Clinical management of a trauma patient

Two vehicles collide at a stoplight, one owning a reddish light and slamming into the side of another. Plastic breaks, metallic bends and complete silence fills the night, a short calm before a massive storm. Tones blare, women and men clamber out of their beds, adrenalin surging to critical levels; they rush with their cars and tear off into the night. Sirens scream in to the darkness, lamps flash blinding beams deep into the shadows. The crisis response is now active and the ones paramedics and firefighters will soon be upon the accident scene. Once there they will tear into the vehicles, extricating the hurt, damaged bodies, loading them into ambulances and helicopters, and mailing them off to the definitive health care of a hospital’s trauma center. The clock has started ticking, there is no stopping it, and every tick gives the patient closer to death. Rapid effective intervention of the trauma sufferer by definitive care is essential if the patient stands any potential for surviving.

"There is a golden hour between life and death. If you are critically injured you possess less than 60 a few minutes to survive. You might not die right then; it may be three days or two weeks later — but something has happened within your body that is irreparable." – Dr. R Adams Cowley (UMMC, 2010, para. 5)

Clinical Control of a trauma patient

Management of the severely injured trauma sufferer is a complex and vital aspect of the er nurse. Proper operations encompasses multiple specialties and can be a job that requires collaboration with many providers and requires rapid administration. I am going to attempt to supply the framework for the correct management of the multiply wounded individual in this paper. To start I will show the epidemiology of trauma, that may highlight how generally this patient may appear, and will progress into a system-by-system priority assessment.


Traumatic "injuries are the leading reason behind death for kids and adults ages 1-44" years good old. ("Trauma," 2009, p. 1) In fact, unintentional injuries yearly account for nearly 2 million years of potential existence lost. This staggering volume shines a light on just how common injuries occur, and reveals why nurses ought to be prepared for this sufferer to arrive through the ED doors. Nearly 82% of the populace lives in a hour on an even 1 or level 2 trauma centre, and in Brevard County by itself we have HRMC, which is a level 2 trauma middle and serves over 1400 patients each year. ("The Trauma Centre at Holmes Regional Medical Center," n.d.)

Pre-hospital care

Pre-hospital care in Brevard County is definitely primarily the duty of Brevard County Fire Rescue as the transporting organization. Usual response for BCFR is normally a rescue product with two paramedics, both been trained in Pre-hospital trauma life support and with a scope of practice which allows for enough stabilization of the trauma person. However, definitive care must be the goal, as paramedics are not equipped to do a lot more than ensure patient viability to the er. As such, the nurse must be aware that while the patient has received care and attention ahead of arrival, that care may have simply been enough to achieve the patient there and while that is clearly a start the nurse should be prepared to dominate care and start right from the start with an intensive and prompt assessment.


The assessment phase commences with an initial survey of the patient followed by a rapid trauma assessment that hits on the virtually all obvious and most life threatening injuries initially. The initial study follows the recognized mnemonic ABCDE: Airway, Inhaling and exhaling, Circulation, Disability, and Publicity. (Brunker, 2010).

Airway is often assessed initially when you make contact with an individual. The airway must be assessed for patency, protective reflexes (laryngospasm, glottis closure, cough, etc.), if there are any foreign bodies present, check for secretions and buildup of liquids (mainly blood) , and finally you need to look for injury. Injuries can take the form of lacerations, broken teeth, and penetrating items; along with some not so visible injuries such as for example burns around the oral cavity, which can lead someone to believe there may be an airway burn damage, or blistering in the mouth, which might be from caustic agents getting inhaled/swallowed. While assessing airway it’s also advisable to assess the patient’s level of consciousness, this can be done utilizing the Glasgow coma scale. Degree of consciousness could be a great indicator of how well a patient can control his or her own airway. If an individual is unable to control their own airway then right now there has to be an intervention to control it instead of the patient. This will generally be done by using oro-tracheal intubation and you will be performed by the medical professional or by respiratory therapist at the bedside. This will be done on most patients through fast sequence induction, a process by which the individual is normally rendered unconscious and paralyzed employing sedatives/hypnotics and neuromuscular blocking brokers, (Tang, Li, Huang, Ma, & Wang, 2011). Surgical airway access could be necessary if there are the oral path fails or there is a facial injury that inhibits oral intubation (such as fractures, penetrating things etc.). It may also be used if the patient’s airway has become swollen and edematous after an anaphylactic reaction and oral intubation cannot pass through but the airway is still accessible via surgical cric.

Breathing is assessed subsequent and is most simply done by basically observing the patient and determining the amount and depth of the patient’s respirations. After guaranteeing the patient is really breathing (if the patient is not breathing you must begin breathing for the individual) you should apply a pulse oximeter and auscultate lung sounds properly to determine if there is any probability of a hemo/pneumothorax or of diminished/abnormal breathing. It is now time when you apply supplemental O2 and, if possible, supply it employing an adjunct with the capacity of capnography. If the presence of a pneumo or hemothorax is normally detected then intervention should be done, generally in the type of needle thoracostomy, prior to the assessment continues. This will become performed by a physician and you will be done to get time before a chest tube could be placed.

Next is Circulation, which is certainly assessed by evaluating the patients skins color, epidermis temp, and mental status in addition to the obvious checking of pulses for amount/quality/regularity. The colour and temperature of your skin as well as peripheral pulses are great indicators for how very well the patient is perfusing. Care ought to be taken when looking the patient to notice any clear bleeding or pooling of bloodstream. If the individual is hemorrhaging then direct pressure should be applied and the bleeding controlled before moving on. During this time period the patient should have some kind of vascular access began to enable the infusion of fluids and medications. In most of trauma sufferers, IV access will consist of two large bore IV catheters to facilitate the speedy infusion of volume level expanding crystalloids such as for example 0.9% NaCL or Ringer’s Lactate or if the amount of volume damage necessitates it, to infuse uncrossed O-pos blood.

Disability, or neurological deficits should be assessed next and really should get preferable be assessed prior to the patient is certainly sedated or RSIed to establish a baseline for continuing assessment. That is also of superb importance in sufferers with head accidents as neurological deficits can be a sign of raising intracranial pressure, a serious injury that can cause coma or death if untreated.

Exposure is next as far as priorities go, however it can and should be accomplished early on to avoid missing potential accidental injuries. The trauma patient should be exposed completely to eliminate any possible damage and a systematic head to toe assessment should be performed, this assessment should focus on DCAPBTLS: Deformities, contusions, abrasions, punctures/penetrating accidental injuries, burns, tenderness, lacerations, and swelling. These abnormalities are some of the most common abnormalities on a trauma individual and care ought to be taken to make certain the patient’s body system is checked thoroughly, like the back of the patient. This may be done to some extent while nonetheless on a backboard but can only be completely completed once cervical backbone stabilization is in place and a proper log roll can be accomplished.

The E in ABCDE can also be employed for environment, which is usually something that can’t be overlooked even in the initial stages of treatment. The patient will be exposed entirely, in a presumable cool environment, the patient isn’t perfusing properly, and the individual is receiving IV fluids at a rapid rate. All of those factors add up to the possibility of the individual growing hypothermia at some stage; as such, the individual must be warmed at some time, preferable early on in the treatment because of hypothermia in traumatic individuals being associated with an elevated mortality rate. Reduction in a patient’s heat has been associated with much raised oxygen demand, an final result that’s detrimental to a patient who is already suffering from a perfusion problem. In fact, a drastic reduction in body temperature can bring about dysrhythmias that can cause death very swiftly. (Moore, 2008)

After the initial survey and the initial treatment has started, the secondary or concentrated survey must be accomplished. In this re-evaluation, the nurse will give attention to performing a complete assessment as opposed to the rapid trauma assessment already completed. This assessment will also require documenting a patient’s history, history of the present illness, mechanism of injury. This is as well when the nurse goes into detail using areas that may have been overlooked in the fast assessment, it is crucial to be sure that no personal injury is overlooked. During this period there will most likely be diagnostic exams being done, upper body x-rays, CT scans, labs drawn, and cervical backbone x-rays.

Once life-threatening injuries have been managed, the individual will begin to receive even more definitive treatment, including surgery treatment, chest tube positioning and others. This might occur at any time during the nurse’s assessment as interventions happen to be dictated by the patient’s state. Depending on condition, the nurse will perform tertiary surveys, concentrating on specific areas of fascination that the nurse did not address through the initial survey.

This was a brief history of the initial management of a trauma patient but it provides the framework for the trauma nurse to build upon and allows for successful management of a critically hurt patient. Trauma is usually a multidisciplinary specialty that will require many providers to work together; nurses are a crucial portion of the trauma team and may prove to be invaluable. Trauma is one of the most sudden and unpredicted things that can happen to an individual, and the last person an individual may see is the trauma nurse. I will end with the quotation I started with, "There exists a golden hour between life and death. When you are critically injured you contain less than 60 moments to survive. You might not die right then; it can be three days or fourteen days later — but something has happened within your body that’s irreparable." – Dr. R Adams Cowley (UMMC, 2010, para. 5). That 60 minutes is the domain of the trauma nurse, make those a few minutes matter. Above all, non nocere (do no damage).

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