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MICHAEL PETRI, a 54-year-old They also place a 16-gauge intra- injury. But learning details about
roofer, just fell 20 feet from a venous (I.V.) catheter in his left the mechanism of injury can help
building under construction. Ini- forearm and begin an infusion of them predict the types and com-
tially he struck the ground with 0.9% sodium chloride solution. binations of injuries that he may
his feet, then fell onto his left side. If Michael were on his way to have sustained—information that
Conscious and alert at the scene, your hospital’s emergency depart- will help you and the other team
he complains of severe back and ment (ED) for treatment, would members plan effective care.
lower leg pain. His vital signs are: you be prepared to provide imme- Mechanism of injury describes
BP, 140/88; heart rate, 112; respira- diate and appropriate nursing the circumstances and energy
tory rate, 28; SpO2, 96%; and tem- care? In this article, I’ll explain forces that produced the trauma,
perature, 98° F (36.7° C). His the primary and secondary assess- usually blunt or penetrating.
Glasgow Coma Scale (GCS) score ment surveys you need to com- Examples of blunt force trauma
is 15. Michael’s odds of survival plete as soon as he arrives and include injuries from motor-
are good: Of trauma patients who discuss how your findings guide vehicle crashes, falls, assault,
enter the trauma care system with nursing and medical interven- industrial incidents, blast force,
vital signs intact, more than 95% tions. But first, let’s review how to and sports-related injuries. Pene-
survive. prepare for a trauma patient’s trating trauma injuries include
Paramedics administer oxygen arrival in the ED. stab and gunshot wounds,
at a flow rate of 15 liters/minute impaled objects, and damage
via non-rebreather mask and apply Getting ready for your patient from projectiles.
a cervical collar and a backboard to Trauma team members must be As the trauma team awaits
immobilize his neck and spine. prepared to deal with any type of Michael’s arrival at the hospital,
they review the information the arrive, don a fluid-impervious life-threatening injuries are dis-
paramedics provided by radio and gown, gloves, and face and eye pro- covered, the team intervenes to
discuss their concerns about his tection, such as a face shield or optimize oxygenation, ventilation,
possible injuries based on his goggles and mask, in case blood and perfusion. Interventions
mechanism of injury. Knowing that splashes. Ensure ready access to include clearing the airway, pro-
Michael has had a blunt injury personal protective equipment to viding supplemental oxygen, ven-
mechanism and that he landed on prevent delays in patient care. tilating the patient, controlling
his feet in the fall, team members Trauma care always begins with hemorrhage, inserting I.V. devices
suspect they’ll find lumbar spine the primary survey, a rapid assess- and chest tubes, and replacing flu-
compression fractures and lower ment of the patient’s ABCs— ids and blood.
extremity trauma—particularly cal- airway, breathing, and circula- Diagnostic studies follow the
caneus fractures. Knowing that he tion—with the addition of D (dis- primary and secondary surveys,
suffered an impact to his left side, ability) and E (exposure). although blood is usually drawn
they’ll also be ready to assess for The primary survey focuses on when I.V. lines are placed during
traumatic injuries to the chest and what can kill the patient now. It’s the primary survey. Test results fur-
abdomen. followed by the secondary survey, ther define the nature and severity
Your first priority as a member of a complete head-to-toe assess- of the injuries and help guide the
the trauma team is to protect your- ment to identify other serious treatment plan.
self from exposure to blood and injuries that could kill or disable Now let’s take a closer look at
body fluids. Prepare to use standard the patient later. how assessment and interventions
precautions, which are mandatory. Resuscitation occurs simultane- mesh during the crucial first hour
While you wait for the patient to ously with the primary survey. As after an injury.
have the resources to provide the Meeting the standard of care Laskowski-Jones L, Toulson K. Emergency and
mass casualty nursing. In Ignatavicius D, Work-
care he needs, he may need to be Key outcome measures will help man ML (eds), Medical-Surgical Nursing: Critical
transferred to a trauma center. you to determine how well the Thinking for Collaborative Care, 5th edition.
Philadelphia, Pa., Elsevier Saunders, 2006.
In a facility that can provide patient has responded to resusci- Peitzman AB, et al. The Trauma Manual, 2nd edi-
trauma management, the patient tation and help you anticipate his tion. Philadelphia, Pa., Lippincott Williams &
Wilkins, 2002.
may go to the operating room, in- needs. (See Adequate resuscita-
Rapid Response to Everyday Emergencies: A Nurse’s
tensive care unit (ICU), or a surgi- tion? Watch for these indicators.) Guide. Philadelphia, Pa., Lippincott Williams &
cal unit after his trauma workup. An organized team approach in Wilkins, 2006.
Most patients go home after dis- the first hour after a traumatic Linda Laskowski-Jones is vice-president of emer-
charge, but some require inpatient injury provides fast, efficient gency, trauma, and aeromedical services at
Christiana Care Health System in Wilmington, Del.
rehabilitation first. patient care and saves lives.
In Michael’s case, the surgeon Because you and other team mem- The author has disclosed that she has no significant
relationship with or financial interest in any commer-
admits him to the ICU for close bers prioritized assessment and cial companies that pertain to this educational activity.
INSTRUCTIONS
Responding to trauma: Your priorities in the first hour
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1. Which of the following is an example 7. If your patient has a radial pulse, his 13. If typed, crossmatched blood isn’t
of blunt force trauma? systolic BP is at least available, which blood type should a
a. stab wound c. impalement a. 50 mm Hg. c. 70 mm Hg. 24-year-old woman receive?
b. fall injury d. gunshot wound b. 60 mm Hg. d. 80 mm Hg. a. group O, Rh-negative
b. group O, Rh-positive
2. What’s always the first intervention 8. Which of the following is an early sign c. group AB, Rh-negative
for a trauma victim? of hypovolemic shock? d. group AB, Rh-positive
a. Maintain a patent airway. a. cool, damp skin c. unresponsiveness
b. Check vital signs. b. agitation d. bradycardia 14. After a patient with a hemoglobin
c. Perform a head-to-toe assessment. level of 7 grams/dL receives two units of
d. Control hemorrhage. 9. What’s the first intervention for packed RBCs, his hemoglobin level
copious bleeding from a hand wound? should increase to
3. Until cervical spine injury is ruled out, a. Apply direct pressure to the wound. a. 8 grams/dL. c. 10 grams/dL.
open the airway by using a b. Apply pressure over the radial artery. b. 9 grams/dL. d. 11 grams/dL.
a. jaw lift. c. Apply pressure over the radial and ulnar arteries.
b. jaw-thrust maneuver. d. Apply a tourniquet to the wrist. 15. Which statement about the GCS is
c. head-tilt—chin-lift maneuver. true?
d. head-tilt—neck-lift maneuver. 10. What’s the best position for a a. It should be deferred until after pain medication
responsive patient with symptomatic is given.
4. For a trauma patient, when’s the best hypotension? b. A score of 15 demonstrates severe brain injury.
time to insert a gastric tube? a. his head 6 inches lower than his body c. It helps to predict outcomes and disability.
a. before intubation b. his legs elevated 8 inches higher than his heart d. It shouldn’t be used if the patient appears
b. simultaneously with intubation c. reverse Trendelenburg intoxicated.
c. very soon after intubation d. recovery position
d. An intubated patient doesn’t need a gastric tube. 16. Tetanus prophylaxis is indicated if the
11. The smallest bore I.V. catheter insert- patient hasn’t been immunized in the last
5. Crepitus on palpation of the neck and ed in a trauma patient should be a. 2 years. c. 4 years.
chest is a sign of a. 14-gauge. c. 18-gauge. b. 3 years. d. 5 years.
a. cervical spine injury. c. pneumothorax. b. 16-gauge. d. 20-gauge.
b. flail chest. d. hemorrhage. 17. MRI is best indicated for
12. For a clinically unstable trauma a. a mottled leg.
6. The first intervention needed for a patient patient, give packed RBCs after b. an eye injury incurred in a machine shop.
with heart rate of 150 beats/minute, systolic a. infusing D5W for 30 minutes. c. an acute spinal cord injury.
BP of 70 mm Hg, respiratory rate of 40, b. typing and crossmatching. d. a sudden loss of consciousness.
and unilateral diminished breath sounds c. providing 2 mL of 0.9% sodium chloride for
is most likely emergency each 1 mL of blood lost.
a. chest decompression. c. ABG monitoring. d. administering 2,000 mL of lactated Ringer’s.
b. chest radiograph. d. intubation.
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