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High Acuity > Trauma and Triage > Flashcards

Trauma and Triage Flashcards

1
Q

Blunt Trauma Definition and associated forces

A

Can be less-obvious than penetrating
* Forces Associated:
* Shearing
* Acceleration and deceleration forces
* Compression force

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2
Q

The most common organs injured in penetrating trauma:

A

the small bowel (50%), large bowel (40%), liver (30%), and intra-abdominal vascular (25%).

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3
Q

When a penetrating trauma is in close range, there is more __________ than those injuries sustained from a distance

A

kinetic energy

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4
Q

Trimodal Distribution of Trauma Deaths

A
  1. 1st peak: within minutes of injury (on site)
  2. 2nd peak: within 2 hours of injury (in the ER)
  3. 3rd peak: within days to weeks after injury (in the IC/ward)
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5
Q

7 Points of the Trauma Nursing Process

A
  1. Preparation and triage
  2. General impression
  3. Primary survey (A–G) with the corresponding intervention as necessary
  4. Reevaluation (consideration of transfer/need for higher level of care)
  5. Secondary survey (H–I)
  6. Reevaluation (J) and post-resuscitation care
  7. Definitive care, transfer, or discharge
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6
Q

1st step of trauma nursing process:

A

Preparation and Triage
* Activate the trauma team
* Prepare for patient arrival
* PPE and safety

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7
Q

2nd step of trauma nursing process:

A

General impression - assessing for
1. Uncontrolled external hemorrhage?
2. Unresponsive
3. apnic?

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8
Q

3rd step of trauma nursing process:

A

Primary Survey + Corresponding Interventions

Finding the Biggest Issues: the A-G assessment
A: alertness and airway
B: breathing/ventilation
C: circulation/hemorrhage control
D: disability
E: exposure/environment
F: full set of vitals and family
G: get adjuncts and give comfort

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9
Q

If life-threatening conditions are identified during primary survey:

A

interventions are started immediately and before proceeding to the next step of the survey.

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10
Q

Primary Survey: A

A

Alertness and Airway

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11
Q

How do you assess alertness in primary survey?

A

AVPU
Alert
Verbal
Pain
Unresponsive

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12
Q

How do you assess airway in primary survey?

A

Vocalization

Also look for:
* Bony deformity
* Burns
* Edema
* Fluids (blood, vomit, or secretions)
* Foreign objects
* Inhalation injury (burns, singed facial hair, soot)
* Loose or missing teeth
* Sounds (snoring, gurgling, stridor)
* Tongue obstruction

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13
Q

Airway interventions

A

Repositioning
* Jaw-thrust maneuver or Head Life/Chin Tilt

Adjuncts Following Positioning:
* Oropharyngeal Airway (OPA)
* Nasopharyngeal Airway (NPA)
* Endotracheal tube (ETT)

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14
Q

How do you verify ETT placement

A

CO2 detector - yellow to purple
observe chest rise & fall
auscultate epigastrium (should not hear air)
bilat breath sounds (unilateral if entry into right stem)

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15
Q

What is capnography?

A

CO2 detector following ETT placement; allows for placement verification

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16
Q

B in primary survey

A

Breathing and ventilation

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17
Q

How do you assess breathing in primary survey

A
  • Breath sounds (decreased, absent)
  • Depth, pattern, rate
  • Increased work of breathing
  • Dyspnea
  • Open wounds or deformities
  • Skin color (pallor, cyanosis)
  • Spontaneous breathing
  • Subcutaneous emphysema
  • Symmetrical chest rise and fall
  • Tracheal deviation or JVD
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18
Q

If you can’t get past A and B in primary survey:

A

Intubate

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19
Q

C in primary survey

A

Circulation and Control of Hemorrhage

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20
Q

How to assess C in primary survey

A
  1. Inspect and palpate
    * Color
    * Temperature
    * Moisture
  2. Palpate a central pulse
  3. Control hemorrhage
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21
Q

Why palpate for a central pulse in primary survey

A

peripheral pulses may be absent because of injury or vasoconstriction

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22
Q

Central pulse examples

A

Carotid, femoral, brachial

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23
Q

D in primary survey

A

Disability/Neuro Status

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24
Q

What 4 things are assessed with disability in primary survey?

A
  1. GCS (eye, verbal motor)
  2. AVPU (alert, verbal, pain, unresponsive)
  3. Pupils
  4. Glucose
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25
Q

E in primary survey

A

Exposure and Environment Control

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26
Q

How do you assess E in primary survey?

A

Remove all clothing
* Inspect for injuries
Warming measures
* Blankets
* Increase room temperature
* Warmed IV fluids
* Warming lights

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27
Q

F in primary survey

A
  • Obtain a full set of vital signs
  • Facilitate family presence
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28
Q

G in Primary Survey

A

Get adjuncts and Give Comfort

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29
Q

Assessments/Interventions for G in primary survey

A

LMNOP

  • L: Laboratory analysis
  • M: Cardiac monitor; consider 12-lead ECG
  • N: Consider naso- or orogastric tube for stomach decompression/decrease aspiration risk
  • O: Oxygenation and capnography; consider weaning oxygen
  • P: Assess pain using appropriate scale
  • Consider analgesia
  • Nonpharmacologic comfort
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30
Q

4th step of trauma nursing process

A

Reevaluation (consideration of transfer/need for higher level of care)

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31
Q

5th step of trauma nursing process

A

Secondary Survey

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32
Q

3 Components of Secondary Survey

A
  1. history
  2. head to toe
  3. inspect posterior and anticipate interventions
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33
Q

First component of secondary survey

A

History

S- signs and symptoms
A- allergies
M- medications
P- past medical history
L- last oral intake/menstrual period
E - event leading up

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34
Q

Second component of secondary survey

A

Head to toe assessment
* Focus:
* Manage the injuries
* Optimize respiratory and cardiac function

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35
Q

Third component of secondary survey

A

Inspect Posterior
* Unless contraindicated by known or suspected spine or pelvic injury
* Turn, inspect and palpate
* Remove backboard

and Anticipate Interventions

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36
Q

6th step of trauma nursing process

A

Keep re-evaluating VIPP

V - vitals
I - injuries and interventions
P - primary survey
P - pain

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37
Q

What is the Trauma Triad of Death?

A
  1. hypothermia
  2. coagulopathy
  3. acidosis
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38
Q

Treating _____ is key in the presence of hypovolemia in trauma

A

Hypothermia

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39
Q

Why is the treatment of hypothermia key in the presence of fluid loss?

A

Hypothermia:
* Inhibits platelet function
* Slows coagulation factor activation
* Body temp low, blood will flow
* Blood clots best at 37 degrees

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40
Q

Triage assigns priorities based on:

A

Resources

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41
Q

What is MEWS?

A

Modified Early warning system (MEWS)

A screening and scoring tool to identify hospitalized patients at risk for deterioration

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42
Q

What 6 things does MEWS assess?

A
  1. RR
  2. HR
  3. SBP
  4. LOC (AVPU)
  5. Temp
  6. Hourly urine for 2 hours
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43
Q

Best MEWS score

A

0

44
Q

What actions do you take for a 1-2 MEWS?

A

q2h observations and inform charge nurse

45
Q

What actions do you take for a 3 MEWS?

A

q1-2h observations and inform charge nurse

46
Q

What actions do you take for a 4 or greater MEWS?

A

q30min observations, ensure medical advice is sought + contact outreach team

47
Q

RR Mews Scoring

A

2 - < 8
0 - 9-14
1 - 15-20
2 - 21-29
3 - > 30

48
Q

HR Mews Scoring

A

2 - < 40
1 - 40-50
0 -51-100
1 - 101-110
2 - 111-129
3 - > 129

49
Q

SBP Mews Scoring

A

3 - < 70
2 - 71-80
1 - 81-100
0 - 101 - 199
2 - > 200

50
Q

LOC Mews Scoring

A

3 - unresponsiveness
2- responds to pain
1- responds to voice
0 - alert
1 - new agitation/confusion

51
Q

Temp Mews Scoring

A

2 - < 35
1 - 35.1 -36
0 - 36.1 - 38
1 - 38.1 - 38.5
2 - > 38.6

52
Q

Hourly Urine Output Mews Scoring

A

3 - < 10
2 - < 30
1 - < 45

53
Q

Level 1 CTAS (Canadian Triage Acuity Scale)

A

Resuscitation

Conditions that are considered threats to life/limb requiring immediate aggressive interventions

54
Q

Level 2 CTAS (Canadian Triage Acuity Scale)

A

Emergent

Conditions that are a potential threat to life/life or function requiring rapid medical interventions

55
Q

Level 3 CTAS (Canadian Triage Acuity Scale)

A

Urgent

Conditions that could potentially progress to a serious problem requiring emergency interventions

56
Q

Level 4 CTAS (Canadian Triage Acuity Scale)

A

Less urgent

Conditions that related to a potential for deterioration that would benefit from intervention

57
Q

Level 5 CTAS (Canadian Triage Acuity Scale)

A

Non urgent

Conditions that may be acute but non urgent and intervention can be safely delayed

58
Q

CTAS Level 1 Condition, time to assessment and re-evaluation

A

Threat to life/limb

Immediate assessment

Continuous re-evaluation

59
Q

CTAS Level 2 Condition, time to assessment and re-evaluation

A

Potential threat to life/limb/function

15 min assessment

q15 re-evaluation

60
Q

CTAS Level 3 Condition, time to assessment and re-evaluation

A

Potential to progress to serious problem

30 min assessment

q30 re-evaluation

61
Q

CTAS Level 4 Condition, time to assessment and re-evaluation

A

may progress to urgent status

60 min assessment

q60 re-evaluation

62
Q

CTAS Level 5 Condition, time to assessment and re-evaluation

A

acute/chronic but not urgent

120 min assessment

q120 re-evaluation

63
Q

Four Phases of Disaster Management

A
  1. Preparedness
  2. Response
  3. Recovery
  4. Mitigation/Prevention
64
Q

What is the Mass Casualty Triage System?

A

RPM 30, 2, Can Do

Assess resps (<30), perfusion (<2), and mental status (can do commands)

65
Q

According to RPM, if a patient is walking around they are categorized as:

A

Minor

66
Q

According to RPM, if a patient is not walking around and not breathing after airway reposition they are categorized as:

A

Expectant

67
Q

According to RPM, if a patient is not walking around, breathing, but have one or more RPM features, they are categorized as:

A

Immediate

68
Q

According to RPM, if a patient is not walking around, breathing, and have no RPM features, they are categorized as

A

Delayed

69
Q

Minor Triage Category

A

Able to walk

70
Q

Delayed Triage Category

A

Not able to walk, spontaneous breathing, RR < 30, radial pulse present/cap refill < 2, obeys commands

71
Q

Immediate Triage Category

A

Not able to walk, then either:
- breaths after airway reposition
- RR > 30
- radial pulse absent/cap refill > 2
- doesn’t obey commands

72
Q

Expectant Triage Category

A

Not able to walk, apneic after airway reposition

73
Q

How does pediatric triage differ from adult?

A

Following airway reposition, if apneic still assess pulse and attempt 5 rescue breaths

RR values 15-45

74
Q

Information on triage tag

A

Basic info: injuries, vitals, meds, decontamination, parent/child connection

Once triaged: bottom torn off (triage is lowest category)

75
Q

Code Red

A

Fire

76
Q

Code orange

A

Incoming mass casualty

77
Q

Code green

A

evacuation

78
Q

Code black

A

bomb threat

79
Q

Code purple

A

hostage situation

80
Q

Code white

A

violent act

81
Q

code silver

A

active assailant with weapon

82
Q

code yellow

A

missing patient/resident

83
Q

Code blue

A

cardio-respiratory arrest

84
Q

code brown

A

hazardous materal/spill

85
Q

code t-alert

A

tornado

86
Q

What intervention occurs alongside airway and alertness assessment in primary survey and why?

A

cervical spine stabilization (holding c-spine) or immobilization occurs with airway because…
* High c-spine injury can compromise airway/cut off drive to breath
* Already assessing neck, so makes sense to lump here

87
Q

What 3 things show need for c-spine stabilization?

A
  1. mechanism of injury
  2. indication of head injury
  3. change in LOC
88
Q

What airway interventions can/can not be done on indication of c-spine compromise?

A

Jaw thrust = any

head tilt = not done on suspection

89
Q

OPA Considerations

A
  • shorter than ETT
  • nurses can place
  • not done on conscious (gag reflex)
90
Q

NPA Considerations

A
  • when OPA (mouth) isn’t best option
  • cannot be placed with head injury/suspected cranial vault fracture
  • used in conscious or unconscious patient
  • nurses can place
91
Q

Intervention for B in primary survey

A

Bag Valve Mask - maximize oxygen
Intubation

92
Q

What is C-ABC mean?

A

If patient presents with uncontrolled hemorrhage, it is managed before airway

93
Q

Why assess glucose in primary survey?

A

Trauma patients have increased metabolic rate. Low sugars cannot facilitate high metabolic need

Low blood sugar can cause lower LOC; differentiate low GCS from injury/sugars

94
Q

Common traumatic chest injuries

A
  1. rib fractures
  2. flail chest
  3. pulmonary contusion
  4. tension pneumothorax
  5. Open pneumothorax
  6. Massive pneumothorax
95
Q

Flail Chest

A

type of rib fracture requiring intervention – breaking away of lateral ribs so frontal ribs are not attached, not responding to inhalation/exhalation

When they move during breathing or other movement, these fractured ends can cause damage to the surrounding muscles, blood vessels, or even to your lungs and heart. This can cause internal bleeding, which can be life-threatening.

96
Q

Pulmonary contusion

A

bruising of lungs

97
Q

Tension pneumothorax definition and care

A

increased air pocket causing mediastinal shifting

Emergent Care: Needle decompression (14G) penetrates lung and cath left in for air release (2 ICS MCL)

Definitive care: chest tub

98
Q

Cardiac tamponade

A

fluid buildup in pericardial sac squishing heart so that it cannot appropriately contract and fill

99
Q

Intervention for abdominal injuries

A

Damage control surgery: usually unknown what is going on

Goal is hemostasis – stop the bleeding; temporary closure; prevention of contamination
* Proper closure in days following

100
Q

Risk with pelvic injuries and symptoms

A

iliac artery lacerations

  • Perianal ecchymosis
  • Pain on palpation of iliac crests
  • Hematuria
  • Lower extremity rotation or paresis
101
Q

3 Types of Level 1 CTAS Patients

A
  1. major trauma
  2. serious car accident
  3. heart stopped
102
Q

5 Types of Level 2 CTAS Patients

A
  1. severe trauma
  2. suspected heart attack
  3. suspected stroke
  4. large broken bone
  5. trouble breathing
103
Q

6 Types of Level 3 CTAS Patients

A
  1. moderate trauma
  2. fainting
  3. head injury
  4. asthma attack
  5. temperature > 40
  6. seizure
104
Q

4 Types of Level 4 CTAS Patients

A
  1. minor trauma
  2. cut requiring stitches
  3. small broken bone
  4. sore ear eye or throat
105
Q

5 Types of Level 5 CTAS Patients

A
  1. minor trauma
  2. removal of stitches
  3. renewing prescription
  4. vomiting/diarrhea without dehydration
  5. coughing/congestion

High Acuity (20 decks)

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