Thoracic Trauma from the Prehospital to the Emergency Room: What is the role of the Nurse? Tiago Amaral |MSc, RN, PHRN, CNS|
[email protected]
1 June 2015
Co-‐Authors: Artur Marona Beja |MSc, RN, CNS| Fernanda Fonseca |RN, MSc student|
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Enumerate and describe the nurse’s role and skills in the continuum of care of the patient with thoracic trauma from pre-‐hospital to the emergency room.
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Trauma: Epidemiology, causes and distribuition of deaths
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Thoracic Trauma: facts
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Nursing skill’s at Prehospital and ER
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Thoracic Trauma: Continuity of care
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Nursing care and team care to the victim of Thoracic Trauma
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Emergency Thoracotomy procedure at Trauma Room CHLC
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Emergency Thoracotomy procedure: nursing skill’s and role
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5.8 million people die each year as a result of injuries.
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Netherlands: § Direct costs 1 billion euros/year; § Indirect costs: 4 billions euros/year.
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1st cause of death among children, teenagers and young adults ( ≤ 44 years).
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3rd cause of death in all age groups in Western countries.
Kosar et al. Cost-effectiveness of an integrated 'fast track' rehabilitation service for multi-trauma patients involving dedicated early rehabilitation intervention programs: design of a prospective, multi-centre, non-randomised clinical trial. Journal of Trauma Management & Outcomes 2009, 3:1. Kleber et al. Overall Distribution of Trauma-related Deaths in Berlin 2010: Advancement or Stagnation of German Trauma Management? World Journal of Surgery 2012; 36:2125-2130.
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Prehospital: § Polytrauma; § Severe Traumatic Brain Injury (TBI);
§ Exsanguination.
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Hospital: § Polytrauma; § Severe TBI; § Exsanguination;
§ Multiple organ failure (MOF).
Kleber et al. Overall Distribution of Trauma-related Deaths in Berlin 2010: Advancement or Stagnation of German Trauma Management? World Journal of Surgery 2012; 36:2125-2130.
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Reports of injuries in the chest appeared as early as 3000 BC in the Edwin Smith Surgical Papyrus.
Ursic & Curtis. Thoracic and neck trauma. Part two. International Emergency Nursing 2010, Volume 18 (1); pp. 47-‐53
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Patients with trauma to the chest present with some of the most life-‐threatenning conditions in emergency care.
TNCC. 2007. Emergency Nurses Association
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Injuries to the thorax and its contents comprise some of the most deadly and dramatic injuries in trauma care, and demand rapid action on the part of those caring for such patients. Ursic & Curtis. Thoracic and neck trauma. Part two. International Emergency Nursing 2010, Volume 18 (1); pp. 47-‐53
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About 20 % of all deaths could be potential survivors requiring invasive procedures such as thoracic drain.
Kleber et al. Overall Distribution of Trauma-‐related Deaths in Berlin 2010: Advancement or Stagnation of German Trauma Management? World Journal of Surgery 2012; 36:2125-‐2130.
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Mortality secondary to injuries by Trunkey (1983)
Trimodal distribution
Investigations shows Large reduction late deaths
Kleber et al. Overall Distribution of Trauma-‐related Deaths in Berlin 2010: Advancement or Stagnation of German Trauma Management? World Journal of Surgery 2012; 36:2125-‐2130.
Gunst, M. et al. Changing epidemiology of trauma deaths leads to a bimodal distribution. Baylor University Medical Center Proceedings 2010; 23 (4); pp. 349-354.
Late deaths: meaning?
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Development of an integrated trauma system;
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Improvement in organ replacement therapies;
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Advances in resuscitation;
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Advances in critical care;
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Surgical team of trauma ;
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Improvement in prehospital care.
Gunst, M. et al. Changing epidemiology of trauma deaths leads to a bimodal distribution. Baylor University Medical Center Proceedings 2010; 23 (4); pp. 349-354.
Suserud. A new profession in the pre-‐hospital care field: the ambulance nurse. Nursing in Critical Care 2005 Nov-‐Dec;10(6):269-‐71.
Suserud. A new profession in the pre-‐hospital care field: the ambulance nurse. Nursing in Critical Care 2005 Nov-‐Dec;10(6):269-‐71.
WHERE IS A PATIENT... MUST BE A NURSE!
Suserud. A new profession in the pre-‐hospital care field: the ambulance nurse. Nursing in Critical Care 2005 Nov-‐Dec;10(6):269-‐71.
Trauma Centre and INEM Professionals (RRC -‐ VMER -‐ and HEMS) ¡
ALS
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ALS in Trauma
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Paediatric ALS
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Paediatric ALS in Trauma
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Intensive Care
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MCI
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Critical care transport
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“Green lines”: stroke, Sepsis, trauma, ACS. Administração Regional de Saúde do Norte, IP. Comissão Regional do Doente Crítico -‐ um ano de reflexão e mudança!. 2009, p. 15-‐16
TRAUMA: Chain of survival
Assistance is based on an appropriate, correct and timely intervention. Breaking the chain compromises the life of our victim. Soreide. Strengthening the trauma chain of survival. British Journal of Surgery 2011; 99(Suppl 1): 1–3.
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The continuum of clinical care provided to trauma patients extends from the time of injury through to longterm recovery and final outcomes.
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Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum. Richmond & Aitken. A model to advance nursing science in trauma practice and injury outcomes research. Journal of Advanced Nursing 2011, 67(12), 2741–2753.
Richmond & Aitken. A model to advance nursing science in trauma practice and injury outcomes research. Journal of Advanced Nursing 2011, 67(12), 2741–2753.
Richmond & Aitken. A model to advance nursing science in trauma practice and injury outcomes research. Journal of Advanced Nursing 2011, 67(12), 2741–2753.
¡ On the way § How many victims? § What were the mechanisms of injury? § Need more help?
¡ Arrived to the scene… § Safety conditions?
Came one trauma victim with pre-‐hospital team want we to know?
Injury Mechanism Front impact
Thoracic injury Thoracic Vollet anterior Blunt Chest Trauma Pneumothorax Aortic transection (deceleration injury)
Side impact
Thoracic Vollet Lateral Pneumothorax Diaphragmatic rupture
Pedestrian hit
Aortic transection Injury of abdominal viscera
TNCC. 2007. Emergency Nurses Association
INITIAL ASSESSMENT A.
Airway patent / stabilization cervical spine
B.
Ventilation
C.
Circulation with bleeding control
D.
Neurological dysfunction
E.
Exposure
SECONDARY ASSESSMENT
F.
Evaluation of all Vital Signs / family
G.
Provide comfort measures / pain
H.
History, head-‐to-‐toe Assessment
I.
Inspection posterior surfaces
Trauma room team receives information: -‐ How many victims -‐
What type of victims
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What type of injuries
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What have done PH team
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What have to be done / what do you expect
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Estimated Time of Arrival (ETA)
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Systematic evaluation
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Systematized records
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Sharing the same language
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Education critical ill patient
Care improvement » Quality
Thoracotomy performed in the emergency department for trauma patients in extremis is usually initiated as a left antero-‐lateral incision at the level of the fourth or fifth intercostal space.
Mejia et al. Emergency Department Thoracotomy. Spring 2008, vol.20 (1); p1-‐84.
Emergency thoracotomy may be defined as that occurring either immediately at the site of injury, in the emergency department, or in the operating room, as an integral part of the initial resuscitation.
Hunt et al. Emergency thoracotomyin thoracic trauma – a review. Injury, Int. J. Care Injured 2006. 37, 1—19
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The need for rapid intervention in those patients deemed appropriate for the procedure, the life and death nature of the decision, and the low but finite functional survival rates following ET for trauma, have made the conduct of this procedure a subject of great controversy among trauma experts.
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In order to help health professionals to act quickly and accurately when an emergency thoracotomy is performed at the trauma room, we have created a sectoral Emergency thoracotomy procedure at ER.
of the procedure are: § to treat pericardial tamponade; § control hemorrhage; § treat systemic air embolism; § perform open cardiac massage; § temporarily occlude the thoracic aorta.
Thoracotomy box
Board large base
§ Sequence of procedures before thoracotomy
▪ Sequence Procedure Materials needed § Type of surgical approach to chest
§ Following procedures when creating access
▪ Sequence Procedure Materials needed
¡ After life-‐saving approach
§ Transfer Operating Room or ICU. § Rarely the chest is closed in the emergency room. § The chest covered with sterile drapes to prevent
further infection.
§ Nurse 1 -‐ support in instrumentation § Nurse 2 -‐ Prepare the necessary material and will
restoring the surgery table. § Nurse 3 ▪ Prepares and administers drugs ▪ supports the anesthesia ▪ monitoring the patient
▪ Monitors and records vital signs ▪ Connect the internal paddles and operates the defibrillator ▪ Nursing records ▪ Monitors and maintains the body temperature of the patient.
§ Nurse 4 ▪ assistance to the family ▪ collect relevant data (history of chest trauma)
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Preparation and positioning of the patient
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Infection control and prevention of exposure to microbial risk
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Records ▪ period of time thoracotomy was performed ▪ length of time that the patient has been in cardiac arrest ▪ period of time in direct cardiac massage ▪ number of joules when defibrillate ▪ time period in which there was clamping of the aorta ▪ amount of administered fluids ▪ administered drugs (drug, dose and route) ▪ names of players nurses ▪ Count the sterile compresses
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Trauma care is delivered in multiple settings across a time continuum
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Recovery following injury often continues for months or years
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Trauma nurses are optimally placed to improve the communication and integration of patient care across the continuum
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Articulation of the settings in which trauma care is delivered and the linkages between those settings.
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Identification of the long-‐term goals of trauma care and the associated nursing priorities
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Achieve intermediate outcomes in the prehospital and emergency department that will influence the long-‐ term results.
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The trauma care cannot be viewed as distinct episodes of care but must be conceptualized across the time / space continuum.
QUESTIONS
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Thoracic Trauma from the Pre-‐Hospital to the Emergency Room: What is the role of the Nurse? Tiago Amaral |RN, PHRN, MSc, CNS|
[email protected]
1 Junho 2015
Co-‐Authors: Artur Marona Beja |RN, MSc, CNS| Fernanda Fonseca |RN, MSc student|