Introduction
Emergency management of a patient with multiple trauma is complex and takes place in several stages requiring a great deal of specialized forces and expertise for providing care.
Definition
Emergency nursing care of trauma patients is the process of integrating professional practices in limiting the impact of injury, aiding in healing, and recovery of the patient.
Goals
- To identify and treat life-threatening injuries.
- To prevent exacerbation of existing injuries or the appearance of additional injuries.
Principles
- Complete paraclinical and imaging for diagnosis in the presence of clinical signs.
- “Golden hour,” which emphasizes the importance of rapid sequences of diagnosis and treatment.
- Assess, intervene, and reassess.
Primary Assessment and Management
The concept of the “golden hour” refers to the first hour after the accident, during which the patient is advised to report to a trauma center and receive definitive treatment.
The approach includes the following:
- Triage in case of multiple victims.
- Primary assessment-ABCDE-with immediate therapeutic measures for patients with life-threatening injuries.
- Consideration of the need for patient transfer to a more specialized medical center.
- Secondary survey, which includes a complete physical examination, “head-to-toe,” and patient medical history.
- Continuous monitoring and re-evaluation.
- Definitive care.
Emergency and Trauma Care Management
| Observation | Management |
| ABCDE Assessment | Airway Insert an airway or endotracheal tube.Proceed to orotracheal intubation in patients with altered GCS less than 9. Prepare for suction at airway level.Insert a gastric tube in all intubated patients and non-intubated patients; it decreases the risk of vomiting and aspiration. Tracheostomy: In patients with severe isolated “traumatic brain injury,” tracheostomy is performed in the second or third week after admission. |
| Breathing Assess the quality of breathing and administer supplementary oxygen. Use mechanical ventilation when needed.Insert a chest tube if needed; it is mandatory for patients with pneumothorax (diagnosed) to have a chest drainage tube. | |
| Circulation Control external bleeding.Establish two large-caliber intravenous lines and begin crystalloid solution infusion. Restore blood volume losses using crystalloid fluid and blood. Insert a urinary catheter to monitor urine output. Monitor the patient’s cardiac rhythm and rate. | |
| Disability (neurological intervention) The rigid column strap with head-side stabilizers and the front and lumbar fastening bands is used to achieve complete immobilization of the spine after patient evaluation and airway management have been performed. | |
| Exposure and environmental Cover the patient with warm blankets or an external warming device to prevent developing hypothermia. | |
| Positioning | The patient should be positioned properly with the neck in neutral position and the head end of the bed elevated to 30° which facilitates cerebral venous drainage especially for patients with CSF rhinorrhea and otorrhea.Rigid cervical collars should be loosened or removed to decrease ICP. |
| Brain tissue oxygen-directed management | Early recognition and removal of hematomas. Intubation and ventilation with FiO2 and minute ventilation adjusted to set SpO2 >93% and to evade PaO2 <60 mmHg.PaCO2 set at 35-45 mmHg unless ICP is increased when PaCO2 is maintained between 30 and 40 mmHg. Maintenance of normothermia (~35°C-37°C).Sedation by administering propofol during the initial 24 hours, succeeded by sedation and analgesia with lorazepam, morphine, or fentanyl. Head end elevated to 15°-30° and knee elevated. If seizures are present, administer anticonvulsants (phenytoin) for 1 week or more. Treat hypovolemia by administering a crystalloid infusion (0.9% normal saline, 20 mEq/L, KCI 80-100 mL/h). |
| Temperature management | Normothermia should be maintained with the use of antipyretic medications, surface cooling devices, or even endovascular temperature management catheters. |
| Stress ulcer (Curling’s ulcer) prophylaxis | Early enteral feeding.H2 blockers, proton pump inhibitors. Sucralfate is recommended for the prophylaxis of stress ulcers. |
| Nutrition | Early initiation of nutrition is recommended.Parenteral nutrition is superior to enteral nutrition in improving outcomes.1-1.5 g/kg protein is recommended. |
| Fluid therapy | Restoring vascular capacity, tissue perfusion, and cardiac flow rate.Hypertonic saline can be used for patients with complications of traumatic brain injury and systemic shock. |
| Hemostatic therapy | Prothrombin complex concentrate, fresh frozen plasma, and/or vitamin K should be given for patients with warfarin-associated intracerebral hemorrhage (ICH).Platelet count should be maintained >75,000 with platelet transfusions, if necessary, for patients with thrombocytopenia. |
| Glucose management | Patients with hyperglycemia should be managed with insulin protocol in patients with value >200 mg/dL for improving the outcome. |
| Medical management | Prevent increased intracranial pressure. |
| Surgical management | Depressed skull fractures that are open or complicated need surgical repair.Decompressive craniectomy helps in positive patient outcome. |
Functions of the Emergency Nurse
- Use triage to determine priorities based on assessment and anticipation of the patient’s needs.
- Provide direct measures to resuscitate, if necessary.
- Provide preliminary care before the patient is transferred.
- Supervise patient care and ancillary personnel.
- Provide health education, support, and protection for the patient and family.
Documentation
- Document the date, time, and treatment received by the patient.
- Document complications if any for further communication and management.
Evaluation
Patient:
- Attained patent airway.
- Obtained optimum gas exchange.
- Shows no signs of complications.
- Is hemodynamically stable.
Special Considerations
- Understanding the cause of trauma helps predict potential complications.
- The first hour after injury is critical for survival and reducing long-term complications.
- Apply direct pressure, tourniquets, or hemostatic agents to stop bleeding.
- Maintain cervical spine immobilization if spinal injury is suspected.
- Use splints or traction to stabilize fractures and prevent further damage.
- Prioritize oxygenation, ECG monitoring, and medication administration for conditions like myocardial infarction.
- Rapid intervention for stroke, seizures, or traumatic brain injury is essential.
- Ensure airway patency and provide oxygen therapy or mechanical ventilation if needed.
- Children have unique physiological responses to trauma and require specialized care.
- Older adults may have pre-existing conditions that complicate trauma management.
- Trauma can affect both maternal and fetal health, requiring OB-GYN consultation.
- Monitor blood pressure, heart rate, oxygen saturation, and neurological status.
- Use analgesics while avoiding medications that may worsen underlying conditions.
- Ensure proper positioning, wound care, and infection control.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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