Claire Roberts delivered an energetic talk at VetsSouth in Exeter in February 2018, outlining the steps to efficiently dealing with trauma patients in practice. “Traumatic injury is tissue damage caused by external force or violence; generally, we’re looking at blunt trauma or some sort of penetrative trauma,” she explained, listing some common examples such as road traffic accidents and dog and cat attacks.
The first step is to clear the injured area. “Make sure that even if you see one little wound, you do a thorough look at patients to reveal any hidden trauma,” Claire said. Just because a cat has landed on its feet does not mean everything is OK – these patients will often have extensive internal trauma. “Prepare for the worst and hopefully it will be better than you planned for,” she advised.
Emergency triage is the sorting and allocation of treatment to patients according to a system of priorities designed to maximise the number of survivors. The prioritising principle here is: “Being the worst makes you first”. Even if you only see an emergency once every couple of months, Claire said, it’s important that you “have some sort of triage system in place to maximise efficiency and to assist teams in working together to get the most successful outcomes”. She advised that practices arrange regular emergency drills involving the whole team.
A telephone call is usually the first point of contact in emergency cases. At this point, it can be noted whether the client’s primary complaint is medical or traumatic. “Trying to calm the client down will help to get the most relevant information from them as quickly as possible,” Claire said. She recommends having a standardised telephone triage form available and documenting all emergency telephone calls to help keep the conversations short and to the point.
The initial assessment
First, it is key to make sure you are wearing gloves and cover any open wounds that aren’t going to be dealt with straight away – Claire highlighted that most wound infections will occur once the patient enters the practice.
The initial assessment should be a quick, targeted clinical examination of around 60 seconds. It should be used to identify whether there are any life-threatening problems so they can be dealt with immediately, the speaker explained.
Using the ABC principle, if there’s a problem with the airway, fix it before moving on to breathing and circulation.
Trauma patients have a high incidence of concurrent injury to other systems which are often silent on presentation
Breathing and circulating blood can then be considered before moving on to a whole-body examination to determine and address any additional problems.
Identifying concurrent injuries
Trauma patients have a high incidence of concurrent injury to other systems which are often silent on presentation, Claire said. She reminded delegates to be mindful of pulmonary and cardiac contusions, particularly in patients with thoracic trauma.
The speaker was keen to get across the statistics associated with concurrent injury risk because knowing the likelihood of occurrence with different types of trauma should help the practice prepare for the patient. Many patients with a forelimb trauma and half of patients with thoracic trauma will also have pulmonary contusions, she noted, and 60 percent of animals presenting with a forelimb fracture will also have chest injuries.
Trauma patients commonly have pulmonary contusions and around 50 percent have pneumothorax. Patients may also have rib fractures, pleural effusion, haemothorax or subcutaneous emphysema, and up to 9 percent will experience a diaphragmatic hernia.
Claire noted that pulmonary contusions will be picked up on auscultation far earlier than radiography. “The VN that’s constantly using a stethoscope to listen to the lungs and heart will pick up pulmonary contusions within about six to eight hours of a traumatic incident. You’re looking at 24 to 36 hours before it will show up on radiography. You get good at this if you listen to every patient’s thorax every day with a stethoscope – eventually you know what the norm is.”
There are some things you can do for every patient. “The best thing you can do in an emergency is give the patient oxygen,” Claire said, also advising the provision of fluid therapy and adequate analgesia.
“If I know a patient is coming in with trauma, I would prepare for them to have pneumothorax treated. Have all your equipment ready – maybe even have a little kit in practice in case of patients that present with pneumothorax or haemothorax.”
She went on to give specific advice relating to common traumatic conditions and signs presented by patients.
This happens if there are several fractured ribs next to each other and this section of the ribs gets flattened into the lungs, explained Claire, causing the patient to lose the ability to take in enough oxygen. “If we know a patient has floating ribs on the right-hand side, it would be far better to lie that patient in right lateral recumbency to support the ribs and help them ventilate on the side that’s working properly.”
Claire emphasised that open-mouth breathing in cats is severe end stage: “If you’re seeing cats open-mouth breathing, they need to be handled with extreme care. It can progress rapidly into respiratory arrest.” She noted that cats and dogs tend to go into a hypoxic respiratory arrest before they go into cardiac arrest, so signs of hypoxic arrest will be seen first.
The speaker highlighted that in 22 percent of patients with a pelvic fracture, there will be injury to the urinary system. Almost 60 percent of cats that have experienced blunt trauma will have urine in their abdominal cavity. And the majority (84.6 percent) of those are due to a ruptured bladder. This needs to be monitored – either flagged up on your hospital sheets or part of your care plans, Claire said.
“We’d expect a trauma patient to produce some urine within the first four hours of being in hospital. If not, we should be badgering vets to come and look.” Check electrolytes for any abnormalities; if they do have a ruptured bladder or trauma to the urethra or ureter, they will require surgical intervention, she said.
Bites or ballistic trauma
Half of these patients will have concurrent pulmonary injury and potential bowel perforation. This trauma can be
When the patient is moved through to wards, there should be an IV catheter in place, blood work should have been taken and monitoring equipment should be used
difficult because there is a little wound on the surface but much more under the surface.
Traumatic head injuries
In these patients, it is important to look at ways to limit the amount of intracranial swelling. Traumatic injuries can lead to brain injury and neurological dysfunction, and can cause severe clinical signs. “There are simple nursing measures we can put in place that can have amazing benefits for these patients.” Claire advised against taking blood samples from the jugular in these patients and avoiding procedures that might induce coughing or sneezing – including nasal catheters.
Monitoring the patient
When the patient is moved through to wards, there should be an IV catheter in place, blood work should have been taken and monitoring equipment should be used. Prioritise which monitoring equipment is used on which patients based on the anticipated complications, the speaker said, adapting it as the patient’s status changes.
“Pulse oximeters are key in critical patients,” Claire noted, suggesting that veterinary nurses experiment with the probe positioning. “The Achilles tendons in cats are quite useful. The vulva [also] has a very good blood supply.”
“You should be intubating cats and dogs every week and should be practising intubating in lateral recumbency,” the delegates were told. Trying to lift the head of a very bradycardic patient, or one with head trauma, can send them into cardiac arrest.
Blood pressure should be taken. In all critical patients, trends should be monitored. Remember that pain will depress the respiratory/cardiovascular system; you must give pain relief and be the driving force behind it. Pain score them, she said. “We don’t have to give methadone every four hours – if the patient is painful two hours later, give something, whether it’s a top-up or another drug.”
Nurses can have the biggest impact on outcome when it comes to trauma patients. “We are our patients’ advocates,” Claire emphasised, recommending that nurses document everything they see and act on it. In her concluding remarks, she said to: “Trust your hunches, they’re usually based on facts filed away just below the conscious level.”