INTRODUCTION TO TRAUMA NURSING

TRAUMA NURSING PHILOSOPHY

•EMPIRICS -What is the scientific basis for my actions?

•ETHICS- Is there an ethical principle to guide my actions?

•ESTHETICS - Do my action Creates Artistry?

•PERSONAL KNOWING- Do I know what I do; Do I know what I know?

WHAT IS TRAUMA NURSING?

•The 2003 American Nurses Association Nursing Social Policy
Statement suggest the following four features be identified in a
definition of Nursing.

•Recognition of all responses a person may have to illness (injury)

experiences
•Integration of both subjective and objective data
•Use of empirical or Scientific knowledge to diagnose and intervene
•Use of caring relationship to promote health and healing

TRAUMA NURSING ROLES AND RESPONSIBILITIES

1.Designs, manages and coordinates care
2.Engages in and promotes a nurse-patient relationship to provide
care.
3.Documents the care of trauma patient
4.Evaluates research and incorporate findings in practice
ASSESSMENT AND STABILIZATION OF THE TRAUMA
PATIENT
OBJECTIVES
1. Describe the components of primary assessment
2. Correlates life-threatening conditions with the specific
component of the primary assessment.
3. Identify interventions to manage life threatening conditions
identified during the initial assessment.
4. Identify the components of secondary assessment.
5. Describe how to conduct a complete head-to-toe assessment.

THE TRAUMA SYSTEM

•Death from trauma has a trimodal pattern of distribution.
1. The first morbidity peak occurs within seconds or minutes of injury.
- These deaths result from lacerations of the heart, large vessels,
brain, or spinal cord. Because of the severity of such injuries,
few patients are salvageable.

2. The second morbidity peak takes place minutes or hours after

the traumatic event.
- Deaths in this period generally result from intracranial
hematomas or uncontrolled hemorrhage from pelvic fractures,
solid organ lacerations, or multiple wounds. Care received
during the first hour after injury (the so-called “golden hour”) is
crucial to trauma patient survival.

3. The third morbidity peak occurs days to weeks following trauma.

- Death during this period results from sepsis, multi-organ failure,
or respiratory or other complications.
“INITIAL ASSESSMENT” includes the following elements:

• Preparation
• Triage
• Primary survey (ABCDEs) with immediate resuscitation of patients
with life-threatening injuries
• Adjuncts to the primary survey and resuscitation
• Consideration of the need for patient transfer
• Secondary survey (head-to-toe evaluation and patient history)
• Adjuncts to the secondary survey
• Continued post resuscitation monitoring and reevaluation
• Definitive care

Note: When treating injured patients, clinicians rapidly assess injuries

and institute life preserving therapy. Because timing is crucial, a
systematic approach that can be rapidly and accurately applied is
essential. This approach, termed the “initial assessment,” includes the
following elements:
The primary and secondary surveys are repeated frequently to
identify any change in the patient’s status that indicates the need
for additional intervention.

I. PREPARATION
- The prehospital system ideally is set up to notify the receiving
hospital before personnel transport the patient from the scene.
This allows for mobilization of the hospital’s trauma team
members so that all necessary personnel and resources are
present in the emergency department (ED) at the time of the
patient’s arrival. Prehospital providers must make every effort to
minimize scene time, a concept that is supported by the Field
Triage Decision Scheme, shown in (n FIGURE 1-2)
 II. TRIAGE

 Triage situations are categorized as multiple casualties or mass

casualties.

1. MULTIPLE CASUALTIES
Multiple-casualty incidents are those in which the number of
patients and the severity of their injuries DO NOT EXCEED the capability
of the facility to render care.
In such cases, patients with life-threatening problems and those
sustaining multiple-system injuries are TREATED FIRST.

2. MASS CASUALTIES
In mass-casualty events, the number of patients and the severity of
their injuries DOES EXCEED the capability of the facility and staff.
In such cases, patients having the greatest chance of survival
and requiring the least expenditure of time, equipment, and supplies
are treated first.

MULTIPLE CASUALTIES MASS CASUALTIES

# OF PTS & THE
SEVERITY OF THEIR DO NOT EXCEED DOES EXCEED
INJURIES
WHO ARE TREATED - Life threatening - patients having
FIRST? problems the greatest
- Multiple-System chance of
Injuries survival
- requiring the least
expenditure of
time, equipment,
and supplies
APPROACH TO CARE OF THE TRAUMA PATIENT

A AIRWAY with consideration given to cervical

spine injuries
B BREATHING And ventilation
C CIRCULATION With Hemorrhage Control
D DISABILITY Neurologic Status
E EXPOSURE Of the patient and environmental
control (remove patient’s clothing, and
keep the pt warm)
F FULL SET OF V/S focused adjuncts, and family presence
G GIVE COMFORT verbal reassurance, touch, pharma and
MEASURES non-pharma mgmt of pain
H HISTORY &
HEAD-TO-TOE
ASSESSMENT
I INSPECT THE
POSTERIOR
SURFACE

III. THE PRIMARY ASSESSMENT

 The first five letters in the mnemonic (A-B-C-D-E) represent the first
part of trauma resuscitation: airway, breathing, circulation,
disability, and exposure and environmental control.

 Clinicians can quickly assess A,B,C, and D in a trauma pt

(10 second assessment by identifying themselves, asking the pt
for his or her name, and asking what happened.
Note:
 An appropriate response suggest that there is no major airway compromise
(ability to speak clearly)
 Breathing is not severely compromised ( ability to generate air movement
to permit speech and the level of consciousness is not markedly decreases
( alert enough to describe what happens).
 Failure to respond to these questions suggest abnormalities in
A,B, C, or D
 The warrant urgent assessment and mgmt.

AIRWAY MAINTENANCE WITH RESTRICTION OF CERVICAL SPINE MOTION

An adequate airway is required for breathing and circulation; therefore
assessment and protection of the airway is always paramount in care of the
trauma patient. Patients at particular risk of a compromised airway are those with
altered levels of consciousness (Glasgow Coma Scale score of 8 or less) and those
with maxillofacial and neck injuries.

ASSESSSMENT
 Open and inspect the pt’s airway while maintaining cervical
spine protection.
 Vocalization
 Is the pt able to talk? Is the pt crying or moaning?
 Tongue obstructing the airway
 Loose teeth or foreign objects
 Blood, vomitus, or other secretions
 edema
 If the pt has been intubated or an alternative airway has been
inserted before arrival at the hospital, confirm that the airway is
in the correct place
 Observe for equal rise and fall of the chest with ventilation
 Listening over the epigastrium and then over the lung fields
 Using specific device to confirm tube placement
Exhaled CO2 detector
Esophageal detection device
 Obtaining a chest radiograph
 NOTE: This rapid assessment for signs of airway obstruction includes
inspecting for foreign bodies; identifying facial, mandibular, and/or
tracheal/laryngeal fractures and other injuries that can result in
airway obstruction; and suctioning to clear accumulated blood or
secretions that may lead to or be causing airway obstruction. Begin
measures to establish a patent airway while restricting cervical spine
motion.

AIRWAY AND CERVICAL SPINE ASSESSMENT AND INTERVENTIONS

 NEVER INSERT A NASOPHARYNGEAL AIRWAY into patients with facial

trauma. Consider the nasopharyngeal airway for conscious
patients who require assistance to maintain their airway.
 Contraindication with nasal fracture or actively bleeding.
Placing an NPA in pt with head or face fracture could further
damage the structural integrity of bone and surrounding tissue or
result in direct penetration of the NPA into the brain.
 Stridor – is a high pitched wheezing sound caused by disrupted
airflow; musical breathing
CERVICAL SPINE ASSESSMENT AND INTERVENTIONS
BREATHING AND VENTILATION
Even with an open airway, a patient must be able to exchange gases
through the airway for effective breathing. Therefore assessment and
interventions for breathing should always follow those for the airway.

BREATHING ASSESSMENT AND INTERVENTIONS

 Injuries that significantly impair ventilation in the short term include

TENSION PNEUMOTHORAX, MASSIVE HEMOTHORAX, and
TRACHEAL OR BRONCHIAL INJURIES.
 A simple pneumothorax can be converted to a tension
pneumothorax when a patient is intubated and positive pressure
ventilation is provided before decompressing the pneumothorax
with a chest tube.
CIRCULATION WITH HEMORRHAGE CONTROL
The exchange of gases associated with breathing is useful only if
the circulatory system can circulate those gases.
Circulatory deficits in trauma are frequently related to the
presence of shock, especially hypovolemic or obstructive shock.
Circulatory compromise in trauma patients can result from a
variety of injuries. Blood volume, cardiac output, and bleeding are
major circulatory issues to consider.
Hemorrhage is the predominant cause of preventable deaths
after injury. Identifying, quickly controlling hemorrhage, and initiating
resuscitation are therefore crucial steps in assessing and managing
such patients. Once tension pneumothorax has been excluded as a
cause of shock, consider that hypotension following injury is due to
blood loss until proven otherwise. Rapid and accurate assessment of
an injured patient’s hemodynamic status is essential.

ELEMENTS OF CLINICAL OBSERVATION THAT YIELD IMPORTANT

INFORMATION WITHIN SECONDS:
1. LEVEL OF CONSCIOUSNESS - When circulating blood volume is
reduced, cerebral perfusion may be critically impaired, resulting
in an altered level of consciousness.
2. SKIN PERFUSION - This sign can be helpful in evaluating injured
hypovolemic patients. A patient with pink skin, especially in the
face and extremities, rarely has critical hypovolemia after injury.
Conversely, a patient with hypovolemia may have ashen, gray
facial skin and pale extremities.
3. PULSE - A rapid, thready pulse is typically a sign of hypovolemia.
Assess a central pulse (e.g., femoral or carotid artery) bilaterally
for quality, rate, and regularity. Absent central pulses that
cannot be attributed to local factors signify the need for
immediate resuscitative action.
 Identify the source of bleeding as external or internal. External
hemorrhage is identified and controlled during the primary
survey. Rapid, external blood loss is managed by direct manual
pressure on the wound.
 Tourniquets are effective in massive exsanguination from an
extremity but carry a risk of ischemic injury to that extremity. Use
a tourniquet only when direct pressure is not effective and the
patient’s life is threatened.
 Definitive bleeding control is essential, along with appropriate
replacement of intravascular volume. Vascular access must be
established; typically two large-bore peripheral venous catheters
are placed to administer fluid, blood, and plasma. Blood samples
for baseline hematologic studies are obtained, including a
pregnancy test for all females of childbearing age and blood type
and cross matching.
 To assess the presence and degree of shock, blood gases and/or
lactate level are obtained. When peripheral sites cannot be
accessed, intraosseous infusion, central venous access, or venous
cutdown may be used depending on the patient’s injuries and the
clinician’s skill level.
 Aggressive and continued volume resuscitation is not a
substitute for definitive control of hemorrhage. Shock associated
 with injury is most often hypovolemic in origin. In such cases,
initiate IV fluid therapy with crystalloids.
 All IV solutions should be warmed either by storage in a warm
environment (i.e., 37°C to 40°C, or 98.6°F to 104°F) or
administered through fluid warming devices. A bolus of 1 L of an
isotonic solution may be required to achieve an appropriate
response in an adult patient. If a patient is unresponsive to initial
crystalloid therapy, he or she should receive a blood transfusion.
Fluids are administered judiciously, as aggressive resuscitation
before control of bleeding has been demonstrated to increase
mortality
 and morbidity. Severely injured trauma patients are at risk for
coagulopathy, which can be further fueled by resuscitative
measures. This condition potentially establishes a cycle of
ongoing bleeding and further resuscitation, which can be
mitigated by use of massive transfusion protocols with blood
components administered at predefined low ratios (see Chapter
3: Shock).
 One study that evaluated trauma patients receiving fluid in the
ED found that crystalloid resuscitation of more than 1.5 L
independently increased the odds ratio of death. Some severely
injured patients arrive with coagulopathy already established,
which has led some jurisdictions to administer tranexamic acid
preemptively in severely injured patients. European and
American military studies demonstrate improved survival when
tranexamic acid is administered within 3 hours of injury. When
bolused in the field follow up infusion is given over 8 hours in
 the hospital (see Guidance Document for the Prehospital Use of
Tranexamic Acid in Injured Patients).
 DISABILITY
The “D” in primary assessment is meant to remind caregivers to assess
neurologic status. Profound alterations in neurologic function may indicate
significant neurologic trauma. The negative long-term effects of neurologic
trauma can sometimes be minimized with prompt interventions; therefore
assess neurologic status early so that appropriate interventions can be
initiated promptly.

EXPOSURE AND ENVIRONMENTAL CONTROL

 Clothing can obscure obvious injuries; therefore remove all
clothing from the patient as part of the primary assessment.
 After completing the assessment, cover the patient with warm
blankets or an external warming device to prevent him or her
from developing hypothermia in the trauma receiving area.
Warm intravenous fluids before infusing them, and maintain a
warm environment.
 The patient’s body temperature is a higher priority than the
comfort of the healthcare providers, and the temperature of the
resuscitation area should be increased to minimize the loss of
body heat. The use of a high-flow fluid warmer to heat crystalloid
fluids to 39°C (102.2°F) is recommended. When fluid warmers are
 not available, a microwave can be used to warm crystalloid
fluids, but it should never be used to warm blood products.

FACTORS THAT INCREASE THE RISK OF A PATIENT BECOMING

HYPOTHERMIC DURING TRAUMA RESUSCITATION, INCLUDING:

1. Ambient temperature of the resuscitation room (which is lower

than body temperature)
2. Infusion of large amounts of fluids or blood products that are
below body temperature
3. Elevated blood alcohol levels (resulting in vasodilation)
4. Impaired thermogenesis secondary to shock and brain injuries
5. Age (pediatric and older patients have decreased abilities to
regulate body temperature)
6. Moisture on the body from environmental conditions and
bleeding
7. Use of anesthetics and paralytics for intubation (which
decreases internal heat production)
8. Injuries to the pelvis, extremities, abdomen, and large blood
vessels (which carry a greater risk of heat loss)

** If the core body temperature of a trauma patient drops below 95°F

(35°C) during resuscitation, the patient has an increased risk of the
following: • Developing acidosis • Tissue and cerebral hypoxia •
Increased diuresis with exacerbation of hypovolemia • Infection due
to suppression of the immune system • Coagulopathies, including
disseminated intravascular coagulation
ADJUNCTS TO THE PRIMARY SURVEY WITH RESUSCITATION

 Electrocardiography
 Pulse oximetry
 Carbon dioxide (CO2) monitoring, assessment of ventilatory
rate and arterial blood gas (ABG) measurement
 urinary catheters can be placed to monitor urine output and
assess for hematuria.
 Gastric catheters decompress distention and assess for
evidence of blood.
 Other helpful tests include blood lactate, x-ray examinations
(e.g., chest and pelvis), FAST, extended focused assessment
with sonography for trauma (eFAST), and DPL.
 IV. THE SECONDARY ASSESSMENT

FULL SET OF VITAL SIGNS

If a complete set of vital signs has not yet been obtained, it is
appropriate to do so at this point. These vital signs will serve as a
baseline for continued reassessment. Patients with suspected chest
trauma should have apical and radial pulse rates documented and
blood pressure assessed in both arms.

*** Once the primary assessment is complete and issues involving the
patient’s airway, breathing, circulation, disability status, and
exposure and environmental control have been addressed,
proceed to the secondary assessment. THIS IS NOT A FINAL
EXAMINATION; it is a rapid, thorough inspection of the patient’s entire
body from head to toe. Unlike the primary assessment, issues noted
on secondary assessment are not treated immediately. They are
noted and then prioritized for later intervention. If the patient
develops an airway, breathing, or circulatory problem at any time,
return at once to the primary assessment and intervene as indicated.
The last four letters of the mnemonic (F-G-H-I) make up the
secondary assessment.
•Patients with chest trauma who are at risk for aortic trauma should
have blood pressure and pulse measured in both arms and one leg.
A difference of 10 mm Hg or more in blood pressure or a difference
in pulse quality between sites should raise the index of suspicion for
AORTIC TRAUMA.

FOCUSED ADJUNCTS
 Continuous cardiac and oxygen saturation monitoring
 Placement of a gastric tube
 Insertion of an indwelling urinary catheter (unless there is
evidence of lower genitourinary trauma)
 Collection of appropriate laboratory studies
 Focused assessment with sonography for trauma (FAST)
 Age (pediatric and older patients have decreased abilities)

FAMILY PRESENCE
The presence of the family during the resuscitation of trauma
patients has been shown to improve family members’ ability to cope
with the situation.
There is strong evidence that it may also assist the patient who is
aware of their presence during this stressful time. Based on this
evidence, the Emergency Nurses Association has adopted a formal
position statement encouraging family presence at the bedside of
critically ill or injured patients.

GIVE COMFORT MEASURES

The trauma victim is often in physical and psychological distress.
Pharmacologic and non-pharmacologic methods of reducing pain
and anxiety are available for this population.
***The secondary survey does not begin until the primary survey
(ABCDE) is completed, resuscitative efforts are under way, and
improvement of the patient’s vital functions has been demonstrated.

HISTORY
If the patient is awake, alert, and cooperative, try to elicit
pertinent medication, allergy, and medical history information.
Family members are also a resource for these data.
If a patient is transported via prehospital personnel, they will also
serve as an excellent resource, providing information regarding the
mechanism of injury, injuries suspected, and treatment prior to arrival,
including vital signs in the field.

The AMPLE history is a useful mnemonic for this purpose:

• Allergies
• Medications currently used
• Past illnesses/Pregnancy
• Last meal
• Events/Environment related to the injury
HEAD-TO-TOE EXAMINATION
PITFALL: PELVIC FRACTURES CAN PRODUCE LARGE BLOOD LOSS.
 Prevention
 Placement of a pelvic binder or sheet can limit blood loss from
pelvic fractures.
 Do not repeatedly or vigorously manipulate the pelvis in patients
with fractures, as clots can become dislodged and increase blood
loss.

PITFALLS:
1. EXTREMITY FRACTURES AND INJURIES ARE PARTICULARLY
CHALLENGING TO DIAGNOSE IN PATIENTS WITH HEAD OR
SPINAL CORD INJURIES.
 Prevention
 Image any areas of suspicion.
 Perform frequent reassessments to identify any developing swelling
or ecchymosis.
 Recognize that subtle findings in patients with head injuries, such as
limiting movement of an extremity or response to stimulus of an
area, may be the only clues to the presence of an injury.

2. COMPARTMENT SYNDROME CAN DEVELOP

 Prevention
 Maintain a high level of suspicion and recognize injuries with a high
risk of development of compartment syndrome (e.g., long bone
 fractures, crush injuries, prolonged ischemia, and circumferential
thermal injuries).

V. REEVALUATION
 Trauma patients must be reevaluated constantly to ensure that new
findings are not overlooked and to discover any deterioration in
previously noted findings

INSPECT POSTERIOR SURFACE

 With the back exposed, look for bruising, discoloration, and any
open wounds.
 Palpate the vertebral bony prominences for deformity, movement,
and pain.
 Remove any clothing or wet items left under the patient.
 If the spine is cleared or the patient can lie still, remove the
backboard (according to institutional protocol).
Therapeutic Interventions
 Consider padding or removing the backboard.
 Assess for signs of skin breakdown.
**It is essential to remember that 50% of the body’s surface lies against
the stretcher. Failing to roll the patient and inspect the back can result
in numerous injuries being missed. Cervical spinal alignment must be
maintained by using approved logrolling techniques.

REEVALUATION AND ASSESSMENT

 Reassess pain and provide additional pain medication (as
indicated) but watch for respiratory depression.
 Narcotic analgesics also may mask subtle signs of neurologic
deterioration.
 Monitor urinary output and intervene as necessary.
 As in all aspects of health care, thorough documentation is
essential. Because of the multiple assessments, interventions,
 and reassessments, recording trauma patient care in a timely
fashion is crucial.
 The patient who has sustained a trauma requires consistent and
uniform care from all members of the team. If life-threatening
injuries are found, the team needs to intervene and correct
them. Care of the trauma patient is enhanced by the use of a
team approach and a consistent assessment technique such as
the A-I mnemonic.

***As long as the trauma patient is in the emergency department,

assessment is never complete. Re-evaluate patients regularly to
identify deterioration and injuries that were overlooked. Additionally,
trauma patients may have underlying medical conditions that were
not addressed during the initial resuscitation. Consider the following:

EFFECTIVE ANALGESIA usually requires the administration of

opiates or anxiolytics intravenously (intramuscular injections are to be
avoided). These agents are used judiciously and in small doses to
achieve the desired level of patient comfort and relief of anxiety while
avoiding respiratory status or mental depression, and hemodynamic
changes.
For adult patients, maintenance of URINARY OUTPUT at 0.5
mL/kg/h is desirable. In pediatric patients who are older than 1 year,
an output of 1 mL/kg/h is typically adequate. Periodic ABG analyses
and end-tidal CO2 monitoring are useful in some patients.

VI. DEFINITIVE CARE

 Whenever the patient’s treatment needs exceed the capability of the
receiving institution, TRANSFER IS CONSIDERED. This decision requires a detailed
assessment of the patient’s injuries and knowledge of the capabilities of the
institution, including equipment, resources, and personnel.
REVISED TRAUMA SCORE