Take critical steps when a trauma patient arrives
Take critical steps when a trauma patient arrives
If your facility isn’t a Level 1 Trauma Center, you probably don’t care for trauma patients with multiple injuries on a daily basis. That’s exactly why you must be familiar with the signs and symptoms that occur when a patient starts to decompensate, advises Sharon S. Cohen, RN, MSN, CEN, CCRN, trauma clinical nurse specialist at Broward General Medical Center in Fort Lauderdale, FL.
"The key is, what do you need to treat very quickly to get the patient to surgery right away?" she says.
Caring for trauma patients requires you to shift your mindset, adds Cohen. "In the ED, we often focus on the medical side more than the surgical side," she says. "With trauma patients, we’re working up the surgical side, then everything becomes medical."
Save your patient’s life
The steps you take when a trauma patient arrives potentially can save a patient’s life, emphasizes Cohen. "What you do in the time between receiving the patient and assessing and resuscitating them in time for surgery is what makes the difference for the patient’s life," she says.
To improve care of trauma patients, do the following:
• Don’t assume you always will see tachycardia when looking for signs of shock.
Tachycardia is a sign of possible hypovolemic shock in trauma patients, says Cohen. "This is the most common form of shock in the trauma patient," she explains. "It is the result of a dropping cardiac output, indirectly measured by blood pressure."
Although tachycardia is the key clinical sign of early shock, it won’t be present in some patients, such as individuals on beta-blockers, says Cohen. In this case, you’ll need to consider other clinical assessment findings, such as decreasing blood pressure, decreasing level of consciousness, and obtunded abdomen, she says.
The patient still may be in hypovolemic shock state even though you don’t see an increased heart rate, says Cohen. "The heart rate will never get up there, because the patient is on beta-blockers," she says. "Until proven otherwise, go with the worst-case scenario: Assume that the patient is in hypovolemic shock."
• Don’t place patients with known spinal injuries on longboards.
You mistakenly may believe that a longboard protects a trauma patient’s spine, but this belief is inaccurate, according to Glenn Carlson, RN, MSN, CCRN, clinical nurse specialist at Bronson Methodist Hospital in Kalamazoo, MI.
"The only purpose a longboard serves is convenience during transport," he says. "The long board does not protect the spine, unless the patient is strapped in such a way that would prevent them from sitting up."
Use spinal precautions to prevent further injury, says Carlson.
If a patient has a known spinal injury, remove patients from the longboard as soon as possible, he advises. "Do not place the patient back on a long-board when an injury is known," says Carlson. "The problem with the longboard is pressure ulcer development that can occur within 45 minutes."
However, the ulcer may not be evident for 24-48 hours, and by then, it could be a Stage II ulcer or worse, he adds.
"If a patient is uncooperative and consistently tries to get up, a longboard can be utilized as long as the straps also are utilized," Carlson says. Also in this situation, consider sedation to protect the patient, he says. "Once all patient transport has been accomplished, remove the longboard and continue with spinal precautions," Carlson advises.
Glasgow: The gold standard
• Know how to assess for brain injury.
The Glasgow Coma Scale is the gold standard for assessment of neurological status after a head injury, says Carlson. Obtain a baseline score, and perform continuous assessments, he advises.
"The frequency can be as much as every 10 minutes for unstable head injured and four hours for the stable head injured patient," says Carlson. "The standard is at minimum hourly and as needed."
The importance of maintaining a systolic blood pressure of more than 90 mmHg cannot be overemphasized, says Carlson. "Those who have even a transient drop in systolic blood pressure can suffer secondary brain injury that may determine their outcome for quality of life and survival," he says.
Patients with head injuries should have vital signs measured at least every hour and more frequently as necessary, advises Carlson. "It is especially important to assess blood pressure and heart rate in response to treatments like fluid resuscitation," he says.
• Identify supplies needed during transport.
If you are taking the patient outside of the ED for diagnostic testing, check that your monitor batteries are full, and be sure you have extra fluids, a bag-valve mask, and sedation medication if needed, says Kelli Vaughn, RN, BSN, CEN, trauma coordinator at John D. Archbold Memorial Hospital in Thomasville, GA.
"Take the extra time to think about possible scenarios and what you may need if the scenario occurred," she says. For example, if an intubated, chemically paralyzed patient needs a computed tomography scan, bring extra medications with you in case the paralytic wears off, she advises.
The department you are taking the patient to may have everything you need, but you may not be familiar with the location of these items, she notes. "Once a patient becomes unstable, seconds count," says Vaughn. "You do not need to spend that time searching for equipment."
Sources
For more information on improving care of trauma patients, contact:
- Glenn Carlson, RN, MSN, CCRN, Clinical Nurse Specialist, Bronson Methodist Hospital, 601 John St., Kalamazoo, MI 49007. Telephone: (269) 341-8424. E-mail: [email protected].
- Sharon S. Cohen, RN, MSN, CEN, CCRN, Trauma Clinical Nurse Specialist, Broward General Medical Center, 1600 S. Andrews Ave., Fort Lauderdale, FL 33316. Telephone: (954) 355-4990. Fax: (954) 468-5270. E-mail: [email protected].
- Kelli Vaughn, RN, BSN, CEN, Trauma Coordinator, John D. Archbold Memorial Hospital, P.O. Box 1018, Thomasville, GA 31799-1018. E-mail: [email protected].
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