Trauma can be defined as a "blunt or penetrating external force exerted on the body causing injury" (Cole, 2004). Traumatic injuries are one of the leading causes of death in people under 40. Blunt trauma may be caused by forces such as acceleration, deceleration, compression, etc.. Falls, motor vehicle crashes (MVCs), sports injuries and assault are all common causes of blunt trauma. Penetraing trauma, on the other hand, is caused by an object that enters the body and penetrates organs. Bullets, knives, glass, and other sharp objects are just a few examples of objects that are capable of penetrating organs (Cole, 2004).

Arrival

Most victims of trauma arrive via ambulance or helicopter. On occasion, a patient may arrive via personally owned vehicle (POV) or they may be dropped off at the door. When arriving via air or ambulance, the trauma team is somewhat prepared because a report has been called to the emergency department prior to arrival. It is essential for trauma doctors, nurses, respiratory therapists, X-ray technicians and other assistants to be ready for anything to happen once the patient arrives. Upon arrival, the people who arrived with the patient are responsible for relaying pertinent data and assessment findings to the hospital trauma team while getting the patient into the trauma room and transferred to the table. Once the patient lands on the table, the chaos ensues.

Primary Survey

The primary survey includes the inital assessment and the resuscitation phase. The intial steps may be revealed through the mnemonic ABCDE.

Airway with cervical C spine control

Breathing and ventilation

Circulation and hemorrhage

Disability and dysfunction

Exposure and environment control

In the event that the patient arrives conscious and able to talk, the nurse and trauma team while assessing the patient may also collect a focused verbal history. The menomic AMPLE can be followed in this focused history.

Allergies

Medications

Pertinent past medical history

Last food/drink

Events leading up to trauma

Airway with C spine Control

The airway is the first priority The airway must assessed and maintained while the cervical spine is immobilized. The airway is assessed for obstruction, edema, foreign bodies, etc., which may occlude air from getting to the lungs. In the event that the patient does not have an established airway, the patient will be either intubated via an endotracheal tube or nasotracheal tube or an airway may have to be obtained through surgical intervention ( i.e. cricothyroidotomy, emergent tracheostomy).

It is important to maintain C- spine alignment and immobilization in the event of C- spine damage to prevent further or possible paralysis or compression of the spinal cord. In the event that the airway is obstructed or occluded, the nurse or individual assessing the airway should use the jaw thrust maneuver without extending the neck to prevent possible damage to the C- spine (Dries & Hayes, 2007).

Breathing

The breathing assessment is the next critical assessment of the trauma victim. The assessment is focused on the patient's ability to ventilate and oxygenate.The chest and neck should be inspected for respiratory motion, deviated trachea, open chest wounds, and breath sounds. Oxygen saturation readings are a good indicator of how well the patient is being oxygenated. Generally, the airway assessment quickly leads into the breathing assessment (Cole, 2004).

Critical findings of the breathing assessment include the absence of spontaneous ventilation, absent or asymmetric breath sounds (indicative of pneumothorax or malpositioning of the endotracheal tube), dyspnea, hyperresonnance or dullness on chest percussion (suggesting hemothorax or tension pneumothorax), and gross chest wall instability or defects that compromise ventilation (i.e flail chest, sucking chest wound) (Dries & Hays, 2007).

While intubation may help to establish an airway, other interventions such as tube thoracostomy (chest tube insertion) may be necessary to relieve the effects of pneumothoraces. Chest tube placement is performed by the physician, but the nurse should be alert to the possibility of necessary tube thoracostomy, and should have the necessary supplies ready and easily accessible (Trauma.org, 2004). The tube is inserted into the pleural space to allow for release of air, blood or tension within the chest wall.

Circulation/ Hemorrhage

Circulation is assessed by heart rate, blood pressure, capillary refill time, neck vein distention, etc.. It is important to note that hemorrhaging and the source and cause should be immediately identified to prevent further blood loss and the possibility of hypovolemic shock. It is during this phase of the assessment that large bore intravenous (IV) access be established and blood be obtained for laboratory analysis. A STAT hematocrit or "spun crit" are done immediately to determine the extent of blood loss.

Generally, the victim who has lost blood or sustained open injuries requires fluid resuscitation and/or blood transfusion. Internal hemorrhaging cannot be diagnosed without a computed tomography (CT) scan or ultrasound. Decreases in the hemoglobin or hematocrit readings, in the absence of external hemorrhaging, is often time a good indicator or red flag that the patient is bleeding internally (Trauma.org, 2007).

Diability/ Dysfucntion

The disability of the patient is determined by performing gross mental status and motor examinations. Gross mental status is determined by using the Glasgow Coma Scale (GCS). Pupils, verbal response and motor response are the three main areas assessed when using the GCS. Critical findings include fixed or dilated pupils, absence of spontaneous movement of extremities, and gross motor delays. A thorough assessment of mental status must be done to rule out brain or spinal cord injuries (Dries & Hays, 2007).

Exposure/Environment Control

The final step in the initial critical assessment or the primary survey is to completely remove all of the patient's clothing (in the event that they are still on upon arrival) for a full physical assessment. A minimum of four people should be used to "log roll" the patient while maintaining C-spine precautions to provide for an assessment of the posterior chest, head and back. Many trauma patients have lost fluids which can cause a hypothermic state in the event that they are not properly warmed. Warm blankets, warm IV fluids and warming lights all help to reduce the risk of hypothermia (Cole, 2004).

Conclusion

The above assessment guide provides a quick look at the initial assessment of trauma patients. This assessment is to be done very quickly and the appropriate interventions should also follow quickly to reduce the likelihood of permanent patient damage or death. The trauma team must work together in completing this assessment and often times, interventions are simultaneously implemented by one member of the team while others work to complete the assessment. Team work, collaboration and quick critical thinking are all essential components to the trauma room environment.

References

Cole, E. (2004, June 23). Assessment and Management of the Trauma Patient. Nursing Standard, 18, 45-51. Retrieved June 26, 2007, from PubMed database.

Dries, D. J., & Hays, W. (2007, February 8). Initial Evaluation of the Trauma Patient. Retrieved June 27, 2007, from http://www.emedicine.com/med/topic3221.htm

Trauma.org (2004, February). Tension Pneumothorax. Retrieved June 27, 2007, from http://www.trauma.org/index.php/main/article/396/