What is the nurses priority in a trauma (new to ER)

star77, MSN, RN · Mar 3, 2011

AcBCD... Etc. (TNCC is really helpful, I'll echo this fact).

And honestly, it depends on your hospital's protocol/system and resources (Level 1, Level 2...) and HOW BAD/WHAT KIND of trauma you are receiving. Is it a burn? Is it a penetrating? Blunt?

If it's really bad and that patient is circling the drain on the table, and you're the primary nurse, you might be directing someone to run to blood bank with the non-crossmatched papers for your O neg or O pos blood, or you might be dealing with titrating a pressor, or hey, you could be looking for a third line in a limb that isn't burned to a crisp while pressure bagging a few liters in your other peripheral lines while a doc is hopefully putting in a central line, or you could be calling out the numbers on your monitor to someone who's hopefully charting for you (generally on a bad trauma you'll get at least 3 other RNs helping, plus a slough of gawkers/runners, at least you hope). You might help encourage closed-loop communication among ortho/trauma surgery/cardiothoracic/ED physician team. And you might be doing all of these things at once. All while helping maintain AcBCD....etc.

If it's a minor car accident "hey we're not gonna take off the c-collar until your x-rays are back" kind of thing, yeah, that's different than a 65% TBSA partial and full thickness burn with bilateral tib-fib fxs, obvious femur deformity, systolic of 86/p on scene, unstable pelvis, tubed, and a positive FAST exam. Very different. But the methodology is the same. I guarantee that second patient is going to the OR, while the first patient is someone you have to monitor "just in case" (and one of my "just in case" folks ended up having a basilar skull fracture... hence we use the TNCC methodology).

The interventions are pretty standardized. Your equipment and system may vary, and the intensity of intervention may vary, but it's the same systemic assessment in the same order for a reason. When you get something really bad and you're focused on the alphabet, it pulls you back into your job and you don't freeze. There have been some traumas that have made me drop my jaw. There are some I've seen where I've cried uncontrollably in the bathroom 10 minutes after that patient has gone to the OR and it's all over (kids - you see people do some horrible things to one another, and when kids are abused it really gets to me). But in the moment, I follow what needs to happen and do what's best for the patient, which is dictated by TNCC and the AcBCD pneumonic

(Airway/c-spine, Breathing, Circulation, Disability/Deformity, Expose/Environment, Full set of Vitals/Fucntional Adjuncts/Family, Give Comfort, Head to Toe, Inspect the back)

ZippyGBR, BSN, RN · Mar 3, 2011

If you're primary nurse all you really do is get report from the medic.
After that you are never closer than 4 people from ever putting hands
on YOUR patient.

i'm sorry if that's the case you need lessons in how to run a resus room ...

even if all the trauma team are present as part of a pre alert the Primary Nurse is a vital link to keep it all sane along with the physician team leader.

ever had three or more trauma patients hit your ED at one time ? with the best will in the world and even in a teaching hospital you will not get 3 full trauma teams ( with middle grade or seniors from ED, General surgery, Ortho and Anaesthesia ) ... so the third or subsequent patients are reliant on good assessments by the Nurse who initially assesses them to identify life and limb threatening injuries to redirect the trauma team if needed in consultation with the Senior ED physician and Charge Nurse for that clinical area ...

If you're secondary nurse then woo-hoo!, you get to put them on a monitor
(if there is no tech/cna on the trauma team) and you might even get to place
a 2nd large bore IV before they're gone.

why are you denigrating this role? the second nurse is a vital ink especially if you are going to carry out procedures in the resus room ( e.g. traction splint if it;s not been put on pre-hospital, reducing limb threatening fracutre dislocations , anaesthetising the patient - especially if you don'[t have a Anaesthetic assistant ( whether Nurse, ODP, RT or a junior doc) as part of your trauma team

Although I will concede that TNCC has some good information
you never actually get to use it. Get use to neuro checks. Because if
your patient really isn't seriously hurt then you usually end up sitting in
a cold, well-lit room doing neuro checks for hours until the doctors decide
what to do with the patient.
Don't sweat trauma.

discounting my pre-hospital role where i am often the the first Health Professional on Scene I have used what I have been taught from PHTLS and TNCC as well as ALS and various other alphabet soups day in day out in all the hospital clinical environments I have worked in. I have been praised by Senior Staff both Nursing and Medical for the way in which i can control and manage the care of a critically ill patient rather than it all descending into a flap-fest where the patient is forgotten amid the panic and ******* contests ... i'm particularly proud of a first shock ROSC and

herowneulogy, BSN, RN · Mar 4, 2011

Enjoying reading the responses

allnurses Guide · Mar 4, 2011

Although I will concede that TNCC has some good information
you never actually get to use it. Get use to neuro checks. Because if
your patient really isn't seriously hurt then you usually end up sitting in
a cold, well-lit room doing neuro checks for hours until the doctors decide
what to do with the patient.
Don't sweat trauma.

All I can say is, I'm glad I don't work in your ER. In mine, nurses are an integral hands-on part of the team, and we use all those assessment skills, using the mnemonic which actually matches our T sheets. I've used my TNCC many many nights. :twocents:

Larry77, RN · Mar 4, 2011

Enjoying reading the responses

After I read the controversial response I knew this was going to be a fun thread...don't question the value of an RN on this website-you are liable to get a beaten

dthfytr, ADN, LPN, RN, EMT-B, EMT-I · Mar 4, 2011

Get yourself a TNCC course ASAP. All c-spines are fractured until proven otherwise, Always remember your A B C's, re-evaluate often, look listen poke and probe everywhere so you can chart a thorough assesment, as a baseline in case things change. Never take another persons word for it. I once heard no breath sounds where a doctor swore they were present and clear. X-ray showed a 100% pneumothorax. Guess whose charting was more accurate? I don't mean it as a competition or to slam the doctor, you are part of a team. Since nobody's perfect, the more team members involved, the less likely something will be missed.

Altra, BSN, RN · Mar 4, 2011

The reality about trauma is that you really don't do much of anything.
(Even you high-speed, low-drag level 1 types).
If you're primary nurse all you really do is get report from the medic.
After that you are never closer than 4 people from ever putting hands
on YOUR patient.
If you're secondary nurse then woo-hoo!, you get to put them on a monitor
(if there is no tech/cna on the trauma team) and you might even get to place
a 2nd large bore IV before they're gone.

The above might fly for the textbook ideal: a trauma is transported to a Level I ED during the daytime on a weekday when every service is in house, the ER is fully staffed, the trauma bay doesn't already have 3 patients in it ... etc. etc. etc.

But what about the trauma that shows up at the front door -- the vehicle that pulls up with, "we need some help here - my buddy's been shot."

Or the multi-victim trauma ...

Or countless other scenarios that seem to be the "norm" as much as the ideal presentation with all hands ready on deck.

And even when there are 4 people between you & your patient ... as the primary nurse you better be documenting every single detail that's happening with/to the patient, with all the i's dotted and t's crossed, if your ED wants to keep its trauma accreditation.

dthfytr, ADN, LPN, RN, EMT-B, EMT-I · Mar 4, 2011

And keep extra IV catheters in your pocket! When you're trying for the "2 largebore IV's" and the residents just wont get out of your way, well accidents happen, then use a clean one from your pocket.

AnnieOaklyRN, BSN, RN, EMT-P · Mar 18, 2011

No matter what is wrong with your patient, your priority is and will always be AIRWAY AIRWAY AIRWAY, Breathing, and Circulation... Well unless your doing CPR then its compressions, then airway breathing...

Happy