Nsg disaster management final

NURSING MANAGEMENT OF

DISASTER VICTIMS

WITH

INJURY AND TRAUMA

Dharmendra raval.

Nursing tutor.

College of Nursing

Jamnagar.

04/09/23 dhraval

• Types of Injuries

• Acute management

Triage

In - The - Field

Transport

Emergency Room

• Definitive management - Rehabilitation

Trauma Scoring System

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Incidence

Trauma leading cause of death below 40 years of age

Death from injuries : To rise by 65% by 2020

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ATLS : Advanced Trauma Life Support

• Primary survey, Simultaneous Resuscitation

Identify and Treat – what is killing the victim : ABC

• Secondary Survey

Proceed to identify all other injuries

• Definitive Care

Develop a definitive management plan

Dr.James Styner : 1970’s

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TRAUMA TEAM

• Doctor’s of different specialties

• Nurses

COORDINATION

Universal Precautions :

Gloves, Masks, Visors, Aprons

• Radiographer’s

• Respiratory Technicians

• Clerks

Ambulance Personnel : Emergency Medical Technicians (EMT)

PRACTICED

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Trauma Team

Basic Skills : Emergency Medical Technicians (EMT)

Perform Technically sound CPR

Maintain Airway (ET Intubation ?)

Intravenous Access : Start RL

Reduce and Splint Fractures

Primary Survey of patient - Report

Act with physician : Radio / Phone04/09/23 dhraval

Triage in the field

• Major Causes of Injury

Blunt, Penetrating, Blast, Radiation, Biological

• Quickly ‘Size up the Scene’

Assess – Personnel, Equipment

Proximity of : Fire, Smoke, Falling Debris, Rising Water, Live Electricity, Toxic Contaminants

• Report Briefly for Help : How Many ; How Bad04/09/23 dhraval

TYPES OF INJURY CRUSH INJURIES

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Types of injury

BLUNT INJURIES

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Types of injuryPenetrating Injuries

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Types of injury

EXPLOSIVE FORCE THERMAL INJURIES

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TRIAGE

Those who benefit most : Critically Injured but can be Saved

Critically wounded : Silent, Unconscious

Minor Injuries : Nearest, Noisiest – Shouting for help

French : ‘To Sort’

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Blind to Horrific sitesDeaf to the cries of injured

Wisdom of SolomonPatience of Job

TRIAGE

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MORTALITY

50 % : Die within moments

Out of These : 55 % - Head Injury

: Lacerations of - Heart

- Liver

- Major Blood Vessels

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MORTALITYTrimodal Distribution

• Immediate Death Severe Head Injury

Transected Aorta

• Early Deaths Correctable CausesEpidural or Sudural Hematoma

Hemo pneumothorax

Spleen or Liver Wound

Blood Loss : Multiple extremity injuries

• Late DeathsSepsis

Multiorgan failure

( Level 1 : Expertise, Facilities)

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In-the- field Management

• Extricate the victim

• Unconscious : Assume Cervical Spine Injury

• Prolonged extrication : Begin A - B - C

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In the Field Resuscitation : OVERVIEW

• Extricate the victim

• ABC and Spine stabilization

• Bleeding Control

• Intravenous Line and Fluids

• Warm : Reduce Hypothermia and Slow Coagulopathy

• Protect : Falling debris, rain

• Tag Critical Information : Name, Blood Group, Allergies, Co-morbidities – Diabetes,CAD

• Transportation to Trauma Centre

• Splints for fractures

TRIAGE

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A-B-C

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AIRWAY

Adequacy of Airway ?

Head Injury

Facial Injuries

Shock

Thoracic Trauma

Chin Lift – Jaw Thrust – Finger Sweep – Suction – Oropharyngeal Tube - INTUBATION

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Gentle Maneuvre :

Assistant – gentle linear traction - occiput

Nasopharyngeal Intubation

( Avoid – Midfacial Injuries)

Rarely Tracheostomy

INTUBATION : CERVICAL SPINE INJURY

No patient should expire from lack of Airway because of

concern over Cervical Spine Injury04/09/23 dhraval

Jackson Rees Mask

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BREATHINGIneffective after Intubation

Most Common Cause : Mal-positioned tube

Pneumothorax

Hemothorax

Treatment : Tension Pneumothorax

Clinical Diagnosis (X Ray not available)

Large Bore Needle : 2nd ICS Mid-clavicle

Later : Chest Tube : 4th ICS Mid-axillary

Later : Mechanical Ventillation

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CIRCULATION

In-the-field :

- Continued till Emergency Room

Direct Pressure control of obvious external bleeding

Fluid Replacement

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SPLINTS

Limb Aligned : Pre-made padded Splints

Pillow Splints

Thomas Knee Splint

Air Splint : Popular

Zipper Fails

Pneumatic Anti-shock Garments : Suspected Pelvic #Log roll to backboard –open garment –2 segments

Inflated 50-100 mm Hg in each section

Disadvantage : Compartment Syndrome, Less Ventillatory capacity

Cramer Wire Splint

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LOG ROLL MANEUVRE

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AMBULANCE

Well Maintained Vehicle

Equipment for :

• Extrication

• Spinal Support

• Airway management

• Vital Signs Monitoring

• Intravenous administration

• Cardiac Arrest management : Defibrilator

• Fracture - Splintage04/09/23 dhraval

TRANSPORTATION

Helicopters

Ambulances

Cars

Stretchers

Wheelbarrows

Wagons

Piggy Back

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HOSPITAL TRAUMA TEAM

Team Leader : Most Experienced

• Assess Patient Status• Determine need for tests – delegate• Co-ordinate – other services• Make critical treatment and triage decisions

Team Members :

Identified before

Duties Known

Well Rehearsed04/09/23 dhraval

HOSPITAL TRAUMA TEAM

Team Leader : Head End

Airway Management

Cervical Spine Protection

Naso gastric tube insertionDirects Activities of other Members

Right Side Team Member

IV Access

Foleys Catheterization

Tube Tracheostomy

Peritoneal Tap

Left Side Member if available

Begins Initial Survey

Assists Venous Access

Less Confusion and Noise04/09/23 dhraval

Hospital Emergency Room Management

• 80 % : Non Urgent

Triage

Emergency team pre-informed and prepared

• 10 - 15% : Urgent But Not Immediately Life Threatening

• 5 % : Severe Life Threatening

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Severe Life Threatening

(5 % )

• Half Die Within 1-2 Hours

• Neurologic or Pulmonary impairment

• Splenic rupture

• Orthopaedic or multi-organ injury with hemorrhage

• Exanguinating, Eviscerated, Open Head Injury -

Admitted Directly to Surgery

Hospital Care

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Level – 1 Trauma Centre

• Medical Air Evacuation

• Round the clock

• Expert Support Services in every Speciality

• 365 Days

PROGNOSISResuscitation within 60-90 Minutes in Level -1

Significant Greater chances of Surviving - ADL

Hospital Care

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Less Life Threatening (10-15 %)

Nurses : Stabilize – Furthur Evaluation

• Oxygen : Cannula / Mask

• Connect to Diagnostic Monitors

ECG, Oxygen Saturation , BP Monitored

• ABC and Neurological Function Evaluated

Glasgow Coma Scale

Trauma Score

Hospital Nursing Care

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• Cervical Spine Brace Removed ONLY after

Neurologist and Radiologist Clearance

• Auscultate : Breath Sounds

• Examine for other injuries

Bullet entery site

Stab Wounds

Flail Chest, Pneumothorax

Cardiac Tamponade

Tracheal Deviation04/09/23 dhraval


• Patients arriving with Endotracheal tube, mask, airway :

Check and Secure

• Nurses : Intravenous Line 14 - 18 Gauge

Stabilize limb –Arm Board

Superficial Veins Collapsed : Doctor Cannulate

Femoral, Internal Jugular, Subclavian or Cut Down

• Life Saving - Intravenous Fluids

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Intravenous Fluids : Management

Initial Bolus : Ringer Lactate solution

Adults :1000 ml Child : 20 ml per kg

Response to Bolus : Skin Perfusion, Urine Output, CVP

Repeat Bolus in 5 minutes

BP Not Responding ; HCT < 30-35% : Blood Transfusion

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BLOOD TRANSFUSION


Group O Negative : Pregnant or Child bearing age

Group O Positive (Universal Donor)

Typed or Cross matched blood not available

Waiting – Hastens death by exanguination

Cold Blood : Negative Effect on platelet function and

Cardiac Contractility

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CO-ORDINATE

• Acquire Laboratory Samples

• Orchestrate Patient Transport

• Retrieve Reports

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• Injection TT : Wounds

• Foley’s Catheter : Input-Output Charting

(Unless Suspecting Urethral Injury)

• Splints

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INVESTIGATIONS

X – Rays : Fractures

CT Scans : Head Injuries

Cervical Spine Injuries

Limited cut CT of C -1, C-2

Arteriography : Penetrating Injuries

Diagnostic Peritoneal Lavage : Intra-abdominal bleed - Laprotomy

Doppler, Echo

C-3 ; T-6 ; L-3 ; Open Mouth View

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DOCUMENTATION

• Nurse’s Responsibility : Acquire Information

• Legal Document : Record is crucial

• Flow Sheet : Information and subsequent care - transfer

Name, Age, Next of Kin

Pre-existing medical conditions, Medications

Mechanism of Injury, Presence of implants

Organ Donation, Will04/09/23 dhraval

TRAUMA SCORING SYSTEMS

Evaluate Trauma Management and Outcome

• Input (Triage)

• Treatment

• Outcome

Anatomical Scoring

Physiological Scoring

Abbreviated Injury Score

Injury Severity Score

Glasgow Coma Scale

Trauma Score

Revised Trauma Score

TRISS Methodology

Individual Patient

System of patient care

MorbidityMortality

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Trauma Score

Used to assess : Traffic accident patients

Makes use of Abbreviated Injury Scale (AIS)

Value correlates : Mortality risk

Immediately / Rapidly fatal Injuries : Excluded

Injuries assigned : 5 Body Regions

Score :1 to 5

INJURY SEVERITY SCORE (ISS)

Square of three highest scores added : ISS04/09/23 dhraval

INJURY SEVERITY SCORE (ISS)

Trauma Score

5 Body Regions

General

Head and Neck

Chest

Abdomen

Extremities and Pelvis

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INJURY SEVERITY SCORE (ISS)Trauma Score

Score : Abbreviated Injury Score (AIS)

1 : Minor Injury

2 : Moderate Injury

3 : Severe But not life threatening

4 : Life threatening But Survival Likely

5 : Critical But Uncertain Survival

0 : No Injury

6 : Fatal (dead on arrival)04/09/23 dhraval

Abbreviated Injury Score (AIS)

Limb Injuries 1. Minor

2. Moderate

Minor Sprains

Undisplaced long bone & Pelvic #

Open Fractures / Dislocation – digits

3. Serious, Non life threatening

Displaced simple long bone #

Multiple hand & foot #04/09/23 dhraval

4. Severe, Life threatening, Survival Possible

Simple open long bone #

Displaced Pelvic #

Dislocation – major joints

Major Nerves or Vessel injury

Multiple Closed #

Limb Amputation

5. Critical, Survival Uncertain

Multiple Open #

6. Fatal (dead on arrival)

(AIS) Limb Injuries

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INJURY SEVERITY SCORE (ISS)Trauma Score

Region InjuryDescription

AIS SquareTop Three

Head & Neck Cerebral Contusion 3 9

Face No Injury 0

Chest Flail Chest 4 16

Abdomen Minor Contusion of LiverComplex Rupture Spleen

2 5

25

Extremity Fractured femur 3

External No Injury 0

Injury Severity Score: 50

Minimum Score : 0 Maximum Score : 75

Mortality : Increased Score and Age04/09/23 dhraval

REVISED TRAUMA SCORE

Rapidly Assess : Patients at Scene of Accident

Points for Respiratory Rate+

Points for Systolic BP

+

Points for Glasgow Coma Scale

Maximum Score : 12 (Least affected)

Minimum Score : 0 (Most Affected)04/09/23 dhraval

10-29 / Minute : 4

>29 / Minute : 3

6-9 / Minute : 2

1-5 / Minute : 1

Nil : 0


Respiratory Rate

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Systolic Blood Pressure

89 mm Hg : 4

76-89 mm Hg : 3

50-75 mm Hg : 2

1-49 mm Hg : 1

Nil : 0

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GLASGOW COMA SCALE

13 –15 : 4

9 –12 : 3

6 – 8 : 2

4 - 5 : 1

2 : 0

Respiratory Rate + Systolic BP + GCS = RTS

Eye Opening

Spontaneous : 4

On Command : 3

On Pain : 2

Nil : 1

Best Motor Response

Obeys : 6

Localizes Pain : 5

Normal Flexor : 4

Abnormal Flexor : 3

Extensor : 2

Nil : 1

Verbal Reponse

Oriented : 5

Confused : 4

Words : 3

Sounds : 2

Nil : 1

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TRISS METHODOLOGY

Trauma and Injury Severity Score (TRISS)

Designed to Evaluate Trauma Care

Calculates Expected Survival :

Based on Patients characteristics

Use : To compare outcomes from different treatment centres

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Indications : Immediate Surgery

BP Falling (After I.V Bolus, Blood)

Abdominal Peritoneal Lavage : Rule out Intra-abdominal injury

( CT : If BP Moderately Stable )

IF Head Injury, Mid face Injury or Cervical Spine Injury :

CT Head

X Ray Spine

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Indications : Immediate Surgery

Systolic BP Not Restored : Second Phase

Surgical Management

• Hemorrhage Secondary to :

Liver, Spleen , Renal Injury : Laparotomy

Aortic, Vena Cava, Pulmonary Vessel Injury : Thoracotomy

Depressed Skull Fractures, Acute SDH : Craniotomy

• Prevention of Pulmonary Failure

• Pelvic # , Femur Shaft #

• IF Stable : All Open #, Displaced # NOF, Talar Neck04/09/23 dhraval

Delayed Operative Procedures

Within 6-8 Hours

Compartment Syndrome

Open Fractures

Vascular Injuries

Spine : First 5-7 Days

Elbow, Ankle, Hind foot :

Delay 8-10 days (if not done in 8-10 hours)

Within 24 Hours : Intra-articular Fractures

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Nutritional Status

Role of Parenteral Nutrition

Head Injury

Maxillo facial Injury

Gut Loss

Intake < 2000-3000 cal / day

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Recovery and Rehabilitation

Very Important Role : Musculo-skeletal Injuries

Fixation of all fractures

Physiotherapy

Occupational Therapy

Psychotherapy

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ATLS : Advanced Trauma Life Support

• Primary survey, Simultaneous Resuscitation

Identify and Treat – what is killing the victim : ABC

• Detailed Secondary Survey

Proceed to identify all other injuries

• Definitive Care

Develop a definitive management plan

SUMMARY

• Constant Re-evaluation

04/09/23 dhraval

04/09/23 dhraval

Nsg disaster management final

Health & Medicine

Transcript of Nsg disaster management final