ER ICU Nursing Care Plans
The aim of this booklet is to help residents, medical students, and nurses involved in trauma care, in the management of the injured patient, especially during the first few critical hours. Most topics in trauma are discussed, with special emphasis on common pitfalls. The clinical protocols in use in the Division of Trauma and SICU are also included. I am indebted to Aida Aguilar for preparing the manuscript and overseeing the printing.
D. Demetriades, M.D., Ph.D., FACS
Los Angeles, CA, 2009
INITIAL ASSESSMENT AND RESUSCITATION
OF THE INJURED PATIENT
In severe trauma, assessment and resuscitation should be performed simultaneously. The purpose of the initial evaluation and management is to diagnose and address life-threatening problems, which can cause death or serious morbidity if not treated early. This is called Primary Survey.
The primary survey includes 5 components, which should always be followed in strict order.
A. Airway Maintenance with Cervical Spine Protection
B. Breathing and Ventilation
C. Circulation and Hemorrhage Control
D. Disability/Neurological Status
E. Exposure/Environmental Control
After the 5 main components of the Primary Survey, continue with F,G,H:
F. Foley Catheter
G. Gastric Tube
H. Hertz – Trauma Ultrasound
1. Clear the oropharynx of blood, mucus and foreign bodies.
2. Lift the angle of the jaw or the chin to prevent the tongue from falling back and obstructing the airway. (Don’t overextend the neck; the patient might have a spinal injury!).
Use of oropharyngeal tubes in patients with gag reflexes may induce vomiting and aspiration. Remember that oropharyngeal tubes have limited use! Perhaps their only use is in patients with orotracheal tubes, to prevent the patient from biting the endotracheal tube.
Choose the correct length oropharyngeal tube. The distance between the angle of the mouth and the earlobe is an easy way to choose the right size tube.
**If the above measures are not sufficient or if the patient is unconscious (GCS=<8), endotracheal intubation is the next step. (Size 8 for adult males, size 7 for females, or the size of the patient’s small finger irrespective of age).
Apply cricoid pressure during intubation to prevent aspiration. Keep applying the pressure until the cuff of the tube has been inflated. Make sure that the tube is in the
Make sure that the tube is in the correct place by checking for CO2 return, listening for bilateral breath sounds and obtaining a chest x-ray.
If endotracheal intubation is impossible (e.g. in severe facial trauma), the next step is a cricothyroidotomy. In emergencies there is no place for tracheostomy. In patients with short, fat necks, the procedure can be difficult. TOC
Cervical Spine Protection
High index of suspicion depending on the history of the accident: (traffic accidents, falls, certain sports).
Avoid rough manipulation of the head and neck. Use hard collars to immobilize the neck. Immobilize the whole body on a long spinal board.
Obtain appropriate radiological evaluation. Symptomatic or unevaluable patients with suspicious mechanisms of injury should be evaluated with CT scan of the cervical spine. Radiological evaluation should be done only after the patient has been stabilized, if necessary after an emergency operation. Clearance of the cervical spine is NOT an emergency!
B. BREATHING AND VENTILATION
• Inspect for symmetrical chest movements. Auscultate for breath sounds bilaterally. Palpate the trachea for deviation and the chest wall for fractures or emphysema.
• Life-threatening problems to be identified during primary survey:
1. Flail chest: Monitor pulse oximetry and blood gases, intubate and ventilate if there is hypoxia or respiratory distress. Consider early intubation in elderly or severe multitrauma patients.
2. Open, sucking/blowing wound in the chest wall: Do not suture or pack before thoracostomy tube insertion. Danger of tension pneumothorax! A Square gauze taped on only 3 sides can be applied while preparing for chest tube insertion.
3. Tension pneumothorax: Initial decompression with needle insertion through the
2nd or 3rd intercostal space anteriorly, mid-clavicular line. Thoracostomy tube.
C. CIRCULATION AND HEMORRHAGE CONTROL
1. Assess BP, heart rate and evidence of bleeding.
2. Control any external bleeding by direct pressure.
3. In penetrating injuries of the neck, where venous injuries are suspected, put the patient in the Trendelenberg position, (head down) to prevent air embolism.
4. If there is shock, insert one or two large intravenous lines and start fluid resuscitation.
Following trauma there are 3 groups or conditions, which can cause shock:
This is the most common cause of post-traumatic Hypotension and could be due to external or internal blood loss.
Vascular access with two or more large bore intravenous lines. Access to central veins can be achieved by means of subclavian, jugular or femoral vein catheterization. In patients with neck or arm injuries, the intravenous line should be inserted on the opposite side to avoid extravasation of the infused fluid from a proximal venous injury.
In children younger than 6 years consider intra-osseous infusion, if a peripheral vein is not available.
The infusion rate depends on the length and diameter of the catheter and NOT on the size of the vein.
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