1. Laskowski-Jones, Linda RN, APRN-BC, CCRN, CEN, MS

Article Content

Michael Petri, a 54-year-old roofer, just fell 20 feet from a building under construction. Initially he struck the ground with his feet, then fell onto his left side. Conscious and alert at the scene, he complains of severe back and lower leg pain. His vital signs are: BP, 140/88; heart rate, 112; respiratory rate, 28; SpO2, 96%; and temperature, 98[degrees] F (36.7[degrees] C). His Glasgow Coma Scale (GCS) score is 15. Michael's odds of survival are good: Of trauma patients who enter the trauma care system with vital signs intact, more than 95% survive.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Paramedics administer oxygen at a flow rate of 15 liters/minute via non-rebreather mask and apply a cervical collar and a backboard to immobilize his neck and spine. They also place a 16-gauge intravenous (I.V.) catheter in his left forearm and begin an infusion of 0.9% sodium chloride solution.


If Michael were on his way to your hospital's emergency department (ED) for treatment, would you be prepared to provide immediate and appropriate nursing care? In this article, I'll explain the primary and secondary assessment surveys you need to complete as soon as he arrives and discuss how your findings guide nursing and medical interventions. But first, let's review how to prepare for a trauma patient's arrival in the ED.


Getting ready for your patient

Trauma team members must be prepared to deal with any type of injury. But learning details about the mechanism of injury can help them predict the types and combinations of injuries that he may have sustained-information that will help you and the other team members plan effective care.


Mechanism of injury describes the circumstances and energy forces that produced the trauma, usually blunt or penetrating. Examples of blunt force trauma include injuries from motor-vehicle crashes, falls, assault, industrial incidents, blast force, and sports-related injuries. Penetrating trauma injuries include stab and gunshot wounds, impaled objects, and damage from projectiles.


As the trauma team awaits Michael's arrival at the hospital, they review the information the paramedics provided by radio and discuss their concerns about his possible injuries based on his mechanism of injury. Knowing that Michael has had a blunt injury mechanism and that he landed on his feet in the fall, team members suspect they'll find lumbar spine compression fractures and lower extremity trauma-particularly calcaneus fractures. Knowing that he suffered an impact to his left side, they'll also be ready to assess for traumatic injuries to the chest and abdomen.


Your first priority as a member of the trauma team is to protect yourself from exposure to blood and body fluids. Prepare to use standard precautions, which are mandatory. While you wait for the patient to arrive, don a fluid-impervious gown, gloves, and face and eye protection, such as a face shield or goggles and mask, in case blood splashes. Ensure ready access to personal protective equipment to prevent delays in patient care.


Trauma care always begins with the primary survey, a rapid assessment of the patient's ABCs-airway, breathing, and circulation-with the addition of D (disability) and E (exposure).


The primary survey focuses on what can kill the patient now. It's followed by the secondary survey, a complete head-to-toe assessment to identify other serious injuries that could kill or disable the patient later.


Resuscitation occurs simultaneously with the primary survey. As life-threatening injuries are discovered, the team intervenes to optimize oxygenation, ventilation, and perfusion. Interventions include clearing the airway, providing supplemental oxygen, ventilating the patient, controlling hemorrhage, inserting venous access devices and chest tubes, and replacing fluids and blood.


Diagnostic studies follow the primary and secondary surveys, although blood is usually drawn when I.V. catheters are placed during the primary survey. Test results further define the nature and severity of the injuries and help guide the treatment plan.


Now let's take a closer look at how assessment and interventions mesh during the crucial first hour after an injury.


Primary survey: Managing immediate threats

By taking a standardized approach to assessment and treatment, the trauma team can address the most significant risks to life first. As always, start with the ABCs.


Airway. The first part of the primary survey is always assessing the airway. This includes checking for potential injury to the cervical spine. Until cervical spine injury has been ruled out, open the patient's airway using a jaw-thrust maneuver with manual, in-line stabilization of the neck. If you find food, blood, vomitus, or other debris, suction the airway quickly to prevent aspiration. To better remove secretions, you may need to carefully logroll the patient to his side. Manually stabilize his neck and spine as you do so.


If the patient can't maintain a patent airway because of copious secretions, an impaired level of consciousness, or other critical injuries, he'll need endotracheal intubation. Insert a large-diameter (#18 French catheter) gastric tube as soon as possible after intubation to decompress his stomach and remove gastric contents. Remember, even after the airway has been secured, he could still vomit and aspirate.


If the patient has any head or midface trauma, pass the gastric tube orally. Nasogastric tube insertion would be risky because a disruption of the cribriform plate (the bone between the sinuses and the brain) could allow the tube to be inadvertently inserted into the cranium.


If massive facial injuries prevent oral endotracheal intubation, the patient will need surgical airway placement (typically a cricothyrotomy).


When Michael is brought into the trauma room, he can speak clearly and provide an account of the accident. Because he can converse, his airway assessment is straightforward: He has a patent airway. However, he's still considered to be at risk for cervical spine injury. Spinal precautions continue until cervical injury is ruled out.


Breathing. Assess your patient's breathing next. Note respiratory rate and depth, chest expansion, and accessory muscle use and auscultate breath sounds bilaterally. Also palpate for crepitus or subcutaneous air in the neck and chest, which can indicate a pneumothorax or airway injury. Find out if he has pain with breathing or on palpation. Injuries that can impair ventilation include rib fractures (especially a flail chest), a pneumothorax, a hemothorax, and spinal cord or head trauma.


Supplemental oxygen is always indicated at this stage. For a spontaneously breathing patient like Michael, a non-rebreather mask with the flow rate set at 12 to 15 liters/minute is appropriate. However, if the patient isn't breathing well enough to sustain optimal oxygenation, begin manual bag-valve-mask ventilation to support his ventilatory efforts until he can be intubated and mechanically ventilated.


If the patient has severe respiratory distress and hypotension as well as unilateral decreased or absent breath sounds, suspect a tension pneumothorax, a potentially fatal complication requiring rapid treatment. To perform an emergency chest decompression, the trauma team physician will perform a needle thoracostomy, inserting a 14-gauge I.V. catheter into the patient's chest at the second intercostal space, midclavicular line on the affected side. A rush of air from the catheter confirms the presence of a tension pneumothorax. The catheter is left in place until a chest tube can be inserted.


In the meantime, a syringe or commercial Heimlich valve (or similar device) is attached to the catheter hub so that air can escape without being drawn back into the chest. If available, have a chest tube drainage system that can collect blood for autotransfusion on hand during chest tube insertion, in case a hemothorax is present.


Michael's ventilatory efforts are adequate. His breath sounds are clear and equal bilaterally, but he complains of pain in his left side on palpation. The supplemental oxygen he's receiving via the non-rebreather mask (which was applied by the paramedics) is kept at a flow rate of 15 liters/minute. His SpO2 is now 100%.


Circulation. Once you've assessed and supported your patient's breathing, attend to his circulatory status. Assess for the presence and quality of peripheral pulses to quickly estimate BP, as follows.


* If he has a radial pulse, his systolic BP is at least 80 mm Hg.


* If he's lost his radial pulse but still has a femoral pulse, he has a systolic BP of at least 70 mm Hg.


* If he lacks all pulses except a carotid pulse, he has a systolic BP of at least 60 mm Hg.



Note the patient's skin color and level of consciousness (LOC). Pallor and cold, clammy skin indicate shock.


His LOC is an important indicator of cerebral perfusion. Agitation is common in the early stages of shock. (Think of the "fight or flight" response.) As shock progresses, his LOC will decline until he's unconscious.


Obtain a complete set of vital signs, including temperature, as soon as possible. Use this set of vital signs as a baseline for comparison with subsequent measurements. You may need to take vital signs every 5 to 15 minutes until the patient's condition improves.


A key part of your circulatory assessment is to identify and control hemorrhage. External hemorrhage is usually, but not always, obvious. Logroll the patient to inspect his back and buttocks for bleeding.


To control bleeding, apply direct pressure over the site of hemorrhage. If this isn't effective by itself, apply pressure over the major arterial pulse point proximal to the bleeding site.


Use a tourniquet only if you must stanch severe hemorrhage in an extremity to save the patient's life. Using a tourniquet puts the limb's viability at risk.


Next, ask yourself if the mechanism of injury makes internal hemorrhage likely. If the patient has signs and symptoms of shock without visible bleeding, he may have an occult internal hemorrhage that requires surgery.


Besides assessing and documenting his circulatory status, you may need to intervene to sustain circulation. For a patient who's in shock, consider both noninvasive and invasive strategies to support his BP. Keep him supine and elevate his legs 6 to 8 inches (15 to 20 cm) to promote venous return and improve cardiac output. Don't put him in the Trendelenburg position because this can cause his stomach to compress his diaphragm, impairing ventilation.


Make sure he has venous access with two large-bore I.V. catheters (ideally 14- to 16-gauge) to facilitate rapid fluid and blood product administration if needed. Draw blood for lab analysis. Send specimens for typing and crossmatching, complete blood cell count, serum glucose, electrolytes, and a coagulation profile. Depending on the patient's condition and suspected injuries, you may also need specimens for other studies, such as creatine kinase, amylase, and serum lactate.


An arterial blood gas (ABG) analysis can help clinicians assess the patient's oxygenation status and determine whether or not he's in shock. If ABG results show a base deficit that's greater than 2 mEq/liter, suspect ongoing hemorrhage, internal injuries, or insufficient resuscitation.


As ordered, administer an appropriate crystalloid solution for I.V. volume replacement, such as 0.9% sodium chloride or lactated Ringer's solution. Warm the solution in a commercial fluid warmer or use a high-volume infuser/warming device. Don't administer D5W for volume replacement because the dextrose will be metabolized and leave free water, a hypotonic solution that won't stay in the vascular space.


Provide 3 mL of crystalloid solution to replace each 1 mL of blood lost. If you infuse 2 liters of crystalloid solution and the patient's BP hasn't returned to the normal range, be prepared to administer blood products.


Typing and crossmatching typically take 30 to 40 minutes, which may be too long for a trauma patient to wait. When immediate blood transfusion is needed, the only option is to give uncrossmatched universal donor blood, as ordered. Give group O, Rh-negative packed red blood cells (RBCs) to female patients of childbearing age or younger. Male patients and women who can't become pregnant can receive group O, Rh-positive blood. Remember that 0.9% sodium chloride is the only solution you can infuse in the same I.V. line as blood.


Expect each unit of packed RBCs to raise the patient's hemoglobin by 1 gram/dL unless he's continuing to hemorrhage. During the infusion, remain vigilant for a transfusion reaction. Signs and symptoms of a transfusion reaction vary according to what type of reaction it is. For instance, intravascular hemolysis may cause fever, lower back pain, pain at the I.V. site, hypotension, and renal failure. If you suspect a transfusion reaction, discontinue the infusion immediately and follow your hospital's protocol for managing transfusion reactions.


During the primary assessment, Michael's vital signs change significantly from those obtained by the paramedics: His BP drops to 96/58, his SpO2 falls to 95%, his heart rate increases to 120, his respiratory rate remains at 28, and his temperature is now 97.4[degrees] F (36.3[degrees] C). He has no external hemorrhage, so the physician suspects a spleen injury because he knows the left chest and abdomen were injured in the fall and the lower left rib cage is tender. You hang a liter of 0.9% sodium chloride using a high-volume fluid infuser/warmer and begin the infusion via the second I.V. access line previously established with a 14-gauge catheter.


Disability. To evaluate disability, you'll evaluate the patient's LOC, pupil response, and gross sensorimotor function. To document his baseline LOC, quickly assess and record an initial GCS score. If possible, determine his GCS before he receives any drugs that could alter his LOC to better enable you to predict his outcome. For example, if a patient's GCS score on arrival at the hospital is 4, his prognosis for recovery is much worse than a patient whose initial score is 12.


Keep in mind that accurate scoring can be impaired by traumatic, toxic, and metabolic causes. Even if the patient shows evidence of alcohol or drug use, never assume that his altered mental status is due purely to intoxicants until injury and other medical causes are ruled out. (See Using the Glasgow Coma Scale.)


Note whether the patient can recall the events surrounding the traumatic event. Amnesia about the event suggests that he lost consciousness.


Next, assess his pupils for size, equality, shape, and response to light. Unequal or abnormal pupil response can indicate direct ocular trauma or head injury and elevated intracranial pressure or the effects of drugs, such as atropine (pupil dilation) or opioids (pupil constriction).


The final component of the disability evaluation is an assessment of gross sensorimotor function. Try to determine if the patient has any numbness, tingling, or other abnormal sensations in his body after the traumatic event and if he can move his limbs. Injuries to the extremities, spinal cord, head, blood vessels, or nerves can cause sensorimotor deficits.


Michael's GCS score stays at 15. He didn't lose consciousness during or after the fall and he can recall the event vividly. His pupils are equal (4 mm/4 mm) and round, and react to light normally. Despite the pain in his back and leg, Michael's gross sensorimotor function is intact.


Exposure. The final component of the primary survey is exposure. Remove the patient's clothing completely so you can inspect his entire body for injuries. Use good judgment when removing clothing; trying to remove a shirt by pulling or manipulating it may worsen the injury or pain. Cutting clothing away with trauma shears is usually best.


Once you've removed clothing, protect the patient from hypothermia, which is particularly dangerous to any trauma patient because it impairs blood coagulation, interferes with resuscitation efforts, and increases the risk of acidosis and death.


Take these measures to prevent heat loss and rewarm the patient.

Table. Using the Gla... - Click to enlarge in new windowTable. Using the Glasgow Coma Scale

* Remove wet clothing and sheets. Cover the patient with warm blankets.


* Increase the room temperature to 75[degrees] F to 80[degrees] F (23.9[degrees] C to 26.7[degrees] C).


* Infuse only warm crystalloid solutions.


* Consider using commercial patient-warming devices, such as heat lights or temperature-regulating blankets.



When Michael is exposed, you note that he has abrasions over his lower left ribs and deformities in both feet. You quickly cover him with heavy blankets that have been kept in a blanket warmer. The room temperature had been raised to 78[degrees] F (25.6[degrees] C) before his arrival, and he's been receiving warmed I.V. fluids.


Secondary survey: Uncovering other serious threats

Once you've completed the primary survey and managed any immediate threats to the patient's life, begin a secondary survey for injuries that could kill or disable him later. Start at his head and assess him methodically, moving down his body systematically as you search for injuries. Inspect for contusions, abrasions, lacerations, deformities, discoloration, edema, foreign bodies, and other abnormalities.


Auscultate breath sounds and heart sounds. Assess all body areas to locate areas of pain or tenderness, crepitus, deformity, loss of function, and the location and quality of pulses. If you suspect he has a fracture of an arm or leg, assess the neurovascular status of the limb, then splint it to prevent movement and decrease pain. Assess neurovascular status again after splinting. Administer I.V. opioid analgesia as ordered and make sure that pain is managed optimally.


At this point, the trauma physician will consider ordering an indwelling urinary catheter to accurately measure urinary output, an indication of renal perfusion, and to check for blood in the urine. First, though, he'll perform a rectal examination to check for blood or evidence of urethral injury, such as a high-riding prostate gland in a male patient. (If the urethra is injured, the patient may need to have a suprapubic catheter inserted instead.)


Before inserting a urinary catheter, look for blood at the urethral meatus. If you see blood, notify the physician and don't insert the catheter. The patient will need further diagnostic testing (for instance, a retrograde urethrogram or cystogram) before a catheter can be safely inserted.

Table. Get AMPLE inf... - Click to enlarge in new windowTable. Get AMPLE information

Reassess the patient's vital signs and GCS score as frequently as needed, depending on his condition. Also try to obtain a more complete history from the patient or significant others. Use the mnemonic "AMPLE" to help you remember the key information to gather. (See Get AMPLE information.)


Assess carefully for medications the patient has taken that could affect his condition and treatment. For example, taking an anticoagulant, such as warfarin, or a platelet inhibitor, such as daily aspirin therapy, will make him much more prone to bleeding from his injuries. If he's using any of these drugs, tell the health care provider immediately so that he can order appropriate reversal agents or take measures to counteract anticoagulation effects.


Assess the patient for steroid use. If he's taking a steroid medication, he many need an I.V. steroid bolus so that he can physiologically respond in a stress or shock state. If you don't know the date of his last tetanus immunization or if it was more than 5 years ago, administer tetanus prophylaxis.


Michael's secondary survey is remarkable for pain on palpation in his lumbar spine, tenderness and abrasions over his left lower rib cage anteriorly, and heel pain and swelling in both feet. You insert a urinary catheter and perform a dipstick urine test, which is positive for a small amount of blood.


Next up: An eye on diagnostics

After the primary and secondary surveys are complete, prepare your patient for a series of X-rays and scans. He'll have a stat portable chest X-ray to identify rib fractures or mediastinal or diaphragmatic injury and to assess for a pneumothorax or hemothorax. He'll also need a cervical spine X-ray series to check for cervical spine injury. The X-ray will also confirm the correct position of chest and endotracheal tubes and central venous catheters. Depending on the results of the primary and secondary surveys, he may have additional X-rays of the pelvis, spine, extremities, or other areas.


He may have bedside ultrasonography with the focused abdominal sonography for trauma (FAST) technique, which is used to rapidly examine all four abdominal quadrants and the pericardium to identify the presence of free fluid, usually blood.


If he's lost consciousness or shows evidence of a head injury, he'll need a computed tomography (CT) scan of his head. Other CT scans of the spine, chest, abdomen, or pelvis may be indicated to help the health care provider plan treatment.


Your patient may need a vascular ultrasound or an arteriogram if he has vascular injuries, decreased or absent pulses, evidence of limb ischemia, or a widened mediastinum, indicating a possible aortic injury.


Magnetic resonance imaging (MRI) is rarely used for diagnosing acutely injured patients because it takes too long and safely placing an injured patient into the MRI tube is difficult. In addition, the patient might have ferrous metal in his body (for example, implants, or metal fragments left in his eyes from industrial work). Any ferrous metal is dangerous in an MRI room and is a contraindication for MRI.


However, the patient may need an MRI if he shows any evidence of an acute spinal cord injury. Be sure to carefully assess him for ferrous metal objects. If they can be removed, do so before taking him to the MRI. The technologist will ask him if he has any implants or fragments in his eyes from metal work. If he does, an MRI is contraindicated.


Michael's diagnostic workup includes a bedside FAST examination; chest, pelvis, and lower extremity X-rays; a full series of spinal X-rays; and CT scans of his chest, abdomen, and lumbar spine. The tests identify these injuries: fractures of the 9th and 10th ribs on the left side, an L3 compression fracture, bilateral calcaneus fractures, a renal contusion, and a grade III spleen injury.


Providing definitive care

The definitive care phase begins after the patient's injuries have been identified and initial lifesaving interventions have been performed. If your hospital doesn't have the resources to provide the care he needs, he may need to be transferred to a trauma center.


In a facility that can provide trauma management, the patient may go to the operating room, intensive care unit (ICU), or a surgical unit after his trauma workup. Most patients go home after discharge, but some require inpatient rehabilitation first.


In Michael's case, the surgeon admits him to the ICU for close monitoring and pain management. She elects to manage his spleen injury nonoperatively because his vital signs normalized after he received 2 liters of resuscitation fluids. His rib fractures and renal contusion require only observation at this time. Orthopedic and spine surgeons are consulted to treat his calcaneus fractures and L3 compression fracture.


Meeting the standard of care

Key outcome measures will help you to determine how well the patient has responded to resuscitation and help you anticipate his needs. (See Adequate resuscitation? Watch for these indicators.)


An organized team approach in the first hour after a traumatic injury provides fast, efficient patient care and saves lives. Because you and other team members prioritized assessment and interventions for Michael according to recognized standards of trauma care, you've given him the best chance for survival and a full recovery.


Adequate resuscitation? Watch for these indicators


* Hemodynamic and renal parameters within normal limits


* Core body temperature normal


* Serum lactate less than 2 mmol/liter


* No base deficit


* Arterial pH of 7.35 to 7.45


* Hemoglobin greater than 9 grams/dL (based on individual needs)


* Ionized calcium within normal limits. (Blood transfusion can lower serum calcium because of the calcium-binding effects of the citrate preservative in banked blood products.)


* Serum potassium of 3.5 to 5.3 mEq/liter


* Coagulation profile within normal limits


* Pain under control




1. Clontz AS, Tasota FJ. FAST results: Using focused assessment with sonography for trauma. Nursing2004. 34(2):21, February 2004.


2. Laskowski-Jones L. Trauma and shock. In Kee JL, et al. (eds), Fluids and Electrolytes with Clinical Applications: A Programmed Approach, 7th edition. Clifton Park, N.Y., Thomson-Delmar Learning, 2004.


3. Laskowski-Jones L, Toulson K. Emergency and mass casualty nursing. In Ignatavicius D, Workman ML (eds), Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 5th edition. Philadelphia, Pa., Elsevier Saunders, 2006.


4. Peitzman AB, et al. The Trauma Manual, 2nd edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2002.


5. Rapid Response to Everyday Emergencies: A Nurse's Guide. Philadelphia, Pa., Lippincott Williams & Wilkins, 2006.