Abstract

Follow this a quick, evidence-based system to guide your initial

assessments and interventions of a patient who's sustained
serious traumatic injuries.

Article Content

Michael Petri, a 54-year-old roofer, just fell 20 feet from a building

under construction. Initially he struck the ground with his feet,
then fell onto his left side. Conscious and alert at the scene, he
complains of severe back and lower leg pain. His vital signs are:
BP, 140/88; heart rate, 112; respiratory rate, 28; Spo 2, 96%; and
temperature, 98[degrees] F (36.7[degrees] C). His Glasgow Coma
Scale (GCS) score is 15. Mr. Petri odds of survival are good: Of
trauma patients who enter the trauma care system with vital
signs intact, more than 95% survive.
Paramedics administer oxygen at a flow rate of 15 L/minute via
non-rebreather mask and apply a cervical collar and a backboard
to immobilize his neck and spine. They also place a 16-gauge I.V.
catheter in his left forearm and begin an infusion of 0.9% sodium
chloride solution.
If Mr. Petri were on his way to your hospital's ED for treatment,
would you be prepared to provide immediate and appropriate
nursing care? In this article, I'll explain the primary and secondary
assessment surveys you need to complete as soon as he arrives
and discuss how your findings guide nursing and medical
interventions. But first, let's review how to prepare for a trauma
patient's arrival in the ED.

Getting ready for your patient

Trauma team members must be prepared to deal with any type of
injury. But learning details about the mechanism of injury can help
them predict the types and combinations of injuries that he may
have sustained-information that will help you and the other team
members plan effective care.

Mechanism of injury describes the circumstances and energy

forces that produced the trauma, usually blunt or penetrating.
Examples of blunt force trauma include injuries from motor
vehicle crashes, falls, assault, industrial incidents, blast force, and
sports-related injuries. Penetrating trauma injuries include stab
and gunshot wounds, impaled objects, and damage from
projectiles.
As the trauma team awaits Mr. Petri arrival at the hospital, they
review the information the paramedics provided by radio and
discuss their concerns about his possible injuries based on his
mechanism of injury. Knowing that Mr. Petri has had a blunt injury
mechanism and that he landed on his feet in the fall, team
members suspect they'll find lumbar spine compression fractures
and lower extremity trauma-particularly calcaneus fractures.
Knowing that he suffered an impact to his left side, they'll also be
ready to assess for traumatic injuries to the chest and abdomen.
Your first priority as a member of the trauma team is to protect
yourself from exposure to blood and body fluids. Prepare to use
standard precautions, which are mandatory. While you wait for the
patient to arrive, don a fluid-impervious gown, gloves, and face
and eye protection, such as a face shield or goggles and mask, in
case blood splashes. Ensure ready access to personal protective
equipment to prevent delays in patient care.
Trauma care always begins with the primary survey, a rapid
assessment of the patient's ABCs-airway, breathing, and
circulation-with the addition of D (disability) and E (exposure).
The primary survey focuses on what can kill the patient now. It's
followed by the secondary survey, a complete head-to-toe
assessment to identify other serious injuries that could kill or
disable the patient later.
Resuscitation occurs simultaneously with the primary survey. As
life-threatening injuries are discovered, the team intervenes to
optimize oxygenation, ventilation, and perfusion. Interventions
include clearing the airway, providing supplemental oxygen,

ventilating the patient, controlling hemorrhage, inserting venous

access devices and chest tubes, and replacing fluids and blood.
Diagnostic studies follow the primary and secondary surveys,
although blood is usually drawn when I.V. catheters are placed
during the primary survey. Test results further define the nature
and severity of the injuries and help guide the treatment plan.
Now let's take a closer look at how assessment and interventions
mesh during the crucial first hour after an injury.

Primary survey: Managing immediate threats

By taking a standardized approach to assessment and treatment,
the trauma team can address the most significant risks to life
first. As always, start with the ABCs.
Airway. The first part of the primary survey is always assessing
the airway. This includes checking for potential injury to the
cervical spine. Until cervical spine injury has been ruled out, open
the patient's airway using a jaw-thrust maneuver with manual, inline stabilization of the neck. If you find food, blood, vomitus, or
other debris, suction the airway quickly to prevent aspiration. To
better remove secretions, you may need to carefully logroll the
patient to his side. Manually stabilize his neck and spine as you do
so.
If the patient can't maintain a patent airway because of copious
secretions, an impaired level of consciousness, or other critical
injuries, he'll need endotracheal intubation. Insert a largediameter (18 French catheter) gastric tube as soon as possible
after intubation to decompress his stomach and remove gastric
contents. Remember, even after the airway has been secured, he
could still vomit and aspirate.
If the patient has any head or midface trauma, pass the gastric
tube orally. Nasogastric tube insertion would be risky because a
disruption of the cribriform plate (the bone between the sinuses
and the brain) could allow the tube to be inadvertently inserted
into the cranium.

If massive facial injuries prevent oral endotracheal intubation, the

patient will need surgical airway placement (typically a
cricothyrotomy).
When Mr. Petri is brought into the trauma room, he can speak
clearly and provide an account of the accident. Because he can
converse, his airway assessment is straight-forward: He has a
patent airway. However, he's still considered to be at risk for
cervical spine injury. Spinal precautions continue until cervical
injury is ruled out.
Breathing. Assess your patient's breathing next. Note respiratory
rate and depth, chest expansion, and accessory muscle use and
auscultate breath sounds bilaterally. Also palpate for crepitus or
subcutaneous air in the neck and chest, which can indicate a
pneumothorax or airway injury. Find out if he has pain with
breathing or on palpation. Injuries that can impair ventilation
include rib fractures (especially a flail chest), a pneumothorax, a
hemothorax, and spinal cord or head trauma.
Supplemental oxygen is always indicated at this stage. For a
spontaneously breathing patient like Mr. Petri, a non-rebreather
mask with the flow rate set at 12 to 15 L/minute is appropriate.
However, if the patient isn't breathing well enough to sustain
optimal oxygenation, begin manual bag-valve-mask ventilation to
support his ventilatory efforts until he can be intubated and
mechanically ventilated.
If the patient has severe respiratory distress and hypotension as
well as unilateral decreased or absent breath sounds, suspect a
tension pneumothorax, a potentially fatal complication requiring
rapid treatment. To perform an emergency chest decompression,
the trauma team physician will perform a needle thoracostomy,
inserting a 14-gauge I.V. catheter into the patient's chest at the
second intercostal space, midclavicular line on the affected side.
A rush of air from the catheter confirms the presence of a tension
pneumothorax. The catheter is left in place until a chest tube can
be inserted.

In the meantime, a syringe or commercial Heimlich valve (or

similar device) is attached to the catheter hub so that air can
escape without being drawn back into the chest. If available, have
a chest tube drainage system that can collect blood for
autotransfusion on hand during chest tube insertion, in case a
hemothorax is present.
Mr. Petri's ventilatory efforts are adequate. His breath sounds are
clear and equal bilaterally, but he complains of pain in his left side
on palpation. The supplemental oxygen he's receiving via the
non-rebreather mask (which was applied by the paramedics) is
kept at a flow rate of 15 L/minute. His Spo2 is now 100%.
Circulation. Once you've assessed and supported your patient's
breathing, attend to his circulatory status. Assess for the presence
and quality of peripheral pulses to quickly estimate BP, as follows.
* If he has a radial pulse, his systolic BP is at least 80 mm Hg.
* If he's lost his radial pulse but still has a femoral pulse, he has a
systolic BP of at least 70 mm Hg.
* If he lacks all pulses except a carotid pulse, he has a systolic BP
of at least 60 mm Hg.
Note the patient's skin color and level of consciousness (LOC).
Pallor and cold, clammy skin indicate shock.
His LOC is an important indicator of cerebral perfusion. Agitation
is common in the early stages of shock. (Think of the "fight or
flight" response.) As shock progresses, his LOC will decline until
he's unconscious.
Obtain a complete set of vital signs, including temperature, as
soon as possible. Use this set of vital signs as a baseline for
comparison with subsequent measurements. You may need to
take vital signs every 5 to 15 minutes until the patient's condition

improves.
A key part of your circulatory assessment is to identify and control
hemorrhage. External hemorrhage is usually, but not always,
obvious. Logroll the patient to inspect his back and buttocks for
bleeding.
To control bleeding, apply direct pressure over the site of
hemorrhage. If this isn't effective by itself, apply pressure over
the major arterial pulse point proximal to the bleeding site.
Use a tourniquet only if you must stanch severe hemorrhage in an
extremity to save the patient's life. Using a tourniquet puts the
limb's viability at risk.
Next, ask yourself if the mechanism of injury makes internal
hemorrhage likely. If the patient has signs and symptoms of shock
without visible bleeding, he may have an occult internal
hemorrhage that requires surgery.
Besides assessing and documenting his circulatory status, you
may need to intervene to sustain circulation. For a patient who's
in shock, consider both noninvasive and invasive strategies to
support his BP. Keep him supine and elevate his legs 6 to 8 inches
(15 to 20 cm) to promote venous return and improve cardiac
output. Don't put him in the Trendelenburg position because this
can cause his stomach to compress his diaphragm, impairing
ventilation.
Make sure he has venous access with two large-bore I.V. catheters
(ideally 14- to 16-gauge) to facilitate rapid fluid and blood product
administration if needed. Draw blood for lab analysis. Send
specimens for typing and crossmatching, complete blood cell
count, serum glucose, electrolytes, and a coagulation profile.
Depending on the patient's condition and suspected injuries, you
may also need specimens for other studies, such as creatine
kinase, amylase, and serum lactate.
An arterial blood gas (ABC) analysis can help clinicians assess the

patient's oxygenation status and determine whether or not he's in

shock. If ABC results show a base deficit that's greater than 2
mEq/L, suspect ongoing hemorrhage, internal injuries, or
insufficient resuscitation.
As ordered, administer an appropriate crystalloid solution for I.V.
volume replacement, such as 0.9% sodium chloride or lactated
Ringer's solution. Warm the solution in a commercial fluid warmer
or use a high-volume infuser/warming device. Don't administer
D5W for volume replacement because the dextrose will be
metabolized and leave free water, a hypotonic solution that won't
stay in the vascular space.
Focus on stopping the patient's hemorrhage, rather than on
volume replacement with crystalloid solutions such as 0.9%
sodium chloride solution. Rapid transfer to the OR for emergency
surgery to control bleeding is associated with better patient
outcomes than infusing large quantities of I.V. fluids in an attempt
to raise the hemorrhaging patient's BP. In this case, low BP may
actually prevent more blood loss, providing somewhat of a
protective effect until the hemorrhage can be controlled. Also,
because packed red blood cells (PRBCs) don't contain clotting
factors, the latest strategy is to administer PRBCs and fresh
frozen plasma in close to a 1:1 ratio, so that the patient receives
essential clotting factors to help hemostasis. The patient also may
need platelet infusions.
Typing and crossmatching typically take 30 to 40 minutes, which
may be too long for a trauma patient to wait. When immediate
blood transfusion is needed, the only option is to give
uncrossmatched universal donor blood, as ordered. Give group O,
Rh-negative PRBCs to female patients of childbearing age or
younger. Male patients and women who can't become pregnant
can receive group O, Rh-positive blood. Remember that 0.9%
sodium chloride is the only solution you can infuse in the same I.V.
line as blood.
Expect each unit of packed RBCs to raise the patient's hemoglobin
by 1 gram/dL unless he's continuing to hemorrhage. During the

infusion, remain vigilant for a transfusion reaction. Signs and

symptoms of a transfusion reaction vary according to what type of
reaction it is. For instance, intravascular hemolysis may cause
fever, lower back pain, pain at the I.V. site, hypotension, and renal
failure. If you suspect a transfusion reaction, discontinue the
infusion immediately and follow your hospital's protocol for
managing transfusion reactions.
During the primary assessment, Mr. Petri's vital signs change
significantly from those obtained by the paramedics: His BP drops
to 96/58, his Spo2 falls to 95%, his heart rate increases to 120, his
respiratory rate remains at 28, and his temperature is now
97.4[degrees] F (36.3[degrees] C). He has no external
hemorrhage, so the physician suspects a spleen injury because he
knows the left chest and abdomen were injured in the fall and the
lower left rib cage is tender. You hang a liter of 0.9% sodium
chloride solution using a high-volume fluid infuser/warmer and
begin the infusion via the second I.V. access line previously
established with a 14-gauge catheter.
Disability. To evaluate disability, you'll evaluate the patient's LOC,
pupil response, and gross sensorimotor function. To document his
baseline LOC, quickly assess and record an initial GCS score. If
possible, determine his GCS before he receives any drugs that
could alter his LOC to better enable you to predict his outcome.
For example, if a patient's GCS score on arrival at the hospital is
4, his prognosis for recovery is much worse than a patient whose
initial score is 12.
Keep in mind that accurate scoring can be impaired by traumatic,
toxic, and metabolic causes. Even if the patient shows evidence of
alcohol or drug use, never assume that his altered mental status
is due purely to intoxicants until injury and other medical causes
are ruled out.
Note whether the patient can recall the events surrounding the
traumatic event. Amnesia about the event suggests that he lost
consciousness.

Next, assess his pupils for size, equality, shape, and response to
light. Unequal or abnormal pupil response can indicate direct
ocular trauma or head injury and elevated intracranial pressure or
the effects of drugs, such as atropine (pupil dilation) or opioids
(pupil constriction).
The final component of the disability evaluation is an assessment
of gross sensorimotor function. Try to determine if the patient has
any numbness, tingling, or other abnormal sensations in his body
after the traumatic event and if he can move his limbs. Injuries to
the extremities, spinal cord, head, blood vessels, or nerves can
cause sensorimotor deficits.
Mr. Petri's GCS score stays at 15. He didn't lose consciousness
during or after the fall and he can recall the event vividly. His
pupils are equal (4 mm/4 mm) and round, and react to light
normally. Despite the pain in his back and leg, Mr. Petri's gross
sensorimotor function is intact.
Exposure. The final component of the primary survey is exposure.
Remove the patient's clothing completely so you can inspect his
entire body for injuries. Use good judgment when removing
clothing; trying to remove a shirt by pulling or manipulating it
may worsen the injury or pain. Cutting clothing away with trauma
shears is usually best.
Once you've removed clothing, protect the patient from
hypothermia, which is particularly dangerous to any trauma
patient because it impairs blood coagulation, interferes with
resuscitation efforts, and increases the risk of acidosis and death.
Take these measures to prevent heat loss and rewarm the patient.
* Remove wet clothing and sheets. Cover the patient with warm
blankets.
* Increase the room temperature to 75[degrees] F to 80[degrees]
F (23.9[degrees] C to 26.7[degrees] C).

* Infuse only warm crystalloid solutions.

* Consider using commercial patient-warming devices, such as
heat lights or temperature-regulating blankets.
When Mr. Petri is exposed, you note that he has abrasions over his
lower left ribs and deformities in both feet. You quickly cover him
with heavy blankets that have been kept in a blanket warmer. The
room temperature had been raised to 78[degrees] F
(25.6[degrees] C) before his arrival, and he's been receiving
warmed I.V. fluids.

Secondary survey: Uncovering other serious

threats
Once you've completed the primary survey and managed any
immediate threats to the patient's life, begin a secondary survey
for injuries that could kill or disable him later. Start at his head
and assess him methodically, moving down his body
systematically as you search for injuries. Inspect for contusions,
abrasions, lacerations, deformities, discoloration, edema, foreign
bodies, and other abnormalities.
Auscultate breath sounds and heart sounds. Assess all body areas
to locate areas of pain or tenderness, crepitus, deformity, loss of
function, and the location and quality of pulses. If you suspect he
has a fracture of an arm or leg, assess the neurovascular status of
the limb, then splint it to prevent movement and decrease pain.
Assess neurovascular status again after splinting. Administer I.V.
opioid analgesia as ordered and make sure that pain is managed
optimally.
At this point, the trauma physician will consider ordering an
indwelling urinary catheter to accurately measure urinary output,
an indication of renal perfusion, and to check for blood in the
urine. First, though, he'll perform a rectal examination to check for
blood or evidence of ure-thral injury, such as a high-riding
prostate gland in a male patient. (If the urethra is injured, the

patient may need to have a suprapubic catheter inserted

instead.)
Before inserting a urinary catheter, look for blood at the urethral
meatus. If you see blood, notify the physician and don't insert the
catheter. The patient will need further diagnostic testing (for
instance, a retrograde urefhrogram or cystogram) before a
catheter can be safely inserted.
Reassess the patient's vital signs and GCS score as frequently as
needed, depending on his condition. Also try to obtain a more
complete history from the patient or significant others. Use the
mnemonic "AMPLE" to help you remember the key information to
gather. (See Get AMPLE information.)
Assess carefully for medications the patient has taken that could
affect his condition and treatment. For example, taking an
anticoagulant, such as warfarin, or a platelet inhibitor, such as
daily aspirin therapy, will make him much more prone to bleeding
from his injuries. If he's using any of these drugs, tell the health
care provider immediately so that he can order appropriate
reversal agents or take measures to counteract anticoagulation
effects.
Assess the patient for corticosteroid use. If he's taking a
corticosteroid medication, he may need an I.V. corticosteroid
bolus so that he can physiologically respond in a stress or shock
state. If you don't know the date of his last tetanus immunization
or if it was more than 5 years ago, administer tetanus
prophylaxis.
Mr. Petri's secondary survey is remarkable for pain on palpation in
his lumbar spine, tenderness and abrasions over his left lower rib
cage anteriorly, and heel pain and swelling in both feet. You insert
a urinary catheter and perform a dipstick urine test, which is
positive for a small amount of blood.

Next up: An eye on diagnostics

After the primary and secondary surveys are complete, prepare

your patient for a series of X-rays and scans. He'll have a stat
portable chest X-ray to identify rib fractures or mediastinal or
diaphragmatic injury and to assess for a pneumothorax or
hemothorax. He'll also need a cervical spine X-ray series to check
for cervical spine injury. The X-ray will also confirm the correct
position of chest and endotracheal tubes and central venous
catheters. Depending on the results of the primary and secondary
surveys, he may have additional X-rays of the pelvis, spine,
extremities, or other areas.
He may have bedside ultrasonography with the focused
assessment sonography for trauma (FAST) technique, which is
used to rapidly examine all four abdominal quadrants and the
pericardium to identify the presence of free fluid, usually blood.
If he's lost consciousness or shows evidence of a head injury, he'll
need a computed tomography (CT) scan of his head. Other CT
scans of the spine, chest, abdomen, or pelvis may be indicated to
help the health care provider plan treatment.
Your patient may need a vascular ultrasound or an arteriogram if
he has vascular injuries, decreased or absent pulses, evidence of
limb ischemia, or a widened mediastinum, indicating a possible
aortic injury.
Magnetic resonance imaging (MRI) is rarely used for diagnosing
acutely injured patients because it takes too long and safely
placing an injured patient into the MRI tube is difficult. In addition,
the patient might have ferrous metal in his body (for example,
implants, or metal fragments left in his eyes from industrial work).
Any ferrous metal is dangerous in an MRI room and is a
contraindication for MRI.
However, the patient may need an MRI if he shows any evidence
of an acute spinal cord injury. Be sure to carefully assess him for
ferrous metal objects. If they can be removed, do so before taking
him to the MRI. The technologist will ask him if he has any
implants or fragments in his eyes from metal work. If he does, an
MPJ is contrain dicated.

Mr. Petri's diagnostic workup includes a bedside FAST

examination; chest, pelvis, and lower extremity X-rays; a full
series of spinal X-rays; and CT scans of his chest, abdomen, and
lumbar spine. The tests identify these injuries: fractures of the 9th
and 10th ribs on the left side, an L3 compression fracture,
bilateral calcaneus fractures, a renal contusion, and a grade III
spleen injury.

Providing definitive care

The definitive care phase begins after the patient's injuries have
been identified and initial lifesaving interventions have been
performed. If your hospital doesn't have the resources to provide
the care he needs, he may need to be transferred to a trauma
center.
In a facility that can provide trauma management, the patient
may go to the operating room, ICU, or a surgical unit after his
trauma workup. Most patients go home after discharge, but some
require inpatient rehabilitation first.
In Mr. Petri's case, the surgeon admits him to the ICU for close
monitoring and pain management. She elects to manage his
spleen injury nonoperatively because his vital signs normalized
after he received 2 liters of resuscitation fluids. His rib fractures
and renal contusion require only observation at this time.
Orthopedic and spine surgeons are consulted to treat his calcaneus fractures and L3 compression fracture.

Meeting the standard of care

Key outcome measures will help you to determine how well the
patient has responded to resuscitation and help you anticipate his
needs. (See Adequate resuscitation? Watch for these indicators.)
An organized team approach in the first hour after a traumatic
injury provides fast, efficient patient care and saves lives.
Because you and other team members prioritized assessment and
interventions for Mr. Petri according to recognized standards of

trauma care, you've given him the best chance for survival and a
full recovery.

Get AMPLE information

This mnemonic will remind you of the critical history to gather
from your trauma patient or his significant other:
A llergies
M edication use
P ast medical history
L ast meal
E vents or environment related to the injury.

Adequate resuscitation? Watch for these

indicators
* Hemodynamic and renal parameters within normal limits
* Core body temperature normal
* Serum lactate less than 2 mmol/L
* No base deficit
* Arterial pH of 7.35 to 7.45
* Hemoglobin greater than 9 grams/dL (based on individual
needs)
* Ionized calcium within normal limits. (Blood transfusion can
lower serum calcium because of the calcium-binding effects of the
citrate preservative in banked blood products.)
* Serum potassium of 3.5 to 5.3 mEq/L

* Coagulation profile within normal limits

* Pain under control

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we wrong for the last 60 years? J Trauma. 2008;65(2):272-278.
Emergency Nurses Association. TNCC: Trauma Nursing Core
Course Provider Manual, 6th ed. Des Plains, IL, 2007.
Laskowski-Jones L, Toulson K. Concepts of emergency and trauma
nursing. In Ignatavicius D, Workman L. (eds.). Medical-Surgical
Nursing: Patient-Centered Collaborative Care, 6th ed.
Philadelphia, PA, Saunders Elsevier, 2010.
Laskowski-Jones L. Trauma and shock. In Kee JL, Paulanka BJ, Polek
C. (eds.). Fluids and Electrolytes with Clinical Applications: A
Programmed Approach, 8th ed. Clifton Park, NY, Delmar Cengage
Learning, 2010.