Transcript Navigating the Road to Recovery: Priorities in the Care of Trauma

Navigating the Road to
Recovery: Priorities in the
Care of Trauma Patients
Kristie Hertel MSN,CCRN,ACNP-BC
Advanced Practice Provider
Trauma and Surgical Critical Care
Objectives
• Identify appropriate resuscitation fluids and end
points of resuscitation
• Identify appropriate pain management agents to
use through out the spectrum of care
• Describe difficulties in case management
• Describe changes in nursing priorities from
admission to discharge
Case Study
• 29 y/o male involved in motor vehicle roll over
collision. Single vehicle collision. +ETOH.
Combative at scene. Not following commands.
Air transported to closest trauma center.
Arrives to emergency department in full cervical
spine precautions. GCS has declined enroute.
Patient is moaning, withdraws to pain, and will
not open his eyes to painful stimuli. Initial BP
100/65 with HR 115, RR 26, SpO2 97% on
NRB. Given fentanyl and versed enroute.
Case Study
Priorities?
Emergency Room Priorities
• Primary Survey
– Airway w/ Cspine
– Breathing
– Circulation
• Secondary Survery
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Disability
Exposure
Full vitals, family, foley, OGT
Give comfort
History
Inspect head to toe
Case Study
• Primary Survey
– Moaning, able to maintain airway but GCS 8
• Intubate
– Diminished breath sounds on R
• Thoracostomy tube to R
– 2 large bore IVs in place, no active areas of
hemorrhage, central pulse +2
• Controlled rate unless hypotension and then consider
transfusion of PRBC
Case Study
• Seconday Survery
– GCS 8, Pupils L 3mm/R, R 5mm/sluggish
• Consider mannitol
– RLE shortened and externally rotated; abrasions to chest/abd/face
• Hare traction
– VS: HR 122, RR 15 (BMV), BP 90/55, SpO2 100%; no family present,
foley placed, OGT placed
• Borderline hypotension w/ probable areas of hemorrhage, transfuse PRBC
– Etomidate/succ given for intubation, patient covered w/ warm blankets
• Monitor sedation/comfort level
– No known past history, per EMS: pateint traveling at high rate of speed,
lost control on corner, left road and rolled vehicle mulitple times,
+restrained
Case Study
• Patient goes to CT scan
– CTH: Large R SDH, sm L temporal contusion
– CT Chest: B rib fractures, no flail, B pulm
contusions, residual ptx R w/ adequate placement of
chest tube
– CT A/P: grade 1 splenic lac, no bony abnormalities
in pelvis
– CT Cspine: C6-7 transverse process fractures
– R femur: midshaft fracture
Case Study
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Neurosurgery consulted
Orthopedic Surgery consulted
Critical Care consulted
Patient taken from ED to OR by Neurosurgery for
craniotomy and evacuation of SDH. ICP monitor
placed
• While in OR, orthopedic surgery placed IM rod to R
femur
• Post op: patient admitted directly from OR suite to
ICU
Case Study
Priorities?
ICU Priorities
• Neuro
– ICP management, sedation, analgesia
• Pulm
– Vent settings, pulm toilet
• CV
– BP management, monitor lactic acid levels
• GI
– Nutrition, PUD proph
• Renal
– Monitor urine output, monitor CK, monitor Bun/CR
• Heme
– DVT proph, monitor serial H/H given splenic lac
• ID
– Antibiotics
ICU Priorities
• Neurologic system
– ICP management
• Mannitol
• 3% saline (infusion vs bolus)
• Nursing measures (elevated HOB, Ccollar not tight,
decreased stimulation
– Sedation
• Short acting agent
– Propofol
– Versed
– Precedex
ICU Priorities
• Analgesia
– Short acting narcotic (Fentanyl) as a drip
– When to change to Morphine or Dilaudid
– When to start per tube narcotics
• Extended release vs immediate release
– Adjunct to narcotics (NSAIDs, neuropathic meds,
muscle relaxants)
– Adjustments for elderly patients
ICU Priorities
• Precedex
– When to use
• Not as first line agent
• Adjunct to propofol
• Weaning from sedation
• AWS
– Who appropriate to use with
• Anyone who is not bradycardic or hypotensive
– Appropriate ranges
• 0.2-1.4mcg/kg/min
– Appropriate duration
• No duration, no long term effects, may get rebound HTN
ICU Priorities
• Pulmonary System
– Vent management
• What mode
– PRVC, SIMV, APRV
• Optimal ABGs
• Oxygenation issues
– Rescue steriods
– Pulmonary toilet
• Suctioning
• Bronchodialators
ICU Priorities
• Cardiovasular system
– IVF
• LR or NS
– End Points of Resuscitation
• Lactic Acid, Base deficit
– Vasopressors
• Dopamine
• Noriepinephrine (Levaphed)
• Neosynephrine (Phenylephrine)
ICU Priorities
• Gastrointestinal System
– Nutrition
• Access
• When to feed
– PUD prophylaxis
• H2 blocker vs PPI
– Glycemic control
• Goal FSBS
– Bowel regimen
• SCI
ICU Prioties
• Renal System
– Monitor UOP
– Monitor CK
– Correction of electrolytes
ICU Priorities
• Hematology
– Monitor H/H d/t spleen
– Transfusion products as indicated
– DVT prophylaxis
• SCDs, Lovenox, subcutaneous heparin
• When to start
ICU Priorities
• Musculoskeletal system
– Neurovascular assessments
• Monitor for compartment syndrome
• Wound care of incisions
ICU priorities
• Tertiary exam
– Review xrays, CT scans
• Order films if indicated
– Full head to toes assessment
• Look for lacerations, road rash,
– Follow up on labs
ICU Priorities
• Cultures
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When to send cultures
What cultures to send
Central lines
Foley catheters
• Antibiotics
– Post op coverage
– No coverage for ICP monitor
– When to start for infectious process
ICU Ongoing Management
• VAP prevention
– Oral care, deep oral suctioning, HOB elevation w/
TF
• CAUTI prevention
– Early catheter removal
• CBSI prevention
– Remove central lines as soon as possible including
PICCs
Transfer to Floor
• Communication
– Situation
• Don’t forget family dynamics
– Background
• Injuries, surgeries, future surgeries
– Assessment
• Head to toes by system
– Recommendations/current therapies
Floor Priorities
• Nutrition
– Enteral and oral feeds
• Pain management
– Wean off all IV meds
• Mobility
– PT/OT consults
• Pulmonary management
– IS, flutter valve, respiratory treatments, chest physiotherapy,
supplemental oxygen weaning
• Wound Care
– Appropriate dressings
Floor Priorities
• Family education
– Wound care
– Activity limitations
– What to watch for
• Discharge Planning
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Home
Rehab
LTAC
SNF
Discharge Planning
• Home
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DME
Wound Care
HH
Support at home
Transportation
Access into/out of home
Discharge Planning
• Rehab
– PT/OT/ST
– Endurance
– Home support
Discharge Planning
• LTAC
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Insurance
Medications
Wound Care
Comorbidities
Respiratory
Discharge Planning
• SNF
– Insurance
• PASSAR II
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Family preference
Length of Stay at facility
Age
Required treatments
• Trach
• Wound care
• Level of independance
Thank You!!!