Advanced Trauma Life
Support
STUART TOULSON
In the days of Mother Goose, putting Humpty Dumpty together again couldn't be done: but today, with trauma specialists (pre-hospital personnel, surgeons, nurses) who function on the principle of the 'Golden Hour' (the first hour post-injury during which the shock process must be reversed if the patient is to be saved), it often happens. (Ward, 1985, p. 1)
Introduction
In the United Kingdom, approximately 25,000 people are killed every year as a direct consequence of trauma whilst a further 50,000 sustain major injuries (Robertson and Redmond, 1991). In the under-35 age group, the total number of fatalities due to such injuries exceeds the combined total for deaths caused by both cardiovascular disease and cancer (Irving, 1990). As with most critical illnesses, the quality of the initial assessment and management of the severely injured patient influences the final outcome. An organized, aggres¬sive and consistent approach to trauma management therefore results in optimum patient care (Davies et al., 1992; American College of Surgeons 1993).
This chapter does not aim to be an exhaustive account of trauma resuscitation but offers a basic overview of the standard advanced trauma life support (ATLS) approach to patient care and the subse¬quent role of the accident and emergency (A&E) nurse. It will high¬light why the need for trauma training exists for nursing staff and will stress the importance of a team approach within trauma management.
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2 Accident and Emergency Nursing
Overview of ATLS Principles
Deaths due to trauma follow three distinct patterns:
(1) The first peak occurs within seconds to minutes after injury, often
due to lacerations of the brain, brain stem, high spinal cord,
heart, aorta or other large vessels.
(2) The second death peak happens within minutes to a few hours
after injury - referred to as the 'Golden Hour'. These deaths are
due to potentially preventable conditions including subdural or
extradural haematomas, haemopneumothorax, ruptured spleen,
lacerations of the liver, pelvic fractures or other multiple injuries
associated with a significant loss of blood.
(3) The final group dies several days to weeks after injury, usually as a
result of sepsis and organ failure (American College of Surgeons,
1993).
It is the protection of life within this first hour following injury that ATLS training addresses as it is deaths within this time frame that are viewed as potentially preventable. A team approach to resuscitation of the trauma patient therefore involves a rapid initial assessment with subsequent restoration of the body's vital functions. A thorough and orderly evaluation is then performed to ensure that less obvious injuries are not overlooked. The underlying principle is to presume that serious injuries are present until proven otherwise and detracts from the old style approach of treating only visible symptoms. Patient management includes:
• a primary survey;
• subsequent resuscitation phase;
• a secondary survey;
• a definitive care phase.
Mechanism of injury
A thorough history in respect of the injury-producing mechanism is a useful tool in the diagnosis of resultant injuries and the paramedics are especially competent at providing and relaying such information to the A&E team. Such injury types are classified according to the direction and amount of force involved: the energy wave extending away from the point of impact in blunt trauma and laterally from the missile pathway in penetrating trauma.
Advanced Trauma Life Support 3
Mechanisms of injury that should alert the A&E nurse to the possibility of significant underlying injury include:
• falls of 20 feet or more;
• patient ejection from a vehicle;
• patient involved in a vehicle 'rollover';
• death of a same-vehicle occupant;
• impacts greater that 20 mph without restraint or 30 mph with
restraint;
• pedestrian hit at 20 mph or greater;
• patient in close proximity to an explosion;
• 30 degree deformity of car;
• passenger compartment intrusion - 18° on patient side or 24° on
opposite side.
In addition to these criteria the nurse should calculate a patient's overall trauma score and should alert the trauma team/request senior medical assistance immediately should the score be anything less than the maximum 12 (see Table 1.1).
Table 1.1 Revised trauma score
Glasgow coma Systolic blood Respiratory Trauma
scale (GCS) pressure rate score
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
The respective injuries that differing mechanisms of injury may cause are highlighted in Table 1.2.
The mnemonic 'AMPLE' is used to highlight key areas of infor¬mation that the nurse should elicit alongside those relating to the mechanism of injury:
A - allergies;
M — medications;
P — past medical history;
L - last time ate or drank;
E - events/environment (injury mechanism).
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Accident and Emergency Nursing
Table 1.2 Mechanisms of injury and potential injury patterns
Mechanism of injury
Suspected injury patterns
Frontal impact:
• Bent steering wheel
• Knee imprint in dashboard
• Bull's-eye fracture of windshield
Side impact to vehicle
Rear impact vehicle collision Ejection from vehicle
Pedestrian
• Cervical spine fracture
• Anterior flail chest
• Myocardial contusion
• Pneumothorax
• Transection of aorta (decelerating
injury)
• Fractured spleen or liver
• Posterior fracture/dislocation of hip
and/or knee
• Contralateral neck sprain
• Cervical spine fracture
• Lateral flail chest
• Pneumothorax
• Traumatic aortic rupture
• Fractured spleen or liver (depending
on side of impact)
• Fractured pelvis or acetabulum
• Cervical spine fracture
Such a mechanism can result in virtually all mentioned injury patterns and mortality is significantly increased
• Head injury
• Chest and abdominal injuries
• Fractures of lower extremities
Source: American College of Surgeons (1993).
The Primary Survey
This is designed to identify all life-threatening conditions to enable subsequent medical/nursing intervention to commence. The survey involves a rapid examination of the patient by an experienced ATLS-trained doctor. The author would stress that any ATLS-trained nurse should also be prepared to adopt this role if required until senior medical help arrives and may therefore have to guide junior medical colleagues in the principles of the primary survey. The survey is an adaptation of the well-established ABCs of cardiac
Advanced Trauma Life Support 5
resuscitation and utilizes all history as obtained from the accident scene. The following criteria are assessed/performed in strict order:
A — airway maintenance with cervical spine control;
B - breathing and ventilation;
G - circulation with haemorrhage control;
D - disability or dysfunction;
E - exposure/environmental control.
It cannot be over-stressed that it must be assumed that all trauma patients have sustained a cervical spine injury and that neck immobi¬lization be maintained, even during emergency airway interventions, until such an injury has been categorically excluded by senior medical staff. This is a prime nursing role and the recommended technique of cervical spine (c-spine) immobilization is with proficient application of a stiff-neck collar with sandbags placed either side of the head and strong tape applied across the patient's forehead prior to fixation to the trolley or spinal board.
Resuscitation Phase
During this phase shock management is initiated, management of patient oxygenation reassessed and haemorrhage control re-evaluated. Any life-threatening conditions identified in the primary survey are constantly reassessed as management is continued.
Secondary Survey
This involves a comprehensive head-to-toe examination, including the recording of all vital signs. Each region of the body is examined individually and in an orderly sequence to ensure that no injury is missed - the 'tubes and fingers into every orifice' philosophy. Stan¬dard trauma X-rays of c-spine, chest and pelvis are ordered at this stage. Strict log-rolling techniques with total spine immobilization must be maintained when examining the patient's back at the end of this survey as moving the patient's back incorrectly may result in an unstable spinal injury causing permanent paralysis. Good nursing care dictates that any spinal board should be removed at this point for patient comfort should his/her medical condition allow and that any fragments of glass etc. are removed.
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Accident and Emergency Nursing
The secondary survey does not begin until the primary survey has been completed and the resuscitation of life-threatening conditions has begun.
Definitive Care Phase
All of the patient's injuries are managed including fracture stabiliza¬tion, wound dressing, tetanus immunization and any necessary oper¬ative interventions that are not immediately life-threatening. The patient may subsequently be transferred at this stage to either a ward or a specialist unit.
The following will highlight the assessment and associated medical/nursing intervention required for all potentially life-threatening conditions identified within the primary survey.
Airway
The nurse should expect either actual or potential airway obstruction in any patient presenting following injury, and assisting in establishing and maintaining a patent airway (whilst maintaining c-spine control) is therefore the first priority. Partial or complete airway compromise may occur unexpectedly following trauma, and definitive airway interven¬tion aims to protect the patient from airway obstruction and aspiration, allowing adequate oxygenation and ventilation. Assessment and continuous reassessment of the patient is therefore essential.
During the initial assessment of the airway the nurse must observe for signs of current or impending airway obstruction and must intervene accordingly.
Assessment will include:
• Is the patient agitated (suggesting hypoxia)?
• Is the patient drowsy (suggesting hypercarbia)?
• Is the patient using accessory muscles of ventilation?
• Is the trachea midline?
• Are there any abnormal breath sounds (e.g. gurgling/stridor/
crackles/wheezing/snoring)?
Airway obstruction may present as a result of foreign bodies (teeth, gastric contents etc.) or obstruction by the tongue in the semi-conscious
Advanced Trauma Life Support 7
patient, and clearing the airway is an obvious nursing prerequisite to the more complex techniques of airway management.
Basic Airway Intervention
• Chin lift and jaw thrust: The chin lift manoeuvre is performed by
placing two fingers of one hand under the mandible and gently
lifting upward to position the chin anteriorly. The jaw thrust is
performed by manually elevating the angles of the mandible to
obtain the same effect.
• Oropharyngeal airway: This is a mechanical adjunct to the manoeu¬
vre described above and its use should be familiar to the A&E
nurse.
• Nasopharyngeal airway: These are better tolerated in the semi¬
conscious patient and carry a lesser risk of causing vomiting.
Their use is contraindicated in patients with suspected skull
fractures.
• Endotracheal intubation: This is viewed as the 'gold standard' for
airway protection and must be performed with strict in-line cervi¬
cal spine immobilization and may require nurse assistance to
perform cricoid pressure. Indications for endotracheal intubation
include apnoea, respiratory insufficiency, upper airway obstruc¬
tion (actual or potential) and protection of the lower airway from
foreign bodies.
• Nasotracheal intubation: This is again contraindicated in patients
with suspected facial or basilar skull fractures.
Inability to intubate the patient indicates an immediate need for advanced surgical airway intervention.
Advanced Airway Intervention
• Cricothyroidotomy: This is indicated in any patient who has a strong
indication for intubation but in whom the trachea cannot be intu-
bated. It has become the procedure of choice over the traditional
tracheostomy as the trachea resides deeper in the neck and
involves a highly vascular surrounding area.
• Needle cricothyroidotomy: This can provide up to 45 minutes of extra
time so that intubation can be completed, and involves a large-
bore needle being inserted into the trachea lumen through the
8 Accident and Emergency Nursing
cricoid membrane. The plastic cannula is then connected to a high-flow oxygen source and intermittent insufflation commenced. This is a last resort, however, and merely buys time.
Nursing intervention must include ensuring that 100% oxygen is administered to the patient since maintaining oxygenation (and so preventing hypercarbia) is an essential goal in trauma resuscitation.
Breathing
The nurse should observe and record:
• respiratory rate;
• presence of chest symmetry/tracheal deviation;
• obvious open sucking chest wounds;
• use of accessory muscles;
• patient colour/pallor;
• mental status.
Life-threatening chest injuries to exclude include:
• Tension pneumothorax: Any patient presenting with respiratory
distress, tracheal shift, distended neck veins, dullness to chest
percussion, hypotension and tachycardia should alert the nurse
to the probability of a tension pneumothorax and the associated
need for immediate decompression. This occurs owing to the
presence of a one-way valve air leak from the lung or through
the chest wall. Air is subsequently forced into the thoracic cavity
and becomes trapped, resulting in complete collapse of the
affected lung and eventual shift of internal organs. This is an
emergency clinical diagnosis and should not wait for X-ray
confirmation.
• Open pneumothorax: This results in an open sucking chest wound
causing an imbalance between intrathoracic and atmospheric
pressures. Ventilation is impaired and subsequent hypoxia devel¬
ops. Management includes the application of a sterile three-sided
dressing (allowing air out but not in) and chest tube insertion.
• Large haemothorax: This involves significant blood loss into the chest
cavity (> 1500 ml) resulting in both hypotension and hypoxia.
Advanced Trauma Life Support 9
Initial treatment in A&E involves adequate fluid replacement and decompression of the chest cavity by chest tube insertion.
• Flail chest: This occurs when a segment of the chest wall loses bony
continuity with the rest of the thoracic cage and causes hypoxia
owing to disruption of normal chest wall movement. Treatment
usually involves intubation and controlled ventilation.
Circulation
Shock can be defined as inadequate organ perfusion and tissue oxygenation. It is important to note that blood loss is the most common remedial cause of morbidity and mortality following trauma, and all types of shock may present (although hypovolaemia is the most common). The first priority in the evaluation of the trauma patient, therefore, is to recognize the presence of shock; this is based on clinical findings and a high sense of suspicion on the part of the nurse rather than on any laboratory results.
It is important for the nurse to realize that the compensatory mechanisms of shock may prevent a fall in systolic blood pressure until the patient has lost up to 30% of his or her blood volume. Early signs of tachycardia and peripheral vasoconstriction are therefore important and, as a golden rule, any patient who is cool and tachy-cardic should be presumed to be in shock until proven otherwise. Nurse assessment indicating early signs and symptoms of hypo-volaemic shock (which reflects underlying physiology) include:
• hypotension (due to hypovolaemia with possible subsequent
myocardial insufficiency);
• skin pallor (vasoconstriction due to catecholamine release);
• tachycardia (due to catecholamine release);
• confusion, aggression, drowsiness and coma (due to cerebral
hypoxia and acidosis);
• tachypnoea (due to hypoxia and acidosis);
• general weakness (due to hypoxia and acidosis);
• thirst (due to hypovolaemia);
• reduced urine output (due to reduced perfusion) (Baskett, 1991).
Subsequent fluid resuscitation involves the insertion of two large-bore cannulae (size 14 or 16) and use of blood-giving sets (without
10 Accident and Emergency Nursing
use of air inlets because of the associated high pressure involved) to ensure a rapid fluid transfusion. Use of a level one blood-warming system is advised to allow rapid transfusion of warmed fluids.
There is a continuing debate regarding which fluid to use in the initial resuscitation of the hypovolaemic patient until type-specific blood or O Rhesus negative packed cells can be obtained. The choice centres around crystalloid fluids such as Hartman's solution and colloid fluids such as Haemaccel. The former has the advantage of being isotonic, so will permeate both the depleted intravascular system and subsequently the depleted extracellular fluid. The latter, however, remains within the circulation, resulting in a more rapid improvement of the patient's haemodynamic status. In practice a combination of both seems to give the best results although isotonic electrolyte solutions are now advocated during the initial fluid resus¬citation phase (American College of Surgeons, 1993) with two litres given stat and further fluid replacement being based upon the subse¬quent response.
In summary, circulatory assessment/intervention centres around:
• control of external bleeding — this is generally controlled by para¬
medics prior to arrival in A&E but may be continual and signifi¬
cant in quantity. Direct pressure should be used and tourniquets
considered only in the most severe circumstances;
• the efficiency of the cardiac pump - empty or collapsed neck
veins should alert the nurse to the presence of hypovolaemia
whilst distended neck veins suggest the presence of underlying
pump failure. It is also important to note that these two condi¬
tions may coexist;
• the volume status (degree of shock) - see Table 1.3.
During the primary survey, several absolute emergencies must be recognized and treated:
(1) Cardiac arrest: This will follow the standard resuscitation guidelines although may be heavily dependent upon fluid replacement. Subse¬quent emergency thoracotomy within the A&E department may provide the best chance of survival for the following conditions:
Advanced Trauma Life Support
11
• to control great vessel and cardiac bleeding;
• to release cardiac tamponade;
• to optimize cardiac output;
• to redistribute the available blood to vital organs by cross-
clamping the descending aorta.
(2) Cardiac tamponade: This causes impairment of the heart action due
to blood within the pericardium following injury and may result
from blood loss as small as 30 mls. Any patient who is shocked
with distended neck veins, cool extremities and no tension pneu-
mothorax should be suspected of having a cardiac tamponade
that will require rapid medical aspiration.
(3) Myocardial contusion: This may occur following deceleration
injuries or crush injuries to the chest and may rapidly result in
cardiac arrhythmias.
(4) Myocardial infarction: Underlying infarction may have been the
cause of the accident or a result of subsequent coronary under-
perfusion.
Table 1.3 Classification of hypovolaemic shock according to blood loss
Class 1 Class 2 Class 3 Class 4
Blood loss (ml) Up to 750 750-1500 1500-2000 >2000
Blood loss (%) Up to 15% 15-30% 30^0% >40%
Pulse rate <100 >100 >120 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure Normal or Decreased Decreased Decreased
increased
Respiratory rate 14-20 20-30 3030 >35
Urine output (ml) >30 20-30 5-15 Negligible
Mental state Slightly Mildly Anxious Confused
anxious confused Lethargic
12 Accident and Emergency Nursing
Disability
A rapid assessment of cerebral function is performed using the AVPU method with associated recording of pupillary response:
• Is the patient Alert?
• Does he/she respond to Verbal stimuli?
• Does he/she respond to Painful stimuli?
• Is he/she Unresponsive?
Exposure
All the patient's clothing is removed to allow a thorough front and back assessment of the patient, with the nurse remembering the basics of patient warmth and dignity.
The Trauma Team
The multiply injured patient has, by definition, multiple problems and adequate treatment necessitates a team approach. Trauma teams must be organized appropriately and work well in a well-equipped resuscitation room (Driscoll and Skinner, 1991) and research has highlighted that a structured organized team, with predetermined roles and responsibilities for both nursing and medical staff, has a direct positive bearing on patient outcome (Lomas and Goodall, 1994). The ATLS system is designed such that a single doctor or nurse can safely and systematically assess the treat¬ment priorities of the multiply injured patient until help arrives, because tasks are performed in sequence, one after the other. In real¬ity, this 'vertical' approach is rarely needed and the 'horizontal' team approach is practised with a significant reduction in resuscitation times. Team members may vary, but the following are advocated for optimal team performance and patient care:
• team leader (the most experienced member of the A&E team);
• anaesthetist (of senior level, with assistant — nurse or ODP);
• general surgeon (of senior registrar level or above);
• orthopaedic surgeon (of senior registrar level or above);
• A&E SHO;
• two nurses (or three if no ODP to assist anaesthetist);
• radiographer;
Advanced Trauma Life Support 13
• scribe (nurse/doctor);
• porter (outside the resuscitation room ready to transfer bloods etc).
Roles and responsibilities may also vary between departments, but it is advocated that predetermined action cards are provided for all staff with regular trauma scenarios to clarify roles and to enhance team-building, respect and understanding between team members. It is also advised that team members meet on a monthly basis to discuss any trauma calls and any problem areas in need of address.
Nurse Training in Trauma Care
The arrival in A&E of a critically injured patient is potentially one of the most difficult situations that can confront a nurse, especially as several patients can be brought in simultaneously from the same inci¬dent (Walsh, 1985). A nurse is usually the first member of the hospital personnel to meet injured patients within the A&E setting, and must have the skills to assess the injuries quickly and accurately and decide upon the urgency with which they will be treated (Hamilton, 1993). Incorrect care or lack of intervention may result in death, further disability or irreversible damage to the brain or spinal cord (Jones, 1986) and the goal of doing the patient no harm requires total immo¬bilization of the spine until injury has been excluded (Tippett, 1993).
In a survey of A&E nurses, Hamilton (1991) concluded that half lacked knowledge in caring for the multiply injured patient. The author reported that 66% of junior nurses had received no formal training in trauma care despite the fact that 81 % may have been left in charge of a trauma patient. It was clear that both nursing and medical staff should share a common core of knowledge because a coordinated and well-rehearsed approach to trauma patient care, where all assessment and interventions are performed simultane¬ously, is essential for quality care (Castille, 1991). The ATLS working party concurred that nurses were very much equal partners in team management of trauma care and should have access to the same theoretical training as their medical colleagues (Skinner, 1991). The high rate of self-funded places by nurses on such courses has previ¬ously highlighted that a strong motivation to improve knowledge exists (Eyre, 1993) whilst formal nurse training using an abbreviated ATLS model has also demonstrated measurable improvement in both thought and action priorities (Gautam and Heyworth, 1994).
14 Accident and Emergency Nursing
Indeed, many doctors now agree that the widespread introduction of ATLS courses and trauma teams has significantly improved the initial management of severely injured patients (Nolan, 1995).
Conclusion
Advanced trauma life support has now become well established throughout the world as the gold standard for trauma care. Gone are the days of nurses and doctors treating only what the eye could see by applying pressure to a bleeding wound whilst failing to recognize that the patient is apnoeic. The systematic and standardized nature of ATLS enables a nurse to enter any A&E department and become a safe and valuable member of the trauma team. It has resulted in the two professions of medicine and nursing working side by side as an efficient and coherent team, with the common goal of saving lives and with mutual respect for the role that each speciality plays.
Suggested Further Reading
American College of Surgeons (1993) The Advanced Trauma Life Support Course.
Chicago: American College of Surgeons.
British Medical Journal (1991) ABC of Major Trauma. London: British Medical Journal.
References
American College of Surgeons (1993) Advanced Trauma Life Support Course.
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Earlam R (Eds) ABC of Major Trauma. London: British Medical Journal. Castille K (1991) Trauma training for nurses. Nursing 4(32): 22-3. Davies S, Hill P, Wood L, Maryosh J (1992) Assessing trauma. Nursing Times 88(17):
54-7. Driscoll P, Skinner D (1991) Initial assessment and management. In Skinner D, Driscoll
P, Earlam R (Eds) ABC of Major Trauma. London: British Medical Journal. Eyre G (1993) Shock treatment. Nursing Times 89(34): 30-3. Gautam V, Heyworth J (1994) The value of the abbreviated ATLS course for accident
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Stoughton, p 86.
Advanced Trauma Life Support 15
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