You are part of a team of emergency room nurses who will be providing care to clients being transported from a multiple casualty accident involving a tourist bus and several cars that occurred on the Long Island Expressway.
The incident commander has triaged the 17 victims according to the trauma triage protocol and arranged transport to the nearest medical facilities. Since your institution is a level I Trauma Center, you will be receiving 2 multitrauma patients via helicopter and ambulance. The information provided from the transport team is as follows:
1. 63 year old female, passenger of bus, rolled X 1, not seat-belted. Alert, anxious, + CP & DB, point tenderness/crepitus to left sternum, multiple contusions face and lower extremities; LLE shortened and stabilized. HR 136 irregular, RR 36, BP 80/50, PO 96% on 100% non rebreather mask. PMH atrial fibrillation on Digoxin and Coumadin. Spinal immobilized LLE in neutral position.
2. 55 year old male, driver, not seat-belted, no airbag. Awake at times but drifts off to sleep.
Complaining of right sided chest pain and point tenderness, + deformity to right wrist and open fracture to left tibia/fibula (tib/fib). HR 122 regular, RR 40, BP 100/60, PO 96% on 100% non rebreather mask. PMH: Bone Marrow Transplant for the treatment of CML on immunosuppressants. Spinal immobilized, pillow splint to right wrist and LLE.
ETA 5 minutes.
Based on the trauma triage protocol below, what factors in your client report indicate that the criteria for transfer to the Trauma I facility is necessary?
(Source: http://www.uph.org/Portals/0/TRAUMA%20TRIAGE.pdf
)

Patient 1: enter the pertinent data
Anatomic criteria
Physiologic criteria
Mechanism of injury criteria
Preexisting conditions
Patient 2: enter the pertinent data
Anatomic criteria
Physiologic criteria
Mechanism of injury criteria
Preexisting conditions
What special concerns arise in a client receiving anticoagulation therapy ?
Prior to providing care, your ED RN preceptor reviews the role of the Primary RN during a trauma code:
He explains the role as follows:
The preceptor explains that there are several float nurses to the Emergency Department today and need to select one additional RN to meet the staffing requirements for the trauma resuscitation room .
Which of the following staff members should you suggest to include in the team? a. A novice RN who has worked for twenty years as an LPN in the Emergency Department b. A medical surgical nurse with 10 years experience in orthopedics. c. A coronary care nurse studying to become a nurse practitioner. d. A PACU nurse who has experiencing in the CVICU.

Your preceptor reinforces that you will need to prepare to care for a client with head, chest musculoskeletal trauma and pulls the Trauma algorithms to review wit h you prior to the clients’ arrival.
While the trauma team leader performs the primary survey the clients remain immobilized due to the risk of spinal trauma until X-rays are reviewed and the clients are cleared to remove the equipment.
The preceptor reviews the chest trauma algorithm emphasizing the key points are
A, B,C,D, E, ATLS resuscitation, secondary survey Bloodwork & chest Xray:

Stridor?
10<RR >24
Unable to speak
Open/clear airway (C spine precautions)
Adjunct airway insertion if needed
BVM for hypoventilation
ET intubation if not breathing spontaneously
Cricothyroidotomy if indicated
Expose chest and check RR, depth, bilateral movement, tracheal deviation, palpate for subcutaneous emphysema, pulse oximetry & ETCO2
Hyperresonance on affected side
Paradoxical chest movement
Supplemental oxygen administration
Needle decompression/ chest tube insertion for tension pneumothorax
Chest tube insertion for open pneumothorax
Ventilator support for flail chest and prepare for OR
ABGs and continuous pulse oximetry
Check HR, dysrhythmia, skin color, capillary refill, JVD, BP, pulse pressure, Ausculate for muffled heart sounds, dullness to percussion
Check for signs of bleeding
Perform neurochecks, check for head contusion fractures, and lacerations. Check for battle signs and CSF leak
Check for asymmetry & motor/sensory loss in extremities,
CPR if no pulse
Periocardiocentesis for Becks triad (JVD, muffled heart sounds, hypotension) in cardiac tamponade
2 large bore IVs for volume replacement with warmed Lactated Ringers or Normal saline and Trauma labwork
Chest tube for hemothorax
Replace blood as indicated
Cardiac monitor, Chest Xray, 12 lead EKG
Maintain pulse oximetry and mean arterial pressure to preserve cerebral perfusion
CT head for head trauma
Sedation and Ventilator support for TBI
IV Steroids for spinal trauma
Stabilization and neurovascular monitoring for extremity trauma
Frequent Neurochecks and Peripheral vascular checks
Remove all clothing, apply warmed blankets and monitor core temperature, VS, NGT,
Foley Catheter, cardiac monitor, 12 Lead EKG and pulse oximetry. Secondary survey, head to toe assessment, full trauma labwork, and prepare for OR if indicated

Based on review of the algorithm, what procedures would you need to prepare to assist in? (Define the indications for each):
Endotracheal intubation:
Chest tube insertion:
Pericardiocentesis:
Your preceptor pulls the Trauma flowsheet for each patient and starts to prepare the rooms. (Print the trauma flowsheet Source: http://doh.sd.gov/trauma/PDF/TraumaFlowSheet.pdf
After reviewing the client report, trauma algorithm, RN responsibilities, and the trauma flow sheet; what equipment would you want immediately available in each room?
Patient 1(use the client report trauma flowsheet to complete)
Airway
Breathing
Circulation
Disability
Tubes
Procedural equipment
Patient 2 (use the client report trauma flowsheet to complete)
Airway
Breathing
Circulation
Disability
Tubes
Procedural equipment
Patient 1 arrives. The ED staff transfer the client from the helicopter pad and transfer the client to trauma room 1. The primary survey reveals the following:

Patient 1
Primary survey:
Airway: Airway patent on 100% non rebreather, + tachypnea, RT using BVM on
100% oxygen
Breathing: +dyspnea, paradoxical chest wall movement , lung sounds decreased left side, dullness to percussion
Circulation: Carotid and femoral pulses present, heart sounds muffled, +JVD capillary refill > 2 seconds, Bleeding controlled, skin color mottled
Disability Opens eyes spontaneously, confused, obeys commands
G
H
R
E
C
S
P
O
2
176
82%
NIBP MAP RR
76 / 50 58.7 38
How do you interpret these findings?
The primary RN reports the decreasing pulse pressure, JVD and hypotension as well as the decreased breath sounds and left sided dullness to percussion to the team leader. As one RN inserts 2 large bore
IV sites, another gets the thoracotomy tray and chest tube drainage device as well as equipment to perform pericardiocentesis .
Chest tube:
How should the RN prepare the client for chest tube insertion?
How is the drainage device set up prior to insertion?
What is the expected drainage if dullness to percussion is noted?
What assessments indicate that the chest tube insertion was successful?

What assessments and monitoring should be implemented following insertion? (Consider blood loss)
Pericardiocentesis:
How should the RN prepare the client for pericardiocentesis?
How is the procedure performed?
What assessments indicate that pericardiocentesis was successful?
What assessments and monitoring should be implemented following insertion? (Consider blood loss)
Following chest tube insertion and pericardiocentesis the clients VS are as follows:
RR: 26, HR 132, BP 90/50, T 97 F Pulse ox 90%
2 liters of IV Lactated Ringers are infusing. Trauma labs are drawn. The team leader initiates treatment for Flail chest and the Respiratory Therapy is preparing to intubate the client. The team leader orders the RN to administer Versed (Midazolam) and Succinylcholine (paralytic) and a second RN continues with cutting off the remainder of the client’s clothing and covers the client with warmed blankets.
.
How should the RN prepare the client for intubation?
How is the procedure performed?
What assessments indicate that endotracheal intubation was successful?
What assessments and monitoring should be implemented following insertion?
Patient 2 arrives via ambulance and is assigned to trauma room # 2. The primary survey reveals the following:
Airway: Airway patent on 100% non rebreather, + tachypnea, RT using BVM on 100% oxygen
Breathing: +dyspnea, + pt tenderness to right chest wall, asymmetric chest expansion, lung sounds decreased right side, hyperresonant to percussion
Circulation: Carotid and femoral pulses present, radial pulses thready. heart sounds normal ,
- JVD capillary refill > 2 seconds, Bleeding controlled, skin color pale
Disability Opens eyes to verbal stimuli, Verbal: Inappropriate words, localizes pain

E
C
G
H
R
148
S
P
O
2
86%
NIBP MAP RR
90 / 50 63.3 40
How do you interpret these findings?
The team leader asks for the thoracotomy tray and chest tube drainage device. The RT continues to
BVM the client as one RN inserts 2 large bore IV sites.
Chest tube:
How should the RN prepare the client for chest tube insertion?
How is the drainage device set up prior to insertion?
What is the expected drainage if hyperresonance to percussion is noted?
What assessments indicate that the chest tube insertion was successful?
What assessments and monitoring should be implemented following insertion? (Consider air leakage)

Following chest tube insertion the client ’s VS are as follows:
RR: 30, HR 130, BP 96/50, T 96 F Pulse ox 92%
2 liters of IV Lactated Ringers are infusing. Trauma labs are drawn. Respiratory Therapy is preparing to intubate the client. The team leader orders the RN to administer Versed (Midazolam) and
Succinylcholine (paralytic) a second RN continues with cutting off the remainder of the client’s clothing and covers the client with warmed blankets.
What continuing monitoring would the RN initiate as the team proceeds to the secondary survey?
The ED supervisor is checking on the progress of both trauma rooms and notes that the secondary surveys are completed. Thoracic surgery, Neurosurgery, & Orthopedic surgery is present. The surveys reveal:
Patient 1
Head/scalp Bruising noted to scalp and face, no lacerations, no crepitus/depressions no battle signs or
Patient 2
Large contusion to left temporal lobe, no crepitus no depression
Eyes PEARL, EOMs intact No raccoon eyes
Mouths
Ears
Neck intact
No drainage
Cervical collar in place. Trachea midline no subcutaneous edema
Chest Paradoxical chest wall movement, crepitus Left sternal border. + flail chest.
18 Fr chest tube drained 500 mL sanguineous drainage to suction. present Heart sounds
Abdomen Distended , diffuse tenderness, last food intake 2 hours ago
Bowel sounds hypoactive
PEARL, unable to perform EOMs, no raccoon eyes
Two avulsed teeth
Blood tinged serous drainage from left ear
Cervical collar in place. Trachea midline no subcutaneous edema
Asymmetric chest wall movement. 20 Fr chest tube draining scant amount sanguineous drainage with continuous bubbling in water seal.
Present following pericardiocentesis
Soft non-tender was last eating when driving hypoactive
Pelvis + pain
Posterior Multiple contusions no deformity
Extremities LLE: + deformity, shortened, thready DP pulses bilaterally, sensation intact. Toes mobile stable
Multiple contusions no deformity
Right wrist: + deformity, decreased mobility+ parasthesia
Left Tib fib: open fracture, bone exposed, bleeding controlled debris removed with saline irrigation.
Decreased LLE DP pulse + parasthesia

How would you prepare to transfer the client for CT?
ET tube and ventilation
Cardiac monitoring and Vital sign monitoring
Chest tube drainage
Pericardiocentesis catheter
Foley catheter
Orogastric tube
LLE splint
The client’s CT head indicates no hemorrhage and the client is returned to the trauma room. On return the pulses in the LLE are decreased, sensation is decreased and the temperature is cooler. The x-ray indicates that the femoral head is shattered.
What do these finding signify?
The orthopedic surgeon instructs the RN’s to apply Bucks traction . Review the policy
What is the pre-application assessment?
What findings would cause you to alert the surgeon?

According to eMedicine, the following complications can occur with a fracture femur and replacement.
What signs and symptoms indicate that the client may be experiencing these complications and how could they be prevented?
Hemorrhagic shock
Fat Embolism
Signs and symptoms Prevention/management
Neurovascular compromise
Osteomyelitis
Delayed union
DVT
Dislocation
The leader reviews the labs, and order the RN to administer 2 units of fresh frozen plasma (FFP) and
Vit K. Client 1 is transferred to the OR.
Review the client’s secondary survey. The RN informs the team leader of continuous bubbling in the water seal and a second chest tube is inserted. The client’s vital signs stabilize. A follow-up chest x ray reveals that the pneumothorax is resolving. The CT head confirms a temporal lobe fracture that is nondisplaced without hemorrhage that is being managed by the neurosurgeon and the orthopedic surgeon evaluates the client’s wrist ad tib/fib fractures and determines that the client requires open reduction of both fractures.
How would the RN assess for recurring air leaks form the chest tube?
How is the treatment for an open fracture different from a closed fracture?
What risks arise from open fractures?
One of the RNs administers tetanus toxoid. What is the purpose of this agent?
How is the peripheral neurovascular assessment different for upper and lower extremities?

Client 2 is transferred to the OR and returns to the PACU with an ICP monitoring device (NUR 240 unit
4) and external fixator to the Tib/fib and cast to the right wrist. A neurosurgical NP attends to the client’s neurological assessment.
What musculoskeletal assessments should be performed immediately the client’s tib/fib and wrist fractures?
According to Emedicine , the following complications can occur with a tib/fib fracture:

Neurovascular compromise

Compartment syndrome

Peroneal nerve injury

Infection

Gangrene

Osteomyelitis

Delayed union, nonunion, or malunion

Amputation or skin loss

Posttraumatic arthritis

Fat embolism
What would you expect to be included in the plan if care?
Following an SICU stay, the client is transferred to a rehabilitation facility for his head trauma and continued physical therapy.
When you are reporting the discharge plan to the receiving nurse, what would you include in the instructions for signs of the following?
Neurovascular compromise
Compartment syndrome
Peroneal nerve injury
Osteomyelitis
Fat embolism
What would you explain has been performed for cast and pin site care?