Page 649 - ACCCN's Critical Care Nursing

626 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

of other injuries, for example neurological trauma or
TABLE 23.1 Criteria for activation of trauma teams 26,27 skeletal trauma, will vary for each individual patient and
will be dependent on the physiological impact of the
Physiological criteria Injury criteria injuries. Neurological and spinal cord injury are reviewed
in Chapter 17.
Heart rate <50 or >120 Penetrating injury to head, neck
beats/min or torso
Respiratory rate <10 or >29 Burn to ≥20% body surface area MECHANISM OF INJURY
breaths/min Fall ≥5 metres The most common causes of traumatic injury include
Systolic blood pressure Multiple trauma
<90 mmHg Crush or degloving injury to road traffic crashes, falls and collisions. While falls
Glasgow Coma Scale Score <10 extremity account for the greatest number of injuries requiring hos-
28
Skin pale, cool or moist Amputation proximal to the wrist pitalisation, injuries sustained in road traffic crashes
Paralysis or ankle tend to be more severe given the high velocity of the
Trauma arrest Motor vehicle crash with ejection trauma, and account for the greatest number of major
injuries, including those injuries requiring a critical care
admission. 28-30
The mechanism of injury is recognised as affecting both
where there is a suspicion of internal haemorrhage or survival and requirement for admission to the intensive
pneumothorax. 24
care unit. Patients who are injured in a road traffic crash
TRAUMA TEAMS experience a similar mortality to those injured through
falls (approx 3% in all patients and 10–17% in major
There are a number of different ways to organise the early injury patients), with both groups having a higher mor-
care of trauma patients. The most common method used tality than patients injured in assaults and collisions with
is through the establishment of multidisciplinary trauma objects (<1% in all patients and 12% in major injury
teams that can provide immediate, expert assessment, patients). 28,29 The older age group, with associated comor-
resuscitation and treatment of traumatised patients, espe- bidities, is likely to account for many of the deaths in the
cially those with multiple injuries. Many hospitals that group injured through falls. In addition, patients injured
receive trauma cases operate trauma teams that are either in road traffic crashes tend to spend longer in the inten-
activated or placed on standby, via pagers or telephone, sive care unit than patients injured through falls or
based on communications from paramedic personnel in assaults and collisions, and experience a greater number
25
the prehospital setting. This activation is based on a of injuries. 28
combination of physiological and injury criteria (see
Table 23.1). Age is sometimes added to the patient crite- GENERIC NURSING PRACTICE
ria, with those under 5 years or over 65 years receiving Nursing care of trauma patients is characterised by the
particular attention. A number of hospitals have two need to integrate practices directed towards limiting the
levels of trauma team activation, with more severe impact of the injury and healing injuries to multiple
injuries activating the full trauma team and less severe body areas in a complex process. The delivery of critical
activating a partial team. The use of two-tiered trauma care services must be systematic and must cross depart-
team activation has not been shown to affect patient mental and team barriers to achieve a coordinated
outcomes. 17 approach. This section outlines the principles of care
relevant to all trauma patients, including positioning,
COMMON CLINICAL PRESENTATIONS mobilisation, and prevention or minimisation of the

Trauma generally occurs to a specific area of the body trauma triad components of hypothermia, acidosis and
(e.g. the chest or the head) or consists of an injury caused coagulopathy.
by a specific external cause (e.g. burns). This section has
been arranged according to these specific types of injury, Positioning and Mobilisation of
including skeletal, chest, abdominal and from burns. the Trauma Patient
Specific considerations relating to penetrating injuries Appropriate positioning and mobilisation provides a sig-
have been covered separately, although the majority of nificant challenge for nurses involved in the acute care of
care for patients with penetrating injuries will follow the the trauma patient. Positioning refers to the alignment
principles of the area for injury. For example, a patient and distribution of the patient in the bed, for example
with a penetrating injury of the abdomen will generally supine, Fowler, semirecumbent or prone. In addition to
be cared for in the same way as all patients with abdomi- these fundamental nursing postures, there is positioning
nal trauma. of the limbs (i.e. elevated arms and legs). Mobilisation
refers to the movement of joints by the patient, to shift
Patients with multitrauma will also be cared for accord- from one place to another. This movement may be
ing to the principles of care for each specific injury, restricted to rolling within the bed, or moving out of
although consideration of priorities is essential. Care the bed.
should follow the common principles of airway, breath-
ing and circulation, therefore concentrating on respira- The principles of positioning and mobilisation are gener-
tory and circulatory compromise first, before moving on ally not different from those in other critically ill patients,
to the treatment of other injuries. The relative importance and should incorporate the need to: