Emergency Care Nursing Assignment: Case Study On Complex Trauma Patient

Question

Task: For this emergency care nursing assignment, you are required to write a 2500 word, referenced case analysis that covers four aspects of the case: Write one introduction, answer all four parts and write a conclusion to summarise your work.
You are the registered nurse on duty required to assume the care of Mr James and perform the initial triage. Luke James is a 22-year-old male brought in by ambulance, who was involved in a high-speed motor vehicle crash, when the car he was driving collided with a tree. He was found conscious but confused, still strapped in the seat and had no recollection of the incident.

Part A – From the information provided above address the following points:
• Briefly discuss the mechanism of injury and physical trauma you need to look for apart from the stated injuries
• Discuss the immediate priorities of assessment and management of Luke’s clinical status
Part B – During your assessment, you note that Luke has a lot of pain in the head and neck area and intermittent tingling in his hands. The next set of observations show: further fall in BP to 80/40mmHg, with oxygen saturation of 89%. He remains tachycardic. In view of Luke’s deterioration, you assess him for signs of shock.

• Outline two possible causes of Luke’s shock. Briefly compare and contrast their pathophysiology
• Discuss the appropriate management strategy required to stabilise Luke and prevent further deterioration. Part C – Luke is treated with high flow oxygen but his O saturation remains low at 90%. His venous gases show that he is hypoxemic and acidotic. There is also a significant decrease of air entry on the right side of his chest. He has become responsive to pain only and his GCS is now 10.
• Discuss the principles of airway and ventilation management needed to correct Luke’s respiratory failure.
• Identify the likely thoracic injury, the required management and the associated nursing care
Part D – Luke was intubated, is sedated and mechanically ventilated. His vital signs have stabilised. A decision is made to transfer him to the closest trauma centre, located two hours away by road from your facility.
• Explain the appropriate mode of transport for inter hospital transfer.
• Discuss the nursing considerations and management principles required to ensure a safe and efficient patient transfer.

Answer

Introduction
The following case study examined in the emergency care nursing assignment is related to emergency care for managing a patient named Luke James, who suffers from complex trauma arising from a car accident. It has been a car crash arising out of high-speed driving, and now that the patient has been admitted to the nearest health centre, he is under critical condition. His car had collided with a tree, and he became unconscious. He was trapped in the car for almost half an hour. The trauma had been majorly on the right side of the body. Crucial bruises were found in the 5th and 6th ribs. The iliac crest has been majorly damaged, and signs of deformity have been observed in the right leg. He has been suffering from breathing troubles and intense pain.The main priority of the patient, Luke is treatment of his traumatic shock and the entire treatment plan and procedure is based on that priority only.

Trauma mechanism and assessment of clinical status
Mechanism of trauma in RTA
Apart from the stated injuries, other types of physical trauma and mechanism of injury need to be looked for in this type of RTA or Road Traffic Accidents. It is imperative to assess the mechanism of such injuries as it would be conducive to finding out the exact degree of severity of such trauma. The mechanism of injury would be applied here to gauge the intensity of damages caused to the bones, muscles, organs and skin. By having a clear idea about the severity of the trauma, it would be much easier to administer the treatment accordingly. The mechanism of injury or MOI varies from person to person, depending on each individual's specific type of physical condition(Sinha et al., 2021).

Other than the identified injuries, various other factors of complications or comorbidity also need to be assessed under such circumstances. It is imperative to find out the Hx or medical history of the patient. It is still unknown whether the patient Luka James suffers from any chronic heart disease. If he is suffering from any heart ailment, that would have a negative impact on his ability to compensate for the trauma. If he has a history of any kidney or liver disease, he might have a problem of blood-thinning that would interrupt his body's normal blood clotting mechanism. We also need to assess whether he suffered from any type of brain damage or not. Any such damage in the brain would bring changes in the patient's normal behaviour. It is equally important to treat such a mechanism of injury as a moving target. It is entirely different for each individual. We need to find out if there is any injury that might be life-threatening and accordingly initiate adequate measures of supportive treatment.

Assessment of trauma
The priorities of trauma assessment would determine how the clinical status of Luca will be managed in this case. We will be following the basic trauma assessment methods as per the latest clinical guidelines of Australia. Every state and territory of Australia have been following such components of trauma care system that has already been implemented. The trauma care in Australia is largely guided by the NRTAC or National Road Trauma Advisory Council to improve the safety on road by minimising such road accidents as has happened in case of Luke.As per the latest guidelines of the Australian trauma care system, pre hospital care is the basic component of the trauma care system that needs to be provided to Luke. This would be the maiden interaction of Luke with the system of trauma management.

This is then followed by the primary survey of the patientor triage, which was done, once Luca was brought into the health centreand as per the severity of his bodily damage the patient needs to be sorted. The most suitable tool of triage needs to be implemented depending on the field condition of the patient. The main aim of following the triage is to take a patient like Luke to the most appropriate hospital at the most appropriate time. The guideline states the parameter of respiratory distress when the rate of breathing per minute is more than 30, the pulse rate is more than 130 and the level of consciousness falls to GCS<13. Luke has been termed critical under all these parameters.

The emergency medical services of EMC have already laid down the findings of the initial survey or triageof the patient. The primary survey had been initiated right during the presentation of the EMS. Considering the condition of Luca, all efforts were made so that all relevant information about Luca can be obtained from the EMS before they depart from the spot. As part of the advanced trauma life support, the primary survey was conducted following the airway, breathing, circulation, disability, and exposure sequence. In medical terms, this is also the ABCDE of primary trauma assessment. After the primary survey, the secondary survey follows. At this level, it has to be seen whether the patient requires any immediate surgical action or not. This survey involves getting further information about the patient, which is Luca in this case. A thorough exam is conducted from head to toe, along with diagnostic testing. Special care should be taken to detect any blunt trauma of the abdomen which might have caused any severe internal injuries of the organ, any abdominal trauma which is penetrative, or thoracic trauma that might also be penetrative(L Patil, 2016). The degree of the extremeness of such trauma also needs to be ascertained to detect any compartment syndrome or fractures. The secondary survey of such immediate trauma assessment would include identifying Luca's past history of allergies, medications, and surgery.

Shocks related to this case
Shock Assessment
Two possible causes of shock from which Luke is suffering may be as follows. In this case, we would discuss hypovolemic and neurogenic shock. The hypovolemic shock is caused mainly due to loss of blood. If the amount of blood loss is more than one-fifth of the average blood level of the body, then this shock will occur. In this case, it is assumed that Luke has lost a considerable amount of blood due to the injuries he suffered from(Salam, 2017). It is also required to check whether there has been any sort of internal bleeding, particularly in the gastrointestinal tract of Luke. Such loss of circulated blood may also be caused due to loss of excess body fluid like too much perspiration or vomiting. It is evident from the initial survey that Luke has been found conscious, but he was utterly confused along with weakness.The reason for identifying this shock lies in the cause that the patient has a high chance of severe injuries in heart, lungs or artery for which hypovolemic shock has been discussed here. The cause of neurogenic shock is most common in such cases of car accidents as such high-speed car accidents have a high chance of damaging the spinal cord or the central nervous system. Any injuries to these parts of the human body would stop sending controlling messages to the body's nervous system. As such, all other functions of the body will get damaged extensively. If such signals from nerves get stopped in the blood vessels, the vessels will cease to function correctly.The reason for identifying this shock lies in the cause that the patient has been suffering from acute pain and for that neurogenic shock has been discussed here.

The pathophysiology of hypovolemic shock is an outcome of depletion in the intravascular volume, which can be caused by either excessive loss of blood or loss of body fluid or loss of both. At the same time, the neurogenic shock is an outcome of both secondary and primary injuries causing parasympathetic response done by the vagus nerve and also leads to loss of sympathetic tone. This causes instability in heart rate, body temperature and blood pressure.

Management of hypovolemic shock
The appropriate management strategy needed to stabilise Luke by preventing any further deterioration in his current condition would require proper management of hypovolemic shock, which is one of the major concerns. Any failure to adequately address such management of shock might result in loss of organs for Luke. The fatality rate of hypovolemic shock is most active within the first 24 hours only. A blood test along with the test of blood chemistry would be very helpful in providing exact information about the electrolyte and salt level in the body. It would also help find out how the liver and kidney function. A CBC or complete blood count test would help find out the volume of blood that has been lost in this case("Rupture of Adrenal Artery Pseudoaneurysm with Late Manifestation of Hypovolemic Shock", 2021).

For identifying any sources of internal bleeding, some tests are to be done immediately, including a CT scan to find the exact visual condition of the various organs of the body. This is to be followed by an echocardiogram to evaluate how better the heart can pump up and squeeze blood. Endoscopy is also needed to ascertain any source of internal bleeding in the gastrointestinal part of the body.

As an immediate measure of treatment, the first attempt must be made to prevent any loss of fluid so that the volume of blood can be stabilised before any further complications can arise. The volume of lost blood needs to be replaced with crystalloids given through intravenous fluids. Since this fluid is just like a saline solution, such a liquid's consistency is very thin. If needed, a solution with thicker concentration called colloids can also be used depending on the condition of Luke. Once the blood volume stabilises and the shock is brought under control, the underlying injuries can be treated accordingly.

Respiratory management and associated nursing care
Resuscitation
The principles of airway and ventilation management that would be needed to correct the respiratory failure of Luke would require administering the resuscitation process of using the ABCDE approach. This denotes using the Airway, Breathing, Circulation, Disability and Exposure mechanism for treating and evaluating the patient.This process of resuscitation is best suited for all sort of emergencies arising out of such trauma (Noorbakhsh&Kriley, 2018). A or airway obstruction removal is a vital activity to save a patient like Luke from threats of hypoxia and would also save him from further risks of damaging heart, kidney, brain or any cardiac arrest. Using very elementary methods of clearing the airways is enough to help the patient out of criticality. This can be done by multiple ways like suction of airways, or by other common manoeuvres of opening airway or by inserting nasopharyngeal or oropharyngeal airway. If these methods do not work then tracheal intubation might ne needed to be applied.

B or breathing is vital to treat any instant threats to the life of Luke. He is already showing ample signs of respiratory distress as per the concentration of oxygen and SpO2 reading showing in the pulse oximeter. Based on such condition the patient needs to be given oxygen and a proper checking of the tracheal position of the patient is also required to be done at this stage.

C or circulation is important because under such conditions of trauma, the primary reason of shock is always due to hypovolaemia unless something else is proven. Considering the pulse rate and the blood pressure of Luke using IV fluid with a close monitoring is highly recommended in this case. D or disability for identifying the most common reasons for unconsciousness like hypercapnia, cerebral hypoperfusion or profound hypoxia. The conscious level of the patient must be assessed very rapidly using the AVPU method to find out the response of the patient to different types of stimuli. A close monitoring of the blood glucose level is also very important at this stage. E or exposure of the full body is necessary to examine the patient properly. At this point the dignity of the patient needs to be honoured and any scope of heat loss should be minimised.

Thoracic injury in RTA
The likely thoracic injury are those injuries which might cause injury to the wall of the chest and also damages the thorax contents. The organs that are mostly affected are mainly the lungs, pleura, lower tracts of the respiratory organ and great vessels. The most common threat of injury that can affect the thoracic areas are like haemothorax and pneumothorax. The aorta gets injured the most. The rib fractures in this case needs to be investigated. In this case, special focus must be given on injuries related to oesophageal, diaphragmatic and tracheobronchial areas. Such type of thoracic traumas can often get fatal. As such thoracic injuries might lead to obstructions of respiration, arrests in respiration and also it becomes difficult to regulate the bleeding(Sharma, 2019).
The assessment, intervention and probable revival might involve a large volume of time pressure. The management of thoracic injury involves frequent repetition of clinical diagnosis. The pathophysiology depends on properly examining the rib cages, intercostal musculature and costal cartilage. It has to be examined whether Luke is suffering from any blunt injury to the aorta. This might prove severe resulting out of any intimal cut to the entire transaction of the aortal region. As an immediate measure oxygen must be given by using either a breathing tube or face mask or by nasal prongs. Intravenous fluids should also be given and if needed blood transfusion should be arranged. Performing a tube thoracostomy can prove to be very useful in this case. If required surgical interventions are to be administered in case drainage of pleural cavity is needed. The nursing care plans for treating such thoracic injury would include closely monitoring the respiratory status, managing the drainage of chest tube and to take care of the supportive care.

Inter hospital transfer
Transfer of trauma patients
The inter-hospital transfer for such major trauma service or MTS needs to be well equipped with continuing care and using the right mode of transport. The basic principle of such a transport is to ensure a better level of patient care. Such a management of interhospital transfer must be better than at the referral point. Emergency ambulances must be arranged for such a transfer. This ambulance will be having a pair of crew members. As per the standing norms of Australia at least one of the officers of the ambulance should be an advanced or at least a paramedic (Myers & Nolan, 2021). The responsibility of such transfer should lie with a medical practitioner who is properly qualified. A proper handover to the retrieval doctor from the referring doctor and from the retrieval doctor to the receiving hospital is very crucial. It is also to be ensured that such retrieval and transfer must be activated at a very early stage. This is as per the guidelines denoting the chain of responsibility of such inter-hospital transfers. A patient like Luke who is meeting all the needs of a major trauma transfer the adult retrieval team must be contacted within an hour of his arrival in the health centre. As soon as the preliminary notification of such transfer for Luke is made, the retrieval service team will immediately arrange for a coordination consultant who is having enough relevant experience and expertise for giving proper advice related to such clinical management that is needed the most for such transfer of trauma patients. A teleconference involving multiparty would be arranged. This would include the clinicians and based on such a tele meeting all the required facilities can be arranged as per the requirement.

As per the guidelines of transfer the transport vehicle must ensure safety and security for the staffs and the patient. The vehicle must have enough space for access of the patient and also to permit performing any critical medical interventions. Along with this enough gas, and power is needed to run the life support systems along with enough suction. There should be smooth access for safe and proper embarkation and disembarkation. There should be enough light and proper climate control system within the vehicle.Whatever vehicle is used, all such vehicle must be well equipped with IV access, provisions of secure airway, vital sign stabilisation and proper provisions for suitable monitoring. These are to be arranged compulsorily before departure to ensure a safe and secure transfer of the patient. As per the guidelines a proper clinical record of the patient containing his latest health status before, after and even during the transfer along with applicable health conditions, therapy given and the environmental factors, all needs to be documented properly.

Efficient patient transfer
The nursing considerations needed to ensure a safe and efficient patient transfer would include preparing the patient properly, completing the required records and then shifting the patient to another place. The nurse needs to take care of a few factors to ensure a smooth transfer. One of the most important things among that is to have a prior discussion with the medical staff of the receiving facility about the condition of a critical trauma patient like Luke in this case. This would ensure that all the arrangements would be kept ready in the receiving unit and minimum time would be lapsed before the next set of treatment gets started for the patient(Lin et al., 2021). Time is very important, and the nurse has to ensure a proper time management while organising for the interhospital transfer. Based on such discussion with the receiving unit, the transportation would be arranged. The management principles to be followed for ensuring a smooth inter-hospital transfer would require an initial assessment(Espaillat, 2017). This would involve evaluating the mode of transport, completing all the necessary documentation, communicating verbally to the nurse of the receiving unit about the condition of the patient, arranging proper equipment and finally handing over the patient to the receiving unit.

Conclusion
It can be concluded based on the above discussion that in case of such critical trauma patients like Luke James, the primary treatment is very crucial(Vuong et al., 2017). It is extremely important to adopt the right mechanism of trauma care in RTA. This also involves a proper assessment of the trauma, the types and causes of shocks and how to manage such shocks. Implementing the right measures of CPR and management of thoracic care is equally important. Finally, such a trauma patient needs a proper inter-hospital transfer as per the guidelines of the state following the principle of support management for such transfers.

References
Espaillat, K. (2017). Abstract TP243: Evaluation of Transfer Time for Trauma, Stroke and Cardiac Patients. Stroke, 48(suppl_1). https://doi.org/10.1161/str.48.suppl_1.tp243
L Patil, S. (2016). To evaluate the introduction of a focussed assessment with sonography in trauma (FAST) scan into the early assessment of trauma patients. International Journal Of Scientific Research And Management. https://doi.org/10.18535/ijsrm/v4i12.10 Lin, S., Nolan, B., Dashi, G., &Nathens, A. (2021). The relative importance of clinical factors in initiating interfacility transfer of major trauma patients: A discrete choice experiment. Trauma, 146040862110317. https://doi.org/10.1177/14604086211031744 Myers, V., & Nolan, B. (2021). Characteristics associated with delays in decision to transfer injured patients. Trauma, 146040862110496. https://doi.org/10.1177/14604086211049635
Noorbakhsh, M., &Kriley, I. (2018). Management of severe respiratory failure in complex trauma patients.Emergency care nursing assignmentJournal Of Emergency And Critical Care Medicine, 2, 26-26. https://doi.org/10.21037/jeccm.2018.01.08 Rupture of Adrenal Artery Pseudoaneurysm with Late Manifestation of Hypovolemic Shock. (2021), 6(3). https://doi.org/10.33140/jcrc.06.03.05
Salam, M. (2017). Motor vehicle accidents: The physical versus the psychological trauma. Journal Of Emergencies, Trauma, And Shock, 10(2), 82. https://doi.org/10.4103/0974-2700.201584 Sharma, S. (2019). Thoracic spine injury associated with Thoracic duct injury and chylothorax. Journal Of Medical Science And Clinical Research, 7(1). https://doi.org/10.18535/jmscr/v7i1.59 Sinha, V., Chaudhary, N., Jha, S., Chaudhari, N., &rathva, K. (2021). Management of Maxillofacial Trauma in Road Traffic Accident (RTA) at Tertiary Care Center. Indian Journal Of Otolaryngology And Head & Neck Surgery. https://doi.org/10.1007/s12070-020-02299-6 Vuong, P., Sample, J., Zimmermann, M., &Saldinger, P. (2017). Trauma team activation: Not just for trauma patients. Journal Of Emergencies, Trauma, And Shock, 10(3), 151. https://doi.org/10.4103/jets.jets_147_16