Thoracic Trauma from the Prehospital to the ...

121 downloads 195 Views 9MB Size Report
TRAUMA: Chain of survival. Assistance is based on an appropriate, correct and timely intervention. Breaking the chain compromises the life of our victim.
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|  

  ¡ 

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.  

 

 

2  

¡ 

Trauma:  Epidemiology,  causes  and  distribuition  of  deaths  

¡ 

Thoracic  Trauma:  facts  

¡ 

Nursing  skill’s  at  Prehospital  and  ER  

¡ 

Thoracic  Trauma:  Continuity  of  care  

¡ 

Nursing  care  and  team  care  to  the  victim  of    Thoracic  Trauma  

¡ 

Emergency  Thoracotomy  procedure  at  Trauma  Room  CHLC  

¡ 

Emergency  Thoracotomy  procedure:  nursing  skill’s  and  role    

3  

¡ 

5.8  million  people  die  each  year  as  a  result  of  injuries.    

¡ 

Netherlands:     §  Direct  costs  1  billion  euros/year;   §  Indirect  costs:  4  billions  euros/year.      

 

 

   

¡ 

1st   cause   of   death   among   children,   teenagers   and   young   adults  (  ≤  44  years).  

¡ 

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.

¡ 

Prehospital:   §  Polytrauma;   §  Severe  Traumatic  Brain  Injury  (TBI);  

§  Exsanguination.  

    ¡ 

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.

¡ 

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  

  ¡ 

Patients  with  trauma  to  the  chest  present  with  some  of  the   most  life-­‐threatenning  conditions  in  emergency  care.    

   

   

         

 TNCC.  2007.  Emergency  Nurses  Association  

¡ 

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  

  ¡ 

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.    

¡ 

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?    

§ 

Development  of  an  integrated  trauma  system;  

§ 

Improvement  in  organ  replacement  therapies;    

§ 

Advances  in  resuscitation;  

§ 

Advances  in  critical  care;  

§ 

Surgical  team  of  trauma  ;  

§ 

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  

¡ 

ALS  in  Trauma  

¡ 

Paediatric  ALS  

¡ 

Paediatric  ALS  in  Trauma  

¡ 

Intensive  Care  

¡ 

MCI  

¡ 

Critical  care  transport  

¡ 

“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.      

¡ 

The continuum of clinical care provided to trauma patients extends from the time of injury through to longterm recovery and final outcomes.

¡ 

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  

-­‐ 

What  type  of  injuries  

-­‐ 

What  have  done  PH  team    

-­‐ 

What  have  to  be  done  /  what  do  you  expect    

-­‐ 

Estimated  Time  of  Arrival  (ETA)  

 

¡ 

Systematic  evaluation  

¡ 

Systematized  records  

¡ 

Sharing  the  same  language  

¡ 

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    

¡ 

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.    

 

  ¡ 

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)  

¡ 

Preparation  and  positioning  of  the  patient  

¡ 

Infection  control  and  prevention  of  exposure  to  microbial  risk  

¡ 

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  

¡ 

Trauma  care  is  delivered  in  multiple  settings  across   a  time  continuum  

¡ 

Recovery   following   injury   often   continues   for   months  or  years  

¡ 

Trauma  nurses  are  optimally  placed  to  improve  the   communication   and   integration   of   patient   care   across  the  continuum  

¡ 

Articulation  of  the  settings  in  which  trauma  care  is   delivered  and  the  linkages  between  those  settings.  

¡ 

Identification  of  the  long-­‐term  goals  of  trauma  care  and   the  associated  nursing  priorities  

¡ 

Achieve  intermediate  outcomes  in  the  prehospital  and   emergency  department  that  will  influence  the  long-­‐ term  results.  

¡ 

The  trauma  care  cannot  be  viewed  as  distinct  episodes   of  care  but  must  be  conceptualized  across  the  time  /   space  continuum.  

QUESTIONS  

43  

44  

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|