1. By: Michael Putnam RN Adapted from ENA; TNCC
Trauma Management
By: Michael Putnam RN
Adapted from ENA; TNCC
Info from TNCC

2. Overview
Trauma patients are treated very differently depending on the type hospital you are in
People usually attend to the most graphic of injuries first
This often lead to other more serious injuries being missed

3. Overview con’t
The Emergency Nurses Association (ENA) established a set of evidence based practices that could be used internationally: Trauma Nursing Core Curriculum (TNCC)
In York Region most trauma is diverted to Sunnybrook based on the field trauma triage guidelines
Peads Trauma goes to Sick Kids
Trauma Triage guidelines
Blunt or penetrating trauma with signs of hemodynamic instability defined by bp less than 90 mmHg or hypovolemia
+/- crush injuries
3rd degree burns >10% bsa or over joints, chest, and face or neck
4 over 16 y/o or showing secondary sex characteristics
CONTRAINDICATIONS
Unsecured airway except pentrating trauma
Travel time >30min from transport decision
ACP vs PCP
If pcp is unable to control airway then no transfer
Paeds…. Decision of Base Hospital Program the must patch for order

4. Patient Management A – Airway B – Breathing C – Circulation
D – Disability
E – Expose/Environment
F – Five Interventions/Full Vitals
G – Give Comfort
H – History/Head to Toe
I – Inspect the Back
This is the RN approach to Trauma… the MD ATLS is slightly different, but the concepts are the same….

5. IMPORTANT Like all things they must be done in order.
1 comes before 2 and A comes before B

6. EMS History Taking MIVT format Mechanism Injuries Sustained
Vital Signs
Treatment Rendered
Have the crew remain until you are certain you have all the information
*** photo’s

7. Airway Assess Interventions C – Spine must be maintained!
Patent? Obstruction? Vocalizing?
Interventions
Suction, Jaw Thrust, OPA, NPA, ETT, NTT, surgical airway.
C – Spine must be maintained!
R/T will be invaluable in controlling airway, however you should be able to manage it in the interim.

8. Breathing Assess Interventions
Breathing? (rate, rhythm) chest symmetry, integrity of chest, accessory muscle use, chest auscultation, trachea position, jugs
Interventions
O2 by NRB
BVM if necessary
Chest tube, chest seal, needle decompression if needed

9. Circulation Assess Interventions
Pulse? Present? Skin condition, exsanguating trauma, BP (if enough people), heart sounds
Interventions
CPR
Control bleeding, elevate,
IV (2X 14G or 16G): Use warmed solutions when possible or central line? Blood or N/S
Labs
Thoracotomy
Pneumatic Anti-shock garments – very rarely used but can be very effective
Thoracotomy – very rarely done at YCH pt will require immediate transfer to tertiary care

10. A Note on Fluid Resuscitation
Bigger is better…a 14 G peripheral line is better than a 3 Lumen Central Line.
Central Line options
6 – 8.5F cordis, 2-3 lumen, 1-3 lumen slic
Crystalloid versus colloid
Saline versus Ringers
IV line choices
Gravity versus pump
Colloid infusions… 3-5 units prbc’s = ffp
In relatively healthy adult start with 2 L fluid challenge
For central line… subclavian is primary choice, but take what you can get.

11. Disability (mini-neuro)
A- Alert
V – Verbal
P – Painful
U – Unresponsive
Pupils: Size - Equal, Reactive to Light?
GCS… Sum of its parts more important than the total
GCS is more important as the sum of its parts versus the total number
E 1-4
V 1-5
M 1-6

12. Secondary Identify most life threatening injuries by this point
Secondary assessment will identify other minor injuries

13. Expose/Environment Removal of all clothing, board straps, etc.
Attempt to maintain warmth where possible
Warmed fluids, blankets

14. Five Interventions
Monitor with SpO2 and BP (12 lead) maintain SpO2  95%
Foley – Contraindicated?
N/G Tube – Contraindicated?
Labs (if not done in “C”)
Family

15. Give Comfort Pain control Verbal reassurance Stimuli reduction
Advocate for your patient…. Fentanyl is a good choice… potent narcotic.. Rapid on.. Rapid off

16. History MIVT Domestic Violence ? PmHx, Meds, Allergies, LNMP
Tetanus Status

17. Head to Toe Soft Tissue Injuries Bony Deformities Full Neuro exam
Eyes, Ears, Nose, Neck
Chest, Abdo, Pelvis, Extremities

18. Inspect
Roll Patient off Back Board inspect the back/posterior with Log Roll
Keep Neck Stable at all times!

19. trauma.org

20. trauma.org

21. Charting Example Pt arrived to 14B @1432 CTAS 1
M – 32 y/o female belted driver into concrete embankment at minimum 100km/h, no airbag, star pattern on windshield, 30 minute extrication time.
I - ? Closed head injury was initially conscious GCS 13 now GCS 3, ? # L femur
V – initially 138/70 HR 110 Resp 24 now 100/50 HR 130 Resp 6
T – OPA, collar, board, assist resps with BVM, sager to L femur, IV 18 G to R Hand with N/S at KVO
A – clear, no vomit, no blood, no teeth OPA in place no apparent gag, intubation by MD lidocaine 100mg 1435 etomidate 20mg IV by 1436 Sux 80mg IV by Insert 8.0 ETT 23cm at teeth, positive bilateral breath sounds, and positive ETCO2. Easy to bag.
B – ventilate at 12/min chest clear, no trauma identified, chest stable no crepitus or deformity.
C – pulse 95/min strong and regular. Skin pale warm and dry, B/P 95/40. 2nd iv 14 G into L A/C with N/S at KVO labs drawn from reseal.
D – pupils L 4 R 6 non reactive.

22. Salvation from tragedy…
Organ Donation…
Salvation from tragedy…

23. Questions
trauma.org

24. Take Home Points A,B,C,D Keep them warm IV’s bigger the better
Only do what needs to be done to get them out, or does not delay transfer.

25. Summary We don’t get much trauma What we do get we can be better at
Think transfer early