Major Trauma Assessment

Trauma is the leading cause of death for all individuals under the age of 35 (Madigan, 2007). Trauma can be described as any type of injury caused by an outside source (Merriam-Webster OnLine, n.d.). The term major trauma is used for events that involve sudden overwhelming injury and shock to multiple body systems. However, major trauma has no consistently accepted definition. In common usage, it is a means to convey the extreme of seriousness and extent of complex injury caused by an external force.

In an effort to standardize trauma care and promote consistent data collection the Trauma Care Systems Planning and Development Act of 2007 was passed as Public Law 110-23, 121 Stat. 90-99. The beauty of this bill provides increased trauma care nationally and therefore, improves survival rates for victims of traumatic injuries. Seventy five percent of the nation's population is served by a local trauma center. The $12 million funding from this bill will be disseminated throughout the 50 states to provide funding and access to improved care (Nations' Emergency Physicians Herald Passage of Trauma Care Act of 2007, n.d.).

Table one lists the 47 states and the number of verified trauma centers according to the American College of Surgeons for a total of 413 verified trauma centers. The verification process ensures the presence of essential trauma center criteria. Verification is in effect for three years (Verified Trauma Centers, n.d.).

The Society of Trauma Nurses celebrates its 16th anniversary in 2014 for formal regulatory supervision of the (ATCN) Advanced Trauma Care for Nurses course. Providers were recognized for their expertise through the (ATLS) Advanced Trauma Life Support. Nurses had the opportunity to audit the ATLS courses but had no recognition for attendance nor were they able to do more than observe. Nurses are persistent and wanted their own ATLS courses and between 1983 and 1998 four nurses developed ATLS for nurses which eventually became known as ATCN to avoid copyright infringement issues. ATCN is recognized by the American College of Surgeons as one of the criteria required for verification (Case, 2012).

Regardless of the level of the trauma center, one thing that is always a requirement for the hospital is to have a Registered Nurse on duty, who has successfully completed the Trauma Nurse Course to supervise other nurses who have not completed the Trauma Nurse Course (Joint committee on Administrative Rules, n.d.).

One generally considers trauma to be the result of an accident, but according to the Emergency Nurses Association the term accident has become an obsolete term. Accidents can be considered avoidable and therefore, preventable. Trauma, on the other hand, is most likely unintended. Understanding that trauma can occur at any time, the responsibility of the medical field is to ensure there are adequate resources available to those in need.

Essential to treating trauma patients is the knowledge of the mechanism of injury. The force and impact of the body in relation to the energy imposed by the trauma plays an important role in the extent and nature of the injury to the internal and external organs of the body.

Mortality rates are the easiest result of traumatic injury to track. Information on the numbers of disabling injuries and loss of productive time is much more difficult to measure, yet has an enormous impact.

When working with major trauma rapid, accurate assessments are an integral part of recognizing and dealing with the injury. From the instant the first trained responder arrives on the injury scene, event victims should be evaluated in a systematic progression of assessments speeding them to the most appropriate and beneficial care for their wounds. There are injury assessment scales and tools that can be used to make determinations of severity of injury. The type and quality of assessments used greatly impacts the effectiveness of the trauma care offered.

Assessment using an injury rating scale provides an objective measure of the degree of injuries present as well as a statistical prediction of recoverability from the trauma. Consistent use of a recognized injury rating scale facilitates speedy and appropriate decisions regarding, which of the area facilities individual victims should be transported to, which greatly aids the decision process at the scene of an accident or disaster.

Development of injury rating scales is an on-going process, one principle player for which is the Center for Disease Control's International Collaborative Effort (ICE) on Injury Statistics. ICE on Injuries promotes and coordinates efforts to develop effective, efficient measurements of traumatic injury that can give consistent prediction of care needs and outcomes (ICE, 2006).

Of the rating scales in current use, versions of the system known as the Injury Severity Scale (ISS) are common. The base ISS scoring system uses a zero to 75 scale to represent degree of injury severity. An Abbreviated Injury Scale (AIS) is assigned to six areas of the body: head & neck, face, chest, abdomen, extremity/pelvis, and external injury. To calculate the degree of injury a number of 1-6 is assigned with six being the highest level of injury indicating an unsurvivable injury. Table 2 demonstrates the AIS (Abbreviated Injury Scale, Trauma Scoring, 1990). Once a victim obtains an AIS of six for any injury, his/her total ISS immediately becomes a 75. After the scoring is completed, the top three injuries are subsequently squared to attain the total ISS (Injury Severity Score, Trauma Scoring, n.d.). For example, the victim of a motor vehicle accident with an injury score of less than 10 on the ISS scale would be appropriate for transport to a local community hospital emergency room after a brief initial stabilization at the scene of the accident. However, the passenger from the same vehicle would be rapidly transported to the nearest certified Level I Trauma Center if they had an ISS score of greater than 15.

Another injury rating scale advocated by the state of New York Department of Health uses the classifications of critical, unstable, potentially unstable, and stable (CUPS) system. This scale uses the initial assessment as well as information about the cause of injury to determine a trauma level and gauge appropriate aftercare placement.

Critical patients		Immediate airway management, rapid transport with further assessment and resuscitation during transport
+
Unstable patients
Potentially unstable		Initial management of the patient may be done on the Scene, transport after initial stabilization
+
Stable patients

When using the CUPS system the presence of any one of the following criteria signifies the presence of Major Trauma: 
Mechanism of Injury:

1. Fall more than 20 feet
2. Survivor of motor vehicle crash in which there was a death of an occupant of the same vehicle
3. Struck by a vehicle moving faster than 20 mph
4. Ejected from a moving vehicle
5. High speed crash with resulting severe deformity of the vehicle
6. Vehicle rollover

Physical Findings

1. Pulse less than 50/minute or greater than 120/minute
2. Systolic blood pressure of 90 mm Hg or less
3. Respiratory rate less than 10/minute or greater than 28/minute
4. Glasgow coma scale less than 13
5. Penetrating injuries of the trunk, head, neck, chest, abdomen or groin
6. Two or more proximal long bone fractures
7. Flail chest
8. Burns involving 15% or more of the body surface or the presence of facial/airway burns
9. Combined system trauma that involves two or more body systems
10. Spinal cord injury or limb paralysis
11. Amputation (except digits)

Level I Trauma Centers typically serve a large city or a population dense area and are expected to be capable of handling large numbers of injured patients. Facilities of this nature are expected to admit a minimum of 1200 trauma patients yearly. Such centers have a dedicated trauma program, trauma service, trauma team, and a medical director. Centers accorded a Level I rating possess departments or divisions of surgery, neurosurgery, orthopedic surgery, emergency medicine, and anesthesia. General surgeons, anesthesiologists, and emergency medicine specialists are immediately available, 24 hours a day, with immediate operative capacity available at all times.

Level II Trauma Centers are able to provide support in the event of mass casualties to a Level I center. This is especially crucial in population dense areas, though frequently Level II Centers serve on their own in less populated areas. When there is no Level I Trauma center readily available, the expectation is present that transfer agreements are in place to provide prearranged transport to a Level I center. Level II centers are expected to have similar clinical capabilities as a Level I; however some specialty services such as cardiac surgery, microvascular surgery, and acute in-house hemodialysis (for example) are not required. Emergency department personnel and equipment should mirror those of a Level I center, yet operating room availability and personnel are not expected to be on duty at all times, merely readily available. A Level II center however must be able to provide CT or MRI testing at all times.

Level III Trauma Centers must have the capability to manage the initial care of the majority of injured patients that might be generated in a major event or natural disaster, and also have 24-hour general surgical coverage. These facilities must also have ready transport available for patients that exceed in-house abilities.

Level IV Trauma Centers should be able to provide initial evaluation, assessment and resuscitation of injured patients, and have 24-hour coverage by a physician. Ready transport again must be available on need to larger facilities with more resources.

Victims of major trauma require a well-organized and trained team made up of staff competent in assessing and treating the wide range of life threatening injuries commonly seen in trauma. Most Level I and Level II Trauma Centers have accepted the trauma team approach, designating specific staff members and service specialties to roles in the care of major trauma victims. When the scene-of-event triage and injury rating assessments are received, the designated trauma leader makes decisions as to who should be on hand for that patient's arrival and initiates preparations. Often the trauma leader is a dedicated emergency services coordinator but sometimes the emergency room physician or a senior emergency room nurse function in the role trauma leader.

The composition of a trauma team will differ somewhat between institutions; however, some elements remain consistent. A designated team leader to coordinate and supervise the joint effort must be present, the emergency room physician, a trauma specialist when available, a general surgeon, an anesthesiologist, radiologist, and an orthopedic surgeon are all essential. Other specialty surgeons such as a cardiovascular surgeon or neurosurgeon should be available on call as needed. Specialized nursing services and personnel include emergency room nurses trained in trauma care, intensive care, operating room personnel, and post operative recovery nurses. Team members from both laboratory and radiology must be present at the time of arrival of major traumas. Respiratory therapists are essential members of the trauma team since managing an effective airway is the number one concern during the initial hospital phase of trauma assessment and treatment. Pastoral care and social work personnel may also be on the trauma team to support family and friends.

Large cities are generally well prepared to handle varying levels of trauma. However, rural areas are more affected by availability of resources. In the rural facilities maintaining trauma registries generally become an added responsibility for staff therefore increasing the workload without compensation. With the implementation of telehealth capabilities more rural facilities are able to communicate with the larger trauma centers to provide stabilization for transport (Soychak, A, et al. Developing a Rural Trauma Outreach Program, April, 2012).

Hospitals historically are very concerned with customer service. An interesting study was conducted by Berg to compare the perception of competence with the correlation of customer friendly staff. Nurses who were friendly and providing family centered care were perceived as more competent and those patients rated their satisfaction at a higher level (Berg, et.al. April 2012, p.104-110).

Every trauma victim must have two assessments; a primary assessment and a secondary assessment. During the primary assessment a patient may be determined to require resuscitation. These priorities follow the Advanced Cardiac Life Support protocols simultaneously with the primary assessment. The secondary assessment comes after the primary and more time can be spent completing this phase of the assessment. During the secondary assessment is when the medical team will determine if the patient will require transfer to a different facility.

With arrival to the trauma center we assess, assess, then assess again. This is a word memory device denoting the three levels of assessment utilized with victims of major trauma.

Immediately on arrival the first assessment, the Primary Assessment begins. Primary assessment must focus exclusively on immediate life threatening conditions. When found, they must be treated immediately and aggressively. If you know your alphabet you can easily follow the assessment plan. One very useful plan of assessment is the ABCDE formula:

• Airway control with cervical spine protection
• Breathing
• Circulation and control of hemorrhage
• Disorders of the central nervous system
• Exposure of the whole body

Don't be distracted! Immediate life-threatening injuries are the focus of the primary assessment; injuries not imminently lethal must wait. Any loss of airway for example, is crucial to the survivability of the patient, and the airway takes precedence throughout initial assessment.

A - Airway loss demands initiation of Advanced Cardiac Life Support and immediate intubation to recapture the airway. Cricotomy or tracheotomy should be used if intubation fails.

Stabilization of the cervical spine is always an issue during these initial maneuvers, and measures should be taken to protect the spine from additional trauma. With practice, trauma team members can continue their initial assessments of both breathing and circulation while stabilization of the cervical spine is occurring. A second person may be needed to maintain cervical neck immobilization at this stage.

B - Breathing is the next priority because the absence of breath effort can cause death in five to eight minutes whether an open airway is present or not. Assess the appropriate oxygen delivery method here because you may need to use a face shield or prepare for intubation.

C - Circulation demands assessment in any form of trauma. It does not take a visible arterial bleed to lead to loss of effective blood volume. Internal bleeding from blunt trauma is just as effective way to die as visible exsanguinations. Listen to what your patient is saying. Is he or she complaining about severe back pain that could be a dissecting AAA?

D Deficits found in the primary assessment indicate the search for neurological injury, and includes level of consciousness and pupil responses. Remember to use the AVPU level of consciousness assessment during this phase.

• A - Alert and awake
• V - Verbal response
• P - Pain
• U - Unresponsiveness

E Exposure is the rapid search for hidden injury. Assessment cannot be thorough when the body is hidden by concealing clothing or objects. As you move down the body during your primary assessment begin removing concealing garments in order to assess for emergently life-threatening damage hidden beneath. Practiced trauma teams often pre-designate one or more staff to the essential task of exposure. Cut the clothing off to get a better view. That's why they call them trauma shears. Cut the clothes off to prevent extraneous movements of the body parts.

A patient was transported by ambulance to the nearest hospital and upon arrival the primary assessment revealed the patient was complaining of dyspnea and left chest wall pain. During the exposure phase of the primary assessment the nurses noted the patient had a distinct paradoxical movement. As the patient inspired the left chest wall moved with the inspiration as well as with the expiration. X-rays revealed the ribs were fractured and the patient's sternum was separated from the ribs creating a flail chest. During the initial stages after the trauma, the muscles generally hold the chest in place and are not as noticeable at the scene due to spasms of those muscles. Patients will benefit by positive pressure.

Events that produce Major Trauma often occur suddenly and without warning. From the time of trauma until injury-specific medical interventions can take place, a series of vital assessments must occur. On arrival, primary assessment by an organized trauma team can ascertain the presence of immediately life threatening dangers. Secondary assessments can establish a framework of information about that persons injuries and condition that allows formation of a plan of treatment using the objective information obtained by initial vital sign measurements and lab values. Focused assessments following that plan allow caregivers to explore and begin treatment of each injury in detail starting with the most crucial.

The implementation of sequential assessments beginning from the time the first trained personnel arrive at the scene of a traumatic injury and continuing to where injury-specific treatments can begin greatly increases favorable outcomes to tragic events of major trauma.

Abbreviated Injury Scale, Trauma Scoring, 1990. (Visit Source). Retrieved April 13, 2014.

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Case, M. October-December 2012. "Advanced Trauma Care for Nurses, A Historical Perspective". (Visit Source). Retrieved February 22, 2014. 

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Soychak, A., Coniglio, R., Caputo, L., Bourg, P.W., Salottolo, K.M., Mains, C. W., & Wallace, R., Developing a Rural Trauma Outreach Program, Journal of Trauma Nursing (20, 2, p. 110-115).

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