Page 648 - ACCCN's Critical Care Nursing

Trauma Management 625

for a multidisciplinary team to receive the patient and Radiological and Other Investigations
commence assessment and treatment concurrently. In the Initial radiological investigations will usually be per-
setting of a mass-casualty incident, triage may be per- formed in the emergency department using portable
formed in the field.
equipment. A radiographer is often a member of the
The formal process of triage provides a means of cate- trauma team that is activated on notification of the immi-
gorising patients based on threat to life. Although there nent arrival of a severely-injured trauma case. Radiologi-
are many different triage systems in use, within Australia cal investigation will be dependent on the type of injury
and New Zealand, the five-level triage categorisation of sustained, but will generally consist of a portable X-ray
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the Australasian Triage Scale (ATS) is widely used. See of the injured area/s if these include the chest, cervical
Chapter 22 for further description of the ATS. spine or pelvis. Other X-rays at this stage are rarely benefi-
cial, or rarely change the course of treatment.
Primary Survey If the patient is sufficiently stable after the secondary
Priorities of care are similar to those in all health settings, survey, more extensive investigation in the radiology
with airway, breathing and circulation taking precedence, department should be undertaken. This will include CT
and disability and exposure/environment being part of scans. It is essential that clinicians consider investigations
the primary survey (see Chapter 22). These components carefully, to ensure that all necessary imaging is under-
of care will often occur simultaneously rather than taken; for example, where a CT scan of the brain is
sequentially. Compromise to airway and breathing may required it is often prudent to also undertake a CT scan
result from direct injury, for example to the trachea, or of the cervical spine. However care should be taken to
indirectly through decreased level of consciousness. avoid investigations that will not change the planned
Compromise to circulation is usually as a result of sig- treatment but may delay urgent interventions such as
nificant blood loss, although it may occur as a result of surgery. Current controversies in radiation exposure and
injuries, such as cardiac contusions in chest trauma, or lifetime-associated cancer risks need to be considered.
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the patient’s preexisting disease. The priorities of care Furthermore, the implications of moving the patient on
during this time reflect the principles of care in any and off imaging tables for repeated imaging is problem-
setting, and include: atic. The patient should be accompanied and monitored
l maintaining life, with priority given to airway, breath- by an appropriately competent nurse during all transfers
ing and circulation for investigation. Where the patient is requiring ongoing
l treating immediate problems such as bleeding advanced life support such as fluid resuscitation or airway
l preventing complications or further compromise. monitoring, it may also be appropriate for a medical
officer to accompany the patient.
Secondary Survey Further radiological investigation may be required as
Following stabilisation of the life-threatening problems part of the tertiary survey. This will depend on the radio-
identified during the primary survey, patients should logical examinations that have been undertaken as part
undergo a secondary survey (see Chapter 22). This is a of the secondary survey, the treatment that has already
systematic examination of the body regions to identify been administered and the current condition of the
injuries that have not yet been recognised. It is essential patient.
that both the front and the back of the patient, as well as
areas covered by clothing, are examined during this Focused assessment with sonography for trauma
process.
Where abdominal trauma is suspected, a focused assess-
Tertiary Survey ment with sonography for trauma (FAST) examina-
A tertiary survey should be conducted on, or soon after, tion 22,23 is likely to be used as part of the secondary survey
the arrival of trauma patients in the ICU. The purpose to determine whether free fluid is present in the abdomi-
of this third survey is to identify injuries that have not nal cavity. The abdomen is scanned in four zones – peri-
yet been detected, assess initial response to treatment cardial, Morison’s pouch (right upper quandrant),
and plan assessment and management strategies for splenorenal (left upper quadrant), and pelvis (Douglas’
future care. pouch). This generally takes 1–2 minutes when per-
formed by an experienced, credentialled clinician. Find-
The tertiary survey consists of another head-to-toe physi- ings are regarded as positive (fluid [blood] observed),
cal examination, assessment of the patient’s condition in negative or equivocal. Technical difficulties can be expe-
the context of his/her earlier condition and the treatment rienced with obese patients. While a positive FAST is
that has been administered, a full review of all diagnostic useful in identifying if a patient should receive urgent
information gained so far, and acquisition of the patient’s surgical intervention, a negative FAST does not rule out
past health history if family members or friends are avail- significant abdominal trauma, and the low sensitivity of
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able. A systematic approach will minimise the number of FAST remains a concern for trauma clinicians. Where a
injuries that are not identified during the first 24 hours patient is undergoing a prolonged trauma resuscitation
of care. It is also important to repeat the tertiary survey phase, there may be an indication to repeat the FAST after
after the patient regains consciousness and begins to 20 minutes. The use of FAST examination outside the
mobilise. Joint injuries may only become apparent during trauma resuscitation and reception phase is occurring
weight-bearing movements. more often and can be undertaken in any clinician setting