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Navigating the Road to Recovery: Priorities in the Care of Trauma Patients

Navigating the Road to Recovery: Priorities in the Care of Trauma Patients. Kristie Hertel MSN,CCRN,ACNP-BC Advanced Practice Provider Trauma and Surgical Critical Care. Objectives. Identify appropriate resuscitation fluids and end points of resuscitation

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Navigating the Road to Recovery: Priorities in the Care of Trauma Patients

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  1. Navigating the Road to Recovery: Priorities in the Care of Trauma Patients Kristie Hertel MSN,CCRN,ACNP-BC Advanced Practice Provider Trauma and Surgical Critical Care

  2. Objectives • Identify appropriate resuscitation fluids and end points of resuscitation • Identify appropriate pain management agents to use through out the spectrum of care • Describe difficulties in case management • Describe changes in nursing priorities from admission to discharge

  3. Case Study • 29 y/o male involved in motor vehicle roll over collision. Single vehicle collision. +ETOH. Combative at scene. Not following commands. Air transported to closest trauma center. Arrives to emergency department in full cervical spine precautions. GCS has declined enroute. Patient is moaning, withdraws to pain, and will not open his eyes to painful stimuli. Initial BP 100/65 with HR 115, RR 26, SpO2 97% on NRB. Given fentanyl and versed enroute.

  4. Case Study Priorities?

  5. Emergency Room Priorities • Primary Survey • Airway w/ Cspine • Breathing • Circulation • Secondary Survery • Disability • Exposure • Full vitals, family, foley, OGT • Give comfort • History • Inspect head to toe

  6. Case Study • Primary Survey • Moaning, able to maintain airway but GCS 8 • Intubate • Diminished breath sounds on R • Thoracostomy tube to R • 2 large bore IVs in place, no active areas of hemorrhage, central pulse +2 • Controlled rate unless hypotension and then consider transfusion of PRBC

  7. Case Study • SecondaySurvery • GCS 8, Pupils L 3mm/R, R 5mm/sluggish • Consider mannitol • RLE shortened and externally rotated; abrasions to chest/abd/face • Hare traction • VS: HR 122, RR 15 (BMV), BP 90/55, SpO2 100%; no family present, foley placed, OGT placed • Borderline hypotension w/ probable areas of hemorrhage, transfuse PRBC • Etomidate/succ given for intubation, patient covered w/ warm blankets • Monitor sedation/comfort level • No known past history, per EMS: pateint traveling at high rate of speed, lost control on corner, left road and rolled vehicle mulitple times, +restrained

  8. Case Study • Patient goes to CT scan • CTH: Large R SDH, sm L temporal contusion • CT Chest: B rib fractures, no flail, B pulm contusions, residual ptx R w/ adequate placement of chest tube • CT A/P: grade 1 splenic lac, no bony abnormalities in pelvis • CT Cspine: C6-7 transverse process fractures • R femur: midshaft fracture

  9. Case Study • Neurosurgery consulted • Orthopedic Surgery consulted • Critical Care consulted • Patient taken from ED to OR by Neurosurgery for craniotomy and evacuation of SDH. ICP monitor placed • While in OR, orthopedic surgery placed IM rod to R femur • Post op: patient admitted directly from OR suite to ICU

  10. Case Study Priorities?

  11. ICU Priorities • Neuro • ICP management, sedation, analgesia • Pulm • Vent settings, pulm toilet • CV • BP management, monitor lactic acid levels • GI • Nutrition, PUD proph • Renal • Monitor urine output, monitor CK, monitor Bun/CR • Heme • DVT proph, monitor serial H/H given spleniclac • ID • Antibiotics

  12. Neurologic system ICP management Mannitol 3% saline (infusion vs bolus) Nursing measures (elevated HOB, Ccollar not tight, decreased stimulation Sedation Short acting agent Propofol Versed Precedex ICU Priorities

  13. ICU Priorities • Analgesia • Short acting narcotic (Fentanyl) as a drip • When to change to Morphine or Dilaudid • When to start per tube narcotics • Extended release vs immediate release • Adjunct to narcotics (NSAIDs, neuropathic meds, muscle relaxants) • Adjustments for elderly patients

  14. Precedex When to use Not as first line agent Adjunct to propofol Weaning from sedation AWS Who appropriate to use with Anyone who is not bradycardic or hypotensive Appropriate ranges 0.2-1.4mcg/kg/min Appropriate duration No duration, no long term effects, may get rebound HTN ICU Priorities

  15. ICU Priorities Pulmonary System Vent management What mode PRVC, SIMV, APRV Optimal ABGs Oxygenation issues Rescue steriods Pulmonary toilet Suctioning Bronchodialators

  16. ICU Priorities Cardiovasular system IVF LR or NS End Points of Resuscitation Lactic Acid, Base deficit Vasopressors Dopamine Noriepinephrine (Levaphed) Neosynephrine (Phenylephrine)

  17. ICU Priorities Gastrointestinal System Nutrition Access When to feed PUD prophylaxis H2 blocker vs PPI Glycemic control Goal FSBS Bowel regimen SCI

  18. ICU Prioties Renal System Monitor UOP Monitor CK Correction of electrolytes

  19. ICU Priorities Hematology Monitor H/H d/t spleen Transfusion products as indicated DVT prophylaxis SCDs, Lovenox, subcutaneous heparin When to start

  20. ICU Priorities Musculoskeletal system Neurovascular assessments Monitor for compartment syndrome Wound care of incisions

  21. ICU priorities • Tertiary exam • Review xrays, CT scans • Order films if indicated • Full head to toes assessment • Look for lacerations, road rash, • Follow up on labs

  22. ICU Priorities • Cultures • When to send cultures • What cultures to send • Central lines • Foley catheters • Antibiotics • Post op coverage • No coverage for ICP monitor • When to start for infectious process

  23. ICU Ongoing Management • VAP prevention • Oral care, deep oral suctioning, HOB elevation w/ TF • CAUTI prevention • Early catheter removal • CBSI prevention • Remove central lines as soon as possible including PICCs

  24. Transfer to Floor • Communication • Situation • Don’t forget family dynamics • Background • Injuries, surgeries, future surgeries • Assessment • Head to toes by system • Recommendations/current therapies

  25. Floor Priorities Nutrition Enteral and oral feeds Pain management Wean off all IV meds Mobility PT/OT consults Pulmonary management IS, flutter valve, respiratory treatments, chest physiotherapy, supplemental oxygen weaning Wound Care Appropriate dressings

  26. Floor Priorities • Family education • Wound care • Activity limitations • What to watch for • Discharge Planning • Home • Rehab • LTAC • SNF

  27. Discharge Planning • Home • DME • Wound Care • HH • Support at home • Transportation • Access into/out of home

  28. Discharge Planning • Rehab • PT/OT/ST • Endurance • Home support

  29. Discharge Planning • LTAC • Insurance • Medications • Wound Care • Comorbidities • Respiratory

  30. Discharge Planning • SNF • Insurance • PASSAR II • Family preference • Length of Stay at facility • Age • Required treatments • Trach • Wound care • Level of independance

  31. Thank You!!!

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