Dramatically improve care of your trauma patients

Be honest: Are you truly comfortable caring for trauma patients? Many ED nurses rarely see these cases, notes Pat Manion, RN, MS, CCRN, CEN, trauma coordinator at Genesys Regional Medical Center in Grand Blanc, MI.

"Whether the nurse works in a large urban ED or a smaller community hospital, the major trauma patient is always a challenge," she says.

Simple practice changes can be potentially life-saving to these patients, she adds. You can significantly improve care of trauma patients by taking the following steps:

  • Obtain an accurate temperature as soon as possible on all trauma patients.

There is a tendency to think that "the patient is too sick to bother with this" or that other things are much more important, says Jean M. Marso, BSN, RN, trauma coordinator at University of Colorado Hospital in Denver.

"Hypothermia only creates more problems for trauma patients, and you need a baseline temperature to know where you are starting from," she says.

Always warm all intravenous (IV) fluids and blood products, says Marso. If warm fluids aren’t enough, you may need to increase the room temperature, add a warming blanket or keep the patient covered by exposing only one part of the body at a time, she adds.

"You won’t know if these measures are enough if you don’t have a baseline body temperature to compare serial temperatures to," she explains.

  • Before obtaining a urine specimen, empty the urinary drainage bag.

"It is easier to monitor the urine output when you start with an empty bag," says Manion. Monitoring urine output is one of the assessment parameters to determine adequate resuscitation, she explains. Intensive care units routinely monitor urine output with special urinary drainage bags, but these bags are rarely used in the ED, Manion adds.

"Starting with an empty urinary drainage bag allows almost continuous visual monitoring of urine output," she says.

  • Keep patients warm.

"There are many factors that can rapidly lead to hypothermia in a trauma patient," says Manion. This is one component of the "trauma triad of death" of hypothermia, academia, and coagulopathy, she notes. Patients are at risk from wet clothing, pre-hospital environmental temperatures, removal of clothing in the trauma bay, the use of intravenous fluid that has not been warmed, and irrigation of open wounds, she says.

By applying three warm blankets horizontally — one from the neck to the lower chest, one from the lower chest to the groin, and one from the groin to the feet — you can continue the physical exam without baring the patient’s entire body, says Manion.

"Keeping the patient covered is a simple way of preventing loss of body heat," she says.

  • Ensure that pelvic fractures are initially stabilized.

"Open-book" pelvic fractures can potentially cause significant blood loss into the retroperitoneal space, and "closing the book" can stabilize the pelvis and decrease the amount of blood loss, Manion notes.

This closing can be accomplished in a variety of ways, including application of an external fixater, use of a pneumatic antishock garment, or commercially available pelvic orthotic devices, says Manion. "If none of these options are available to you, then wrap the pelvis snugly in a sheet and tie the patient’s ankles together," she says. "Do not cross the ankles."

  • Administer uncrossmatched blood using the rapid infuser/fluid warmer.

Uncrossmatched blood is refrigerated, so the patient is in danger of losing a lot of body heat when this blood is being administered, notes Timothy Murphy, RN, MSN, APN, C, nursing director for the trauma program at Robert Wood Johnson University Hospital in New Brunswick, NJ. "If a patient is sick enough to need uncrossmatched blood, then they are probably receiving lots of fluid," he says.

These patients are also susceptible to developing hypothermia from blood loss and receiving large amounts of cool fluid, he says. "The colder they get, the more they bleed."

New trauma nurses often wonder when to set up the Level I rapid infuser/fluid warmer because it is very time-consuming and labor-intensive, he says. This should be done whenever uncrossmatched blood is given, Murphy says.

Other warming techniques include adjustment of the thermostat in the room, a convection warmer, warming lights, or warmed humidified oxygen for ventilated patients, he adds.

  • Record intake and output.

"Many charts that I review do not have this recorded," says Marso.

A Foley catheter usually is put in place for trauma patients, whether stable or unstable, but often no one writes down the initial output, subsequent hourly outputs, or the total output, she says.

"Certain trauma patients are at increased risk for acute respiratory distress syndrome, and the kidneys are a great window to view how the body is responding to resuscitation," Marso says.

Sources

For more information on improving care of trauma patients, contact:

  • Pat Manion, RN, MS, CCRN, CEN, Trauma Coordinator, Genesys Regional Medical Center, One Genesys Parkway, Grand Blanc, MI 48439. Telephone: (810) 606-7891. Fax: (810) 606-9515. E-mail: PManion@genesys.org.
  • Jean M. Marso, BSN, RN, Trauma Coordinator, University of Colorado Hospital, 4200 E. Ninth Ave., Mail Stop A021-630, Denver, CO 80262. Telephone: (303) 372-8905. Fax: (303) 372-0267. E-mail: jean.marso@uch.edu.
  • Timothy Murphy, RN, MSN, APN, C, Nursing Director, Trauma Program, Robert Wood Johnson University Hospital, One Robert Wood Johnson Place, New Brunswick, NJ 08903-2601. Telephone: (732) 418-8095. Fax: (732) 418-8097. E-mail: timothy.murphy@rwjuh.edu.