Initial Assessment ● Preparation and Triage ○ Use universal precautions and don PPE ○ Consider any possible patient exposure to hazardous material that puts the trauma team at risk ○ Safe practice, safe care ○ Ensure resuscitation equipment is readily available ● Across the room observation to identify any uncontrolled external hemorrhage ○ Need to reprioritize to Circulation and Control of Hemorrhage ○ Uncontrolled hemorrhage is the major cause of preventable death in trauma patients ● Primary Survey - Inspect, Auscultate, Palpate ○ A: Airway and alertness with cervical spine stabilization ■ AVPU (Alert/verbalstimuli/painful stimuli/unresponsive) ■ Jaw-thrust maneuver to open the airway and assess for obstruction ● Tongue obstruction ● Loose teeth, foreign objects ● Blood, vomitus, secretions ● Edema ■ Listen for obstructive airway sounds (snoring, gurgling, stridor) ■ Feel for subcutaneous emphysema or deformities ■ Definitive Airway devices = ET tube ● Assess for proper placement (ETCO2, bilat breath sounds, absence of gurgling over the epigastrium) ■ Suction the airway if needed, then reassess ○ B: Breathing and ventilation ■ Are they breathing? How well are they breathing? How long can they keep it up? ■ Spontaneous breathing? Symmetrical rise and fall? ■ Depth, pattern, and rate ■ Skin color ■ Breath sounds ■ Palpate bony structures for possible rib fractures, subcutaneous emphysema, soft tissue injury ■ Open the airway if needed ● Use oral airway adjunct, assist ventilations, then prepare for definitive airway ○ C: Circulation and Control of Hemorrhage ■ Any signs of uncontrolled external bleeding? ● Apply direct pressure or use a tourniquet ■ Skin color, temp, and moisture? ■ Listen to heart and lung sounds ■ Palpate central pulses for rate, rhythm, and strength ■ 2 large-bore IVs ● IO if needed ■ Initiate Warmed isotonic crystalloid solution infusion at a controlled rate ● Consider balanced resuscitation needs ● Rapid infusion protocols ■ Component Therapy = replacing patient loss by administering RBCs, plasma, and platelets = balanced approach ● Suggested for fluid resuscitation instead of standard approach (large volumes of IV fluids) ○ D: Disability (Neuro status) ■ GCS (not accurate if patient is intubated) and trends ■ Assess pupils ■ Need for CT of head and cervical spine? ○ E: Exposure & Environment ■ Remove all clothing ■ Inspect for any uncontrolled bleeding or any obvious injuries ■ Keep the patient warm ● Blankets, fluids, room temp, O2 ● Aggressive measures are to be taken to prevent loss of body heat ● Hypothermia + hypotension + acidosis = TRAUMA TRIAD OF DEATH ○ F: Full set of VS and Family presence ■ Monitor ef ectiveness of resuscitation ef orts and trend VS December 2017; TNCC 7th Edition ■ Facilitate family presence as soon as a member of the trauma team is available to act as a liaison to the family ○ G: Get Resuscitation Adjuncts (Get Stuff!) ■ L: Labs (ABGs, Type and Screen, Lactic Acid) ● Lactic acid is an excellent reflection of tissue perfusion ● Base deficit of -6 is associated with poor outcomes ■ M: Monitor cardiac Rhythm ■ N: Naso or Orogastric tube ■ O: Oxygenation and Ventilation = Pulse ox and ETCO2 ● SpO2 > 95% ● ETCO2 norm = 35-45 mmHg ■ P: Pain ● Assess for pain using appropriate pain scale ● Give nonpharmacologic comfort measures ○ Repositioning, ice therapy, padding, etc. ● Order appropriate analgesic medication ● Reevaluation for signs of internal uncontrolled hemorrhage and consider the need for patient transfer ○ Portable radiograph ○ Initiate steps for transfer to another facility ● Secondary Survey ○ H: History and Head to toe assessment ■ History from EMTs, Patient, Family ■ MIST = MOI, Injuries, S/S, Tx ■ SAMPLE = Symptoms, Allergies, Meds, PMH, Last oral intake, Events/environmental ■ Head ● Eyes, Ears, Nose ■ Neck & cervical spine ● Tracheal deviation = late sign of tension pneumothorax ■ Chest ● Assess heart, lungs, and bones ● Work of breathing ■ Abdomen & FLANKS ● Presence or absence of bowel sounds ■ Pelvis/Perineum ● Palpate instability of pelvis (gentle pressure over the iliac wings downward and medially and over the symphysis pubis) ● Assess any contraindications for foley catheter ○ Insertion of foley is no longer part of primary assessment due to high risk of CAUTI ■ Inspect and palpate all four Extremities ● Neurologicalstatus, color/temp/moisture, sensation, pulses, etc. ○ I: Inspect Posterior surfaces ■ Team assist with log rolling the patient ■ Rectal examination ○ Re Evaluation of adjuncts ■ What injuries were found? ■ What tests were ordered? ■ Abx and Tetanus ■ Wound care ■ Pain meds ■ Splints ● Reevaluation and Post-resuscitation Care ○ Repeat Primary Survey (ABCDE) ○ Vitalsigns ○ Pain and response to medications ○ Injuries and ef ectiveness of treatment ● Definitive care or Transfer ○ Need for specific subspecialty care ■ Neurosurgery or orthopedics ■ ICU ■ Trauma surgeon December 2017; TNCC 7th Edition Chapter 2: Teamwork and Trauma Care ● Vital Roles to the trauma team ○ Patient: ■ The trauma nurse’s highest priority is to ensure the patient remains the focus of the provision of the trauma care ○ Team leader ■ Organizes the team; sets clear goals; makes decisions through input of other team members; empower other members; model teamwork behaviors ■ Responsible for maintaining situational awareness, clear communication, and encouraging mutual support ○ Core Team ■ Group of care providers works independently to manage a trauma patient from assessment to disposition ○ Contingency and support services ■ Support the core team to facilitate optimal trauma care ● Characteristics of an effective team ○ Effective team members are dynamic, interdependent, and adaptive, moving toward the common goal of optimal trauma care. ● Key foundations to successful teamwork in the care of the trauma patient ○ Communication ○ Cooperation ○ Coordination ● Strategies for effective communication ○ SBAR ○ DESC (Describe the situation/Express concerns/Suggest alternative/state Consequences) ○ CUS (I’m concerned/uncomfortable/stressed) ○ Callout and Check Back ● Communication Tools ○ Brief ■ A planned teamwork event designed to form the team, designate team roles and responsibilities, establish climate and goals, and engage the team in goals ■ Done before event ○ Huddle ■ Ideally done before trauma patient’s arrival ■ Purpose of problem solving and regaining situational awareness ○ Debrief ■ Where learning occurs ■ Purpose is process improvement Chapter 4: Biomechanics, Kinematics, and Mechanisms of Injury ● Kinematics: the study of energy transfer as it applies to identifying actual or potential injuries ● Biomechanics: the general study of forces and their effects ● Mechanism of Injury: how external forces are transferred to the body resulting in injury ● Newton’s Three Laws ○ First Law of Motion: a body at rest will stay at rest unless acted on by an outside force ○ Second Law of Motion: the acceleration of a body is parallel and directly proportional to the net force acting on the body, is the direction of the net force, and is inversely proportional to the mass of the body (F = m x a) ○ Third Law of Motion: for every action there is an equal and opposite reaction resulting from the transfer of energy ● Law of Conservation of Energy: energy can neither be created nor destroyed, but it can change form ● Kinetic Energy = ½ mv^2 ○ Mass and velocity contribute to the energy present in a moving object, but it is not a constant ratio ○ When mass is doubled, the net energy is doubled ○ When velocity is doubled, energy is quadrupled ■ High velocity gunshot (rifle) wounds cause more damage than medium-velocity gunshot (handgun) wound even though the handgun projectile is physically larger or heavier ● Five Forms of Energy ○ Mechanical: energy transfer from one object to another in the form of motion ○ Thermal: energy transfer of heat in the environment of a host ○ Chemical: heat energy transfer from active chemical substances ○ Electrical: energy transfer from light socket, power lines, or lightning ○ Radiant: energy transfer from blast sound waves, radioactivity such as a nuclear facility, or rays of the sun ● Forces of Energy Transfer ○ External December 2017; TNCC 7th Edition ■ Deceleration forces: caused by sudden stop of the body’s motion (i.e. falls and collisions) ■ Acceleration forces: result from a sudden and rapid onset of motion (parked car that is hit by a vehicle traveling at a high rate of speed) ■ Compression force: an external force applied at time of impact ● Stationary objects ● Objects in motion (bullets, bats, balls, fists, feet, etc.) ● Blast forces ○ Internal ■ Forces that resist the applied external force (described as “stress”) ■ How it protects the body from injury ● Compression strength: the ability to resist crush force ● Tensile strength: the ability to resist pulling apart ● Shear strength: the ability to resist a force applied parallel to the tissue ● Types of Traumatic Injury ○ Blunt trauma