Use these tips for severe trauma injuries in your ED

Delays can dramatically affect outcomes

On the way to being rushed to a Level 1 trauma center after being hit by a car, a boy's airway suddenly filled with blood. As a result, he was diverted to Arlington Heights, IL-based Northwest Community Hospital's ED, where nurses immediately suctioned the child to clear his obstructed airway. Two large bore intravenous lines (IVs) were started to ensure the patient's volume was stabilized due to the blood loss.

"We were able to intubate him, ensuring his stability, and they were able to continue on to the Level 1 hospital," says Laura Aagesen, RN, MBA, Northwest's trauma coordinator. "The child was discharged to a rehabilitation facility and later was able to go home to his family. Without clearing the airway and establishing a more definitive airway, the patient would have died. "

No matter what the size or capabilities of your ED, always be ready for a trauma case to come through your doors, says Aagesen. "Do equipment and stock checks every shift so equipment is available and ready to use in seconds," she recommends. "Severely injured patients will at times appear at your doorstep."

To improve care of trauma patients, do the following:

• Always use a standardized approach.

"This ensures your initial evaluation will capture all injuries, both severe and minor," says Aagesen. "Using the ABCs allows you to intervene on a life-threatening injury and avoid depleting your already critical patient of oxygen and fluids which are essential for survival."

Once you are sure the tongue or foreign body is not obstructing the patient's ability to breathe, move on to assessing the patient's breathing, Aagesen says. "The rate, depth, and labor of respirations, along with breath sounds, are an indication of the effectiveness of a patient's ability to breathe," she says. "Circulation is then evaluated by the overall appearance of the patient."

Altered mental status, restlessness, anxiety or confusion, skin temperature, and color can be indicators of poor perfusion and risk for shock, says Aagesen. "Large-bore IVs need to be established to ensure the ability to give large boluses or warmed fluids or blood to the patient," she says.

Your findings may call for intubations, needle decompression, or pericardiocentesis to correct a life-threatening injury, says Aagesen. "Immediate intervention is the key to the patient's stabilization and recovery," she says.

• Don't underestimate the severity of injury.

"This often results in being taken off-guard when diagnostics such as a [computerized tomography] scan reveal life-threatening injuries, or when the patient's mental status or vital signs become unstable," says Aagesen.

Your patient may appear to be stable and doing well on arrival, but if injuries go undetected, the patient could deteriorate slowly, she says. "Quick interventions to rule out such injuries should be done with a heightened sense of urgency, similar to a patient with chest pain being ruled out for a myocardial infarction," says Aagesen.

One elderly man's condition suddenly deteriorated after he presented for a trip and fall injury with normal vital signs. His heart rate gradually climbed to the 130s and his blood pressure dipped to 90/30. "When I went to fix his gown, I saw his ribs were purple. I did a full body check and found the simple abrasions that he presented with were now hematomas and large areas of ecchymosis," says Regina Curry, RN, an ED nurse at Thomas Jefferson University Hospital in Philadelphia.

The man's nose started to bleed profusely, and Curry alerted the ED physician, placed another intravenous line, and sent for a second complete blood count. "The hemoglobin came back at five. This patient then became an ICU [intensive care unit] candidate and required 1:1 nursing to stabilize him," she says.

• Give each ED nurse a specific role.

At Thomas Jefferson's ED, each nurse has a specific role when an unstable critically ill trauma patient arrives, says Curry. "One nurse is designated to document, and the other will get IV access and have critical care medications on hand ready to administer," she says. "They will get the equipment for intubation and central line insertion at the bedside ready to go."

Potentially lifesaving treatments in the ED include airway management, putting tourniquets on arterial bleeding, and placing chest tubes — and all of these require a team approach, says John Kelly, RN, MBA, nurse manager of the ED at Boston Medical Center. "It is crucial that we all work together for the patient and that we get the patient where they need to go," he says. "Whether that is to the operating room, surgical ICU, or CT, unnecessary delays can have a dramatic impact on a trauma patient's outcome."

Sources

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

  • Laura Aagesen, RN, MBA, Trauma Coordinator, Northwest Community Hospital, Arlington Heights, IL. Phone: (847) 618-4005. E-mail: laagesen@nch.org.
  • Regina Curry, RN, Emergency Department, Thomas Jefferson University Hospital, Philadelphia. E-mail: reginacurry@usa.net.
  • John Kelly, RN, MBA, Nurse Manager, Emergency Department, Boston Medical Center. Phone: (617) 414-4208. Fax: (617) 414-4205. E-mail: john.kelly@bmc.org.