Introduction

Trauma may be defined as ‘blunt or penetrating external force exerted on the body resulting in injury’ (Eckes-Roper 2003: 1). Trauma is not a new disease; however, it continues to be a leading cause of death and disability in all age groups, especially in the first four decades of life (Cole 2008).

Historically people have suffered traumatic injuries caused by modes of transport (the horse and cart for example), assaults, falls and work-related incidents. Conflict also causes death and disability due to traumatic injury. Contemporary trauma care was born out of wartime experience, and lessons learned from the two world wars and the Vietnam War have helped to shape current trauma practice, especially in relation to intravenous fluid therapy and surgical interventions (Cole & McGinley 2005).

Trauma patients are cared for by a variety of practitioners in many clinical settings – from the paramedic at the roadside, to the nurse in a rehabilitation unit; however, trauma is a relatively new specialty in its own right. In the late 1980s The Royal College of Surgeons of England carried out a retrospective review of 1000 trauma deaths in England and Wales (Anderson et al 1988). The report that followed identified that approximately one third of the deaths were preventable and were often due to treatable causes such as hypoxia and haemorrhage, and organisational issues. Following this, the Advanced Trauma Life Support (ATLS) protocols (American College of Surgeons [ACS] 2004) were adopted by many Emergency Departments to guide trauma care and standardise patient management. However, in November 2007 the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) launched Trauma: Who Cares? (Findlay et al 2007). This study has reported that nearly 50% of severely injured patients in the UK did not receive good-quality care. Deficiencies in organisational and clinical aspects of trauma care were identified and NCEPOD has called for significant improvements in pre-hospital and in-hospital trauma care.

Much of the trauma literature focuses on the care that the patient receives in the Emergency Department (ED). This is the area of the hospital where patients with unscheduled or unplanned injuries or illnesses are assessed and treated and was formerly known as the Accident and Emergency department (A&E). However, this is only one part of the patient’s journey and does not really reflect the reality of contemporary trauma nursing. This chapter will outline the principles of care needed for the trauma patient, from pre-hospital care through to definitive care. Reflection boxes will help you to consider a trauma case history and reflect on the care needed. Contemporary evidence-based practice will be discussed, with links to web-based critical thinking exercises and further reading material.

Trauma: epidemiology and the need for injury prevention

Traumatic injury can be unintentional or intentional and continues to be a significant health problem. Trauma does not capture the public attention in the same way as other diseases such as cancer, cardiac disease or meningitis; however, traumatic injury is a disease. It has a host (the patient) and a mode of transmission (a vehicle, fire, knife) (ACS 2004) and the statistics are shocking. Trauma affects all age groups and it is the main cause of death in young people, under the age of 40. Annually in the UK, 14 500–18 000 deaths occur as a result of trauma, with 60 000 patients being admitted to hospital each year as a result of a road traffic collision (RTC) (Bonnett et al 2003). In the UK the incidence of severe traumatic injury is estimated at 4 people in every million per week. With approximately 60 million people in the UK, this means 240 severely injured patients per week (Findlay et al 2007).

The irony is that trauma in civilian settings is preventable. There is often a fatalistic ‘accidents will always happen’ attitude towards the cause of injuries; a death following a traumatic event, such as a car accident or a fall at work, is often publicly perceived as an unavoidable fatality (Chiara et al 2006). However, this is incorrect. Traumatic injury should not be thought of as an accident – this word implies a random circumstance, whereas injuries occur in specific, usually preventable patterns. Individuals in high-risk situations or environments, such as children playing near a busy road, adults driving a car at speed or following alcohol consumption, working without protective equipment or carrying a knife provide a chain of events that results in traumatic injury. Legislation such as seat belt laws, environment modifications such as road-calming measures and health promotion campaigns by organisations such as the Royal Society for the Protection of Accidents (RoSPA) have all helped to reduce death and disability, however more needs to be done. Trauma nurses who care for the injured are ideally placed to practise health promotion and injury prevention strategies, either during interactions with patients or by supporting injury prevention strategies such as the Safety and Risk Education Programme (RoSPA 2008).

Mechanism of injury

Following a traumatic event, information about the mechanism of injury may help identify up to 90% of a patient’s injuries (ACS 2004). Mechanism of injury can be classified into four main groups (Greaves et al 2001a):

In general, 98% of the trauma in the UK is blunt, caused by injury, and other mechanisms make up the rest. However this picture is changing in urban settings with penetrating injury becoming more prevalent.

Blunt trauma causes injury as a result of energy transfer leading to tissue compression and disruption (Eaton 2005). Common injuries include crushing, rupturing or shearing of organs or tissues, fractures (open and closed) and traumatic amputations (Middlehurst 2008). Blast injuries can cause a combination of blunt and penetrating injuries, due to the patient being thrown by the force of the blast, and surrounding objects or people being thrown at the patient.

Penetrating trauma causes injury when an object or missile with a small frontal area and high kinetic energy penetrates the skin and underlying tissues of the body (Eaton 2005). In general, penetrating forces are considered high and medium energy – firearms and fragments from blasts – and low energy such as knives, broken glass and other sharp objects (Middlehurst 2008).

The nurse assessing a trauma patient should consider the mechanism of injury, especially when it is suggestive of a serious, high-energy force. Patients may not appear to have sustained obvious injuries following a traumatic event, especially if the injury is internal. However, a high index of suspicion and careful assessment and reassessment of the patient is essential in every clinical setting to detect deterioration or the onset of complications (Middlehurst 2008).

Death following trauma

Death due to traumatic injury occurs in one of three time periods, described as the trimodal death distribution (ACS 2004) (Figure 27.1). This has significance for trauma nurses working throughout all the areas of trauma care.

Figure 27.1 Trimodal death distribution in trauma.

The first period is where death occurs within seconds to minutes of sustaining the injury. Deaths are caused by very severe injuries such as major vessel (aorta, vena cava) disruption, severe traumatic brain injury, high spinal cord injury or apnoea. This period can only be significantly reduced by preventing the incident occurring in the first place.

The second period is where death occurs minutes to hours following the injury. Deaths are caused by injuries resulting in overwhelming hypoxia and hypovolaemia or a rapidly accumulating intracranial haematoma pressing on the brain. Nurses and practitioners working in pre-hospital and emergency care settings must carry out prompt assessment and resuscitation to recognise problems, seek expert help early and minimise death in this period.

The third period is where death occurs days or weeks after the initial injury. This is usually due to complex complications that have arisen such as multi-organ failure, coagulopathy (failure of normal clotting mechanisms), acute respiratory distress syndrome or overwhelming sepsis. Nurses working in definitive trauma care settings are responsible for assessment, monitoring and support of patients, in order to detect potential complications and maximise recovery.

Disability

It must be remembered that death is not the only outcome following traumatic injury. Worldwide, large numbers of people are left permanently disabled following intentional or unintentional injury, causing a huge financial and social burden on society (WHO 2008). Disabilities following injury include:

A combination of increased injury prevention awareness and better patient care can help to reduce the number of disabilities and provide better outcomes for society.

Pre-hospital care

Pre-hospital care is defined as the provision of skilled medical help at the scene of an accident, medical or other clinical emergency, and during transport of the patient to hospital (Noble-Mathews 2005). In most UK settings this will involve staff from an ambulance service, using road vehicles or possibly helicopters to assess, resuscitate and then transport trauma patients to hospital. Currently in the UK there are only a few pre-hospital care nurses working in the field of trauma, in comparison to the USA and other European countries.

As well as good clinical knowledge, pre-hospital care paramedics and nurses need specialist skills, such as ensuring scene safety or extrication of patients trapped in vehicles. This is achieved through education and training and also collaboration with other emergency services such as the police and fire and rescue teams.

Emergency department

Many Emergency Departments use a system of assessing (or triaging) the patients on arrival to determine the severity of their injury, and then streaming (or directing) them to the appropriate clinical area (Bickerton et al 2005). The ED is usually divided into sections where patients with minor injuries can be seen and treated in a designated area away from those who are more seriously ill or injured. The minor injuries section is where single system traumatic injuries such as ankle or wrist fractures, soft tissue injuries or uncomplicated wounds can be seen and treated.

Once the major trauma patient has arrived at the hospital they should be cared for in a resuscitation area. This is a clinical area which is designed to have the necessary equipment and space readily available to enable a trauma team to care for the patient efficiently and effectively. In the ED it is vital that there is a predetermined system, such as the Advanced Trauma Life Support (ATLS) protocols (ACS 2004), to guide personnel through the initial assessment of the patient. Using a systematic approach (A, B, C, D, E) helps the trauma team to identify life-threatening conditions quickly and to treat them appropriately (Box 27.1).

Initial assessment and management of the patient: the primary and secondary surveys

Initial assessment and management of the trauma patient is usually performed in two stages: the primary survey and later the secondary survey (ACS 2004, Cole 2008).

The primary survey

The initial assessment (primary survey) has five components – ‘A, B, C, D, E’:

• Airway with cervical spine control

• Breathing and ventilation

• Circulation and haemorrhage control

• Disability and dysfunction

• Exposure and environmental control.

If any life-threatening condition is identified during the process, it is treated before moving on to the next stage. For example, if the patient is found to have a compromised airway, this is stabilised before the patient’s breathing and ventilation are assessed. Each component is now discussed in detail.

Airway with cervical spine control

The first step of assessment is to find out if the patient has a patent airway (Box 27.2). Following a traumatic event the airway can become obstructed by bleeding in the mouth, swelling of the face, mouth or oropharynx, a reduced level of consciousness or vomiting and aspiration. Expert anaesthetic help should be sought immediately if there is any doubt about the patient’s ability to maintain their own airway.

Box 27.2 Reflection

Emergency airway management

A 35-year-old man has been knocked off his bicycle by a motor vehicle. He appears to have sustained injuries to both legs and is very pale. On arrival to the ED he is drowsy but has a gag reflex. He does not appear to have had a head or face injury.

Activity

• Why is airway assessment and management so important and which airway adjunct should be used to maintain his airway?

All nurses working with trauma patients should be able to perform a systematic approach to airway management. This is essential, as simple manoeuvres may be all that is required to keep the airway patent until anaesthetic help arrives. The sequential approach to airway assessment involves:

1 Talking to the patient – this helps to provide psychological support but also assesses the airway. If the patient is talking freely in a normal voice (i.e. no grunting or hoarseness) then it can be assumed that the airway is patent (Greaves et al 2001b). If there is no response or the patient is making noises from the airway then the next step should be followed.

2 Look in the mouth for signs of obstruction, such as vomit or blood. Suction with a rigid suction catheter attached will help to remove any foreign bodies, which once carefully removed may allow the patient to maintain their own airway.

3 Open the airway using a jaw thrust technique to pull the tongue and soft palate forward. This is used instead of the head tilt/chin lift because the neck must be kept still whilst the airway is opened as trauma patients are always at risk of a cervical spine injury.

4 Insert an airway adjunct. Airway adjuncts should be used in conjunction with an airway opening manoeuvre (jaw thrust) as they will not keep the airway open on their own in the unconscious patient lying supine (Cole 2008). The choice of airway is either an oropharyngeal airway (Guedel) in the unconscious patient without a gag reflex or a nasopharyngeal airway if a gag reflex is present (Greaves et al 2001b).

a Oropharyngeal airway. To ensure the correct size, an oropharyngeal airway is measured from the tragus of the ear to the corner of the mouth (‘soft to soft’) (see Figure 27.2). It is inserted upside down, rotated 180 degrees and then pushed into position. The flange should sit flush with the lips. If the patient gags or coughs during insertion the airway should be removed and a nasopharyngeal airway used instead.

b Nasopharyngeal airway. The size of a nasopharyngeal airway is chosen by ensuring that the diameter of the tube is smaller than the diameter of the nostril. The airway should be lubricated prior to introduction and inserted into the nose with a slight twisting motion. Nasopharyngeal airways extend from the nostril to the nasopharynx, with the wider end sitting at the nostril (Cole 2008).

5 Definitive airway. For patients who have more serious injuries or are unable to maintain their own airway, it may be necessary to protect the airway definitively. This means a secure airway that can remain in place until the patient is able to maintain their own airway, usually endotracheal intubation. This is done by an anaesthetist who will intubate the patient using a laryngoscope and endotracheal (ET) tube. Usually it will be necessary to sedate and paralyse the patient to facilitate this process. The anaesthetist will require a range of drugs and the nurse assisting with the procedure should be familiar with these and have them ready for immediate use. Once the ET tube is in place, a mechanism for ventilation will be required which must be attached to a high percentage of oxygen via a piped oxygen supply. Ideally, all this equipment should be pre-prepared for rapid use. For patients who have sustained massive facial injuries a surgical airway may be the only way to oxygenate them adequately. This requires specialist equipment (e.g. a scalpel, tracheal dilators, a small tracheostomy tube or ET tube that can be attached to a catheter mount), which should be readily available for immediate use in the ED.

Figure 27.2 How to size an oropharyngeal airway.

For any trauma patient it is vital that the cervical spine is protected with in-line immobilisation until a senior clinician can rule out a cervical spine injury. This requires a correctly sized semi-rigid collar to be applied to the neck and manual immobilisation. Alternatively head blocks and tape (attached to an immovable part of the trolley) can be applied to immobilise the head and neck (Figure 27.3).

Figure 27.3 Cervical spine immobilisation.

The nurse assisting with maintenance of the patient’s airway must be vigilant in observing the patient for any signs of nausea or vomiting. With the cervical spine immobilised, the patient is unable to move. If vomiting is likely, the team will have to log roll the patient to protect the spine (Figure 27.4) and assist the patient with suction apparatus. In this case, an antiemetic should be prescribed and administered urgently.

Figure 27.4 The log roll technique.

(Reproduced with permission from Lisa Hadfield-Law, Oxfordshire, UK.)

Breathing and ventilation

The patient’s respiratory rate must be measured and recorded to observe for the efficacy of ventilation, i.e. effective gaseous exchange taking place at the alveolar capillary membrane. Assessment should include the rate, depth and use of any accessory muscles (see Ch. 3). All patients who have a faster than expected respiratory rate (tachypnoea) should be considered to have had chest injury until proven otherwise. All patients who have sustained traumatic injuries are at risk of hypoxia and should receive a high flow of oxygen. This can be delivered via a mask with a reservoir bag (non-rebreathe mask) with a flow rate of 15 L/min (ACS 2004). By the addition of a reservoir bag the patient will receive up to 90% oxygen concentration compared to only 50% oxygen concentration with an ordinary oxygen mask (Resuscitation Council [UK] 2004). Pulse oximetry assists with monitoring of the patient’s oxygenation saturation of arterial blood. An arterial blood gas sample may be taken if the patient is hypoxic or hypoventilating so that the clinician can gain an accurate picture of the patient’s ventilatory status (Cole 2008).

Trauma patients must have their respiratory observations monitored regularly to detect any deterioration.

Major chest injuries can be divided into those that are immediately life threatening and those that are life threatening but are less obvious and often difficult to diagnose. The two groups of injuries have been described as the Lethal six and the Hidden six (Cole 2008) (see Table 27.1). In most cases the life-threatening chest injuries will need a chest drain inserted as part of the initial treatment. The nurse should be familiar with the equipment and assistance needed for chest drain insertion (see Ch. 3).

Table 27.1 Classification of major thoracic injury

The lethal six	The hidden six
Airway obstruction	Traumatic aortic disruption
Massive haemothorax	Tracheobronchial tree injury
Tension pneumothorax	Oesophageal perforation
Open pneumothorax	Cardiac contusion
Cardiac tamponade	Pulmonary contusion
Flail chest	Diaphragmatic tear or rupture

Circulation and haemorrhage control

Haemorrhage is the main cause of early trauma deaths (ACS 2004) and can contribute to problems such as clotting disorders or organ failure once the patient has reached definitive care. In severely injured patients hypovolaemia is common and it is the nurse’s role to closely assess and monitor for signs of hypovolaemic shock (see Ch. 18). This includes regular measurement and recording of the patient’s heart rate, blood pressure, capillary refill time and, where possible, urine output (catheterisation may be necessary to monitor this). Table 27.2 summarises the changes to observations in response to haemorrhage.

Table 27.2 Changes in observations in response to haemorrhage

Pulse rate	Tachycardia due to adrenaline and noradrenaline release (tachycardia is an early sign!) NB: Patients who are on beta blockers or patients who are very athletic will not appear to be tachycardic, although they may be hypovolaemic
Respiratory rate	Tachypnoea (increased respiratory rate) due to increased oxygen demand and compensatory mechanisms
Level of consciousness	Anxiety or confusion due to the reduction in oxygen delivery to the brain
Capillary refill time	Delayed >2 seconds due to systemic vasoconstriction
Blood pressure	Normal or raised due to compensation: systemic vasoconstriction (hypotension may be a late sign!)
Skin colour	Pale, cool peripheries due to systemic vasoconstriction
Urine output	Reduced urine output and increased urine concentration due to antidiuretic hormone and aldosterone production (part of the compensation process)

It is important to remember that tachycardia is an early sign of haemorrhage, whereas alteration of blood pressure is sometimes a later sign. This is because healthy adults and children may compensate during the initial stages of bleeding, and natural production of adrenaline and noradrenaline help to maintain the blood pressure within normal limits until approximately 30% of blood volume has been lost (Matthews & Bentley 2005). Observing the patient’s skin colour can provide some indication of blood loss and talking to the patient will indicate their current mental status. The greater the blood loss, the paler the patient will look (in all skin colours, however pallor may be easier to detect in the oral mucosa of patients with very dark skin) and as oxygen availability decreases in the blood supply, the patient will become increasingly confused, agitated and eventually unconscious (Bonnett et al 2003).

Common sites of haemorrhage following traumatic injury include the chest, the abdominal contents, the pelvis, the shaft of femurs and external haemorrhage from deep wounds. Internal haemorrhage can be difficult to detect by clinical examination and plain X-ray alone. Increasingly, diagnostic imaging such as ultrasound scans (known as FAST: Focussed Assessment with Sonography in Trauma) and computerised tomography (CT) scans are performed in the ED (or as close as possible) so that the source of bleeding can be found quickly. Trauma patients who are bleeding will need to be seen urgently by a senior surgeon to decide whether surgical or conservative treatment is necessary (Cole 2008).

Fluid resuscitation in early trauma

The injured patient needs two wide-bore cannula inserted into large veins, such as those found in the crease of the elbow joint (antecubital fossa). At this point blood is taken for full blood count, clotting, urea and electrolytes and blood grouping (and if necessary cross matching for a transfusion). Intravenous fluid therapy may be necessary if the patient is hypovolaemic. Isotonic crystalloid fluids are recommended such as 0.9% saline or Hartmann’s solution (ACS 2004). Colloids are not used in the early stages of trauma resuscitation as they have been shown to have a detrimental effect on blood clotting (Brohi et al 2003).

The volume of intravenous fluids required will depend on the cardiovascular status of the patient and the injuries that they have sustained. Traditionally, if a patient is bleeding, intravenous fluids are given to keep their blood pressure at a normal level. However, modern trauma practice suggests that if the patient is given a lot of fluids to maintain the blood pressure then there is a risk of causing clotting problems, hypothermia and further bleeding (Cole 2008). Therefore fluids need to be prescribed and administered following careful consideration of the patient’s haemodynamic status and potential injuries. Once intravenous fluids have been commenced it is vital that cardiovascular observations are recorded every 5 minutes to determine whether the patient is responding. A patient who improves following intravenous fluids may not need urgent surgery, whereas a patient who only improves transiently or not at all is unstable and is likely to require an urgent blood transfusion. If the patient’s own blood group and rhesus match is not available, O Rh-negative blood (the universal donor) will be used.

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