Concepts of emergency and trauma nursing

Emergency departments

provide care to all who need it

• can afford, can not etc

Multi-specialty care

interdisciplinary teams

safety focused

critical access hospitals

• job to patch them ip and send them where they need to go

Homeless

• contributing factors: domestic abuse, crime, lack of support

• high incidence of alochol and drug use, chronic illness, malnutrition

• vulnerable to weather exposure, physical violence, sexually transmitted infections, public health concerns: TB

• Seek ED care to achieve shelter and food, comfort, safety

Vulnerable populations

poor

mental health needs

• active crisis, psychosis or suicidality

Substance use

older adults

• worsening of chronic conditions, inability to perfom ADLS

Nurse consideration

maintain non-judgemental attitude

build trust

always use standard precautions

maintain professional boundaries

assess safety

• did you bring any drugs/weapons from home

Communication from ED to next point of care

siutation

pertinent medical history

assessment and diagnostic findings

• especially critical results

Transmission-based precautions and safety concerns

interventions provided in the ED, and response to interventions

• bedside procedures

Staff safety

standard precautions

guards

metal detectors

bulletproof glass

staff-controlled door entry

specially trained officers and dogs

Patient safety

Most common safety issues

• fall risk: side rails up

• Medical errors or adverse events

• patient misidentification: NEED BAND, jane doe

• Skin breakdown

Triage

An organized system of sorting patients into priority levels depending on illness or injury severity

Emergent triage level

Life threatening

• chest pain

• hemorrhage

• respiratory distress

• stroke

• vital sign instability

Urgent triage level

needs quick treatment, but not immediately life-threatening

• severe abdmoninal pain

• fractures

• renal colic

• respiratory infection

• soft tissue injury

Nonurgent triage level

could wait several hours if needed without fear of deterioriation

• fracture (simple)

• rashes

• strains and sprains

• urinary tract infection

Triage: emergency severity index

level I

• unstable, requires immediate life saving interventions

  • Cardiac arrest

Level 2

• high risk situation

  • ½ vitals are off…let them sit and they will decompensate

Level 3

• stable but requires two or more resources

  • diagnostic and 1 intervention

Level 4

• stable, requires only one resource

  • UTI: quick lab test

Level 5

• non-urgent, requires no resources

  • only use assessment and treatment

  • high BP and running out of meds

Human trafficking concerns

be alert for human trafficking

victims are typically seen by a health care provider while under the traffickers concern

physical signs include: headache, dizziness, back pain, missing patches of hair, burns, bruises, vaginal or rectal trauma, jaw problems, head injuries

psychosocial symptoms include: stress, paranoia, fear, sucidal ideation, depression, anxiety, shame, self-loathing

victim may also have unusal tatooing or branding marks

Disposition

provider determines whether patient is

• admitted to hospital

• transferred to specialty care center

• discharged to home with instruction and follow-up

Case manager or social worker coordinates the discharge plan

• arrange appropriate referral and follow-up

• review ED census and trends

• facilliattion of referrals

• plan disposition for patients from vulnerable population

Death in ED

may be anticipated due to long term illness, or may be sudden and unexpected

family presence may be granted during resuscitation

ED staff will prepare body for viewing

if suspicious circumstances or accidental death, leave lines in place

use appropriate verbiage such as “died” or “dead” to avoid confusion

coordinate with crisis trained staff to support family

Trauma

defined as bodily injury in health care

Trauma informed care

• realizing the widespread effect of trauma

• recognizing signs and symptoms of trauma

• integrating trauma knowledge into practices and procedures

• seeking to actively resist retraumitization

  • secondary injury

  • may people may be triggered

Level 1 trauma center

Regional resource facility that provides leadership and total collaboration care from prevention through rehabilitation

large teaching hospitals that severe dense population

Level 2 trauma center

community hospitals that can provide care to vast majority of injured patients

• able to stabilized….patient may be needed to transfer

Level 3 trauma center

Small, rural hospitals, focus on inital injury stabilization and patient transfer if necessary

Level 4 trauma center

Located in a rural or remote settings such as ski areas

Mass casualty/disaster triage

many wounded with limited resources

four level system

Red (immediate): life-threatening injuries that are likely to survive with immediate treatment

yellow (delayed)” definitive treatment needed, but no immediate threat to life'; patients can wait for treament

Green (minimal): minimial injuries, are ambulatory, can self-treat

• superficial laceration, can care for themselves

Black (expectant)” deceased or lethal injuries

• will usually die despite treatment

Role of nursing

run drills to prepare for mass casualty situations

in an actual disaster, off duty nurses may be activated

assist with triage and discharge to free up resources for mass casualty citims

be flexible

greatest good for greatest number of people

Mechanism of injury

describes how patient trauma occured

• blunt

• blast effect

• acceleration- deceleration

• penetrating trauma

• fall

Primary survey

Airway (with cervical spine precautions/ protections)

Breathing and ventilation

circulation (with hemorrhage control)

disability (neologic exam)

exposure

Airway/breathing and cervical spine

stabilize C-spine

manage secretions

administer 100% oxygen with non-rebreather or bag-valve mask

open pneumothorax or significant chest wounds

massive, uncontrolled external bleeding takes top priority if present IMPORTANT

Circulation

Presence of a radial pulse: BP at least 80 systolic

Presence of femoral pulse: BP at least 70 systolic

Presence of a carotid pulse: BP at least 60 systolic

IV/IO access

fluid resusciation

assess skin color and vital signs

Disability

rapid assessment of neurologic status

• GCS = less than 8 intubate!

• Pupil size and reaction

• lateralizing signs

Exposure

remove all clothing for a throough assessment

cutting clothes is most effective and safe

presevere appropriately if needed as evidence

prevent hypothermia using bair huggers and warm blankets

cold=less responsive then normal

Secondary survey

head to toe assessment

temporary wound dressings and splints

diagnostic studies: CT

lab work

detailed history

placement of secondary tubes/drains : OG, NG, foley

cleansing wounds/removal of debris

• road rash, scrub that out to prevent infection

Disposition

Tertiary survery

done within 24 hours of initial resusciation for trauma patients

structured/comprehensive re-examination

identify injuries missed in the inital resuscitation or complications

• changes in physical exam/level of consciousness

• compartent syndrome

• electrolyte disturbances

Address any newly identified injuries/ complications