Trauma Case Study--any tips on prioritizing care from the pros??

Altra, BSN, RN · Feb 21, 2008

There is no teacher like experience, so I'd love to know what those of you with years of experience make of our class case study...Thanks for the tips and advice!
39 year old truck driver, male, admitted to the hospital following an accident in which the cab of his truck caught fire. He was freed from the truck by a passing motorist, who stayed with him until the rescue team arrived. The rescue team decides to call Skycare to transport him to the regional trauma center which has a burn unit. His wife and two daughters have been notified.
How do you stabilize the patient and maintain airway and ventilation while also assessing, stabilizing physical trauma and the degree of his burns?

Your excitement over this case study comes through in your post, and that's great!

However, is there more info? The excerpt you've included here is vague and lacks a lot of detail. If the idea is to get you to think about what needs to be done for this patient in the ED, you need to know more about his condition and what has been done pre-hospital.

isis73 · Feb 21, 2008

I know it is extremely vague, and I do apologize for that--that is all the information we have been given to work with. More info will be given when we show up for our case study and we will have to know how to respond--we have just finished covering increased ICP, cardiovascular and emergency nursing, so the idea is that anything goes and we will need to be able to think on our feet and prioritize care quickly...I am loving the critical care aspect (and hope to work in critical care after graduating in May), but I like to be prepared.

Thanks again for the help, if it really is possible with so little to go on...

ukstudent · Feb 21, 2008

I think that what they are looking for is for your assessments.

You need to assess if any smoke stains are seen around his mouth, nose or in his throat? If yes then you would expect for the pt to be intubated for air way protection.

You also need to assess the percentage of body burned. Use the rule of 9's. You would then want to start fluid resusitation using the parkland formula. 4ml/kg/% of body burnt. 1/2 this amount given over the first 8 hours (after the pt was burnt and not 8hr after you get the pt). The second 1/2 over the following 16 hrs.

The pt was also in a MVA so you would be assessing for other injuries such as broken bones and soft tissue/organ injury. Hypovolemia could be caused by shock from the burn or internal bleeding. Do not forget about the hidden because of the obvious injuries.

I hope this has given you some ideas and direction for your case study.

isis73 · Feb 21, 2008

Yes, that is extremely helpful. I had forgotten about the Parkland formula (having only recently learned it). I think the focus is mostly on assessments, but also on prioritizing care, and your suggestions are all very helpful. (How is your first year as a nurse going? How was the transition from student to nurse?)

Thanks for taking the time to respond and offer the voice of experience!

ukstudent · Feb 21, 2008

Love my job, I am learning something new each time I go in and work. I don't work in the burn department so I hope you get some more answers. The above was from nursing school. I have had plenty of pts with multiple injuries from MVA's though.

As for prioritization think ABC's,

Airway, does the pt have any oral edema, possible loss of consciousness then you need to protect his airway and intubate.

Breathing, smoke inhalation will reduce the pt's ability to breath. Positive pressure vent settings to keep the alveoli open for oxygenation and rate/volume control for ventilation.

Circulation, fluid resuscitation for the hypovolemia and check for any other points of blood loss.

Your pt in the case study should be on a spinal precautions until cleared. He will need a full body x-ray, trauma centers are set up to do this quickly, and a CT scan.

Also with all this focus on the pt, remember that nursing school and nclex loves psychological support and communication. So you could score points if you remember to call for the hospitals pastor/priest/social worker to give emotional support for the wife and children in this time of crisis.

trauma_burnout71 · Feb 21, 2008

How do you stabilize the patient and maintain airway and ventilation while also assessing, stabilizing physical trauma and the degree of his burns?

Great question! Let's keep it simple, believe it or not simplicity pokes it head up in even the most chaotic of moments.

A-B-C's; TNCC outlines exactly how to care for this pt. By maintaining your airway you have in fact began to stabilize this pt. Burn pt require a specific hydration schedule based on weight and % of burn to body. We don't just open up the fluids on these pt's, the can develop fluid overload leading to pulmonary edema rapidly. Simplicity- broken bones are second to airway. Remember, "Life over Limb"

Good luck and Great enthusiasm.

isis73 · Feb 21, 2008

Thanks to both of you! Great advice. And you're absolutely right ukstudent--my teacher's two loves are critical care and psych, so I'm sure she will be interested to know what we are doing to care for the wife and two daughters who are on the way.

And thanks for the warning on fluid volume overload, trauma_burnout71. Why are they at such risk for fluid volume overload? Trying to think that one through...they could go into shock, but then their BP would drop...After being a little burnt on nursing school (the end is finally in sight!), I love all the thinking and learning involved in critical care. Feels good to know I may have found my niche (it was definitely NOT OB-Peds...)

So the biggest priority is airway, and likely intubation since their airway may be irritated and swell secondary to smoke inhalation and the possible loss of consciousness. Second is fluids and establishing an IV to maintain BP and prevent dehydration, being careful not to overload pt (indication for hemodynamic monitoring?) And once these are established, with pt on spinal precautions and heading to x-ray and CT, a call to the hospital chaplain for family support.

Thanks again! (And who wouldn't be enthusiastic with the end of nursing school just around the corner!)

TraumaNurseRN · Feb 21, 2008

ABC's WHILE maintaining c-spine immobilization is key!

BluntForceTrauma · Feb 21, 2008

After ABC's, remember to keep the pt normothermic. Depending on the percentage of burns, the patient it at high risk of becoming hypothermic.

isis73 · Feb 21, 2008

Had the case study today, and you're right--pt had a temp of 96 and with everything else we were trying to think of and work on, we didn't catch it right away. Pt had 36% BSA burned.

SDS_RN, RN · Feb 22, 2008

Remeber that airway and c-spine work simultaneously they are the first step then proceed to B & C.