pulse: BP at least 80 systolic
- Presence of femoral pulse: BP at least 70 systolic
- Presence of carotid pulse: BP at least 60 systolic
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Circulation interventions
- Initiate CPR as needed
- Control bleeding/hemmorhage
- Position for shock (supine with feet up)
- Establish large bore IV access
- Isotonic fluids - LR or NS and blood
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Controlling bleeding
- Firm, direct pressure on the bleeding site with thick, dry dressing material
- Tourniquets not to be used unless bleeding so severe that the risk to limb viability is justified to save a life
- Internal hemmorhage must be suspected in injured pts or those who present with shock
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Disability assessment
- Observe pt responsiveness
- Determine Glascow Coma Scale score
- Assess PERRLA
- Assess gross sensorymotor function - can pt move limbs
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Exposure
- Expose pt to observe for signs of trauma
- Remove all clothing to allow for thorough assessment
- Always cut away clothing with scissors :
- During resusitation when rapid access to pts body is critical
- When manipulating pts limb to remove clothing could cause further injury
- When thermal or chemical burns have caused fabrics to melt to pt
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Evidence collection
- Vital in cases involving:
- Rape
- Elder abuse
- Domestic violence
- Homicide
- Suicide
- Drug overdose
- Assult
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Hypothermia
- Once clothing is removed, hypothermia poses risk to pts (esp those with burns)
- Complicates management of pt:
- Vasoconstriction
- Coagulopathy
- Difficulty with venous/arterial access or assessment
- Increased bleeding
- Slowed drug metabolism
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Interventions to prevent hypothermia
- Remove wet sheets or clothing
- Cover the pts with blankets
- Set room temp to 75-80
- Infuse only warm solutions/blood products
- Heat lamps and warming blankets
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Secondary assessment
- More comprehensive head-to-toe assessment to identify other injuries or conditions
- Inspect for contusions, abrasions, lacerations, deformities, discoloration, edema, foreign bodies, other abnormalities
- Assess all areas to locate areas or pain or tenderness,crepitus, deformity, loss of function
- Reassess VS, GCS, heart/breath sounds PRN
- Obtain hx if possible- AMPLE
- Allergies
- Medication
- Past surgeries/Pertinent medical conditions
- Last meal
- Events leading up to incident
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Secondary interventions
- Splint any limbs
- Dress wounds
- Administer pain meds as ordered
- Tetanus shot- last date unknown or more than 5 years
- Prepare for invasive monitoring and definitive treatment
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Labwork/Diagnostics
- Blood typing and screening or cross-matching
- Blood studies: CBC, Hgb, WBC
- Coagulation studies: Platelets, PTT, PT, INR
- ABGs and electrolytes
- HcG for pregnancy
- BAC/toxicology
- Chest/pelvis radiograph
- CT-head, neck, chest, abd, pelvis
- Ultrasound
- FAST- Focused Assessment with Sonography for Trauma
- Used to assess for fluid around heart, liver, spleen, bladder
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Rules in trauma management
- Every trauma considered C-spine injury until proven otherwise
- Use nasopharyngeal intubation if C-spine injury
- Do not give IM narcotics
- Do not give vasopressors in hemmorhagic shock
- Do not place NG in pts with neck injuries, facial fx, leakage of CSF
- No foley if blood at meatus
- No trendelenberg
- Use tourniquets only as a last resort
- Never use MAST suit without volume replacement first
- Do not clamp chest tubes
- Head injuries do not usually cause shock
- Monitor clients with mechanical ventilation
- No IV in lower extremity if abd injury is suspected
- Do not apply external heat if blood volume deficits exist
- Do not remove impaled objects
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