Nursing Management of

Patient with
General
Trauma and
Triaging
System

Reda Samy
Mohamed
BSN,MSN- Assistant Lect.
Critical care & Emergency
Nursing Dep Faculty of
Nursing – Cairo University
OBJECTIVES

At the end of this lecture

each student should be able
to:
•Discuss types of trauma
•Mention the mechanisms of injury
•Discuss mechanism of injury related to
trauma
•Explain emergency management of post
traumatic injury patients
•Utilize triage principles in management of
post
traumatic injury patients
OUTLINES

-Meaning of trauma and related terms.

-Epidemiology of trauma.
-General categories of trauma.
-Mechanism of injury.
-Types of trauma.
-Trauma scoring system.
-Phases of trauma management.
-Specific trauma assessment and
management.
-Definition of triage.
-Types of triage.
-Start system.
-Role of nurse in triaging system.
TRAUMATOLOGY

Traumatology (from Greek "Trauma" meaning injury

or wound), is the study of wounds and injuries caused
by accidents or violence to a person, and the surgical
therapy and repair of the damage. Traumatology is a
branch of medicine.
 TRAUMA

It is a behavioral or physical state

disorder resulting from severe
mental or emotional stress or
physical injury
A traumatic event is defined as
“sudden and unexpected, and
perceived as dangerous. It
overwhelms our immediate ability
to cope.
“Polytrauma”>>Multisyste
m trauma = injury of two
or more systems.
INJURY
Injury is an unintentional or intentional
damage to the body resulting from acute / sudden
exposure to thermal, mechanical, electrical or
chemical energy or from the absence of such
essentials as oxygen.
*Unintentional Injury such as:

Motor vehicle crashes (MVC), falls, drowning, and fires

*Intentional Injury such as:

Suicide attempts, assaults.
 Epidemiology of Trauma

Trauma is the third leading cause of death in

the united state and the leading source of
mortality for patients between 1 – 44 years of
age.

The peak incidence between 15 & 25 years

(the healthy and productive group).

Trauma affects mainly a young age. Driver

under the influence of alcohol or other drugs
TRAUMA
*Epidemiology
*Trends in trauma deaths
 CLASSIFICATION OF TRAUMA

According to type/ cause

Penetrating
Blunt mechanism
mechanism
BLUNT TRAUMA

Blunt trauma is
commonly caused by

-Road traffic
accidents
-Falls
 Blunt trauma
+
Hypotension
+
Altered mental status
=
Diagnostic and
Therapeutic Dilemma
 MECHANISM OF INJURY BLUNT TRAUMA

Motor vehicle crashes Fall

Motorcycle crashes

Assault

Pedestrian
PENETRATING TRAUMA

Injuries to skin, tissues,

underlying organs, viscera,
and possibly bone

Stab wound Gun

CLASSIFICATION OF TRAUMA

According to severity of injury

Minor trauma Major trauma

CLASSIFICATION ACCORDING TO SEVERITY

1. Minor trauma: Single system or limb

injuries that do not pose a threat to life and
can be appropriately treated in a basic
emergency facility.

2. Major trauma: Serious multiple

system injuries that require immediate
intervention to prevent disability, loss of
limb, or death such as tension
pneumothorax, open pneumothorax,
and Flail chest.
 OTHER CONDITIONS

explosion Crush
s injuries

Hypothermia

Drownin
Burns g
TRAUMA SCORING SYSTEM

Trauma scoring
system

Physiologic
Anatomic Scores
Scores

Revised
Trauma Abbreviated Injury
Scale (AIS)
Score
Trauma scoring system Physiologic Scores

Revised Trauma Score

It uses 3 physiologic parameters:

*(1) Glasgow Coma Scale (GCS)
*(2) Systemic blood pressure (SBP)
*(3) Respiratory rate (RR).
Practitioners code parameters from 0-4
 Physiologic trauma Scores

Revised Trauma Score

- used for field triage, the RTS is determined by adding each of the
coded values together. Thus, the RTS ranges from 0-12 An RTS of
less than 11 is used to indicate the need for transport to a
designated trauma center

- 12 is labeled DELAYED (walking wounded) , 11 is URGENT

(intervention is required but the patient can wait a short time) , 10-
3 is IMMEDIATE (immediate intervention is necessary) , The last
possible label is MORGUE .
 * The Revised Trauma Score
Glasgow Systolic
Respirato
Coma Blood
ry Rate RTS
Scale Pressure
(RR) Value
(GCS) (SBP)
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
 PHASES OF TRAUMA MANAGEMENT

1. Pre-hospital care
Injury identification
Critical intervention
Triage decision scheme to determine best level

of care required

Rapid Transport
Attempt to stabilize patient
2- In hospital management

Triage
Primary survey (A,B,C,D,E)
Secondary Survey (head to toe evaluation &
patient history)

AMPLE history (Allergies, Medications, Past medical

history, Last meal, Events prior)

Stabilization & Transfer

Definitive Care
 2- PRIMARY SURVEY

*A.Airway
*B.Breathing
*C.Circulation
*D.Disability (AVPU)-Alert,Verbal,Pain,Unresponsive
*E.Exposure/Environmental control
AIRWAY
Assessment Intervention
*While maintaining spinal *Position the patient.
stabilization: *Jaw thrust or chin left.
*Vocalization. *Suction/remove foreign
*Tongue obstruction. body.
*Loose teeth/foreign *Oro/nasopharyngeal airway.
objects. *Cervical spine stabilization.
*Bleeding.
*Vomitus/other secretions.
* AIRWAY
*Endotracheal intubation.
*Needle/surgical
*Edema. cricothyrotomy.
BREATHING
Assessment Intervention
* Spontaneous breathing. *Supplemental oxygen.
* Chest rise and fall. *Bag – valve mask
* Skin color. ventilation.
* General rate and depth of
respiration. *Needle thoracocentesis.
* Soft tissue and bony chest *Chest tube.
wall integrity.
*BREATHING
* Use of accessory/abdominal
muscle.
*Non porous dressing
taped on 3 sides .

* Bilateral breath sound.

* Jugular vein and position of
trachea.
CIRCULATIO
N
Assessment Intervention
*Pulse general rate and * Direct pressure over bleeding
quality. site.

*Skin color. * Two large bore cannula with

warmed lactated ringer/ saline.
*Temperature. * Infuse fluid rapidly.
*Degree of diaphoresis. * Blood sample for typing.

*CIRCULATION
*External bleeding. * Pericardiocentesis.
* CPR and advanced life support
measures.
* Blood administration.
* Surgery.
 Life threatening airway
problems
*Airway
obstruction Intervention
(complete or *Airway opening maneuver
partial) * Jaw thrust/chin left
Signs and symptoms: * Suction
• Dyspnea, labored
* Airway adjuncts
respiration.
* Nasal/oral airway
• Decreased/no air
* ETT
movement.
* Laryngeal mask
• Cyanosis.
* Surgical airway
• Foreign body.
* Cricothyrotomy
• Trauma to face or neck.
* Tracheostomy
• Breathless. * High flow O2 (100%)via
• Agitation. non-rebreather mask or
bag valve device.
• Combativeness.
 Life threatening breathing
problems
*Tension
pneumothora Intervention
x
Signs and symptoms:
*High flow O2 (100%)via
• Dyspnea, labored respiration non-rebreather mask
• Decreased or absent breath or bag valve device.
sounds on affected side.
• Unilateral Chest rise and fall *Perform rapid chest
• Tracheal deviation away decompression by
from affected side. needle thoracotomy.
• Jugular vein distention
• Cyanosis
*Place chest tube on
• Tachycardia
affected side.
• hypotension
 Life threatening breathing
problems
*Pneumothora Intervention
x *High flow O2 (100%)via
Signs and symptoms: non-rebreather mask
• Dyspnea, labored or bag valve device.
respiration *Place chest tube on
• Decreased or absent affected side.
breath sounds on
affected side.
*Place occlusive
dressing over any
• May have unilateral
open chest wound
Chest rise and fall
and secure on three
• May have visible wound
to chest or back sides with tape
• History of chest trauma
 Life threatening breathing
problems

*Hemothorax
Intervention
Signs and symptoms:
*High flow O2 (100%)via
• Dyspnea, labored
non-rebreather mask
respiration
or bag valve device.
• Decreased or absent
breath sounds on *Place chest tube on
affected side. affected side.
• May have unilateral Chest
rise and fall *Consider auto-
• May have visible wound transfusion
to chest or back
• History of chest trauma
(usually penetrating)
 Life threatening breathing
problems

*Flail chest
Signs and symptoms: Intervention

• Dyspnea, labored *High flow O2 (100%)via

respiration non-rebreather mask
• Paradoxical chest wall or bag valve device.
movement *Prepare for intubation
• Tachycardia and mechanical
• Chest pain ventilation
 Life threatening circulation
problems
*External
hemorrhage
Signs and symptoms:
• Obvious bleeding site Intervention

*Direct pressure
*elevation
 Life threatening circulation
problems
Intervention

*Shock *High flow O (100%)via

2

non-rebreather mask or
Signs and symptoms: bag valve device.
• Tachycardia *Two large bore cannula
• Weak, thready pulse with warm isotonic
• Cool, pale, clammy
crystalloids (lactated
skin ringer/ normal saline)
• Tachypnea *Administer fluid bolus
• Altered mental status (2 L in adults or 20
• Delayed capillary refill ml/kg in children)
• Oliguria or anuria *Prepare to administer
blood
DISABILITY
*AVPU scale
*A - alert, that is responds to voice
appropriately, i.e. obeys commands.
*V - vocalises, may be inappropriate or
incomprehensible sounds
*P - responds to pain only (should be
assessed in all 4 limbs if initial limb fails to
respond)
*U - unresponsive to pain.
EXPOSURE AND ENVIRONMENTAL CONTROL

- To allow for a through examination of the

trauma patient, all clothing and jewelry must
be removed.

- Anterior, lateral, and posterior surfaces of the

body must be examined for evidence of
trauma.

- Warmed blankets and intravenous solutions

can be helpful in reducing hypothermia.
 Exposure

*Exposure
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Collaborative Accessed 9/20/09 – Yahoo Images
Advanced Emergency Trauma Course
 Exposure

*Exposure
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Advanced Emergency Trauma Course
Accessed 9/20/09 – Yahoo Images
2- PRIMARY SURVEY
-It is a more complete
evaluation including vital
signs, history, head to toe
examination and inspection
of the back.

- Some potentially life

threatening injuries
identified by secondary
 SECONDARY
.
ASSESSMENT
F: Full set of vital signs/Five
intervention/ Facilitate family presence

G: Give comfort measures

H: History/Head to Toe
assessment
 F: Full set of vital signs/Five
intervention/ Facilitate family presence

*Obtaining complete vital signs.

*Five interventions:
* Cardiac monitor.
* Pulse Oximeter.
* Urinary catheter if not contraindicated.
* Gastric tube.
* Laboratory studies.
*Facilitate family presence.
 G: Give comfort measures

*Verbal reassurance
*Touch
*Pain control
 H: History

*MIVT: (Mechanism of injury,

Injury, Vital signs, Treatment)

*AMPLE history (Allergies, Medications, Past

medical history, Last meal, Events prior)
 DCAP-BTLS

• Deformities / Instability

• Contusions

• Abrasions

• Punctures/Penetrations

• Burns

• Tenderness

• Laceration

• Swelling
 H: Head to Toe
assessment

*Head and Face:

* Inspect for wounds, ecchymosis,
deformities, drainage from nose and
ears, and check pupil.

* Palpate for tenderness, note bony

crepitus, and deformity.
 H: Head to Toe
assessment
Neck:
* Remove the anterior portion of the cervical collar
to inspect and palpate the neck. Another team
member must hold patient’s head while collar is
removed and replaced.

* Inspect for wounds, ecchymosis, deformities, and

distended neck veins.

* Palpate for tenderness, note bony crepitus,

subcutaneous emphysema, and deformity.
 H: Head to Toe
assessment
Chest:
* Inspect for breathing rate and depth, wounds,
ecchymosis, deformities, use of accessory
muscles, and paradoxical movement.

* Auscultate breath and heart sounds.

* Palpate for tenderness, note bony crepitus,

subcutaneous emphysema, and deformity.
 H: Head to Toe
assessment

Abdomen and flanks:

* Inspect for sounds, distention,
ecchymosis, and scars.

* Auscultate bowel sounds.

* Palpate four quadrants for
tenderness, rigidity, guarding,
mass, and femoral pulses.
 H: Head to Toe
assessment

Pelvis and perineum:

* Inspect for wounds, deformities,
ecchymosis, priapism, blood at the
urinary meatus or in the perineum
area.

* Palpate the pelvis and anal sphincter

tone.
 H: Head to Toe
assessment

Extremities:
* Inspect for wounds, movement,
deformities, and ecchymosis.

* Palpate for pulses, skin temperature,

sensation, tenderness, deformities, and
note bony crepitus.
 5. STABILIZATION AND TRANSFER

*Treated life-threatening conditions and made a second

examination to detect any other injuries. The management
plan of the patient should now be clear. you can then
decide on the best treatment option:

*Transfer to the ward

*Transfer to the operating room
*Transfer to the X-ray department
*Transfer to another hospital.
 6. DEFINITIVE CARE

*Definitive care include monitoring and management of existing

problems, management of preexisting medical conditions and the
identification of injuries missed during treatment of life-threatening
conditions, and monitored for the development of complications
 GOOD TRAUMA CARE

*Quiet – leader speaks, others answer

report, not everyone trying to scream
over each other
*Organized – pre-assigned roles and
responsibilities of team members
*Consistent approach
*Systematic approach to minimize
missed injuries
*Prioritize life threatening injuries first
GOOD TRAUMA CARE CONT.

*Strong leadership
Leader’s job to see the big picture, assign
details to team members
*Responds to change
What appears stable one minute may not
be so the next
Can always return to ABC’s
*TEAMWORK
Trauma care requires coordination of many
services and specialties
 TRIAGE

REDA SAMY
Assistant Lecturer at Critical and Emergency Department- Faculty of Nursing
Definition
*[French, from Trier, to sort.]

*A method of quickly identifying

victims who have immediately life-

threatening injuries AND who have the

best chance of surviving.

 GOAL:
TO SAVE THE LARGEST
NUMBER OF SURVIVORS
FROM A MULTIPLE CASUALTY
INCIDENT
 TRIAGE

WHEN ?

Casualties exceed the number

of skilled rescuers.
 * MCI

Multi Casualty Incident

*An accident or emergency that

overwhelms local response capability
 WHAT CHANGES WHEN
YOU HAVE AN MCI ?
*What are my resources?
*Who is a Patient?
*Which Patient do I treat first?
*Who can be salvaged?
*Who gets transported first?
*Who needs a Trauma/Specialty Center?
*Who can help care for others?
TIME IS VERY
IMPORTANT
THE GOLDEN HOUR
“The critical trauma patient has
only 60
minutes from the time of injury
to reach
definitive surgical care, or the
odds of
a successful recovery diminish
dramatically”.
So what do you have to think
about ?
TRIAGE COMMUNICATIONS
COMMAND STAGING

TREATMENT SAFETY

TRANSPORT
ASSESSMENT
THE INITIAL PROBLEM ON SCENE

Casualties Resources
 THE OBJECTIVE

Casualties Resources
 THE OBJECTIVE

Casualties Resources
 THE OBJECTIVE

Casualties Resources
 THE OBJECTIVE

Casualties Resources
 THE OBJECTIVE

Casualties Resources
 THE OBJECTIVE

Casualties Resources
 THE OBJECTIVE

Casualties Resources
 Casualties Resources

=
Maximum survivors
TYPES OF TRIAGE
*Primary
* On Scene prior to movement

*Secondary
* probably prior to or during transport
 PRIMARY TRIAGE

Rapid patient assessment and

The tagging
Scene Immediate live sustaining care, as
necessary
 TRIAGE CODING
Priority Color
Treatment
Immediate 1 RED

Urgent 2 Yellow
Delayed 3 Green
Dead 0 Black
 START SYSTEM

*Allows rapid assessment of

victims

*It should not take more than

15 sec/ Pt.

*Once victim is in treatment

 START SYSTEM

Clasification is based on three items

*Respiration
*Perfusion
*Mental status evaluation
 START
WHERE YOU
STAND
START FIRST STEP

Can the Patient Walk?

YES NO

Evaluate Ventilation
Green
(Step-2)
(Minor)
 START STEP-2
Ventilation Present?

NO YES

Open Airway

Ventilation Present? > 30/Min < 30/min

NO YES
Red/ Immediate

Black Evaluate Circulation

Red/ Immediate
(Step-3)
 START STEP-3
Circulation

Absent Radial Pulse Present Radial Pulse

Control Hemorrhage
Evaluate Level of
Consciousness
Red/ Immediate
 START STEP-4
Level of Consciousness

Can’t Follow Simple Can Follow Simple

Commands Commands

Red/ Immediate Yellow/ Delayed

 START-OVERVIEW

*Remember RPM

*R- Respirations- 30

*P- Perfusion- Radial Pulse

*M- Mental- Follows Commands

SECONDARY
TRIAGE
 SECONDARY TRIAGE

*Purpose
*Determine among like priority category, higher
priority patient

*When does it happen?

*Generally on extended duration events
*If treatment areas are established, there will
likely be a need for Secondary Triage before
transport
 ASSESSMENT

*ƒ History (Missed information is a missed

opportunity to provide quicker, more
directed care)
*MIST (pre-hospital).
*Primary Survey - ABCDE always first priority.
*Assess for life-threatening injuries.
*Determine Neurological status.
*Look for obvious injuries.
*Secondary Survey (AMPLE).
SUMMAR
Y