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TAEI Manual
(Protocol & Guidelines of Tamil Nadu
Accident and Emergency Care Initiative)
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TAEI Manual
(Protocol & Guidelines of Tamil Nadu
Accident and Emergency Care Initiative)

Tamil Nadu Accident and Emergency Care Initiative

National Health Mission
Health and Family Welfare Department
Government of Tamil Nadu,
Chennai.
*
2018
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Published by
Dr.Darez Ahamed MBBS IAS
Mission Director National Health Mission & Commissioner of Trauma Care
National Health Mission / State Health Society Tamil Nadu
5th Floor, DMS Annexe Building, DMS Complex,
369, Anna Salai, Teynampet, Chennai
Chennai-600 006.
EPBX Board No. [044] 24321310 Fax No. [044] 24320563
Mobile +91 99406 26911 (Click this link https://wa.me/919940626911 to send the message in
Whatsapp)
E-mail Address mail@taeionline.com, rchpcni[at]tn[dot]nic[dot]in

© 2018 : National Health Mission, Government of Tamil Nadu.

Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
The User is allowed to Copy and Redistribute this work for Non Commercial purposes, as
long as it is passed along unchanged and in whole, with credit to National Health Mission

Protocol Information
Protocol Number : TAEI 02
Protocol Version : 2
Protocol First Written on : 24th Oct 2017
Protocol Last Modified On : 22nd June 2018
Design & Layout : Dr.J.Mariano Anto Bruno Mascarenhas, Nodal Officer, TAEI
Tamil Nadu Accident and Emergency Care Initiative www.taeionline.com
 -7-

DEDICATION

to
All Patients
in
Emergency Departments

Whom we saved
&
Whom we failed to save
 -9-

No greater opportunity, responsibility, or obligation can fall

to the lot of a human being than to become a Emergency
Department Personnel. In the care of the suffering, [the
ED Personnel] needs technical skill, scientific knowledge, and
human understanding. . .. Tact, sympathy, and
understanding are expected of the ED Personnel, for the
patient is no mere collection of symptoms, signs, disordered
functions, damaged organs, and disturbed emotions. [The
patient] is human, fearful, and hopeful, seeking relief, help,
and reassurance.

Epigraph modified from

“No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a
physician. In the care of the suffering, [the physician] needs technical skill, scientific knowledge, and human
understanding. . .. Tact, sympathy, and understanding are expected of the physician, for the patient is no mere
collection of symptoms, signs, disordered functions, damaged organs, and disturbed emotions. [The patient] is
human, fearful, and hopeful, seeking relief, help, and reassurance.”
- Harrison's Principles of Internal Medicine, 1950
 - 10 -

Help Needed . . .
1. Protocols, by
Definition, are never
complete nor final.
They need to be
updated on daily, if
not hourly basis.
2. Hence, this manual
will be considered as
Draft Manual for
eternity and your
inputs are needed for
ever.
3. Contribution can be
Scientific, Technical,
Administrative etc
4. You need not be
working in Health
Department to give
your input. You need
not be even a health
care worker. We request contributions from everyone
5. You can Suggest Additions, Deletions, Modifications, Rearrangement of Topics (Insertions,
Deletion, Substitution, and Frameshift if you like Genetics)
6. In addition to the above You can also Copy Edit (ie Correct the Grammar) or Proof Read (ie
Correct the Typos)
7. You can send in your Contributions by WhatsApp +91 99406 26911 (Click this link to send the
message https://wa.me/919940626911) or or by mail to mail@taeionline.com mentioning
the Version Number (Version Number of this draft is α.3.1) and Page Number (found in the top
right)
 - 11 -

Table of Contents
i. Half title page (page i]
ii. Blank (page ii) Section I : Tamil Nadu Accident
iii. Full Title page (page iii)
and Emergency Care Policy
iv. Copyright (page iv)
v. Dedication (page v) Policy
vi. Blank (page vi) 1. Need for TAEI
vii. Epigraph (Page vii) 2. Introduction to TAEI
viii. Blank (page viii) 3. Aims and Objectives of TAEI
ix. Table of contents 4. Stages in Patient Care and TAEI Process
x. List of Protocols & Management Flow Chart
Algorithms 5. Pillars of TAEI
xi. List of Illustrations & List of tables 6. Building Blocks of TAEI
xii. List of Protocols for Display 7. Administrative Frame Work of TAEI
xiii. List of Tables 8. List of TAEI Centres
xiv. List of Infographics 9. Policy for Protocols in TAEI
xv. List of Images 10. Policy for Human Resource in TAEI
xvi. List of Abbreviations Centres
xvii. List of Contributors 11. Policy for Capacity Building (Training)
xviii. How to Use this Manual 12. Policy for Building and Civil Works in
xix. Foreword TAEI Centres
xx. Preface 13. Policy for Equipments in TAEI Centres
14. Policy for Consumables in TAEI Centres
15. Policy for Drugs in TAEI Centres
16. Policy for Electronic and Paper Record
Maintenance in TAEI Centres
17. Policy for Universal Precautions
18. Policy for Rehabilitation
19. Policy for Mass Casualty and Disaster
Management in TAEI
20. Policy for Quality fo Care, Monitoring &
Evaluation in TAEI
21. Policy for Research in TAEI
22. Policy for Linkages to Safe Systems
Approach (eg Road Safety) in TAEI
23. Health Care Finance for TAEI
Knowledge Bases
24. A Brief History of TAEI (Till Date)
25. Inter Department, National and
International Collaborations in TAEI
26. Studies undertaken till now in TAEI
 - 12 -
Section II: General TAEI 41. Code Blue Poison
42. Code Blue Burns
Protocols 43. Disaster Triage / Disaster Management
(Mass Casualty Management)
Pre Hospital
ER Care
PH.1 Call
Protocols
PH.2 Reach 44. Protocols for Buildings and Civil Works in
Emergency Department
PH.3 Transit 45. Protocols for Equipments in Emergency
Department
46. Protocols for Consumables in Emergency
Department
Incidence 47. Protocols for Drugs in Emergency
Knowledge Bases Department
27. Incidence and Importance of Time 48. Protocols for Stationary and Records in
Protocols Emergency Department
28. Protocols for Transit 49. Protocols for Human Resource Allocation
29. TAEI Case Sheet in Emergency Department
30. Position during Transit 50. Protocols for Shift Procedures &
Handover in Emergency Department
Transfer 51. Protocols for Training for Emergency
Department Health Care Workers
RE.1 Referral 52. Protocols for Emergency Room
Protocols Monitoring & Evaluation in Department
31. Protocols for Inter Hospital Transfer of Knoweldge Base
patients for Referral from one hospital to 53. Team Concept in ER
another
32. Protocol for Inter Hospital Shifting of ER.1 Triage
Patients for Opinions and Investigations Protocols
54. Triage
RE.2 Intra Hospital Transfer
Protocol ER.2 Primary Survey
33. Protocols for Intra Hospital Transfer of Protocols
for Take Over 55. 30 Second Quick Primary Survey (QPS)
34. Protocols for Intra Hospital Shifting of for a Conscious Patient
patients for Opinions and Investigations 56. BLS for an Unconscious Patient
Knowledge Bases
Hospital Emergency Codes 57. Primary Survey & Initial Assessment and
Management of Polytrauma
HE.1 Pre Intimation to Hospital and
Hospital Preparation Airway
Protocols Protocol
35. Protocols for Pre Arrival Intimation 58. Airway Management Protocol
Knowledge bases 59. Choking
36. Golden Hour a. Adult
37. Hospital Emergency Codes b. Paediatric
Protocols c. Infant
38. Code Blue Brain 60. Asthma
39. Code Blue Heart
40. Code Blue Abdomen
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Breathing 87. Combi Tubes / Esophageal Tracheal
Protocol Airway
61. No Breathing, Irregular Breathing, Rapid 88. Intubation
Breathing 89. RSI
62. Anaphylaxis 90. Needle and Surgical Cricho
91. Tracheostomy
Circulation 92. Nebulisation
Protocol
Breathing
63. Assessment of Shock
64. Assessment of “Chest Pain” - Acute Protocol
Coronary Syndrome 93. Nasal Prongs
65. eFast 94. Simple Face Mask
66. Compartmental Syndrome 95. Venturi Mark
Knowledge Base 96. Non Re breathing Mask
67. Reading of ECG 97. Ventilator
a. For Airway Obstruction
Disability b. For Lung
Protocol
68. AVPU Score Procedures
69. Glasgow Coma Scale (GCS) 98. Ambu Bag
70. Paediatric Glasgow Coma Scale 99. Single Hand and Double Hand EC
71. Pupils Technique
72. Reflexes 100. Needle Decompression
73. Neurological Examination 101. ICD

Environment Knowledgebase
102. Ventilator Management in
Protocols
Emergency
74. Hyperthermia
103. ETCO2
75. Heat Stroke
Procedures
76. Log Rolling and Pelvic Binder Circulation
ER.3 Resuscitation Protocol
104. Cardiac Arrest
Protocols 105. Pregnancy Cardiac Arrest
77. Management of Pain 106. Paediatric Cardiac Arrest
107. Management of Shock
Airway
108. Bleeding and Hypovolemia,
Protocols Management of Shock : Fluid
78. Basics and Advanced Airways Resuscitation, Hemorrhagic Control
Procedures 109. “Chest Pain” - Acute Coronary
79. Manual Inline Stabilisation Syndrome
80. Cervical Spine Stabilisation 110. ACS for STEMI and NSTEMI
81. Helmet Removal 111. Return of Spontaneous Circulation
82. Head Tilt - Chin Lift - Jaw Thrust – Adult
83. Suction 112. Return of Spontaneous Circulation
84. NPA – Paediatric
85. OPA 113. Tachy cardia & Brady Cardia
86. Supraglottic Devices Protocol – Adult
a. LMA 114. Tachy Cardia & Brady Cardia
b. Igel Insertion Protocol – Paediatric
Procedures
 - 14 -
115. CPR and “DC Shock” – BLS and b. Chemical Injuries / Burns
AED Defibrillation c. Electrical Injuries / Burns
116. Advanced Cardiac Life Support : 141.
Synchronised Electrical Cardioversion Procedures
117. “Venflons” and “Butterflies” - 142.
Peripheral Intravenous Cannula Insertion
118. “Central Line” aka (Subclavian, Environment
Jugular, Femoral) Central Venous Access Protocol
119. Intraosseous Access 143. Adult Hypoglycemia Protocol
120. Pericardiocentesis Procedures
121. 3 way occlusive dressing in Open 144. Gastric Lavage
Injuries
122. Pelvic Binder Application ER.4 AR Entry
123. Direct Compression Technique Protocol
145. eMLC
Disability
Protocol ER.5 Secondary Survey
124. Management of Agitated Patients Protocol
125. Adult Seizures 146. Secondary Survey
126. Paediatric Seizures 147. AIS
127. Stroke Protocol 148. ISS
128. Head Injury Protocol (Mild 149. MHIPS
Moderate Severe) 150.
129. Spinal Injury
130. Facio Maxillary Injury ER.6 Investigations
131. Protocol for Hanging and
Mechanical Asphyxia Protocol
132. Protocol for Drowing 151. Biochemistry
133. Thoracic Injuries 152. Pathology
a. Tension Pneumothorax 153. X Rays
b. Cardiac Tamponade 154. eFAST
c. Hemothorax 155. USG
d. Flail Chest 156. CT
e. Open Pneumothorax 157. MRI
f. Tracheobronchial Tree
g. Blunt Cardiac Injuries ER.7 Specialist Opinion
i. Myocarditis Protocol
h. Traumatic Diaphramatic Rupture 158. Anaesthesiologist Opinion
i. Blunt Esophageal Injury 159. Neurosurgeon Opinion
j. Subcutaneous Emphysema 160. Neurologist Opinion
k. Pulmonary Contusion 161. Cardiologist Opinion
l. Rib Fracture 162. General Physician Opinion
134. Abdominal Injuries 163. General Surgeon Opinion
135. Pelvic Injuries 164. Obstetrician Opinion
136. Extremities 165. Paediatrician Opinion
a. Upper Limb 166. Ophthalmologist Opinion
b. Lower Limb 167. ENT Surgeon Opinion
137. Paediatric Trauma 168. Plastic Surgeon Opinion
138. Trauma in Pregnancy 169. Vascular Surgeon Opinion
139. Trauma in Old Age
140. Burns ER.8 Monitoring and Re evaluation
a. Thermal Injuries / Burns Protocol
 - 15 -
170. Criteria for Monitoring Care Post Discharge
Protocol
Hospital Care
187. Protocols for Care Post Discharge
Protocol
171. Change from ER To Departments : PD.1.a Follow Up
Handover Protocols
Protocol
188. Protocols related to Follow Up
HC.1 Emergency Intervention
Protocol PD.1.b Post Mortem
172. Protocols for Emergency
Protocol
Intervention
189. Protocols related to Death
173. Craniotomy Protcol
190. When Dead Patient has no
Relatives
HC.2 Elective Intervention
Protocol PD.2 Completion
174. Protocols for Elective Intervention
Protocol
191. Protocols related to Completion of
HC.3 PACU Care
Treatment
Protocol
175. Protocols for PACU Care Administrative Follow Up
HC.4 ICU Care Protocol
192. Protocols for Administrative
Protocol
Follow Up
176. Protocols for ICU Care
AD.1 Critical Case Review
HC.5 Post Op Care
Protocol
Protocol
193. Protocols for Critical Case Review
177. Protocols for Post Op Care

HC.6 Ward Care Section III: Specific TAEI

Protocol Protocols
178. Protocols for Care in Ward
STEMI & NSTEMI
HC.7 Physiotherapy Protocol
Protocol 194. STEMI
179. Protocols related to Physiotherapy
180. Protocols related to Speech SCRIPT (Stroke)
Therapy Protocol
181. 195. SCRIPT

HC.8 Outcome Snake Bite

Protocol Protocol
182. Protocols related to Discharge 196. Snake Bite
Knowledge Bases
183. Glasgow Outcome Scale (GOS) Scorpion Sting
184. Karnofsky Performance Status Protocol
Scale 197. Scorpion Sting
185. Japanese Orthopedic Association
Score (JOA) Management Poisoning
186. Protocol
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198. Poison PREM (Paediatric Emergency)
Protocol
Burns 200. PREM
Protocol
199. BURNS

(End of Table of Contents)

x. List of Protocols & Management Algorithms

xi. List of Illustrations & List of tables
xii. List of Protocols for Display
xiii. Abbreviations
xiv. List of Contributors
xv. How to Use this Manual
xvi. Foreword
xvii. Preface
 - 17 -

List of Protocols for Display

1) TAEI Patient Flow Chart
2) Triage Criteria
3) Referral Flow Chart
4) QPS
5) AHA’s Adult Cardiac Arrest Arrest Algorithm (2015
Update) for BLS
6)
7)
8)
9)
10)
11)
12)
13) Head Injury
14) Facial Injury
15) Cervical Spine Injury
16) Blunt Injury Abdomen
17) Stab Injury
18)
19)
20)
21)
22)
23)
24)
25)
26)
27)
28)
29)
30)
31)
 - 18 -

List of Tables
Table Source Details Cross Used in
Number Reference
1 from QoERM Stages in Patient Care Infographic 1
2 from QoERM Primary Survey TAEI Case
Sheet
Primary Survey
3 from QoERM Check List after TAEI Case
Triage Sheet
Triage
4 from QoERM Check List for past TAEI Case
History Sheet
Primary Survey
5 from QoERM Investigations Check TAEI Case
List Sheet
Investigations
6 from QoERM Instructions Check TAEI Case
List Sheet
Secondary
Survey
7 from QoERM Check List for TAEI Case
Surgery Sheet

8 from QoERM Triage Criteria TAEI Case

Sheet
Triage
9 Made for this Hospital Emergency PAI
Book Codes
 - 19 -

List of Infographics
Infographic Source Details Cross Used in
Number Reference
1 from Stages in Table 1 1. Stages in Patient
QoERM Patient Care Care
2. TAEI Case
Sheet
 - 20 -

List of Images
Image Number Source Details Cross Reference Used in
 - 21 -

List of Abbreviations

Abbreviation Full Form

DTNC Duty Trauma Nurse Coordinator
HTNC Hospital Trauma Nurse Coordinator
RMO Resident Medical Officer
ARMO Assistant Resident Medical Officer
KBW Kilogram Body Weight

List of Abbreviations
 - 23 -

Foreword -
 - 24 -

Editors
1. Dr.Darez Ahamed, M.B.,B.S., I.A.S.,
2. Dr.J.Mariano Anto Bruno Mascarenhas, M.B.,B.S., M.Ch., (Neurosurgery)
3. Dr.J.Kathirvel, M.B.,B.S., M.P.H.,
4. Dr.Arthur Amit Suryakumar, M.B.,B.S.,
5. Mrs.J.JeyaLydia Wester, B.Sc., (Nursing) M.P.H.,
6. Dr.Tijo George, B.D.S., M.P.H.,
7. Dr.M.Manikandan, B.P.T., M.Sc., (Emergency & Critical Care)
 - 25 -

Preface How to Use this Manual

This Book has three Sections.

Section I gives an Overview of the Tamil Nadu Accident and Emergency Care Initiative.
In this Section, we see the need for a separate Accident and Emergency Department at
Institution Level as well as the need for a vertical programme to monitor these
departments.

This Section also includes the Operational Guidelines as well as the Monitoring and
Evaluation Mechanisms at State, District and Hospital Level.

Section II describes the Various Stages in Treatment of an Accident (or Emergency)

Patient and the Protocols / Guidelines / Instructions / Checklists at each stage. General
Guidelines to be followed for any patient who needs Emergency Care in included in this
Section. Guidelines Regarding Rehabilitation are also included
Guidelines for Setting up of an Emergency Room (ER) are included in this Section

Section III
Deals with Guidelines / Protocols / Instructions / Checklists for Specific Conditions
like
1. Accidents
2. Chest Pain
3. Cerebrovascular Accidents (Stroke)
4. Snake Bite, Scorpion Sting
5. Poisons
6. Emergencies in Paediatric Patients

1. The Book will have Sections, Sub Sections and if needed Sub-Sub-Sections
2. Each Section, Sub Section will have individual Chapters
3. Each Chapter can be a (a) Protocol or (b) Procedure or (c) Knowledgebase

All Protocols will be in similar format

It will have
(a) the Protocol (Table or Flow Chart) and then
(b) Key Points in the Protocol
(c) Points for Doctors and
(d) Points for Nurses and
(e) Instructions for Trainers

All Procedures will be in Similar Format

It will have
(a) List of Equipments needed for the Procedure
(b) List of Consumables Needed for the procedure
(c) List of Drugs Needed for the procedure
(d) Step by Step Break Up of the Procedure - with details of Equipments, Consumables
and Drugs needed for each step
(e) Instructions for Trainers

All KnowledgeBase Chapters will be in Similar Format

 - 26 -

The Order of Chapters will be same as the Order of Treatment (TAEI Flow Chart)

In Short
1. This is designed to give concise information for Administrators, Medical
practitioners and Paramedical Staff and not intended to provide
comprehensive scientific information
2. Standard Text Books, Reference Books, Original articles, Review papers, Case
reports, Related publications, Websites etc are recommended for further reading.
3. Please Use Pharmacology Books, Information from Manufacturers, Your
Memory, Your Experience before prescribing or administering a drug. Check the
Expiry Date Once, Dose Twice and Contraindications Thrice before
administration
4. The hand book has been revised as on June 2018
5. The publisher (Commissioner of Trauma Care), Health and Family Welfare
Department, the contributors and reviewers do not assume liability for any injury
and / or any damage to persons or property arising out of this publication
Readers are requested to submit their suggestions, views, feed back to
mail@taeionline.com which will be helpful for modifying / revising future editions.
 - 27 -

Section 1
Tamil Nadu Accident and
Emergency Care Policy
 - 29 -
Tamil Nadu has been the Role Model for
Various states in implementing a robust and
efficient health care setup. The State is also
known for introducing various pro people
scheme and implementing them successfully.
Following the tremendous success in reducing
mortality and morbidity, such schemes have
been later adopted by other states as well the
centre. Use of TNMSC in Drug Procurement,
CEmONC Centres, Cadaver Organ Transplant
Programme, SNCU for few such schemes.
Efficient and Effective Public Health
System has reduced infectious diseases and now
the predominant cause of mortality and
morbidity is Non Communicable Diseases.
The Burden of RTA in Tamil Nadu:
The State of Tamil Nadu is the seventh
most populous and highly urbanized in the
country with 14,257 km of National and State
highways. In 2016, the State accounted for
17,311 deaths due to Road Traffic Injury (RTI)
which is 12% higher when compared to 2015. In
the country the State constitutes to a share of
15.9% injuries and 10.7% deaths (MoRTH,
2015). As per the Global Disease Burden report
20171, the DALY’s lost due to Injuries is 13.5 %
(Unintentional injuries, Self harm and
Interpersonal Violence and Transport Injuries).
Chapter 01
Need for TAEI
RTA has been an overwhelming Public health
challenge of the era disproportionately killing
and maiming many in the economically
productive age group. It results in serious
physical, mental and psycho-social impairment,
bringing huge catastrophic expense to the
family, crashing down its peace and security.
Other Non Communicable diseases are
also increasing in incidence due effective
management of communicable diseases as well
as due to the changing socio economic profile of
the state
Because of the increasing incidence of
Accidents, Infarctions, Cerebro Vascular
Accidents (Stroke), Accidental and Deliberate
(Self Harm) Poisoning and Burns along with
increased prevalence of those with residual
morbidity due to these conditions, it is
imperative to pay more and focused attention to
these conditions. Hence there is need of a
dedicated programme aimed at addressing these
conditions at all (Primordial, Primay, Secondary,
Tertiary and Quarternary) levels of health care.
Hence Tamil Nadu Accident and
Emergency Care Initiative (TAEI) has been
conceptualised and created
- 30 -
- 31 -
- 32 -
 - 33 -
As discussed in the previous chapter,
Sensing the shift in the disease pattern,
government of Tamil Nadu has proactively
Formed “Tamil Nadu Accident and Emergency
Care Initiative” (TAEI) for enabling various
public hospitals across the state to effectively
manage the emergency conditions.
In Tamil Nadu, the Road Traffic Injury’s
have been increasing exponentially for which the
Government of Tamil Nadu has been
meticulously taking several steps to reduce the
fatality due to RTA by strengthening the Pre-
hospital, In hospital and Rehabilitative care
under the, “Tamil Nadu Accident and Emergency
Chapter 02
Introduction to TAEI
Care Initiative (TAEI)”, as step in this direction
,the Government has designated vide G.O (MS)
No.231 Dated 22.06.2017 Mission Director,
NHM as the ex-officio Commissioner of Trauma
Care and permission has been accorded to
implement the trauma care network in the name
of “Tamil Nadu Accident and Emergency care
Initiative(TAEI)”. A logo and tagline (Saving
Lives is Our Mission) has been designed and
approved for this Mission.
The Mission Director of National Health
Mission, Tamil Nadu has been designated as Ex
Officio Commissioner of Trauma Care
- 34 -
- 35 -
 - 37 -
Aims and Objectives of TAEI
The Various Aims of TAEI are
1. To Initiate and Maintain and Health
Care Setup to provide Comprehensive
Service to All Medical and Surgical
Emergencies aimed at Reducing the
Mortality and Morbidity
2. To Develop and Implement Protocols
for Uniform and High Quality Care in
Emergency Departments across All
Hospitals
3. To Develop and Implement Protocols
for effective Management to Reduce
Mortality and Morbidity associated
with Non Communicable Diseases,
especially (1) Accidents and Trauma
(2) Myocardial Infarction (3) Cerebro
Vascular Accidents (Strokes), (4)
Burns (5) Poisoning (6) Paediatric
Emergencies
4. To Provide the above services
a. based on Clinical Needs for all
patients
b. with Compassion
c. with highest standards of
excellence and professionalism
d. working across organisational
boundaries and in partnership
with other organisations in the
interest of patients, local
communities and the wider
population
e. in the most effective, fair
manner with sustainable use of
finite resources.
f. being accountable to the
public, communities and
patients
The Various Objectives of TAEI are
1. To attain the SDG Goal: To halve the
number of deaths and injuries from
road traffic accidents by the year 2020
globally.
2. To attain the State Goal: To achieve
halve the number of deaths (8500)
and injuries from road traffic
Chapter 03
accidents by year 2023 in Tamil Nadu
State.
3. To Standardize Managements of All
Medical and Surgical Emergencies
into predefined and distinct stages
and to have specific and clear
protocols for management in each
stage
4. To Triage Patients into Red, yellow
and Green Categories and to institute
appropriate management
5. To ensure definitive treatment for the
injured within the Golden Hour and to
have “Time Norms” for procedures in
the Emergency Department
6. To Start the Process of Rehabilitation
as early as possible
7. To identify and designate TAEI
Centres on the basis of need
(caseload) and location (national
highways, Connecting two capital
cities, Connecting major cities other
than capital city, Connecting ports to
capital city, Connecting industrial
townships with capital city etc) as
Level-1, Level-2, Level-3 centres with
Assured Care in Each Centre based on
the level
8. To Augment the Hard (Civil Works,
Equipments, Consumables, Drugs)
and Soft (Human Resources- New
Posts as well as Filling Vacancies,
Training) Infrastructure in these
centres as per need and
implementation of Standard
Operating Procedures in these centres
9. To install the Basic Life Support
Ambulances Level -IV on an evidence
based approach along the Highways
and Advanced Life Support
Ambulance at Trauma Care Facilities
for inter facility transfer and expand
the ECC facilities provided already to
all high accident density areas.
10. To initiate the development of a state-
wide referral network with both
public and private hospitals through
empanelment of CMCHIS Insurance
 - 38 -
Scheme with forward and backward 12. To converge and co-ordinate with
linkages. engineering, road safety, law
11. To establish “State Trauma enforcement and Transport
Surveillance Centre” with real time departments.
reporting of accident & trauma cases 13. To initiate IEC/ BCC activities for
for the Trauma Registry which will educating the public about the risk
provide evidence based decision for factors and to reduce the incidence of
policy formulation on road safety, road traffic accidental injuries and
injury preventive interventions with spread awareness regarding injury
component for improving of quality prevention and road safety.
care and better out comes and
rational utilization of resources and
Continuous physical & financial
monitoring of the programme.

(End of Chapter)
- 39 -
Chapter 04
Stages in Patient
Care & TAEI Process
Flowchart
TAEI introduces few key concepts
and paradigm shifts in patient care in Tamil
Nadu Medical Services.
1. Patient Care has been
Demarcated into various clearly
defined stages and Steps
2. Time Norms are Fixed for Each
Stage and Each Step
3. Easy to Implement Protocols and
Guidelines for Common
Conditions and Common
Procedures in Emergency
Department have been
formulated
4. Check Lists to help Health Care
Workers are being used
5. Department of Emergency
Medicine
6. Concept of Emergency Rooms
7. Concept of Triage
8. Resuscitation bay
9. eMLC
10. TAEI Number & TAEI Case
Sheet
11. Trauma Registry
12. Rehabilitation

Stages in Patient Care

The Entire TimeLine From the
moment of “Incident” (more about the
Incident in a subsequent chapter) to
Discharge of the patient from the Hospital
after completion of treatment can be divided
into various stages. These stages are for ease
of understanding and are not discrete events.
They overlap each other and happen
simultaneously and the patient receives care
in continuum. For Example, Triage and
Primary Survey overlap. Primary Survey and
Resuscitation happen together. It is again
emphasised that the care the patient receives
is in continuum.
 - 40 -
Code Stage Description
Onset IN.1 Incident The Onset of Emergency
IN.2 First Responder Care By Standers doing First Aid
Pre Hospital PH.1 Call Patient or Relative Calling 108
PH.2 Reach From Call to Picking Up the Patient by 108
Ambulance
PH.3 Transit Picking Up the Patient by 108 Ambulance to
Reception in TAEI Care Centre
Transfer RE.1 Referral Referral Out from One Hospital to Referral In to
Next Hospital
RE.2 Intra Hospital Transfer Transfer of Patients from One Ward to Another
Hospital HE.1 Pre Intimation to Hospital Hospital Being Ready to Immediately Start Treatment
Emergency Codes and Hospital Preparation
ER Care ER.1 Triage Red, Yellow or Green
ER.2 Primary Survey Check ABCDE
ER.3 Resuscitation Manage ABCDE
ER.4 AR Entry AR Entry / eMLC
ER.5 Secondary Survey Detailed Examination
ER.6 Investigations Imaging and Blood Investigations
ER.7 Specialist Opinion Opinion and Management if needed
ER.8 Monitoring and Re Continuous post resuscitation monitoring and re
evaluation evaluation
Hospital Care HC.1 Emergency Intervention Emergency Surgery / Thrombolysis / Angio/ to
Shifting to MDCCU / ICCU / PICU / SNCU /
IMCU / SICU Wards
HC.2 Elective Intervention Elective Surgery
HC.3 PACU Care PACU
HC.4 ICU Care ICU
HC.5 Post Op Care Post Op Ward
HC.6 Ward Care Ward
HC.7 Rehabilitation Physiotherapy, Speech Therapy
HC.8 Outcome Discharge / Death
Care Post PD.1.a Follow Up Following Discharge
Discharge PD.1.b Post Mortem Following Death
PD.2 Completion Released to Primary Care
Administrative AD.1 Critical Case Review To Modify the Protocols and to Improve the Patient
Follow Up Care

Time Norms for Hospital Services

In addition to being Money elsewhere, Time
is Muscle in heart and Neuron in Brain. The
Outcome of a Thrombolysis does not depend only on
the efficacy of the drug. It also depends on how
quickly circulation is restored to the heart. The
Outcome following Evacuation of an extradural
hematoma does not only depend on the Skill of the
neurosurgeon, but also on how quickly it has been
done. In addition to “what to do” , “who to do” and
“how to do” we also need to know “when to do”. It
is in finding answers to this last question, we come
across the concept of Time Norms.
Time Norms are commonly used in almost all
fields. They are used by many departments and
individual doctors in an informal manner.
Codification of few “Time Norms” in Emergency
Department and making them part of a protocol is
yet another initiative of TAEI, which is likely to be
adopted by all departments in future. For those who
find this odd or difficult to understand may please
imagine the board like the one here which would be
seen in all banks. Just like how a bank assures certain
services in certain time span, we need to complete
certain procedures within stipulated time. However, it
is being stressed that hospital resources are finite and
 - 41 -
limited. In cases more than one patient is being
received at the same time, it may not be able to follow
these norms. These norms are for guiding the health
care provider. If the time limit could not be adhered
to due to various factors, it does not constitute
negligence and these time norms cannot be used as a
criteria to evaluate Negligence or Deficiency of Care.
For Example the norms here state that Emergency
Decompression has to be started within 45 minutes
of receiving the patient. However, if the Surgeon is
already operating on another patient or engaged in
some other live saving work, it is obvious that surgery
for this patient who has now come will be delayed.
This does not constitute a medical negligence.
A patient is expected to be in the Emergency
Department for 6 hours and hence the norms are
fixed for few activities

Door Door Time Steps to be completed

Time in in Minutes
Hours
2 1. Triage
Sorting the Patient into Red, Yellow, Green Criteria should be completed within 2
minutes of Receiving the Patient.
Red and Yellow Patients have to be taken to the Resuscitation Bay as per need.
Green Patients Taken to Green Area and managed accordingly.
4 1. Quick Primary Survey for Red and Yellow Patients
(Quick Primary Survey is explained in Detail in subsequent chapters)
8 1. Resuscitation for Red and Yellow Patients Resuscitation involves Management to
Maintain ABCDE.
2. Primary Survey and Resuscitation are done simultaneously for Red and Yellow
Patients for whom the following as to be done Within 8 minutes of Patient
entering the Hospital Premises (2 minutes + 6 Minutes)
• Airway : Suction / ET / Tracheostomy
• Breathing : Ambu / Ventilator
• Circulation : Peripheral IV Line / Central Line + Draw Blood for
Investigations
• Disability : Cervical Collar / Spine Board
• Exposure : Remove Source of Poison / Maintain Temperature
15 1. Complete eFAST and Mobile X Ray for Red and Yellow Patients
2. Dispatch to Lab all Samples Collected from Red and Yellow Patients
3. Complete Catheterisation, ICD if Needed
4. Start Thrombolysis if Indicated
5. Shift to CT if Indicated
30 1. Complete AR Entry. Please note that as per TAEI Protocol AR Entry follows
Resuscitation
2. Closed Reductions to be completed
3. Complete CT If Indicated
4. Shift to MRI if Indicated

45 Emergency Decompression
Cath Lab Procedures
Complete Secondary Survey
1 60 Complete Treatment for Green Patients
Complete Spine MRI if Indicated
2 120 Complete Specialist Opinion
3 180 Spine Fixation in Case of Instability
6 360 Shift Patient from ER to Respective Departments, if Indicated
 - 42 -
Easy to Implement Protocols and Guidelines for
Common Conditions and Common Procedures
in Emergency Department have been formulated
The next innovation under TAEI is the use of
Protocols and Guidelines for Common Conditions
and Procedures in Emergency Department. Major
part of this book is devoted to this
Check Lists to help Health Care Workers are
being used
Check Lists at various stages along with innovative
case sheets are aimed at reducing the work load of the
health care workers. The check lists will be explained
in corresponding chapters
Emergency Department
Emergency Department will be started in all
institutions
Concept of Emergency Rooms
Casualty, Zero Delay Ward, Triage Wards will all be
merged into a Single ER. The ER will have Triage
Area, Resuscitation Bay, Red, Green and Yellow
Zone
Concept of Triage
Concept of Triage will be introduced in TAEI to
evaluate the patient based on Standard Criteria and to
optimally use the resources to deliver quality of care.
ERs will have Triage Area
Resuscitation Bay
Resuscitation bay will be setup in All Institutions.
Patients who are sorted under Red and Yellow
Criteria will be received in Resuscitation Bays and
managed as per Protocols
e Registration of Medico Legal Cases
AR Entry will be made ONLY AFTER
RESUSCITATION. Web Based Interface will be
provided for AR Entries and the Printed Forms can
be signed and filed
TAEI Number & Trauma Case Sheet:
Each Admission will be given an unique TAEI
Number and there will be an eight Page Case Sheet.
This Case Sheet will follow the patient from
institution to institution. Entries will be made in this
case sheet with a carbon copy in the hospital case
sheet. This will serve as referral form and hence the
time delay in preparing discharge summary will be
avoided
Trauma Registry
A comprehensive Trauma Registry will be setup
Rehabilitation
Rehabilitation will be started as soon as possible and
not after discharge
Branding
This initiative aims to establish and strengthen the
Hub and spoke model of Trauma care under the
name– Tamil Nadu Accident and Emergency Care
Initiative (TAEI). It is proposed to brand all the
centres with a logo and tagline “Saving Lives is Our
Mission”
Color Coding
The Emergency Room will be Color coded as RED,
YELLOW, GREEN based on the nature of the
emergency. Color codes will be the first step in triage.
It is proposed to set up Standard Emergency room,
workflow mechanism in the Trauma care facility.
Standard Protocols and Emergency Manuals for
Trauma Care Management:
The TAEI proposes to use the Advanced Trauma
Life Support (ATLS) protocol which is an
internationally accepted protocol in emergency care.
Emergency Room Manual will be developed to
ensure uniformity in care given in emergency rooms
across the State.
Hospital Emergency Codes and Call Outs:
These have been dealt in detail already.
TAEI Number & Trauma Case Sheet:
Each Admission will be given an unique TAEI
Number and there will be an eight Page Case Sheet.
This Case Sheet will follow the patient from
institution to institution. Entries will be made in this
case sheet with a carbon copy in the hospital case
sheet. This will serve as referral form and hence the
time delay in preparing discharge summary will be
avoided
Training:
Training and Capacity building of the Medical,
paramedical and other support staff in the hospitals is
proposed. The personnel will be trained in Advanced
Trauma Life Support (ATLS) Training protocol
uniformly across all Trauma care centers for doctors
and Advanced Trauma Care for Nurses (ATCN).
Technical Support
The technical support and knowledge exchange is
proposed between AIIMS which is the APEX Level
I centre in the country and the Trauma care centers in
our State. It is also proposed as part of the technical
 - 43 -
support to sign an MOU with AIIMS after finalizing
the modalities.
MIS
It is proposed to develop an Management and
Information System (MIS ) in Emergency Room. It is
also proposed to install Display Boards (electronic /
Hand Written) mentioning the status of the patient,
treatment plan and the completion status of the
recommended diagnostics and investigations to
minimize apprehension among the patient relatives
and thus enhance care and service delivery.
It is also proposed to generate unique ID by
integrating the Emergency Room admission MIS with
the CMCHIS software platform Remedinet.
e Registration of Medico Legal Cases
It is proposed to develop software in coordination
with NIC for registering medico legal cases
Monitoring and Evaluation:
It is proposed to measure tangible outcomes of
Trauma care services based on the data collected
from all the centres. The Trauma care registry and the
Injury Surveillance Centre will be responsible for
(End of Chapter)
collection, analysis and providing feed back to the
Centres for necessary improvements. The Indicators
are given in Annexure VI
Rehabilitation:
Is an integral part in trauma care as it is estimated that
nearly 100% of the RTA casualties with severe
injuries, 50% of those with moderate injuries and 10-
20% of those with mild injuries carry disabilities of
physical and psychological nature requiring long term
rehabilitation (Gururaj,2000) Hence good
rehabilitative services need to ensured at all levels of
care.
Under TAEI, comprehensive Medical and
Psychological rehabilitation program will be
developed
Base line and Research studies
It is proposed to conduct base line study for the pilot
project. Scope of work and TOR will be developed
and suitable agencies will be engaged as per the
procurement procedures.
 - 45 -
Chapter 05
Pillars of TAEI
As discussed earlier, Tamil Nadu Accident and Emergency Care Initiative rests on the following 6 pillars,
namely
1. Trauma Care
i. ACUTE SPINAL CORD AND BRAIN INJURY MANAGEMENT CAPABILITY
ii. The trauma center shall have written policies and procedures for triage, assessment,
stabilization, emergency treatment, and transfer (either into or out of the facility) for brain
or spinal cord injured patients. Policies and procedures shall also be written regarding in-
hospital management, including rehabilitation, and the implementation of the preventive
ulcer program, for brain or spinal cord injured patients.
2. Management of Acute Myocardial Infarction (STEMI and NSTEMI)
3. Management of Stroke with SCRIPT
4. Management of Burns
i. Most burn injuries are relatively minor and patients are discharged following outpatient
treatment at the facility where they are first seen. Some burns, however, are serious
enough to require hospitalization, either through direct admission or by referral to
hospitals with special burn treatment capabilities.
ii. The trauma center shall have written policies and procedures for triage, assessment,
stabilization, emergency treatment, and transfer (either into or out of the facility) of burn
patients. Policies and procedures shall also be written regarding in-hospital management,
including rehabilitation, of burn patients.
iii. A. The trauma center is capable of providing specialized care, dedicated beds, and
supplies or equipment appropriate for the care of a patient with major or significant
iv. B. If the trauma center is not capable of providing specialized care, dedicated beds,
and supplies or equipment appropriate for the care of a patient with major or significant
burns, the facility shall have a written transfer agreement with such a facility. The trauma
center shall also have written medical transfer policies and protocols to ensure the timely
and safe transfer of the burn patient.
5. Management of Poisoning
i. STANDARD XI -- ACUTE HEMODIALYSIS CAPABILITY
ii. Acute hemodialysis capability shall be available for trauma patients 24 hours a day.
6. Management of Paediatric Emergencies with PREM
i. PEDIATRIC INTENSIVE CARE UNIT (PICU)
ii.
iii. The critically ill trauma patient requires continuous and intensive multidisciplinary
assessment and intervention to restore stability, prevent complications, and achieve and
maintain optimal outcomes. The trauma service that assumes initial responsibility for the
care of an injured patient should maintain that responsibility as long as the patient remains
critically ill.
iv.
v. A. The adult ICU must be separate and distinct from the PICU.
vi. B. Adult ICU
vii. 1. Physician Requirements
viii. a. The trauma medical director or trauma surgeon designee is responsible for adult
trauma patient care in the ICU.
ix. b. An attending trauma surgeon may transfer primary responsibility for a stable adult
patient with a single-system injury (for example, neurological) from the trauma service if it
is mutually acceptable to the attending trauma surgeon and the surgical specialist of the
accepting service.
x. 2. Nursing Requirements
 - 46 -
xi. a. The ratio of nurses to trauma patients in the ICU shall be a minimum of 1:1.
xii. b. The ICU nursing staff shall satisfy all initial and recurring training requirements,
xiii. C. Pediatric ICU
xiv. 1. Physician Requirements
xv. a. The trauma medical director or trauma surgeon designee is responsible for
pediatric trauma patient care in the PICU.
xvi. b. The trauma center shall track by way of the trauma registry all pediatric trauma
patients, whether under the primary responsibility of the trauma service or of another
surgical or non-surgical service, through the quality management process to evaluate the
care provided by all health care disciplines.
xvii. 2. Nursing Requirements
xviii. a. The ratio of nurses to trauma patients in the PICU shall be a minimum of 1:1.
xix. b. The PICU nursing staff shall satisfy all initial and recurring training requirements, as
listed in Standard VIII, in the time frames provided.
xx. D. Nursing documentation in the ICU and PICU shall be on a 24-hour patient flow
sheet.
xxi. E. There shall be immediate access to clinical laboratory services.

Six Pillars
1. Trauma
2. MI
3. Stroke
4. Burns
5. Poison
6. PREM

Integration of All Six Pillars in ED

• ER
i. Resuscitation Bay
1. Mobile X Ray
2. eFast
ii. Stat Labs
iii. Police Out Post
iv. Room
v. Minor OT
vi. Procedure Room
• EOT
• MDCCU
• CT & MRI & X Ray
• Cath Labs
• Blood Bank
- 47 -
 - 49 -
Chapter 06
Building Blocks of TAEI
Building Blocks of TAEI
1. Protocols
2. Human Resources
3. Capacity Building (Training)
4. Electronic and Paper Record Maintenance
5. Rehabilitation
6. Quality of Care, Monitoring & Evaluation
7. Research
8. Administrative & Institutional Framework
9. Building
10. Equipments
11. Consumables
12. Drugs
13. Linkage to Safe Systems
14. Health Care Financing
15. Interdepartmental, National and International Collaboration

Building Blocks of TAEI

1. Institutional Framework
2. Building
3. HR
4. Equipments
5. Protocols
6. Capacity Building
7. Monitoring
8. Quality of Care
9. Research
10.
 - 50 -

1. Institutional Frame work

Proper Institutional and Administrative Framework designed at the State, District and Facility level.
At the State level,it is proposed to constitute a TAEI Steering Committee and a TAEI Centre under the
overall supervision of the Mission Director NHM who has been designated as the Ex-officio
Commissioner of Trauma Care.
 - 51 -
Similar Administrative structures at the District level with the District Collector as the Chairman,JDHS as
District Trauma Nodal Officer for TAEI, and Hospital trauma nodal officer (HTNO) effective co-
ordination and service delivery.
2. Human resources
As The TAEI ER ‘s are proposed to function 24*7 , a team concept has been developed with adequate
Emergency medical officer (EMO), Nurses (District Trauma Nurse Co-ordinators, Trauma Nurse Co-
ordinator and Triage Nurse) , Lab technician, Radiographers and support staff like the MNA/FNA,
Hospital worker, OT assistants, Data entry operator and security guard
To ensure sustainability of TAEI ER, on a long run, it is ideal to have Emergency Medicine specialist. Until
the Emergency Physician specialist take up the responsibility of ER, it is proposed to be run by the MBBS
doctors, physicians, surgeons who are interested in Emergency Care. A standard Facility based TAEI Core
team template has been created.
• District Trauma Nodal Officer (JD)
• Dean/Medical Superintendent
• RMO
• District Trauma Nurse Co-ordinator
• Hospital TAEI Nodal Officer (HTNO)
• Nursing Superintendent
• General surgeon
• General Physician
• Orthopaedician
• Paediatrician
• Anesthetist
• Neurosurgeon
• TAEI Medical Officer - 8 - (EMO’s)
• TAEI Nurse Co-ordinator – 2 (TNC)
• TAEI Nurse
• POP Technician
• OT Assistant
• MNA/FNA
• Hospital Worker
• Security Guard
3. Building
Standard building designs TCC have been planned to be developed in the future expansion of various
TAEI centers and proposed to develop prototype designs for emergency rooms
4. Equipment
A Standardized list of equipment required for the ER has been prepared and made mandatory for
establishment of ER.
• AED
• Central Oxygen Supply
• Suction Apparatus
• Ventilator
• Pulsoxymeter
• POTC - Machine (incl Cartridges)
• Volume Infusion Pump
• Syringe Infusion Pump
• Mobile X Ray
• Oxygen Flow Meter And Humidifier
• ECG
• Dressing Trolley
• Stretchers/Multi Functional Stretcher
• Wheel Chair
 - 52 -
• Spine Board
• Scoop Board
• IV Stand
• Traction Splints (Hare, Sager, Thomas Ring)
• Crash Cart
• Camera
• Desktop
• Printer
• Flash Autoclave Machine
• Auto Clave Machine
• Spot Light
• Cell Counter
• EC Pulse (CPR Machine)
• Video Laryngoscope
A standard crash cart checklist has been designed such that nurses maintain the stock inventory in 3
shifts.
5. ER protocol:
The TAEI ER Protocols have been designed such that they are in line with the ATLS/ACLS/PALS protocol
1. ER patient process flow
2. STEMI management protocols
3. NSTEMI management protocols
4. Stroke management protocols
5. Burns management protocols
6. Poison and bites/stings management protocols
6. Capacity Building
Capacity building of doctors and nurses is considered the primary step forward. In the pilot hospitals the
Early Management of Trauma Course designed by CMC Vellore was taken up. After which the following
training programs have been developed:
Doctors Training:
Phase I Training of Trainers (TOT) is being conducted for 2 doctors per TAEI center(Anesthetist/
Physician/ surgeon/ orthopedic an)covering a total of 140 doctors over 5 batches at CMC, Vellore. The
training is proposed for a period of 10 days in 2 spells of 5 days each in Trauma emergencies and
Medical and surgical emergencies respectively. A two day observer ship posting is also a part of this
training module.
Phase II Regional Training is proposed to be conducted at the Regional Training Centers such that 1500
Doctors are trained.
Nurses training:
Phase I Training of Trainers (TOT) was conducted over 5 Batches for 10days at CMC Vellore for 165 Staff
nurses in Emergency Care. Currently, 32 DTNC and 133 TNC have been trained from the TAEI network
hospitals.
Now TAEI identifies 7 Regional training Centers which are Medical College Hospitals, for the Phase II
training. It has been proposed to train 870 TAEI nurses in Emergency care over 10 days from the TAEI
network hospitals.
First responder training:
The support staff comprising of Hospital workers/ stretcher bearers/ security personnel is being
provided at the regional level through EMRI. They will be trained in BLS, First Aid in case of Medical/
trauma and environmental emergencies.
Training for Nursing Assistants and Technicians in ER:
A 2 day training program is proposed to be designed and conducted by EMRI for MNA/FNA/ OT
technicians / POP technicians / X ray Technicians etc in order to impart the emergency management
skills.
Phase II regional level training
 - 53 -

7. Quality of care
TAEI Critical Case Reviews of the RTA deaths and near miss cases in ER will be carried out as per
protocols.
8. Monitoring and evaluation
TAEI App has been designed in collaboration with IIT , Madras, to collect Trauma related data in the 70
Hospitals, of which Medical college hospital are 26 centres and District Headquarters hospitals 44
centres. It is proposed to expand to cover all CMCHIS Hospitals.
The following are the fields collected in the TAEI App.
• Total Trauma
• Total Admitted
• Total RTA
• Total Fall
• Total Assault
• Total Head injury
• Total Surgery
• CT Done
• Blood Transfusion
• Refered out
• Brought by 108
• Ift 108
• Brought dead
• RTA died at Hospital
The definition of all the fields has been given to the 70 centers and daily reporting is ensured. The App
will be a precursor for the development of Trauma Registry for the State.
9. Research
Base line survey has been carried out in 10 institutions (The 5 Pilot hospitals and 5 CONTROL Hospitals)
by NIMHANS to capture the Baseline Indicators.

26.19 Standardization of TAEI Emergency Room services:

In the Emergency room equipping the with Pre hospital Notification, proper system of Triage,
Resuscitation Bay(A- Airway with C- Spine Immobilisation, B- Breathing, C- Circulation, D- Disability E-
Exposure’ concept of Resuscitaion ), Colour coding of ER (RED,GREEN,YELLOW zones)differentiate the
prioritization, ER Process Flow , Standard Treatment guidelines, Adequate Human resources,
Appropriate linkage with Multi Disciplinary Teams, Provision of Equipment , Drugs and consumables
resulting in enhanced quality of Care. As per protocol, Patient stabilization will precede the Accident
Report (AR) entry. GCS Scoring and Injury Severity Scoring System is proposed to be mandatory in all the
TAEI Centers. In addition a standardized Case sheet will be put to use.

Point of care Testing and Focused Ultra-sonography (E-FAST) will be provided for prompt diagnosis in
the emergency room settings.
26.20 Multi Disciplinary Critical Care unit (MDCCU):
As per protocol the patient will be transferred intrahospital from ER and poly trauma cases will be
treated in MDCCU. Hence it is proposed to setup MDCCU in phased manner. For Inter Facility Transfer
(IFT), it is proposed to utilise the Adult Retrieval Vehicle (ARV) which is part of the 108 Ambulance Fleet.
A separate protocol has been developed and it is proposed to upgrade 40 BLS into ALS and will be
manned by advanced paramedics engaged by EMRI.
- 54 -
 - 55 -
Chapter 05.
Administrative Frame Work of TAEI
 - 57 -
Chapter 07
Administrative Frame Work of TAEI

Administrative Structure at State Level

• State Trauma Care Steering Committee (Constitution as per Annexure III)
• State Trauma Surveillance Centre which includes a Centre for Injury Survellience and Trauma
Registry. (Constitution as per Annexure IV )
• Ex officio Commissioner for Trauma Care

Administrative Structure at District Level

District Program Unit

• District Collector will be the Chairman for Trauma care
(TAEI)
• Joint Director of Health Services will be the District Trauma
Care Nodal Officer (DTNO)

Structure at Hospital Level

• Hospital Trauma Care Nodal Officer (HTNO) will be

designated
• Dedicated multidisciplinary Team with specialist and super
specialist will be identified at the facility level with the Trauma Nurse Co-ordinator and Triage nurse for
effectively managing care and co-ordination in the Emergency room and for definitive treatment.
The roles and responsibility of DTNO,HTNO,TNC are enclosed as annexure V

5. Administrative Frame Work of TAEI

There is Proper Institutional and Administrative Framework designed at the State, District and Facility
level.
Administrative Structure at State Level
At the State level, a TAEI Steering Committee and a TAEI Surveillance Centre have been formed under the
overall supervision of the Mission Director NHM who has been designated as the Ex-officio
Commissioner of Trauma Care.
The TAEI Steering Committee comprises of the Principal secretary as the chairperson; MD, NHM as the
convener and all Heads of Department, PD, TNHSP, MD, TNMSC, Head, 108, transport commissioner etc
as members. They will meet once in 6 months to decide over important issues and evaluate the system.
The State Trauma Surveillance Centre includes a Centre for Injury Survellience and Trauma Registry,
which will be set up in IIT under the overall guidance of NHM, RGGGH experts.

Administrative Structure at District Level

District Program Unit
• District Collector is the Chairman for Trauma care (TAEI)
• Joint Director of Health Services is the District Trauma Care Nodal Officer (DTNO)
• District Trauma Nurse Co-ordinator (DTNC) is identified in every district for close monitoring
and evaluation of the nurse run model of TAEI ER services.
 - 58 -
Administrative Structure at Hospital Level
• Hospital Trauma Care Nodal Officer (HTNO) is designated in every hospital as the team leader in
the ED.
• Dedicated multidisciplinary Team with specialist and
super specialist will be identified at the facility level with
Trauma Nurse Co-ordinators, Triage nurses and TAEI nurses
for effective management and co-ordination of care at the
Emergency room and for definitive treatment.

6. As per the Government of India guidelines the

State Government has committed to upgrade the hospitals for providing trauma care
in terms of Level I, Level II and Level III based on the Hub and Spoke model.

The Description of these Levels are given in Annexure II

7. Interventions planned under the Tamil Nadu Accident and Emergency Care
Initiative (TAEI ) :
(7) (a) Administrative Structure at State Level
• State Trauma Care Steering Committee (Constitution as per Annexure III)
• State Trauma Surveillance Centre which includes a Centre for Injury Survellience and
Trauma Registry. (Constitution as per Annexure IV )
• Ex officio Commissioner for Trauma Care (GO Received)

(7)(b) Administrative Structure at District Level

District Program Unit

• District Collector will be the Chairman for Trauma care (TAEI)
• Joint Director of Health Services will be the District Trauma Care Nodal Officer
(DTNO)

7 (c) Structure at Hospital Level

• Hospital Trauma Care Nodal Officer (HTNO) will be designated
• Dedicated multidisciplinary Team with specialist and super specialist will be identified at the
facility level with the Trauma Nurse Co-ordinator and Triage nurse for effectively managing
care and co-ordination in the Emergency room and for definitive treatment.
The roles and responsibility of DTNO,HTNO,TNC are enclosed as annexure V
 - 59 -
7(d) Branding
This initiative aims to establish and strengthen the Hub and spoke model of Trauma care
under the name– Tamil Nadu Accident and Emergency Care Initiative (TAEI). It is proposed to
brand all the centres with a logo and tagline “Saving Lives is Our Mission”

7(e) Color Coding

The Emergency Room will be Color coded as RED, YELLOW, GREEN based on the nature of
the emergency. Color codes will be the first step in triage. It is proposed to set up Standard
Emergency room, workflow mechanism in the Trauma care facility.

7(f) Standard Protocols and Emergency Manuals for Trauma Care Management:
The TAEI proposes to use the Advanced Trauma Life Support (ATLS) protocol which is an
internationally accepted protocol in emergency care. Emergency Room Manual will be developed
to ensure uniformity in care given in emergency rooms across the State.

7(g) Training:
Training and Capacity building of the Medical, paramedical and other support staff in the
hospitals is proposed. The personnel will be trained in Advanced Trauma Life Support (ATLS)
Training protocol uniformly across all Trauma care centers for doctors and Advanced Trauma
Care for Nurses (ATCN).

7 (h)Technical Support
The technical support and knowledge exchange is proposed between AIIMS which is Apex
Level 1 Centre in the country and TAEI Centres of our State. It is also proposed as part of the
technical support to sign an MOU with AIIMS after finalising the modalities.
7(i) MIS
It is proposed to develop an Management and Information System (MIS ) in Emergency
Room. It is also proposed to install Display Boards (electronic / Hand Written) mentioning the
status of the patient, treatment plan and the completion status of the recommended diagnostics
and investigations to minimize apprehension among the patient relatives and thus enhance care
and service delivery.
It is also proposed to generate unique ID by integrating the Emergency Room admission
MIS with the CMCHIS software platform Remedinet.
7 (j) e Registration of Medico Legal Cases
It is proposed to develop software in coordination with NIC for registering medico legal
cases
 - 60 -

7 (k) Pilot Project

It is proposed to conduct pilots in following 5 hospitals during the year 2017-18

Sl Name of the Hospital Level

No.
1. Rajiv Gandhi Government General Hospital, Level I (New) 7(m)
Chennai Monitoring
2. Government Medical College Hospital, Villupuram Level II (Upgrading from III) and
District Head Quarters Hospital, Cuddalore Level II (Upgrading from III) Evaluation
3.
:
4 District Head Quarters Hospital, Perambalur Level III (Strengthening
It is
existing)
proposed to
5 Tambaram Taluk Hospital Level III (strengthening)
measure
tangible outcomes of Trauma care services based on the data collected from all the centres. The
Trauma care registry and the Injury Surveillance Centre will be responsible for collection,
analysis and providing feed back to the Centres for necessary improvements. The Indicators are
given in Annexure VI

7(n) Rehabilitation:
Is an integral part in trauma care as it is estimated that nearly 100% of the RTA
casualties with severe injuries, 50% of those with moderate injuries and 10-20% of those with
mild injuries carry disabilities of physical and psychological nature requiring long term
rehabilitation (Gururaj,2000) Hence good rehabilitative services need to ensured at all levels of
care.
Under TAEI, comprehensive Medical and Psychological rehabilitation program will be developed

7(o) Trauma Critical Case Review:

Under TAEI Trauma Critical Case Review will be conduted like maternal death audit. The
following procedure will be adopted.
• Verbal autopsy or community based trauma death audit
• Facility based Trauma Death Audit
• Video Conference at state level including all healthcare professionals involved in patient
care from EMT,Pilot in the ambulance to the doctors and nurses involved in treating the
casualty.
• 7 (p) Base line and Research studies
 - 61 -
It is proposed to conduct base line study for the pilot project. Scope of work and TOR will
be developed and suitable agencies will be engaged as per the procurement procedures.

8 Expansion Plan

The year-wise expansion plan based on the RTA/Trauma load to implement the Hub and
spoke model (TAEI) is as follows:

Expansion in six Total Centres –

Level Present Centres – 2017
years 2023
Level I 0 7 7
Level II 6 13 19
Level III 15 24 39
ECC 03 47 50

The details of the Centres to be newly established, upgraded from lower level to higher
level, strengthening at existing level is given in Annexure VIII.

9 Tangible results:
Once the Hub and spoke model of Trauma Care (TAEI) is established it is expected to
have the following tangible results.
• Emergency Room uniformly standardized in each facility of the state
• Standardised Treatment Protocol and guidelines
• Color Codes for Triage
• Assured service like CEmONC, NICU
• Improved Quality of Care
• Reduction in Mortality
• Reduction in Morbidity

10 Orders Requested
1. Establish and strengthen the Trauma Care Centres in a HUB and Spoke Model named
“Tamil Nadu Accident and Emergency Care Initiative “ (TAEI)

2. Approve the administrative structure for TAEI

 - 62 -
a. State Level
i. TAEI Steering Committee under the Chairmanship of the Secretary to
Government, Health and Family Welfare Department
ii. State Trauma Surveillance Centre
iii. Designation of Ex- Officio Trauma Care Commissioner ( Mission Director ,
NHM)
b. District Level
i. District Level TAEI Unit : District Collector – Chairman
ii. Strengthening the existing Road Safety Committee at District level
iii. JDHS – Designated as District Trauma Nodal Officer (DTNO)
c. Hospital Level
i. Nodal Officer (HTNO)
ii. Roles and responsibilities of all staff in ER

3. Provide approval for 70 Hospitals and 50 Emergency Care Centres ( 12 Approved

under Road Safety funds through EMRI) in DME, DMS, DPH institutions as per levels
designated based of GOI norms (Level I/II/III, ECC) as per the expansion plan.

4. Establishment of Standard Emergency Rooms by following

a. Triage
b. PreArrival Intimation(PAI)
c. Colour coding of ER
d. Patient Management CheckList from Admission to Discharge
e. Emergency Manual
f. Advanced Trauma Life Support (ATLS) Protocols
g. Appropriate linkage with Multi Disciplinary Teams at Hospital levels
h. Appropriate linkage with 108 Ambulance Services
i. MIS
j. Display Boards
k. Branding

5. Provide continuous Capacity Building and Training to the Medical, Nursing and
Paramedical Personnel at all level to handle trauma cases

6. To conduct Trauma Critical case review(2% on RTA’s) as being done in case of

maternal death.
 - 63 -
7. Approve the monitoring indicators to achieve the State goal in reducing mortality and
morbidity.

For Mission Director

 - 65 -
Chapter 08
List of TAEI Centres

❖ Level I Trauma care Centre: Facility will provide the highest level of definitive and
comprehensive care for patient with complex injuries. Emergency physicians, nurses and
surgeons would be in-house and available to the trauma patient immediately on their
arrival. The services of all major super specialties associated with trauma care would be
available 24 * 7. These should be tertiary care centers to which patients requiring highly
specialized medical care are referred.
❖ Level II Trauma care centre : Provides definitive are for severe trauma patients.
Emergency physicians, surgeons, Orthopaedicians and
Anesthetists are in-house and available to the trauma patients immediately on arrival. It
would also have on-call facility for neurosurgeons, pediatricians. If neurosurgeons are not
available, general surgeons trained in neurosurgery for a period of 6 months in eminent
institutions would be made available 24 *7. The centre should be equipped with
emergency department, intensive care unit, blood bank rehabilitation services. The
existing medical college hospitals or hospitals with bed strength of 30 to 5 should be
identified as level II trauma centre.
❖ Level III Trauma care Centre: Facility provides initial evaluation and stabilization
(surgically if appropriate) to the trauma patient. Comprehensive medical and surgical
inpatient services would be made available to those patients who can be maintained in a
stable or improving condition without specialized care. Emergency doctors and nurses are
available round the clock. Physicians, surgeons, Orthopedic surgeon and Anesthetist
would be available round the clock to access, resuscitate, stabilize and initiate transfer as
necessary to a higher – LEVEL Trauma care service. Such hospitals will have limited
intensive care facility, diagnostic capacity, blood bank and other supportive services. The
district / taluk hospitals with a bed capacity of 10 to 20 beds would be selected for level
III care.
❖ Level IV Trauma care: This would be provided by appropriately equipped and manned
mobile ambulance services. These shall be provided by 108 integrated. Emergency
ambulance service 108 AS. NHAI ambulances in coordination with 108 AS MoRTH / NHAI /
NRHM / State Govt., etc.,

❖ Concept of Emergency Stabilization centre (ESC): Golden hour is the first one hour after
the trauma is called the “golden hour” if proper first aid is given, road accident casualties
have greater chance of survival and a reduction in the severity of their injuries. ESC
 - 66 -
centers Stabilize critical trauma Patients and medical emergencies within the golden hour,
thereby providing a longer window for survival and reduces complications.
Annexure III
(i) State Trauma Care Steering Committee:
S. No. Name of The Official Designation
1 Principal Secretary, Health and Family Welfare Chairperson
Department
2 Ex Officio Commissioner of Trauma Care Member
(Mission Director NHM, TN) Secretary
3 Director of Medical Education Member
4 Director of Medical and Rural Health Services Member
5 Director of Public Health and Preventive Medicine Member
6 PD, TNHSP Member
7 MD, TN Medical Supplies Corporation ltd Member
8 Director of Trauma Care ( Level-1 facility @ Chennai) Member
9 State Head 108 Ambulance services Member
10 Head, CMCHIS Scheme Member
11 President, IMA, Private Hospitals network Member
12 Representation from Police, Road Transport, Highways Member
Departments

The State Trauma care Steering Committee will meet once in 6 months.

Roles and Responsibilities

TAEI Core Team
S.No TAEI Core Team Roles and Responsibility
1 Mission Director & Be the overall in-charge of the State
Commissioner of Trauma Trauma Care Services (TAEI)
Care Designate an officer as the State
Program Manager for Trauma care to
co-ordinate the activities in NHM
Convene meetings with the Head of
the Departments to finalize the Medical
officers/Specialists/Super
specialists/Staff nurses and other
 - 67 -
paramedical staff deployment/
redeployment in the already existing
Trauma Care Centers to provide
comprehensive Trauma Care Services
Incur expenditure wherever required
within the discretionary powers of the
Mission Director for
operat00ionalization of services
Undertake baseline survey and other
activities required in the pilot hospitals
for the roll out of the TAEI.
Streamline the daily reporting of the
Trauma Care Centers in order to set
up the Trauma care registry
Start the process of review of the
Critical cases related to Road Traffic
Accidents based on the IP/Death
summary/Post mortem reports
obtained from the hospitals.
Branding the Centers as approved in
the GO
Conduct review meetings with JD,
Deans and Hospital Trauma Care
Nodal Officers.
Capacity building/ Ensure Training of
doctors and health professional in
Trauma Care.

2 State Program Manager Overall Co-ordination, operalisation

and management of TAEI.
Carry out administrative approvals
required for setting up full fledged
TAEI centers in the State
 - 68 -
3 Nodal Officer for Medical
Education
4 Assistant Program Officer
5 Consultant-Nursing
(Public Health specialist)
6 Consultant
(Training)
7 Consultant
(STEMI/STROKE)
8 MIS Data Analyst
9 Bio Medical Engineer
Ensure Training
Streamlining the daily reporting and
setting up of Trauma Registry, etc.
Provide technical support for TAEI
activities, etc.
Assist in TAEI activities in coordination
and technical support.
Provide support for nurse driven model
and coordination.
Provide support for all training
activities.
Provide, conduct and support for
STEMI and SCRIPT training.
Coordinating and monitoring of data
for TAEI center.
Provide support for strengthening of
Emergency Room and equipment
functioning.

TAEI - DISTRICT Program Unit:

The district collector will be the chairman for TAEI at the district level

Roles and Responsibility of District Collector:

TAEI has a three tier monitoring and evaluation system.

At the District level, the District Collector will be the chairman of the TAEI steering
committee.

He / she will chair the monthly TAEI review meetings as part of the Road safety
Council Meeting with the:

District Trauma Nodal Officer (DTNO)

NHM Nodal Officer, DMS side

Hospital superintendent
 - 69 -
Hospital Trauma Nodal Officer (HTNO)

District Trauma Nurse Co-ordinator (DTNC)

Administrative officer- JD office

Superintendent of Police

Regional Transport Officer

Chief education officer

District Manager, 108 Ambulance Service

Chief engineer, Highways Authority

District Fire Officer

District FHS officer

He / she will promote road safety, prepare road safety plans with special attention to
the accident prone spots/ stretches, maintenance of roads, drivers training, accident
analysis, publicity initiatives and efforts, traffic planning, highway patrol, passenger
amenities etc. in the Districts.

He / She will conduct the TAEI Critical Case Reviews of the fatal RTA cases and
near miss RTA cases in TAEI center.

He / she will review the TAEI center activities at the District level and aid in
strengthening and upgradation of TAEI network hospitals.

Annexure IV
State Trauma Surveillance Center :
Aim of STSC:
 To collect, compile, analyze & disseminate injury, trauma related information and share
with policy makers for reducing the burden of morbidities & mortality resulting due to
injuries and to build capacity for providing quality care to the injured.
Objectives:
 To collect, compile, analyze the information from designated trauma care centres for the
use of policy formation and preventive intervention.
 - 70 -
 To link the injury surveillance as per GoI data capture format with all the designated
trauma care centres for collection of injury surveillance related data.
 Coordination for training in field of trauma care.
 To collect information on Pre Hospital Care given to trauma casualties.
 Reporting to National Injury Surveillance Trauma Registry Centre (DGHS, MoHFW).
Injury Surveillance:
➢ Injury Surveillance is important need for generating authentic information about the
injury related information, timely pre hospital care given to the trauma casualties.
➢ This will lead to improved quality of trauma care as well as assist in developing evidence
based policies.
➢ Injury Surveillance will do collecting, collating, analysing and propagating activities
through data capture from the designated trauma care facilities help the policy makers in
order to formulate injury prevention and management strategies.
Trauma Registry:
• Creation of real time online based Trauma Registries at various levels of Trauma Care
Centre’s including private hospitals and networking of all the registries to State and
National Databank.
• The registry will be setup by National Health Mission in co-ordination with IIT, Madras ,
rajiv Gandhi Government General Hospital , Chennai, and experts.
• The Trauma Registries to be outcome based so that the morbidity and mortality data can
be compared across the trauma care centres and more relevant critical gaps can be found
in the management strategies.
This State trauma surveillance center will be part of State Health Society, National Health
Mission.

District Trauma Care Nodal Officer (DTNO)

• JDHS will be the District Trauma Care Nodal Officer of the District bu providing direction
• He will coordinate for all Trauma Care Services in the District which includes 108
Emergency Ambulance Services, Trauma Care Centres in Medical College Hospitals,
designated Trauma Care Centres and other institutions both public and private, where
Trauma and Emergency patients are admitted , treated and rehabilitated.
• He will obtain daily report from the Trauma care centres and after consolidation send the
daily report to the State level nodal officer.
• He will ensure availability of sufficient specialist HR, equipment, consumables and other
logistics in the Trauma care centres under his control in the districts.
• He will monitor the progress of the referred out cases to the higher centres
 - 71 -
• He will conduct review meetings every month to start with to monitor the program in the
district and to improve it by setting right any bottle necks in the smooth functioning of the
program in the district.
• He will conduct sensitization program in the district to create awareness among the health
care providers both public and private and in the community regarding the facilities
available in the Trauma care centres for treatment of Trauma cases.
• He will conduct periodical training programs for the health care providers at various levels
engaged in the Trauma care program on the program, BLS and ALS.
• He will conduct IEC program through media and by other means to create awareness in
the community regarding the factors responsible for the road traffic accidents and for
prevention of accidents.
• He will conduct a critical death audit of Trauma deaths occurring in the hospitals / referral
institutions by utilizing the services of senior medical officers of the concerned specialty
and submit the report to the District Collector and to the State Trauma care Nodal Officer.
The Trauma death audit shall be conducted @ 2 percent cases per month in the districts.
The cases shall be selected based on a matrix to be provided by the State Trauma care
Nodal team.
• He will attend along with the Trauma care centre Nodal Officers in the districts the
monthly video conference on Trauma deaths to be conducted by the State Trauma care
Nodal Officer.
• He shall ensure all eligible trauma case are included under CMCHIS
• He shall represent the trauma care facilities and their usage in the monthly Road safety
meeting at the collector’s office to the collector and get his instructions.
• He/She have to identify more hotspots and take remedial actions/ to prevent accidents/
Stationing an Ambulance nearby.
Hospital Trauma Care Nodal Officer (HTNO)
• He shall be the link between the hospital and the trauma network.
• He will attend the meetings concerned with TAEI as an when required .
• He will be updating the other trauma team in the hospital regarding in academics and
induce them to update themselves.
• He will monitor and maintain rotation of shifts for doctors, staff nurse, other staff involved
with the emergency room for smooth functioning.
• He will maintian appropriate reporting pattern / hierarchy
• To conduct everyday trauma meeting at fixed time to review the cases in order to analyse
how better the team could have managed the case.
• To monitor the strict adherence of protocols and monitor SOP and improvise hospital wise
and update the state team the change of of SOP
 - 72 -
• To monitor the working of the equipments and escalate the problems to the the higher
authority for solutions
• To keep record of preventive maintenence maintenance of equipments with the BME
• He will do Institutional death audit.
• He will maintain records of trauma cases
• He will ensure follow up of the trauma cases
• He will ensure a viability of trauma care casualty
• Preparation of Standard Operating procedure for triaging at casualty level.
• Gap analysis of the diagnostic and investigation facility
• Training needs assessment at hospital level
• Continuing medical education
• Daily reporting format of RADAMS, 108 AS and Trauma care hospital data.
• Certification of trauma care centers in the same line as CEmONC centers
• Co-ordination with DME/DMS/DPH/108

Trauma Nurse Coordinator (TNC):

• The role of trauma nurse co-ordinator is multifaceted.
Clinical
She/He will
• coordinate trauma care management across the continuum of care
• plan and implement clinical protocols and practice management guidelines
• monitor care of patients in hospital
• serve as resource for clinical practice
• Should be trained in ATCN (Advanced Trauma Care for Nurses).
• Ensure no unnecessary delay
• Follow up patients and serve as a link between hospital trauma care team and the patient
Education
 provide staff development in facility as well as in area or region
 participate in case review
 direct community trauma and prevention programs
 Performance Improvement
 monitor clinical outcomes
 monitor systems issues related to quality of care delivery
 develop quality indicators, audits, and case reviews
 identify trends and sentinel events
 help outline remedial actions while maintaining confidentiality
 - 73 -
Administration
maintain operational, personnel, and financial aspects of the trauma program as
appropriate
serve as liaison between trauma staff and administration
represent trauma program on hospital committees or community boards to foster and
enhance optimal trauma care provision and management
Supervision of Trauma Registry
collect, code, score, and develop processes for validating data design registry to facilitate
performance improvement, trend reports, and research while maintaining confidentiality
Consultant
• stabilize the complex network of people and disciplines who work together to provide
quality trauma care
Research
• be involved in research selection and analysis
• facilitate distribution of research findings
• facilitate protocol design for accurate data collection, feedback, and analysis
Roles of Triage Nurse
He/she:
• Should be A registered nurse
• Will play pivotal role in ED
• Should be prepared with emergency equipment and keep environment accessible at any
point of time
• Will collect information upon patients arrival to the hospital ED.
• Will prioritise and sort out patients for care and treatment based on standard guidelines
• Should be good at clinical judgement, critical thinking, communication skills and
accurate/sharp decision making skills.
• Should be trained in ATCN(Advanced Trauma Care for Nurses).

Accident Prone Zones Grid Analysis by TN EMRI:

Annexure VI A
 - 74 -

Annexure VI (B)
Trauma Care Centres Scaling up

Trauma Centres and Levels

6. As per the Government of India guidelines the State Governm

ent has committed to upgrade the hospitals for providing trauma care in terms
of Level I, Level II and Level III based on the Hub and Spoke model.

• Level I Trauma care Centre: Facility will provide the highest level of definitive and
comprehensive care for patient with complex injuries. Emergency physicians,
nurses and surgeons would be in-house and available to the trauma patient
immediately on their arrival. The services of all major super specialties associated
with trauma care would be available 24 * 7. These should be tertiary care centers
to which patients requiring highly specialized medical care are referred.
 - 75 -
• Level II Trauma care centre : Provides definitive are for severe trauma patients.
Emergency physicians, surgeons, Orthopaedicians and
Anesthetists are in-house and available to the trauma patients immediately on
arrival. It would also have on-call facility for neurosurgeons, pediatricians. If
neurosurgeons are not available, general surgeons trained in neurosurgery for a
period of 6 months in eminent institutions would be made available 24 *7. The
centre should be equipped with emergency department, intensive care unit, blood
bank rehabilitation services. The existing medical college hospitals or hospitals
with bed strength of 30 to 5 should be identified as level II trauma centre.
• Level III Trauma care Centre: Facility provides initial evaluation and stabilization
(surgically if appropriate) to the trauma patient. Comprehensive medical and
surgical inpatient services would be made available to those patients who can be
maintained in a stable or improving condition without specialized care.
Emergency doctors and nurses are available round the clock. Physicians,
surgeons, Orthopedic surgeon and Anesthetist would be available round the clock
to access, resuscitate, stabilize and initiate transfer as necessary to a higher –
LEVEL Trauma care service. Such hospitals will have limited intensive care
facility, diagnostic capacity, blood bank and other supportive services. The
district / taluk hospitals with a bed capacity of 10 to 20 beds would be selected for
level III care.
• Level IV Trauma care: This would be provided by appropriately equipped and
manned mobile ambulance services. These shall be provided by 108 integrated.
Emergency ambulance service 108 AS. NHAI ambulances in coordination with 108
AS MoRTH / NHAI / NRHM / State Govt., etc.,

• Concept of Emergency Stabilization centre (ESC): Golden hour is the first one hour
after the trauma is called the “golden hour” if proper first aid is given, road
accident casualties have greater chance of survival and a reduction in the severity
of their injuries. ESC centers Stabilize critical trauma Patients and medical
emergencies within the golden hour, thereby providing a longer window for
survival and reduces complications.

Level 1 2 3
Neurosurgeon 4 1 0
Radiologist 2 2 0
Plastic Surgeon 1 0 0
Anaesthesiologist 6 3 2
Orthopaedic Surgeon 4 3 2
General Surgeon 6 2 2
Casualty Medical Officer 30 8 6
Staff Nurse (including 100 40 25
TNC)
Nursing Attendant 24 16 13
OT Technician 10 5 5
Radiographer 4 4 4
Lab Technician 4 2 2
MRI Technician 2 0 0
Multi Task Worker 40 15 12
Physiotherapist
CT Technician
EMO 10 4 2
 - 76 -

Lev Lev Leve

el I el II l III
Radiology
1 C Arm - Image Intensifier - with CD ROM, Printer, 12" CCD, Double Monitor, Facilities for Electronic Transmission and 1 1 0
Networking for Teleradiology with X Ray and DSA Facilities for OT
2 3D Ultrasonography - Trolley Based 1 1 0
3 Ultrasonography Trolly Based 0 0 1
4 800 mA Digital X Ray Machine with Processor 1 0 0
5 500 mA X Ray Machine with CR System and Camera 0 1 1
6 100 mA Portable X Ray machine 1 1 1
7 64 Slice CT Scan 1 0 0
8 16 or More Slice CT Scan 0 1 0
9 Portable Ultrasonogram 1 0 0

100 mA Portable X-Ray machine

1000 mA digital X-Ray Machine
500 mA X-Ray Machine
3D Ultrasonography – Trolley based
Image Intensifier (C-Arm)-with CD ROM, Printer, 12" CCD, Double Monitor, Electronic Transmission and Networking for
tele Radiology with X-Ray and DSA facility for OT
Angiography C-Arm based + Angiosuite
CT Scan more than 32 Slices
CT Scan 32 Slice
CT Scan
3 Tesla MRI
Portable USG
CR Reader wit Printer
CR Cassettes 17*14
CR cassettes 12* 10
Rehabilitation
1 SW Diathermy 1 1 0
0
1 IFT Machine 1 1 0
1
1 Cervical Traction & Lumbar Traction 1 1 0
2
1 Physiotherapy Equipments 1 1 0
3
Anaesthesiology
1 OT Table - 4 Segments translucent Top with Orthopaedic Attachment 2 2 0
4
1 OT Table - 3 Segments translucent Top with Orthopaedic Attachment 0 0 2
5
1 Cautery Machine - Mono and BiPolar with Underwater Cutting 2 0 0
6
1 Cautery Machine - Mono and BiPolar 0 2 2
7
1 OT Ceiling Light - Shadow Less with inbuilt Camera and Monitor 2 0 0
8
1 OT Ceiling Light - Shadow Less 0 2 2
9
2 Central Suction and Central Pipe Line 1 1 0
0
 - 77 -
2 High Vaccuum Suction Machine 2 2 0
1
2 Suction Machine 0 0 4
2
2 Anaesthesia Machine with Monitor 6 - 8 Channel (Parameters : Agent Monitoring, NIBP, SPO2, ETCO2, ECG, Temp, 4 2 0
3 IBP)
2 Anaesthesia Machine with Monitor (Parameters : Agent Monitoring, NIBP, SPO2, ETCO2, ECG, Temp, IBP) 0 0 2
4
2 Transport Ventilator 1 1 1
5
2 Ventilator with High End Compressor 10 10 5
6
2 ABG Machine Hand Held Analyzer 0 0 1
7
2 Defibrillator with Monitor (Parameters, : NIBP, ECG, SPO2 with AED) 10 10 5
8
2 Monitor (Large Screen with ECG, SPO2, NIBP, ETCO2) 20 10 5
9
3 Operating Microscope 2 0 0
0
3 Operating Headlights 2 2 0
1
3 Manifold System in ICU 1 1 0
2
3 Patient Warming System 1 1 0
3
3 Syring Infusion Pump 5 3 1
4
Orthopaedics
3 Pneumatic Tourniquet 2 2 2
5
3 Power Drill and Power Saw 2 1 1
6
3 Splints and Traction Devices 2 2 0
7
3 General Orthopaedic Instrument Sets 2 2 1
8
large fragment instrumentation set (4.5 system)
Small fragment instrumentation set (3.5 system)
Hemi arthroplasty instrumentation set
Interlocking nail set
external fixator set with instruments
OT
3 General Surgical Instrument Sets 2 2 2
9
4 Thoracotomy Set 1 1 0
0
4 Spinal Surgery Set 1 1 0
1
4 Facio Maxillary Instrument Set 1 0 0
2
4 Craniotomy Instrument Set 2 2 1
3
4 Lab Automatic Blood Gas Analyser Set 1 1 0
4
4 Humidity Control Meter 1 1 1
5
Patho
patho
Binocular self illuminating microscope
Automated hemato analyser-3 parts
 - 78 -
Semi automatic coagulometer
Automated ESR analyser
automated urine analyser with strips
Biochem
Fully automated analyser with harmone assay
Centrifuge (16 buckets)
Electrolyte analyser
Refrigerator
Micropippetes
10 microlitre -fixed
5 microlitre- fixed
1000 microlitre - fixed
10-50- microlitre-variable
4 Blood Bank and Microbiology 1 1 0
6
4 Electricity Back Up 1 1 1
7
4 Laminar Air Flow 1 1 0
8
4 ICU Beds 10 10 5
9
5 10 Bedded Step Down / Recovery Unit with 5 Monitors with 4 chennels 1 0 0
0
5 5 Bedded Step Down / Recovery Unit with 5 Monitors with 4 chennels 0 1 1
1
Fowlers bed
Computer with LAN, Networking & BB facility,Printers, UPS
Telephone,Intercom& mobile phone

stethoscope
Sphigmomanometer
Gauze and Bandage
IV set
Urinary catheter
NG Tube
Thermometer
Weighing scale
Intra-osseous needle
Central Venous lines
Emergency drugs
Torch
Kidney tray

Pilot Projects
It is proposed to conduct pilots in following 4 hospitals during the year 2017-18
Sl Name of the Hospital Level
No.
3. Rajiv Gandhi Government General Level I (New)
Hospital, Chennai
 - 79 -
4. Government Medical College Hospital, Level II (Upgrading from
Villupuram III)
District Head Quarters Hospital, Cuddalore Level II (Upgrading from
3. III)
4 District Head Quarters Hospital, Level III (Strengthening
Perambalur existing) Expansio
5 GH Tambaram Level III (Strengthening n Plan
existing)
The year-wise expansion plan based on the RTA/Trauma load to implement the
Hub and spoke model (TAEI) is as follows:

Present Centres – Expansion in six Total Centres –

Level
2017 years 2023
Level I 0 7 7
Level II 6 13 19
Level III 15 24 39
ECC 03 47 50

The details of the Centres to be newly established, upgraded from lower level to
higher level, strengthening at existing level is given in Annexure VIII.

6. List of Various Levels of TAEI Centres

Level I TAEI Centre:
❖ Level I TAEI Center will provide the highest level of definitive and comprehensive
care for patient with complex conditions as in Red criteria.
❖ Emergency physicians, nurses and surgeons would be in-house and will be
available to on arrival of emergency cases.
❖ The services of all major super specialties associated with the Emergency
Department will be available 24x7.
❖ These should be tertiary care centers to which patients requiring highly specialized
medical care are referred.
Level II TAEI centre :
❖ Provides definitive care for patients requiring treatment during emergency
conditions.
❖ Emergency physicians, surgeons, Orthopaedicians and
Anesthetists are in-house and available to the patients immediately on arrival to
the ED.
❖ It would also have on-call facility for neurosurgeons, pediatricians. If
neurosurgeons are not available, general surgeons trained in neurosurgery for a
period of 6 months in eminent institutions would be made available 24x7.
❖ The centre should be equipped with emergency department, intensive care unit,
blood bank rehabilitation services.
 - 80 -
❖ The existing medical college hospitals or hospitals with bed strength of 30 to 50
should be identified as level II TAEI centre.
Level III TAEI Centre:
❖ Facility provides initial evaluation and stabilization (surgically if appropriate) to the
patient coming to the ED.
❖ Comprehensive medical and surgical inpatient services would be made available to
those patients who can be maintained in a stable or improving condition without
specialized care.
❖ Emergency doctors and nurses are available round the clock. Physicians, surgeons,
Orthopedic surgeon and Anesthetist would be available round the clock to access,
resuscitate, stabilize and initiate transfer as necessary to a higher – level of care
service.
❖ Such hospitals will have limited intensive care facility, diagnostic capacity, blood
bank and other supportive services.
❖ The district / taluk hospitals with a bed capacity of 10 to 20 beds would be selected
for level III TAEI center.
Level IV care:
❖ This would be provided by appropriately equipped and manned mobile ambulance
services.
❖ These shall be provided by 108 integrated emergency ambulance service(108 AS,
National Highway Authority of India ambulances in coordination with 108 AS/
MoRTH / NHAI / NRHM / State Government etc.,
Concept of Emergency Stabilization centre (ECC):
❖ First one hour after the trauma/ incident is called the “Golden Hour” if proper first
aid is given, road accident casualties have greater chance of survival and a
reduction in the severity of their injuries.
❖ ECC centers Stabilize critical trauma Patients and medical emergencies within the
golden hour, thereby providing a longer window for survival and reduces
complications.

TAEI Centres Scaling up

S. HO Nature of Name of the Institution Now at 17 -18 18- 19 - 20- 21- 22- Final
No D Institution 19 20 21 22 23 Statu
s in
2023

1 DM MCH Rajiv Gandhi Government General Hospital, Madras Medical - Level I Level
E College I
2 DM MCH Villupuram Medical College Hospital Level Level II Level
 - 81 -
S. HO Nature of Name of the Institution Now at 17 -18 18- 19 - 20- 21- 22- Final
No D Institution 19 20 21 22 23 Statu
s in
2023

E III II
3 DM MCH Stanley Medical College Hospital - Leve Level
E l II II
4 DM MCH Kilpauk Medical College Hospital Level II Level II Level
E II
5 DM MCH Chengalpet Medical College Hospital - Leve Level
E lI I
6 DM MCH Vellore Medical College Hospitalk Level II Level II Level
E II
7 DM MCH Thanjavur Medical College Hospital - Leve Level
E l II II
8 DM MCH Mahatma Gandhi Memorial Hospital, Trichy - Leve Leve Level
E l II lI I
9 DM MCH Government Rajaji Hospital,Madurai Level II Level II Leve Level
E lI I
10 DM MCH Coimbatore Medical College Hospital - Leve Leve Level
E l II lI I
11 DM MCH Government Mohan Kumaramangalam Medical College Hospital, - Level II Leve Level
E Salem lI I
12 DM MCH Tirunelveli Medical College Hospital Level II Level II Leve Level
E lI I
13 DM MCH Thoothukudi Medical College Hospital - Leve Level
E l II II
14 DM MCH Kanyakumari Medical College Hospital Level II Level II Level
E II
15 DM MCH Theni Medical College Hospital - Leve Level
E l II II
16 DM MCH Thiruvarur Medical College Hospital - Leve Level
E l II II
17 DM MCH Dharmapuri Medical College Hospital - Leve Level
E l II II
18 DM MCH Sivagangai Medical College Hospital - Leve Level
E l II II
19 DM MCH Tiruvannamalai Medical College Hospital - Leve Level
E l II II
20 DM MCH Karur Medical College Hospital Level Level Leve Level
E III III l II II
21 DM MCH Pudukottai Medical College Hospital - Leve Level
E l II II
22 DM MCH Government Royapettah Hospital - Leve Level
E l II II
23 DM MCH Government Medical College Hospital, Omandurar - Leve Level
E l II II
24 DM DHQH Cuddalore Level Level II Level
S III II
25 DM DHQH Perambalur Level Level Level
S III III III
26 DM DHQH Ariyalur Leve Level
 - 82 -
S. HO Nature of Name of the Institution Now at 17 -18 18- 19 - 20- 21- 22- Final
No D Institution 19 20 21 22 23 Statu
s in
2023

S l III III
27 DM DHQH Pollachi Leve Level
S l III III
28 DM DHQH Pennagaram Leve Level
S l III III
29 DM DHQH Dindigul Level II Level
S II

30 DM Taluk Palani Level Leve Level

S III l III III
31 DM DHQH Erode Leve Level
S l III III
32 DM DHQH Kancheepuram Leve Level
S l III III
33 DM Taluk Tambaram Level Leve Level
S III l III III
34 DM DHQH Padmanabapuram Level Leve Level
S III l III III
35 DM Taluk Kulithalai Leve Level
S l III III
36 DM DHQH Krishagiri Level Level Leve Level
S III III l II II
37 DM DHQH Usilampatti Leve Level
S l III III
38 DM Taluk Melur Level Leve Level
S III l III III
39 DM DHQH Nagapattinam Leve Level
S l III III
40 DM DHQH Namakkal Level Leve Level
S III l III III
41 DM DHQH Aranthangi Leve Level
S l III III
42 DM DHQH Ramanathapuram Leve Level
S l III III
43 DM DHQH Mettur Leve Level
S l III III
44 DM Taluk Omalur Level Leve Level
S III l III III
45 DM Taluk Athoor Leve Level
S l III III
46 DM DHQH Karaikudi Leve Level
S l III III
47 DM DHQH Kumbakonam Leve Level
S l III III
48 DM DHQH Uthagamandalam Leve Level
S l III III

49 DM DHQH Periyakulam Leve Level

S l III III
 - 83 -
S. HO Nature of Name of the Institution Now at 17 -18 18- 19 - 20- 21- 22- Final
No D Institution 19 20 21 22 23 Statu
s in
2023

50 DM DHQH Kovilpatti Level Leve Level

S III l III III
51 DM DHQH Manapparai Leve Level
S l III III
52 DM DHQH Tenkasi Level Leve Level
S III l III III
53 DM DHQH Tiruppur Leve Level
S l III III
54 DM DHQH Thiruvallur Level Leve Level
S III l III III
55 DM Taluk Thiruthani Leve Level
S l III III
56 DM DHQH Mannargudi Leve Level
S l III III
57 DM DHQH Cheyyar Leve Level
S l III III
58 DM DHQH Walajapet (Vellore) Level Leve Level
S III l III III
59 DM DHQH Kallakurichi Leve Level
S l III III
60 DM Taluk Ulundurpet Leve Level
S l III III
61 DM DHQH Virudunagar Leve Level
S l III III
62 DM Taluk Rajapalayam Leve Level
S l III III
63 DM Taluk Thirupattur Leve Level
S l III III
64 DM Taluk Dindivanam Leve Level
S l III III
65 DM Taluk Aruppukottai Leve Level
S l III III
 - 85 -
Chapter 09
Policy for Protocols in TAEI

Standing orders for Nurses

Emergency care involves rapid assessment and immediate intervention towards life
saving of the patient. This may require verbal Medication or therapeutic procedure order
instructed by the doctor and administered by the nurses in an emergency care situation.
Hence it becomes important to provide standardized orders for the nurses of
Emergency Department Tamil Nadu. The stipulated rule stands that all drugs are
administered only based on the Written order of the doctor and only in emergency are
the verbal orders are carried out
Standing orders, include protocols, are a special case of written physician's orders.
• A standing order is an order conditioned upon the occurrence of certain clinical events.
... Unlike a standing order, until the physician incorporates the printed order into the
chart, the nurse cannot initiate treatment.

Emergency Standing Orders:

1. Pre-established medication orders, approved by appropriate medical staff is to be
administered by the nurse in the absence of a physician.
2. A "standing order" is a prewritten medication order and specific instructions from the
licensed independent practitioner to administer a medication to a person in clearly defined
circumstances
3. “Standing Order” protects the patient care and the staff nurses in providing the needed
care at the life threatening situations.
4. Standing orders are the collective responsibility of the Doctor ordered and the
nurses who executes the order.
5. Standing orders are always connected to the medication and emergency therapeutic
procedures.
6. Standing orders are given verbally and are documented at the earliest by the doctor and
the nurses having settled down the emergency care. When the order is not clear the
nurses should ask the doctor to repeat it again and document it.
7. All dosage of the drugs will be as per doctor order
8. The standing orders are executed by the registered nurses with minimum of one year
experience. It is the responsibility of the nurse and the doctor to immediately secure the
written order.
9. Verbal orders are given by the doctors only in Emergency situations where the patient
had been assessed

STANDING ORDERS FOR NURSES:

SN Emergency Conditions Standing orders

Injections and IV fluids that can be Adenosine
administered with the doctor’s
Adrenaline IV/Endotracheal
verbal order and ensure that these
orders are obtained in writing after Amiodarone HCl
the emergency.
Atropine sulphate
 - 86 -
Calcium Gluconate 10%
Dopamine HCl
Lignocaine HCl (Xylocard)
Magnesium Sulphate 50%
Nor adrenaline
Sodium Bicarbonate 7.5%
Vasopressin
ALLERGIC REACTION 1. Stop administering all drugs given
earlier.
2. Establish IV access with normal
saline
3. Drugs: The following drugs can be
administered with the doctor’s
verbal
4. Order and ensure that these
orders are obtained in writing
after the emergency.
5. Administer Inj.Pheniramine
Maleate (Avil) 50mg IV for adults.
6. Administer Inj.Pheniramine
Maleate (Avil) as per doctor’s
order for children.
7. Administer Inj.Hydrocortisone
100mg IV.
The above medications may be
administered when the patient
experiences transfusion or drug reactions
such as itching, rashes, bronchospasm,
chills etc.
CARDIO PULMONARY ARREST • In case of cardio respiratory
arrest, activate the emergency
team by activating Code Blue
• Follow the TAEI Cardio
Pulmonary Resuscitation
protocol

ANAPHYLACTIC SHOCK • Administer Inj.Adrenaline 1ml

 - 87 -
(1:10,000) IM
• Ensure a patent airway
• Administer oxygen 4-6 L/min by
face mask.
• Establish an IV access and rush
Inj. Normal Saline 1 lit.
• Administer Inj.Hydrocortisone and
Inj. Avil

❖ HYPOGLYCEMIA • Check blood glucose using

glucometer.
• .Administer Inj.Dextrose 50%
bolus IV
MEDICATION ADMINISTRATION • The clinical nurse who
administers medications is
accountable for all drugs that
she administers to the
patients.
• The concerned person who is
administering should load the
drugs.
NARCOTICS • All narcotic drugs must be
counterchecked and
countersigned by another
Registered Nurse.
• Intravenous narcotics (Bolus)
can be administered in the
presence of the doctor with a
written order.
INJECTION ADMINISTRATION : • IV peripheral Cannulation can be
done by nurses.
• The sensitivity test for Penicillin is
given by the clinical nurse and
the sensitivity is read by the
doctor following which the 1st
dose of all antibiotics can be
 - 88 -
given by clinical nurses
INJECTIONS THAT CAN BE GIVEN Inj. Adrenaline
WITH VERBAL ORDERS IN THE Inj. Atropine
PRESENCE OF A DOCTOR DURING Inj. Aminodarone
AN EMERGENCY. Inj. Calcium Gluconate very slow IV over
10 minutes
On verbal instruction of the Inj. Diazepam
Emergency Department doctor in an Inj. Dexamethasone
emergency, the following drugs are Inj. 50% Dextrose
to be administered and Inj. Hydrocortisone
subsequently written orders are to Inj. Heparin
be obtained from the Emergency Inj. Lasix
Department Doctor. When the Inj. Lidocaine
nurse administers drugs on Inj. Largactil
verbal orders from the Inj. Lorazepam
doctors both the Doctor and Nurse Inj. Midazolam
are accountable for the drug that is Inj. Morphine
administered. Inj. Mannitol
Inj. Phenargan
Inj. Sodium bicarbonate
Inj. Succinylcholin
Inj. Insulin
Inj. Avil
Inj. Ranitidine
Inj. Dilantin
Inj. Fentanyl
Inj. Adenosine
Inj. Haloperidol
Inj. Tranexamic acid
Inj. Pantoprazol
Inj. Ondensetron

Inj. Aminophylline
DRUGS THAT CAN BE ADDED IN AN Inj. Adrenaline
INFUSION IN AN EMERGENCY. Inj. Anti snake venom
Inj. Amiodarone
Inj. Dopamine
 - 89 -
Inj. Glyceryl Tri Nitrate (GTN)
Inj. Heparin
Inj. Pitocin
Inj. Piperacillin Sodium
Inj. Quinine
Inj. Streptokinase
Inj. Urokinase
Inj. Dilantin
Inj. Pantaprazole
Inj. Potassium Chloride
Inj. Insulin
Inj. Ketamine
Inj. Febrinil
Inj. Levipril
Vitamin supplements
PROCEDURES : Emergency nebulisation can be
administered on verbal instruction and
ensure that written order is obtained
after the emergency.

Nausea Inj Emeset 8 mg P/O every 6-8 hrs as

needed
Vomiting Inj Emeset 8 mg IV every 8 hrs as
needed
Inj Perinorm 10mg IV every 8 hrs as
needed
Fever Tab Dolo 650 mg P/O every 6-8 hrs as
needed (if temp >100’F)
Indigestion Mucaine Gel 10 ml P/O every 8 hrly of
SOS
Inj Pan40mg P/O or IV as needed
Constipation Syr Duphalac 15-30ml as needed
Syr Cremaffin 15ml twice daily as
needed
Dulcolax Suppository P/R or enema if
needed
 - 90 -
Anxiety / Sleep problem Tab Alprax 0.25mg P/O
Cough Syr. Benadryl 5-10mg P/O as needed
Wheezing or shortness of breath Nasal oxygen @2 -4 L / min
Nebulisation every 4-6 hrs as needed
and SOS

Scope of Standing Orders

These Standing Orders are not intended to replace clinical judgment and expertise.
STANDING ORDER APPROVAL:
• Every Emergency Department of Tamil Nadu Government Hospitals should have standing
Orders approved by the Medical Superintendent and the Nursing Superintendent.
• The standing order should be available in the written format in the emergency
department
• The standing odder will be revised once in 2 years and Ad Hoc if there is need for urgent
revision based on scientific evidence and need of the Hospital

Draft forwarded to TAEI for the review and approval by the Emergency Physician and
appropriate authorities.
The concerned Emergency Department Medical Head and the Medical Superintendent
can revise and approve it for execution towards quality Emergency patient care in
Tamil Nadu.

Professor.T.Samuel Ravi Kumar

Head Emergency Nursing
College of Nursing
Christian Medical College, Vellore
July 22, 2018

Mrs. Latha Venkatesan , Apollo

 - 91 -
Chapter 10
Policy for Human Resources in TAEI Centres
 - 93 -
Chapter11
Policy for Capacity Building (Training & Certification)
Chapter Outline
1. Four Levels of Capacity Building
2. Aims & Objectives, Recipients, Mode, Duration, Examination and Certification for Each Level

TAEI has Four Levels of Capacity Building for due to acts of commission or Omission
Four Categories of Individuals after the Incident)
1. IEC Activity for General Public 3. To Maximise Management within the
2. TAEI FRC (TAEI First Responder Care) Golden Hours
for Those who are more likely to deal Recipients
with an Emergency 1. School and College Teachers
3. TAEI Protocols for all Health Care 2. Industrial Workers
Workers including Undergraduate 3. Employees of Transport Department
Medical and Paramedical Students 4. Shopkeepers, Fuel Station Workers and
4. TAEI Skills for those who are posted in other common public along the highway.
Emergency Departments and 5. Workers of Unorganised Sectors
Postgraduate Medical Graduates 6. Any Other category of personnel who are
more likely to deal with an Emergency
Level I : IEC Activity for General Mode
1. Class Room Teaching
Public 2. Demonstration with Models and
Aim & Objectives Mannequins
1. To Sensitise All Citizens of Tamil Nadu Duration
about Emergency Care 1. One Day (8 Hours)
2. To Make them Call 108 Ambulance Course Contents
Immediately after an Incident 1. Structure and function of the human body
3. To Avoid Delays in Treatment 2. Dressing & Bandages
Recipients 3. Respiration & Asphyxia
1. All Citizens of Tamil Nadu 4. Wounds & Bleeding
Mode 5. Shock
1. Books 6. Injuries to Bones
2. Brochures 7. Injuries to muscles and joints
3. Print and Visual Media 8. Nervous system and unconsciousness
4. Social Media 9. Burns & Scalds
Duration 10. Poisoning
1. Continuous Activity 11. Miscellaneous condition
Examination Certificate 12. Blood donation
1. Not Needed 13. Handling & Transport of injured persons
14. Contents of First Aid Box
15. HEART ATTACK
Level II : TAEI FRC (TAEI First 16. CPR – Cardio Pulmonary Resuscitation
Responder Care) 17. ABC & Recovery position
Aim & Objectives Examination
1. To Prepare the First Responders Deal 1. MCQ Examination
with any potential Emergency Certification
2. To Prevent or At least Reduce the 1. TAEI FRC Certificate and Badge will be
Secondary Injuries (Injuries happening issued. In addition to this, Digital
 - 94 -
Certificate will be issued to the v. ER.2 Primary Survey
candidates Aadhar Linked Digilocker Check ABCDE
vi. ER.3 Resuscitation
Level III : TAEI Protocols Manage ABCDE
Aim & Objectives vii. ER.4 AR Entry AR
1. To train all healthcare workers to work in Entry / eMLC
Unison and as a Team viii. ER.5 Secondary Survey
2. To Standardize the Care, Skills, Protocols Detailed
across all government Hospitals Examination
Recipients ix. ER.6 Investigations
1. All Health Care Workers Imaging and Blood
2. All Undergraduate Medical Students Investigations
3. All Paramedical Students x. ER.7 Specialist Opinion
Prerequisite Opinion and
1. None. However, those who have Management if needed
undergone TAEI FRC in the past 6 months xi. ER.8 Monitoring and Re
can skip Day one evaluation Continuous
Mode post resuscitation
1. Class Room Training monitoring and re
2. Lectures evaluation
3. Demonstration with Models & c. and 3 will have lectures about
Mannequins TAEI Protocols in the morning and
4. Hands on Training Exam in the Afternoon Session
Duration & Course Contents 2. 2 Days for those who have undergone
1. 3 days For those who have not TAEI FRC in the past 6 months
undergone: a. Day 1 will have lectures and
a. Day 1 will be the TAEI FRC Demonstration and Hands on
Training and exam will be Training about Primary Survey,
conducted at the end of the day Resuscitation, and Other Stages of
and Certificate and Badge will be Patient Care in ER
issued b. and 2 will have lectures about
b. Day 2 will have lectures and TAEI Protocols in the morning and
Demonstration and Hands on Exam in the Afternoon Session
Training about Primary Survey, Examination
Resuscitation, and Other Stages of 1. TAEI FRC Exam at the End of Day One
Patient Care in ER a. MCQ Exams
i. RE.1 Referral 2. TAEI Protocols Exam at the End of Day
Referral Out from Three
One Hospital to Referral In a. MCQ Exams
to Next Hospital b. Clinical Demonstration
ii. RE.2 Intra Hospital Certificate
Transfer Transfer of 1. “TAEI FRC” Certificate and Badge will be
Patients from One Ward to issued. In addition to this, Digital
Another Certificate will be issued to the
iii. HE.1 Pre Intimation to candidates Aadhar Linked Digilocker
Hospital and Hospital 2. “TAEI Protocols” Certificate and Badge
Preparation Hospital will be issued. In addition to this, Digital
Being Ready to Certificate will be issued to the
Immediately Start candidates Aadhar Linked Digilocker
Treatment
iv. ER.1 Triage Red, Yellow Level IV : TAEI Skills Certification
or Green Aim & Objectives
 - 95 -
1. To Impart Specialised and Advanced 3. Demonstration with Models &
Training to Health Care Workers posted Mannequins
in Emergency Departments 4. Hands on Training
Recipients 5. Clinical Posting in an ED in a Medical
1. Those posted in Emergency Departments College / Training Institute
2. Postgraduate Medical Graduates Examination
Prerequisite 1. OSCE
1. TAEI Protocol Training Certificate
Duration 1. “TAEI Skills” Certificate and Badge will
1. 5 days be issued. In addition to this, Digital
Mode Certificate will be issued to the
1. Class Room Training candidates Aadhar Linked Digilocker
2. Lectures

Chapter Essence
In a Nutshell
1. Capacity Building is an ongoing and continuous process
2. Various Levels of Capacity Building are required
3. TAEI Skills Trainees < TAEI Protocol Trainees < TAEI FRU Trainees < General Public
4. TAEI Skills Syllabus > TAEI Protocol Syllabus > TAIE FRU Syllabus > IEC
- 96 -
 - 97 -

TAEI Training :
• FRC Training : 1 Day Training with 8 Sessions
• TPT : TAEI Protocols Training : 3 Days : Day 1 : FRC , Day 2 and 3
• TSG : TAEI Skills Grading: TPT + 5 days

Da Durati Title Description Remarks

y on
09:00 Registrat
to ion
09:30
1 09:30 Pre Test MCQ based Test of 30 Questions
 - 98 -
Da Durati Title Description Remarks
y on
to
10:00
1 2 10:00 Human 1. Basic Physiology Didactic Lecture with Slide Shows and
to Physiolo 2. Importance of Circulation, Videos
10:45 gy 3. Respiration,
4. Brain Function
10:45 Tea
to Break
11:00
1 3 11:00 ABCDE & 1. Airway Didactic Lecture with Slide Shows and
to First Aid a. Importance of Videos
11:45 Basics Recovery Position
2. Breathing
a. Artificial Inj TT ½ cc IM stat
Respiration, Inj Diclo 1amp IM Stat (Paracetamol
b. AMBU, Rectal Suppository for kids) Inj
c. Ventilator Ampicillin 1 gm + Inj GM 80 mg iv stat
3. Circulation
a. Cardiac Massage
4. Disability
a. AVPU
b. Blood Sugart
5. Environment
a. Dressing
1 4 11:45 How to React in Various Scenarios Socratic Discussions with
to 1. Injury Hand and Feet Demonstrations encouraging the
12:30 a. Bleeding trainees to ask more scenarios other
b. than the conditions mentioned
2. Traumatic Amputations 1. Direct Compression of Bleeding
and Crush Injuries of Site (Head, UL, LL)
Fingers, Toes, Extremities, a. Dressing
3. Fracture Dislocation Upper b. TT
Limb c. Anti biotics
4. Fracture Dislocation Lower d. Analgesics
Limb 2. How to preserve the
5. Spine Injuries including amputated part
Cervical Spine 3. Cuff and Collar, Check for Pulse
6. Sudden Musculoskeletal 4. Thomas Splint, Check for Pulse,
Pain / DVT / Gangrene FND
7. Head Injury 5. Philadelphia Collar / Spine
8. Facial Injuries Board / Scoop Board /
9. Eye Injuries 6. ICD, Needle Thoracocentesis
10. Foreign Body Nose and 7.
Throat
a. Choking
b. Epistaxis
c. Hemoptysis
12:30 Lunch
to Break
13:30
 - 99 -
Da Durati Title Description Remarks
y on
1 5 13:30 Common How to React in Various Scenarios Socratic Discussions with
to Scenario 11. Neck Injuries Demonstrations encouraging the
14:15 s a. Kite trainees to ask more scenarios other
b. Hanging than the conditions mentioned
12. Drowning / Submersion Demonstration of AED
13. Chest Injuries Demonstration of CPR
a. Fracture Rib
b. Pneumothorax 8. Philadelphia Collar / Spine
c. Hemothorax Board / Scoop Board /
d. Pericardial 9. ICD, Needle Thoracocentesis
Tamponande 10.
14. Stab Injury Abdomen 11.
a. Bull Gore 12.
15. Blunt Injury Abdomen 13.
16. Pelvic and Perineal Injuries 14.
including Bladder Injuries 15.
17. Multiple Injuries / 16.
Polytrauma 17.
18. Vomiting 18. Vomiting
a. Hematemesis 19. How to Manage Acute
19. Acute Abdomen Abdomen in ER
a. AGE a. Ask for
b. APD i. LMP (in case of
c. Acute Pancreatitis females)
d. Renal Colic ii.
e. Urine Retention b. Look for
f. Ectopic Pregnancy i. Anemia (Ectopic)
20. Labour and Obstetric ii. Jaundice
Emergencies (Pancreatitis due
a. to Obstruction)
iii. Tenderness
iv. PR
v. PV
c. Do
i. eFAST
ii. ECG – All Leads
including Limb
Leads. ECG to
Rule out Inferior
Wall Ischemia
iii.
iv.
d. Investigation
i. USG
ii. Plain X Ray
Abdomen
iii. CT Abdomen
e.
f.
g.
 - 100 -
Da Durati Title Description Remarks
y on
h.
i.
20. ss
21. ss
22.

1 6 14:15 Common 21. Breathlessness Socratic Discussions with

to Scenario a. Asthma Demonstrations encouraging the
15:00 s 22. Heart Attack / Chest Pain trainees to ask more scenarios other
a. Importance of AED than the conditions mentioned
and CPR
23. Head ache Apply Cuff and Collar
24. Stroke #Stabilisation of UL and LL
25. Fits
a. Dos and Don’ts 23. ss
26. Burns 24. ss
27. Anaphylaxis / Allergic 25.
Reactions / Fever 26.
28. Poison / Drug Overdose 27.
29. Snake Bite / Scorpion Sting 28.
Dog Bite / Animal Bites 29.
30. Unconscious Patient 30. Unconsious Patient
a. Munchasen a. FBS, Urea,
Syndrome Creatinine,Electrolytes
31. Alcohol Intoxication / b. Ketone Bodies
Agitated Patients c. Jaundice
32. General Aches and Pains d. CT
e. USG indicated in
i.
31.

15:00 Tea
to Break
15:15
1 7 15:15 Legal 1. Disaster inside Hospitals
to Aspects 2. Legal Aspects in Emergency
16:00 and Mass 3. How to Get Help
Casualty a. Whom to call
b. What all to tell
i. Where are
you
ii. How many
need help
iii. What is the
emergency
iv. What help
you need
c.
4. Mass Casualties / Natural
Disasters
 - 101 -
Da Durati Title Description Remarks
y on
1 8 16:00 Post Test MCQ based Test of 30 Questions
to
16:30
16:30 Valedicto
to ry
17:00

09:00 Registrat
to ion
09:30
2 9 09:30 Pre Test MCQ based Test of 30 Questions
to
10:00
2 1 10:00 Introduc 1. TAEI Introduction
0 to tion 2. Pillars of TAEI
10:45 PAI and 3. Management Flow Chart
Referral 4. How is TAEI Different
and 5. Pre Arrival Intimation and
Callouts Referral
6. Hospital Codes
2 10:45 Tea
to Break
11:00
2 1 11:00 7. Triage
1 to 8. Universal Precautions
11:45 9. Critical Care Transport
a. Pre, Per, Post
Observations
2 1 11:45 Evaluation of Triage
2 to
12:30
2 12:30 Lunch
to Break
13:30
2 1 13:30 10. Team Work
3 to 11. Primary Survey
14:15 12. Resuscitation
2 1 14:15 Evaluation of Primary Survey and
4 to Resuscitation
15:00
2 1 15:00 13. Airway including Manual – Head Tilt and Chin Lift
5 to Intubation Accessory Airway -
15:45 Advanced Airway – Advanced AIrway
2 15:45 Tea
to Break
16:00
2 1 16:00 Evaluation of Airway and
6 to Intubation
16:45
2 1 16:45 14. Breathing : Ambu and Basic Settings
 - 102 -
Da Durati Title Description Remarks
y on
7 to Ventilators
17:30
2 1 17:30 Evaluation of Breathing and
8 to Ventilators
18:15
3 1 09:00 15. Circulation : iv Lines and ECG REcoginition
9 to Central Lines Cardiac Arrest Management
09:30 Algorhythms
Hypovolemic Shock
Fluid Calculation
3 1 09:30 16. eFast
1 to
10:00
3 1 10:00 17. CPR and BLS
2 to
10:45
3 10:45 Tea
to Break
11:00
3 1 11:00 Evaluation of eFAST
3 to
11:45
3 1 11:45 Evaluation of CPR and BLS
4 to
12:30
3 12:30 Lunch
to Break
13:30
3 1 13:30 33. Disability Stroke Management
5 to
14:15
3 1 14:15 34. Environment
6 to
15:00
3 15:00 Tea
to Break
15:15
3 1 15:15 35. Legal Aspects in Emergency
7 to Care
16:00 36. Brain Stem Dysfuction
37. Team Work
3 1 16:00 Post Test MCQ based Test of 30 Questions
8 to
16:30
16:30 Valedicto
to ry
17:00
- 103 -
 - 104 -

List of Topics to be covered in TAEI Protocol Training

The Following are the List of Topics Proposed to be included in the TAEI Protocol Training for Health
Care Personnel working in Emergency Rooms. Please give in your suggestion at
www.taeionline.com/book

S.N Scenario Includes Ask for Look for Do (Doses are for a 60 kg Adult. Investigate Specialist Opinion
o Modify Dose as needed)
1 Injury Hand, 1. Abrasions 1. Other 1. Wash with NS 1. Plastic
Feet (Bruises), Injuries 2. Dressing Surgeon
2. Cuts, 3. 2. Ortho
Lacerations Surgeon
3. Contusions 3. General
4. Deformities Surgeon

2 Traumatic 1. 1. Amputate 1. Pulse All 1. Safeguard the Amputated Part 1. Plastic

Amputation d Parts Four a. Wash the Part in Surgeon
s and Crush 2. Limbs Normal Saline. 2. Ortho
Injuries of 2. b. Wrap it is Sterile Surgeon
Fingers, Gauze soaked in 3. General
Toes, Ampi, GM Surgeon
Extremities, c. Wrap it in Sterile
Moist Towel
d. Place in Plastic Bag
e. Keep in Crushed Ice
f. Avoid Freezing
Isotonic Solution
2. Injection Tetanus
Immunoglobulin if needed
3 Fracture 1. Clavicle, 1. 1. Capillary 1. Cuff and Collar 1. X Ray 1. Ortho
Dislocation 2. Shoulder, Refill 2. Urgent Ortho Call Over if there 2. Surgeon
Upper Limb 3. Humerus, Time is no or feeble pulse on the 2. Vascular
4. Elbow, 2. Peripheral affected Limb Surgeon
5. Radius, Pulse
6. Ulna, 3.
7. Wrist
4 Fracture 1. Hip 1. Capillary 1. Thomas Splint 1. X Ray 1. Ortho
Dislocation 2. Femur Refill 2. Urgent Vascular Surgeon and 2. Surgeon
Lower Limb 3. Knee Time Ortho Call Over if there is no 2. Vascular
4. Tibia 2. Peripheral or feeble pulse on the affected Surgeon
5. Fibula Pulse Limb
6. Ankle 3. Pelvic Binder for Hip Injuries
4. Don’t Catheterise in case of
Doubtful Urological injuries
5 Spine 1. Atlas to 1. Motor 1. Philadelphia Collar 1. MRI 1. Neurosurgeo
Injuries Sacrum Deficit 2. Pelvic Binder for Hip Injuries Spine n
including 2. 2. Sensory 3. Spine Board 2. CT Spine 2. Orthosurgeon
Cervical Deficit 4. Log Roll for Pain / Stepping 3.
Spine 3. Bladder Deformity
Involveme
nt
4. Bowel
Involveme
nt
6 Pain / Loss 1. Gangrene 1. Capillary 1. Doppler 1. Vascular
of 2. DVT Refill 2. Surgeon
Movement 3. Compartme Time 2. General
in ntal 2. Peripheral Surgeon
Extremities Syndrome Pulse 3. Ortho
4. Neuropathy Surgeon
7 Head Injury 1. Scalp 1. Exact 1. AVPU 1. Philadelphia Collar for All 1. CT Scan 1. Neurosurgeo
Injuries Time of 2. Vision Unconscious Patients Brain n Opinion
2. Fracture Loss of 3. Pupils 2. Intubation and Elective 2. CT Scan 2.
Skull Conscious 4. Eye Ventilation for Orbit if
3. EDH ness Movement a. All patients with there is
4. SDH 2. Headache s GCS 9 or Less than Sub
5. ICH 3. Vomiting 5. Weakness 9 Conjunct
4. ENT 6. Neck b. Patients with ival
Bleed Injuries Diffuse Injuries Hemorrh
5. Fits 7. Face c. Patients with age or
Injuries Clinical or Facial
8. Signs of Radiological signs Injuries
Increased of increased ICT
 - 105 -
S.N Scenario Includes Ask for Look for Do (Doses are for a 60 kg Adult. Investigate Specialist Opinion
o Modify Dose as needed)
ICP ie 3. Inj Phenytoin 100 mg iv tds
Bradycard 4. Inj Ranitidine 150 mg iv tds
ia and 5. iv Antibiotics
Hypertens 6. Syp KCl
ion 7. Syp Antacid
9. 8. Head Shave
9. Ryles Tube
10. Catheterisation
11. Head End at 15o to 20o
Elevation
12. Spine Board
a. Log Roll for Pain /
Stepping Deformity
8 MaxilloFacia 1. TMG 1. Vision 1. If there are any bleeding or if 1. ENT Surgeon
l Injuries Dyslocation 2. Eye there is suspicion of bleeding, 2. Neurosurgeo
2. Dental Movement Intubation or Tracheostomy n
Injuries s irrespective of GCS to prevent 3. Ortho
3. Neck Aspiration Surgeon
Injuries 2. Nasal Packing or Throat 4. Plastic
4. Head Packing ONLY AFTER Surgeon
Injuries Intubation / Tracheostomy 5. Dental
5. Loose Surgeon
Tooth

9 Ocular 1. Eye Injuries 1. Vision 1. Eye Irrigation with Normal 1. CT Scan 1. Ophthal
Emergencie 2. Loss of 2. Pupils Saline for 15 to 20 minutes Orbit Surgeon
s Vision 3. Extra 2. Cover the Eye with Sterile 2. CT Scan 2. Neurosurgeo
Ocular Gauze Soaked in Normal Brain n
Movement Saline and cover with a Sterile 3. CT Angio
Towel and Rigid Shield Neck
3. iv Antibiotics : Inj Cipro 200 Vessels
mg iv bd and Inj Metro 500 mg and
iv tds Cerebral
Vessels
10 Foreign 1. Choking Unconscious 1. Anaesthesiolo
Body Nose 2. 1. Follow BLS First gist
and Throat Conscious with Adequate Oxygen 2. ENT Surgeon
Saturation 3. Chest
1. Urgent Anaesthesiologist Physician
/ ENT Surgeon / Chest
Physician Call Over for
Bronchoscopy
2. If Above Specialists or
Facilities are not
available in the
Institution, Urgent
Tracheostomy and then
refer
Inadequate Oxygen Saturation
1. Ask Patient to Cough
2. Infants
a. Back Slaps
b. Chest Thrusts
3. Heimlich’s Maneuver

11 ENT Bleed 1. Base of 1. History of 1. Hypertens 1. If there are any bleeding or if 1. PT, 3. ENT Surgeon
Skull Anticoagu ion there is suspicion of bleeding, aPTT, 4. Chest
Fracture lants 2. Facial Intubation or Tracheostomy INR Physician
2. Epistaxis 2. History of Injuries irrespective of GCS to prevent 2. 5. MGE
3. Hemoptysis Bleeding 3. Chest Aspiration 6. SGE
4. Hemetemes Disorders Injuries 2. Vitamin K 7. General
is 4. Abdomen 3. Streptovit Surgeon
5. Injuries 4. Transexemic Acid 8.
5. 5. Nasal Pack in case of
Confirmed Epistaxis
6. Anti HT in case of Elevated BP
7. Intubation is source of Bleed
is other than Lungs
12 Neck 1. Kite String 1. Mode of 1. Look for 1. Philadephia Collar 1. ENT Surgeon
Injuries & 2. Hanging Injury Bony, 2. Hypothermia Management 2. Psychiatrist
Asphyxias 3. Mechanical 2. Time Arterial, 3. in case of
Asphyxia 3. Venous, Suspected
4. Drowning Muscular Self Harm
(Submersio Injuries
n) 2. Cardiac
Arrhythmi
a
 - 106 -
S.N Scenario Includes Ask for Look for Do (Doses are for a 60 kg Adult. Investigate Specialist Opinion
o Modify Dose as needed)
13 Chest 1. Rib 1. JVP 1. Needle Thoracostomy 1. CTS
Injuries Fracture 2. Oxygen 2. ICD 2. General
2. Pneumotho Saturation 3. Pericardiocentesis Surgeon
rax 3. Hypotensi 4. Occlusive Dressing taped on 3. General
3. Hemothora on three sides Physician
x 5. 3 Way Valve Dressing
4. Pericardial
Tamponade
5. All Other
Blunt
Injuries
6. All Other
Penetrating
Injuries
14 Abdomen 1. Penetrating 1. Mode 1. Anemia 1. Don’t touch the Objects if 1. X Ray 1. General
and Pelvic Injuries of 2. 2. Bleeding they are in contact with the Chest to Surgeon
Injuries Abdomen Urethera body or partially inside the Rule out 2. SGE
and Pelvis 3. Bladder body Diaphrag 3. Urologist
2. Bull Gore Injuries 2. Shift to Theatre as soon as matic 4.
Injuries 4. PR / PV possible Heria
3. Evisceratio 5. 3. Cover the Open Areas With 2. X Ray
n Sterile Towels soaked in Abdome
4. Emasculatio Normal Saline n Erect
n 4. Apply Pelvic Binders 3. USG
5. Perineal 5. Don’t Catheterise in case of 4. CT
Injuries Doubtful Urological injuries Abdome
6. Blunt n
Injuries
15 Multiple 1. 1. Rapid 1. Helmet Removal 1. Electroly 1. General
Injuries / Trauma 2. Philadelphia Collar tes Surgeon
Polytrauma Survey 3. Pelvic Binder 2. 2. Ortho
2. Seat Belt 4. Thomas Splint Surgeon
Injuries 5. eFast 3. Neurosurgeo
3. Helmet n
Injuries
4.
16 Vomiting 1. AGE 1. Food 1. Dehydrati 1. iv Fluids 5. USG
and 2. Food Intake on 2. iv Antibiotics 6. CT
Diarrhoea Poisoning 2. Headache 2. Electrolyt Abdome
e n
Imbalance 7. CT Brain
3. Intra
Cranial
Pressure
17 Acute 1. APD LMP (in case of 1. Anemia 1. eFAST 1. USG
Abdomen 2. Acute females) (Ectopic) 2. ECG – All Leads including 2. CT
Pancreatitis 2. Jaundice Limb Leads. ECG to Rule out Abdome
3. Renal Colic (Pancreati Inferior Wall Ischemia n
4. Acute tis due to 3. USG
Retention of Obstructio 4. Plain X
Urine n) Ray
5. Ectopic 3. Tendernes Abdome
Pregnancy s n
4. PR 5. CT
5. PV Abdome
n
18 Labour and 1. Trauma in 1. Fundus 1. Lower BP in Case of PIH 1. USG 1. Obstetricians
Obstetric Pregnancy Examinati 2. Transfusion in case of
Emergencie 2. Bleeding PV on Bleeding PV
s 3. Pain 2. BP
Abdomen 3.
4.
19 Burns 1. Thermal 1. Lung 1. Burns Protocol
Burns Damage 2.
2. Chemical due to
Burns Inhalation
3. Electrical 2. Entry and
Burns Exit
4. Wound
for
Electrical
Burns
3. Rule of
Nine
4.
20 Fever and 1. Fever 1. Dengue Protocol
Temperatur 2. Heat Stroke
 - 107 -
S.N Scenario Includes Ask for Look for Do (Doses are for a 60 kg Adult. Investigate Specialist Opinion
o Modify Dose as needed)
e 3. Hypertherm
Disturbance ia
s 4. Hypothermi
a
5. Dengue
21 Anaphylaxis 1. Bee Sting
/ Allergic 2. Food
Reactions Poisoning
22 Bites and 1. Snake Bite 1. Snake Bite Protocols
Sting 2. Scorpion 2. Scorpion Sting Protocol
Sting 3. Dog Bite Protocols
3. Dog Bite
4. Animal
Bites
5. Centipede /
Millipede
23 Poison / 1. Accidental 1. Drug History 1. Smell 1. Stomach Wash 1. Drug 1. Nephrologist
Drug and 2. Finger 2. Universal Antidote Levels Opinion
Overdose Intentional Discolorat 3. Specific Antidote 2. Electroly
Poisoning ion 4. Skin Decontamination te
2. Drug Over 3. Pupils 5. Dialysis 3. Renal
dosages Function
s
4. Liver
Function
s
24 Breathlessn 1. Asthma 1. Rule out Cardiac Causes
ess 2. Deriphylline
3. Aminophylline
25 Chest Pain 1. STEMI 1. STEMI and NSTEMI Protocols
2. NSTEMI
26 Head ache 1. Duration 1. Bradycard 4. Fundus Examination 1. CT Brain 1. Neurosurgeo
2. Side ia 5. Plain n
3. Precipitat 2. Hypertens 2. 2. Neurologist
ion Factor ion
3.
27 Stroke 1. SCSRIPT Protocols
28 Fits 1. Status 1. Drug 1. Signs of 1. Injection Phenytoin 600 mg iv 1. CT Brain 1. Neurosurgeo
Epilpepticu Intake ICP in 500 ml Normal Saline at 12 2. n
s 2. Failure to 2. ABCDE drops per minute 2. Neurologist
2. Intake 2. Injection Phenytoin 100 mg
Drugs tds

29 Agitated 1. Alcohol 1. Signs of 1. Mental 1. Physical Restrain 3. CT Brain 1. Neurosurgeo

Patients Intoxication Drug Status 2. Inj Haloperidol 4. MRI n Opinion
2. Psychiatric Intake 2. Speech Brain 2. Neurology
Conditions 2. 3. Pupils Opinion
4. 3. Psychiatrist
5. Opinion
30 Unconscious 1. Altered or 1. Jaundice 1. Pupils 1. Intubation 1. FBS, 1. Neurosurgeo
Patient Loss of 2. Munchase 2. EOM / 2. CMV Mode Ventilation with 2. Urea, n Opinion
Consciousn n DEM Midazolam 2mg/hour and 3. Creatinin 2. Neurology
ess Syndrom 3. Focal Vecuronium 2mg/hour e, Opinion
disproporti e Neurologi 3. Check for RBS 4. Electroly
onate to cal Deficit 4. tes
alteration in 4. Reflexes 5. Ketone
ABCDE 5. Breathing Bodies
2. Abnormali 6. Liver
ties Function
Tests
7. CT
8. USG
 - 108 -

Help Needed . . .
8. Protocols, by Definition, are never complete nor final. They need to be updated on daily, if not
hourly basis.
9. Hence, this manual will be
considered as Draft Manual
for eternity and your inputs
are needed for ever.
10. Contribution can be
Scientific, Technical,
Administrative etc
11. You need not be working in
Health Department to give
your input. You need not be
even a health care worker.
We request contributions
from everyone
12. You can Suggest Additions,
Deletions, Modifications,
Rearrangement of Topics
(Insertions, Deletion,
Substitution, and
Frameshift if you like
Genetics)
13. In addition to the above You can also Copy Edit (ie Correct the Grammar) or Proof Read (ie
Correct the Typos)
14. You can send in your Contributions Online at http://www.taeionline.com/book or by mail to
mail@taeionline.com mentioning the Version Number (Version Number of this draft is α.3.1) and
Page Number (found in the top right)
 - 109 -
This incluincludes the General Information

Three levels of Capacity Building ProposeAlthough the trauma center is a key component of acute care
for the critically injured trauma patient, an effective trauma system encompasses all phases of care, from
prehospital to reintegration into society.

STANDARD XVII -- OUTREACH PROGRAMS

Although the trauma center is a key component of acute care for the critically injured trauma patient,
an effective trauma system encompasses all phases of care, from prehospital to reintegration into
society. By providing multidisciplinary educational opportunities and becoming actively involved in
the formulation of community approaches to trauma care, the trauma center will aid in attaining the
goal of optimal care for all injured patients. It is desirable that the trauma center coordinate their
outreach activities with the local or regional trauma agency, if one exists. Finally, the trauma center
should consider developing these programs in response to identified, targeted local problems. Use of
national injury prevention programs are recommended to avoid replication and eliminate the need to
spend resources to develop a quality program when one has already been developed and tested.
A. The trauma service shall have written evidence documenting active involvement in at least two
public education programs (one general and one pediatric) and two public trauma prevention
programs (one general and one pediatric) per calendar year.
1. Injury prevention programs shall be chosen based upon the epidemiologic needs of the
community served by the trauma center.
2. Hospital-specific evaluation methods shall be implemented to determine the
effectiveness of the injury prevention programs.
B. The trauma service shall provide 24-hour availability of telephone consultation with members
of the hospital's trauma team and physicians of the community and outlying areas. Scheduled
on-site consultations with members of the hospital's trauma team shall be available with
physicians of the community and outlying areas. Evidence of these consultations shall be
documented.
C. Evidence of contact with referring physicians regarding patient transfers shall be documented
in all cases.
D. There shall be evidence of a minimum of 10 multidisciplinary conferences conducted per year
to provide trauma case review for the purpose of case management, education,and correction
 - 110 -
of system issues for both prehospital and in-hospital. The case review must include at least one
adult and one pediatric trauma patient when appropriate.
 - 111 -
Chapter 12
Policy for Building and Civil Works in TAEI Centres
 - 113 -
Chapter 13
Policy for Equipments in TAEI Centres

9. Policy for Equipments in TAEI Centres

1. All staff in the unit should be familiar regarding the operation and precautions in using the
equipment and machinery.
2. All accessories of defibrillator should be available at all times.
3. Any malfunction in any machine should be reported immediately to the Biomedical
Engineer.
4. Clean and disinfect instruments and equipments after each use.
5. Test load for energy charging should be done every shift by unit head nurse and
document in a sheet.
6. Joule delivery system must be checked by:
1. Charging defibrillator to 100 joules and discharging paddles.
2. Charging defibrillator to 200 joules and discharging paddles.
3. Charging defibrillator to 360 joules and discharging paddles.
7. Ensure patient cable is attached to monitor at all times.
8. The Defibrillator machine should always be plugged in AC Power and test load to be done
every shift Preventive maintenance should be maintained.
The following equipment package has been worked out as standard ER package to be
present throughout all the levels of care in the TAEI network hospitals.

ER STANDARDS EQUIPMENTS
S. No. Name of Item MCH DHQ SDH
1 AED 1 1 1
2 Central Oxygen Supply

3 Suction Apparatus 10 5 3
4 Ventilator 3 1 1
5 Pulsoxymeter 3 2 1
6 POTC - Machine (incl Cartridges)
1 1 1
7 Volume Infusion Pump
10 5 3
8 Syringe Infusion Pump
10 5 3
9 Mobile X Ray 2 1 1
10 Oxygen Flow Meter And Humidifier
10 5 3
11 ECG 2 1 1
12 Dressing Trolley 2 2 1
13 Stretchers/Multi Functional Stretcher 2

5 5
14 Wheel Chair 5 3 2
15 Spine Board 2 2 2
16 Scoop Board 2 3 1
17 Iv Stand 10 5 2
 - 114 -
18 Traction Splints (Hare, Sager, Thomas
Ring)
10 5 2
19 Crash Cart 5 3 2
20 Camera 1 1 1
21 Desktop 1 1 1
22 Printer 1 1 1
23 Flash Autoclave Machine 1 1 1

24 Auto Clave Machine 1 1 1

25 Spot Light 2 1 1
26 Cell Counter 1 1 1
27 EC Pulse (CPR Machine)
1 1 0
Video Laryngoscope
28 1 1 1

STANDARD IX -- EQUIPMENT

The rapid resuscitation, emergency management, and subsequent care of trauma patients require
specialized equipment and supplies. This equipment may be expensive and unique to the care of
trauma patients, so personnel should have appropriate training and orientation in the use, care, and
maintenance of this equipment.
Medical supplies and equipment requirements for the care of adult and pediatric trauma patients in
the treatment areas indicated below shall be readily available and shall include at a minimum the
following:
A. Trauma Resuscitation Area
1. Airway control and ventilation equipment, including various sizes of laryngoscopes and
endotracheal tubes, bag valve mask resuscitator, mechanical ventilator oxygen masks
and cannulae, and oxygen.
2. Cardiopulmonary resuscitation cart, including emergency drugs and equipment.
3. Doppler monitoring capability.
4. Electrocardiograph/oscilloscope/defibrillator.
5. Monitoring equipment for blood pressure and pulse and an electrocardiogram (ECG).
6. Pacing capability.
7. Pulse oximetry.
8. Skeletal traction devices.
9. Standard devices and fluids for intravenous (IV) administration.
10. Sterile surgical sets for airway, chest, vascular access, diagnostic peritoneal lavage, and
burr hole capability.
11. Suction devices and nasogastric tubes.
 - 115 -
12. Telephone and paging equipment for priority contact of trauma team personnel.
13. Thermal control devices for patients, IV fluids, and environment.
B. Operating Room

1. Airway control and ventilation equipment, including various sizes of laryngoscopes and
endotracheal tubes, bag valve mask resuscitator, mechanical ventilator suction devices,
oxygen masks and cannulae, and oxygen.

2. Anesthesia monitoring equipment.

3. Autotransfusion.

4. Cardiopulmonary bypass capability.

5. Cardiopulmonary resuscitation cart, including emergency drugs and equipment.

6. Craniotomy/burr hole and intracranial monitoring capabilities.

7. Endoscopes.

8. Invasive hemodynamic monitoring and monitoring equipment for blood pressure,

pulse, and ECG.

9. Operating microscope.

10. Orthopedic equipment for fixation of pelvic, longbone, and spinal fractures and fracture
table.

11. Pacing capability.

12. Standard devices and fluids for IV administration.

13. Thermal control devices for patients, IV fluids, and environment.

14. X-ray capability.

C. Post-Anesthesia Recovery

1. Airway control and ventilation equipment, including various sizes of laryngoscopes and
endotracheal tubes, bag valve mask resuscitator, mechanical ventilator suction devices,
oxygen masks and cannulae, and oxygen.

2. Autotransfusion.

3. Cardiopulmonary resuscitation cart, including emergency drugs and equipment.

4. Intracranial pressure monitoring.

5. Invasive hemodynamic monitoring and monitoring equipment for blood pressure,

pulse, and ECG.
6. Pacing capability.

7. Pulse oximetry.
 - 116 -
8. Standard devices and fluids for IV administration.

9. Sterile surgical sets for airway and chest.

10. Thermal control devices for patients and IV fluids.

D. Intensive Care Unit and Pediatric Intensive Care Unit

1. Airway control and ventilation equipment, including various sizes of laryngoscopes and
endotracheal tubes, bag valve mask resuscitator, mechanical ventilator suction devices,
oxygen masks and cannulae, and oxygen.

2. Auto transfusion.

3. Cardiopulmonary resuscitation cart, including emergency drugs and equipment.

4. Compartment pressure-monitoring devices.

5. Intracranial pressure monitoring capabilities.

6. Invasive hemodynamic monitoring.

7. Orthopedic equipment for the management of pelvic, longbone, and spinal fractures.

8. Pacing capabilities.

9. Pulse oximetry.

10. Scales.

11. Standard devices and fluids for IV administration.

12. Sterile surgical sets for airway and chest.

13. Thermal control devices for patients, IV fluids, and environment.

E. Medical Surgical Unit

1. Airway control and ventilation equipment, including laryngoscopes, endotracheal tubes

of all sizes, bag-mask resuscitator, and sources of oxygen.

2. Cardiopulmonary resuscitation cart, including emergency drugs and equipment.

3. Standard devices and fluids for IV administration.

4. Suction devices.

ER Equipment List
Cost Cost GRA
Cost Cost Tota
per Total per No Total No ND
S. per No. D per Total l No.
Name of M MC MCH DH . of DHQ SD . TOT
N unit of H SDH SDH of
Item CH H (in Q D (in H of AL
o. (in M Q (in (in Cent
(in Rs.) (in H Rs.) SD (in
Rs.) CH Rs.) Rs.) res
Rs.) Rs.) Q H Rs.)
1 Ventilator 1200 3 3600 26 93600 1 1200 31 37200 1 1200 12 14400 69 14520
 - 117 -
000 000 000 000 000 000 000 0000
POTC -
Machine 8000 8000 20800 8000 24800 8000 96000 55200
2 1 26 1 31 1 12 69
(incl 00 00 000 00 000 00 00 000
Cartridges)
EC Pulse
6000 6000 15600 6000 18600 34200
3 (CPR 1 26 1 31 0 0 12 0 69
00 00 000 00 000 000
Machine)
Mobile X 3500 7000 18200 3500 10850 3500 42000 33250
4 2 26 1 31 1 12 69
Ray 00 00 000 00 000 00 00 000
3750 3750 97500 3750 11625 3750 45000 25875
5 Cell Counter 1 26 1 31 1 12 69
00 00 00 00 000 00 00 000
Flash
3000 3000 78000 3000 93000 3000 36000 20700
6 Autoclave 1 26 1 31 1 12 69
00 00 00 00 00 00 00 000
Machine
Video
2000 2000 52000 2000 62000 2000 24000 13800
7 Laryngoscop 1 26 1 31 1 12 69
00 00 00 00 00 00 00 000
e
Volume
3000 3000 78000 1500 46500 9000 10800 13530
8 Infusion 10 26 5 31 3 12 69
0 00 00 00 00 0 00 000
Pump
Pulse 8000 2400 62400 1600 49600 8000 96000 12160
9 3 26 2 31 1 12 69
oxymeter 0 00 00 00 00 0 0 000
Syringe
1 2300 2300 59800 1150 35650 6900 82800 10373
Infusion 10 26 5 31 3 12 69
0 0 00 00 00 00 0 0 000
Pump
1 1500 1500 39000 1500 46500 1500 18000 10350
AED 1 26 1 31 1 12 69
1 00 00 00 00 00 00 00 000
1 Auto Clave 1500 1500 39000 1500 46500 1500 18000 10350
1 26 1 31 1 12 69
2 Machine 00 00 00 00 00 00 00 000
Stretchers/
1 Multi 2500 1250 32500 1250 38750 5000 60000 77250
5 26 5 31 2 12 69
3 Functional 0 00 00 00 00 0 0 00
Stretcher
1 Suction 1100 1100 28600 5500 17050 3300 39600 49610
10 26 5 31 3 12 69
4 Apparatus 0 00 00 0 00 0 0 00
1 2000 1000 26000 6000 18600 4000 48000 49400
Crash Cart 5 26 3 31 2 12 69
5 0 00 00 0 00 0 0 00
1 5000 1000 26000 5000 15500 5000 60000 47500
ECG 2 26 1 31 1 12 69
6 0 00 00 0 00 0 0 00
1 4000 4000 10400 4000 12400 4000 48000 27600
Desktop 1 26 1 31 1 12 69
7 0 0 00 0 00 0 0 00
1 4500 11700 2700 83700 1800 21600 22230
Wheel Chair 9000 5 26 3 31 2 12 69
8 0 00 0 0 0 0 00
1 Dressing 1000 2000 52000 2000 62000 1000 12000 12600
2 26 2 31 1 12 69
9 Trolley 0 0 0 0 0 0 0 00
2 1400 36400 2100 65100 10990
Scoop Board 7000 2 26 3 31 1 7000 12 84000 69
0 0 0 0 0 00
2 1400 36400 1400 43400 1400 16800 96600
Spine Board 7000 2 26 2 31 2 12 69
1 0 0 0 0 0 0 0
2 1000 2000 52000 1000 31000 1000 12000 95000
Spot Light 2 26 1 31 1 12 69
2 0 0 0 0 0 0 0 0
Oxygen
2 Flow Meter 2000 52000 1000 31000 90200
2000 10 26 5 31 3 6000 12 72000 69
3 And 0 0 0 0 0
Humidifier
2 1000 1000 26000 1000 31000 1000 12000 69000
Printer 1 26 1 31 1 12 69
4 0 0 0 0 0 0 0 0
2 1000 26000 15500 43900
Iv Stand 1000 10 26 5 5000 31 2 2000 12 24000 69
5 0 0 0 0
2 15600 18600 41400
Camera 6000 1 6000 26 1 6000 31 1 6000 12 72000 69
6 0 0 0
2 Traction 300 10 3000 26 78000 5 1500 31 46500 2 600 12 7200 69 13170
 - 118 -
7 Splints 0
(Hare,
Sager,
Thomas
Ring)
2 Multi Para
8 Monitor
21533 15513 48727 41919
TOTAL
2000 9500 200 8700
 - 119 -
Chapter 14
Policy for Consumables in TAEI Centres

10. Policy for Consumables in TAEI Centres

9. Crash Cart is a portable trolley containing all drugs and consumables required for
cardiopulmonary resuscitation and emergency care. It is made mandatory for all TAEI
centers as it considered a ‘the magical weapon’ in resuscitation of patients in emergency
room.
10.The Crash cart to be set up as per the TAEI standard guideline
11.The crash cart check list has to be checked by the TAEI ED nurse on duty and counter
signed by the nursing superintendent and HTNO every week and month respectively.
12.Crash cart contents must always be complete and in working condition and should be
checked immediately after a Code Blue procedure.
13.All staffs in the unit should be well oriented with the contents and use of crash cart
14.All medicines should be returned month before the expiration date
15.All equipments and medical supplies should be in proper order and functioning properly
16.Like CEMONC pass book separate TAEI passbooks will be prepared and procurement will
be done on a regular basis through TNMSC.
17.The following are the list of consumables that has been worked out as standard ER
package to be present throughout all the levels of care in the TAEI network hospitals.

ER STANDARD CONSUMABLES
S. No. Name of Item MCH DHQ SDH
III CONSUMABLES
1 Iv Sets Macro 150
2 Iv Sets Micro 30
3 Syringe 2Cc 500
4 Syringe 5Cc 300
5 Syringe 10Cc 50
6 Syringe 20Cc 20
7 Syringe 50Cc 10
8 Extension Line 10Cm 70
9 Extension Line 100Cm 20
10 Surgical Gloves 7.0 200
11 Surgical Gloves 8.0 50
12 O2 Mask Adult 150
13 O2 Mask Paediatric 100
14 Nrbm Adult 100
15 Nrbm Paediatric 70
16 Neb Kit Adult 3500
17 Neb Kit Paediatric 1400
18 Opa 1 2
19 Opa 2 2
20 Opa 3 3
 - 120 -
21 Opa 4 3
22 Npa 6.0 1
23 Npa 7 2
24 Iv Cannula 24G 50
25 Iv Cannula 22G 50
26 Iv Cannula 20G 50
27 Iv Cannula 18G 3
18 Iv Cannula 16G 3
29 3 Way Connector 40
30 Ryles Tube No: 10 1
31 Ryles Tube No: 12 1
32 Ryles Tube No: 14 20
33 Ryles Tube No: 16 15
34 Ryles Tube No: 22 1
35 Intra Osseous Needles -5 1
36 Magills Forceps 40
37 Ecg Leads/ Jelly 1000
38 Bain Circuit 50
39 Chest Tube Insertion Equipment 1
40 Suction Catheter 12F 1
41 Suction Catheter 14F 20
42 Suction Catheter 16F 15
43 Et Tube 4.0 1
44 Et Tube 4.5 1
45 Et Tube 5.0 1
46 Et Tube 5.5 1
47 Et Tube 6.0 2
48 Et Tube 6.5 7
49 Et Tube 7 3
50 Et Tube 8 2
55 Torniquet 40
56 Scissors 30
57 Cloth Plaster 200
58 Iv Stand 30
59 Thermometer 15
60 Blanket 50
61 Suction Catheters( 14, 16 Size)
62 Sterile Gloves (6.5, 7, 7.5, 8.0)
63 Ambu Bag Adult
64 Ambu Paediatric
65 Stethescope Adult
66 Stethescope Paediatric
67 Laryngoscope Adult
68 Laryngoscope Paediatric

69 Laryngoscope 1,2,3,4, Blade Curved

 - 121 -
70 Laryngoscope Straight Blade 1,2

71 Bougie
72 Anatomical Mask Paediatric 0,1,2

73 Anatomical Mask Adult 3,4

74 Micropore
75 Disposable Mask
76 Disposable Apron
77 Foleys Catheter
78 Urobag
79 Suture Removal Scissors

80 Suture Cutting Scissors(Straight)

81 Suture Cutting Scissors (Curve)

82 Pop Scissors
83 Gauze Cutting Scissors
84 Ss Bin (Medium)
85 Ss Bin (Large)
86 Ss Tray (Small)
87 Ss Tray (Medium)
88 Ss Tray (Large)
89 Cheatle Forceps
90 Nagle'S Forceps (Adult)

91 Nagle'S Forceps (Pead)

92 Sponge Holder
93 Art Forceps (Straight)
94 Art Forceps (Curve)
95 Art Forceps (Long)
96 Thumb Forceps (Toothed)

97 Thumb Forceps (Non -Toothed)

98 Sinus Forceps
99 Mosquito Curved
100 Mosquito Straight
101 Needle Holder
102 Tracheal Retractor
103 Bowls
104 Tongue Depressor
105 Knee Hammer
106 Sterilizer (H2O)
107 Btype O2 Cylinder&Flowmeter/Holder
 - 122 -
108 D Type O2 Cylinder& Flowmeter/Holder (Bulk)

109 Glucometer
110 Air Sterilizer
111 Catheterisation Tray
112 Central Venous Lines Tray

113 Lma All Size

114 Emergency Light
115 Fetal Scope
117 Gastric Lavage Tube
118 Gauze Place Bin
119 Googles (Sets)
120 Hair Trimmer Machine
122 Kidney Tray
123 Bed Pan
124 Large Basin For Washing Wounds

125 Macintosh Sheet

127 Otoscope
128 Pen Torch
129 Portable O2 Cylinder
130 Sharp Container
131 Stop Watch
133 Tin - Spin (Metal Cutter)

134 Trolleys
135 Suction Apparatus With Electrical & Manual

136 Weight & Height Machine

137 Mobile Screen

138 Storage Bin
139 Pvc Tray (Small)
140 Pvc Tray(Large)
141 Pvc Tray(Medium)
142 Pvc Box Rectangle (L)
143 Pvc Box Rectangle(M)
144 Pvc Box Rectangle(S)
145 Nail Cutter
146 Razor Set
147 Plastic Tube(M)
148 Shoes For Doctors, Ecp & Emt - Washable
(White)

149 Dust Bin (Medical Disposable) Small

150 Dust Bin (Surgical Disposable) Small

 - 123 -
151 Dust Bin (Disposable) Small

152 Dust Bin (Medical Disposable) Extra Large

153 Dust Bin (Surgical Disposable) Extra Large

154 Dust Bin (Disposable) Extra Large

155 Torch Light - Chargable

156 Opthalmoscope
157 BP App
158 Step Stool for CPR

TAEI ER Consumables List

SN CRASH CART LIST
Draw 1
1 Adult laryngoscope
2 Paed laryngoscope
3 1,2,3,4 curved blade
4 1,2 straight blade
5 Battery
6 Bougie
7 Suction catheter
8 ET tube (7,7.5,8 No)
9 Stylet
10 Tie and Elastoplast
11 Torch with Batteries
12 magills forceps
13 oro pharyngeal airway
14 nasopharngeal airway 6,7
Draw 2
15 ECG leads 3
16 Jelly
17 Sterillium Hand sanitiser

Bag Valve Masks (BVM) in Adult, Child, & Infant Sizes Equipped with
Operable Pressure Relief Valves and Transparent Masks, with Oxygen
18 Reservoir/Accumulator.

19 The Pediatric BVM Shall Have Masks for Neonate, Infant, and Child.
 - 124 -

Single Use, Transparent, Non-Rebreather Oxygen Masks in Adult and

20 Pediatric Sizes

21 Nasal Cannulae in Adult and Pediatric Sizes

Draw 3 - Drugs
22 Adrenalin
23 Atropine 5 amps
24 Adenosin 5 amps
25 Amiodaron 6 amp
26 Dopamine 2 amp
27 Scoline( store in fridge)
Draw 4
28 ABG syringe 2
29 16-22 G Needle
30 IV set
31 Micropore
32 3 way
33 Needles
34 Syringe 50 cc
35 Syringe 2cc, 5cc, 10cc
Draw 5
36 5% dextrose
37 RL
38 NS
39 Intraosseous Needle – 5
PPE -Personal Protection
40 Goggles
41 Surgical Masks

42 Disposable Synthetic Gloves for all Attendants

43 Disposable Biohazard Bags For Non-Sharp Waste

44 Standard Sharps Container Both Fixed and Portable

45 Disinfectant For Solution for Cleaning Contaminated Equipment

Waterless Hand Cleaner, Commercial Antimicrobial (Towelette, Spray, or

46 Liquid)

47 Plastic Aprons or Fluid Resistant Gowns

Immobilsation devices
48 Philadelphia Collar/ C collar
 - 125 -

Rigid Cervical Immobilization Devices in Appropriate -

Adult,
Child, and
Infant Sizes

Head Immobilization Device (NOT SANDBAGS) –

Firm Padding OR
49 Commercially Available Device

50 Upper and Lower Extremity Immobilization Device(s):

Lower Extremity Traction Splint in Appropriate-

Adult and
51 Child Sizes
52 Broad arm slings
53 Triangular slings
54 Roller gauze
55 Wooden piece to splint
56 Pelvic Binder
ICD Kit
57 Needle Holder straight 8''
58 Kellys Clamp- curved 8"
59 Tray with Lid
60 Stainless steel cup
61 Artery forceps straight 6"
62 Artery forceps straight 8"
63 Toothed forceps
64 Gauze
65 Cotton Balls
66 Biopsy Towel
67 Scalpel Holder with blade
68 Suture scissor sharp
69 Chest Tube

Bleeding Control and Wound Management

70 Abdominal Trauma Dressing
71 Sterile Gauze in Various Sizes
72 Gauze Rolls in Assorted Sizes
73 Triangular Bandages
74 Occlusive Dressings or Equivalent

75 Sterile Water or Saline Solutions for Irrigation

76 Arterial Tourniquet
 - 126 -

77 Sterile Burn Sheets or Medical Director Approved Burn Care Supplies

78 Adhesive Tape
79 1” & 2” Hypoallergenic
80 1” & 2” Adhesive

Patient Assessment/Diagnostic Measurements

81 Stethoscope in Sizes to Accommodate all Patients

82 - Paediatric
83 - Adult
84 - Infant

85 Blood Pressure Cuffs in Sizes to Accommodate all Patients

86 - Paediatric
87 - Adult
88 - Infant
89 Thermometer(s)
90 - Oral thermometer
91 - Rectal thermometer
92 - Biohazard thermometer

93 Scissors for Cutting Clothing, Belts, and Boots

94 Broselows Tape
95 Pulse Oximeter with
96 - Adult and
97 - Pediatric Probes
Additional Equipment –

98 Glucometer with Reagent Strips and Single-Use Lancets

99 CPAP Equipment
100 Nebulizer Equipment

101 Equipment to Capture Out-Of-Hospital 12 Lead

102 Advanced Airway (Non-Visualized Approved by Title 172 NAC 11)

103 If Monitoring IV Solutions, Intravenous Fluid Bag Pole or Roof Hook

Miscellaneous Equipment

104 Device Capable for Pediatric Immobilization

105 Ocular Irrigation Device
106 Hot Pack(s)
 - 127 -
107 Cold Pack(s)
108 Emesis Bags/Basin
109 Urinal
110 Bedpan
STOCK
111 Blankets

112 Sheets – At Least One Change Per Cot

113 Pillows
114 Towels
115 Step Stool for CPR

116 Oro-gastric lavage tube (Boas tube)

117 Foleys Catheter
118 Uro Bag
119 Knee Hammer
120 Cheatles Forceps
121 Catheterisation Tray
122 Central Venous Lines Tray
123 Fetal Scope
124 Hair Trimmer
125 Weight and Height Machine
126 Portable Oxygen Cylinder
127 Nail Cutter
128 Raizor set
129 Ophthalmoscope
130 Colour Coded Dust Bins
 - 129 -
Chapter 15
Policy for Drugs in TAEI Centres

Policy for Drugs in TAEI Centres

18.The Drugs in the Crash cart to be set up as per the TAEI standard guideline
19.The crash cart check list has to be checked by the TAEI ED nurse on duty and counter
signed by the nursing superintendent and HTNO every week and month respectively.
20.Crash cart contents must always be complete and should be checked immediately after a
Code Blue procedure.
21.All staffs in the unit should be well oriented with the indications and contra indications of
the drugs in the crash cart
22.All medicines should be returned month before the expiration date
23.Update Crash Cart of the required medicines.
24.Any medicines or item not available in the Crash Cart must be endorsed to the Trauma
Nurse Co-ordinator on duty for immediate requisition and replacement.
25.Keep the Crash Cart clean and in usual order.
26.Locations of medicines and life saving items should not be interchanged to avoid
misguiding the staff and to locate easily when needed.
27.Use medicines, IVF, supplies strictly for emergency purposes only.
28.Keep the Crash Cart in place easily accessible for all staffs.
29.All medications of crash cart should be in a pre-filled or pre-made form.
The following are the list of drugs that has been worked out as standard ER package to
be present throughout all the levels of care in the TAEI network hospitals.
Like CEMONC pass book separate TAEI passbooks will be prepared and procurement will
be done on a regular basis through TNMSC.

ER STANDARD DRUGS
S. No. Name of Item MCH DHQH SDH
II DRUGS
1 Ns -500ml
2 Rl-500ml
3 D25%
4 Inj Atropine
5 Inj Adrenaline
6 Inj Amiodarone
7 Inj Soda Bicarb
8 Inj Midazolam
9 Inj Adenosine
10 Inj Dopamine
11 Inj Dobutamine
12 Inj Ntg
13 Inj Mgso4
 - 130 -
14 Inj Lasix
15 Inj Vasopressin
16 Inj Kcl
17 Inj Ca Gluconate
18 Inj Lidocaine
19 Inj Lorazepam
20 Sterile Water
21 Inj. Paracetamol 1G- Iv
22 Paracetamol Suppository

Emergency Drugs List

II DRUGS in ER
1 Ns -500ml
2 Rl-500ml
3 D25%
4 Inj Atropine
5 Inj Adrenaline
6 Inj Amiodarone
7 Inj Soda Bicarb
8 Inj Midazolam
9 Inj Adenosine
10 Inj Dopamine
11 Inj Dobutamine
12 Digoxin
13 Diltiazem
14 Heparin
15 Inj Mgso4
16 Inj Lasix
17 Inj Vasopressin
18 Beta Blockers
19 Calcium Channel Blockers
20 Inj Kcl
21 Inj Ca Gluconate
22 Inj Lidocaine
23 Inj Lorazepam
24 Barbiturates
25 Benzodiazepine
26 Sterile Water
27 Carbamazipine
28 Calcitonin
29 Scoline (To store in fridge)
30 Antisnake Venom(ASV)
 - 131 -
31 Activated Charcoal
32 N-acetyl Cysteine
33 Nalaxone
34 Inj Ntg
35 Tetanus Toxoid
36 Inj. Tramadol
37 Inj. Paracetamol 1G- Iv
38 Paracetamol Suppository
39 Fentanyl
40 Ketamine
41 Anti Rabies Vaccine
42 Inj.Vit. K
43 Nor Adrenaline
44 Hydrocortisone
45 Pheniramine Maleate
46 Inj Avil
47 Inj Diazepam
48 Inj. Dexamethasone
49 Inj Morphine
50 Inj Largactil
51 Inj Mannitol
52 Inj Phenargan
53 Inj Insulin
54 Inj Ranitidine
55 Inj Dilantin
56 Inj Tranexamic Acid
57 Inj Pantoprazole
58 Inj Haloperidol
57 Inj. Ondensetron
58 Inj Aminophylline
59 Inj Glycerl Tri Nitrate (GTN)
60 Inj Piperacillin Sodium
61 Inj. Quinine
62 Inj Streptokkinase
63 Inj Urokinase
64 Dulcolax Suppository
 - 133 -
Chapter 16
Policy for Electronic and Paper Record Maintenance in
TAEI Centres

12. Policy for Stationary and Records in TAEI Centres

Record maintenance and Documentation are vital component that enable in data
management, streamlining workflow mechanisms and medical research etc.
More so in the electronic record systems which facilitate patient care management,
decision support systems, and other advanced administrative functions.
Now, in the TAEI network hospitals, the Emergency Department should maintain the
following registers:
- Triage Form
- Case Sheets
- Admission Register with Pre arrival Intimation Status
- Discharge Register
- Death Register
- MLC register
- Transfer in and out register
- Crash cart Checklist
The HTNO and TNC should ensure that all the records are complete at any point of time
and are made available.
The case sheets to be audited for completeness , accuracy and legibility of the data once
a month by the HTNO.
Guidelines for Operational Cost towards the TAEI
1. Formation of the Committee with a Nodal Officer for each of these Trauma care Centers
(Institutions under TAEI)

A committee shall be formed with a nodal officer (Hospital Trauma Nodal Officer)with the
following members

SN Composition Medical Colleges Government

Hospitals

1 Chairman Dean Hospital

Superintendent/
CMO

2 Member Secretary Hospital Trauma Hospital Trauma

 - 134 -
Nodal Officer Nodal Officer
(HTNO) (HTNO()

3 Member Hospital Resident Medical

Superintendent Officer

4 Member Trauma Nurse Trauma Nurse

Co-ordinator Co-ordinator
(TNC) (TNC)

5 Member Administrative Administrative

Officer (AO) Officer (AO)

(In case of more (In case of more

than one AO the than one AO the
senior most AO) senior most AO)

2. The committee can decide to spend the operational cost funds for the following

a. Stationeries

b. Printing of sheets , forms

c. Designing and making/ printing of signage , boards, IEC materials

d. Procurementof consumables

e. Xeroxing case sheets

f. Expenses for meetings , critical case reviews

g. Fuel for generators

h. Annual maintenance contract for emergency equipments if not available in M& R

i. Minor Civil Works including Electrical Fitttings if not not available in M & R

j. Data Entry Charges

k. Any other item related to Emergency Care if otherwise

 - 135 -
3. The expenses have to be related to TAEI activities , ER room only and not diverted for
other activities

4. In case there is no separate Bank Account for ER activities , a new Bank account shall be
opened in a Nationalised bank with the head of institution and HTNO as joint account
holders
 - 137 -
Chapter 17
Policy for Universal Precautions

16. Policy for Universal Precautions

Introduction:
The Emergency Department personnel are at high risk of developing infections, specially
the nurses, students and support staff have quite often been exposed to needle stick
injury and as there is weak or absent reporting framework in the institution, several of
them end up with life threatening infections.
Needle stick Injuries continues to remain a silent epidemic among the HCW in the
Government hospitals, hence it is high time a basic minimum Policy for universal
precaution is formulated for the larger benefit.
Policy for Universal Precautions:
“Standard Precautions include a group of infection prevention practices that apply to all
patients, regardless of suspected or confirmed infection status, in any setting in which
healthcare is delivered.
The main purpose of the Universal precautions is to break the chain of infection and is
designed to protect patients, staff and visitors. It should be used for ALL patients at ALL
times!
The following are the cardinal points to be followed in ER.
1. Consider all patients as possible biohazard
2. Assume all blood ,body fluids and tissues to be contaminated
3. Assume all unsterile needles and sharps to be contaminated
4. Hand hygiene: Mandatory careful hand hygiene, preferably with alcohol based hand
sanitizer, before and after procedures and between patients
5. Personal Productive Equipments :
• Gloves, masks, aprons should be worn while encountering a patient in
emergency especially while contact with blood and body fluids is likely or non-
intact skin in All patients.

• Masks & protective eyewear to be worne during procedures likely to generate

droplet of blood or body fluids
• A simple thin Plastic apron to be used inorder to prevent the soaking of the
inner clothes and exposure to harmful microbes

• Goggles or face masks should be worn when splashing of blood or body fluids
is anticipated.

• Appropriately sized face masks should be worn in cases of suspected airborne

infection (e.g., tuberculosis, SARS)
6. All ED personnel should be trained to identify high-risk patients with potential
communicable infections.
 - 138 -
7. Proper Disposal of sharps :
• All used needles and sharps should be deposited in thick walled puncture
resistant containers.
• Bending should be prohibited.
• Do not recap the needles to avoid needle stick injures,
• All used Disposable syringes and needles should be discarded at the point of
generations.
• Do not overfill the sharps container
• Sharps containers will be inspected daily by the house keeping staff. Full
containers will be discarded as per protocol and be replaced by empty
containers.
8. Sharps & Needle stick Injury:
• Sharps pose a potential hazard as they may be contaminated with infectious
substances and can cause injury through cuts or puncture wounds.
• Sharps must be handled with care at all times.
• Always ensure safety syringe like Hypodermic Needles,Phlebotomy Needles,IV
Catheters,Winged-Steel Needles,IV Delivery Systems,Lancets,Scalpels,Suture
Needles, Insulin pen needles, Prefilled syringes , Vacuum tube blood-
collection devices ,Arterial blood syringes are available in ER
9. In case of needle stick injury????
• Wash the wound thoroughly with soap and water
• Eyes to be irrigated with water, saline or sterile irrigants
• Splashes on nose mouth or skin should be washed with water
• Alert your supervisor
• Report to SSHS duty doctor immediately (2009/ 05012)
• Screen the source for HIV,HBV & HCV
• Post exposure prophylaxis for HIV & HBV when indicated.

10.Airborne Precautions are Designed to prevent airborne transmission of droplet nuclei or

dust particles containing infectious agents like:
Tuberculosis, Varicella, SARS, Measles, etc
11. To ensure Transmission based precaution:
• Airborne precaution for disease transmitted by small droplets
• Droplet precautions for diseases transmitted by large droplets.
• Contact precaution for disease transmitted by direct contact with
patients (i.e. wounds, skin infection, enteric infection, etc.)
12. Handling of infected linen :

All clean linen is to be kept covered.

All used linen is to be handled with gloves and deposited in the dirty linen area.

13. Waste Disposal : To follow hospital protocols

14. Patient care Equipments To follow hospital protocols
 - 139 -
15. Disinfection and Sterilization To follow hospital protocols
16. Proper reporting, Diagnostic testing and treatment framework to be
established for HCW affected with Hospital acquired infections.
 - 141 -
Chapter 18
Policy for Rehabilitation

17. Policy for Rehabilitation

Rehabilitation in Emergency Medical Team:
Quality of life outcomes of patients with musculoskeletal trauma are largely influenced
by rehabilitation care and support. Early rehabilitation can result in achieving better
health outcomes, reduce costs by shortening hospital stays, reduce disability and
improve quality of life.
Rehabilitation provider works to ensure the patient achieve the best possible functional
outcome after an injury or illness. They play a vital role in ensuring access to rehab care
by linking people with long term needs and support needs to local services.
In the Emergency Room (ER)
Acute Stage:
The Multi-disciplinary team attending to the patient in ER, must consist of a
Physiotherapist who will meet the patient’s family, counsel them and make a quick
assessment of the patient which will help to :
• Decide on the Musculoskeletal Assessment to avoid complications like contractures
/ mal-unions.

• Perform chest physiotherapy and maintain the normal range of motion of all the
joints to avoid adhesions

• Counselling for assurance and explaining the treatment plan

• Begin full-fledged Rehabilitation treatment plan which will be taken up after the
exit of the patient from ‘ER’

• Collect pre-recorded vitals from ER, Positioning of the patient, issuing instructions
to the staffs on how to shift the patient.

Sub-Acute:
• Major roles depending on the requirement of the patients.

• Restoring mobility should always be considered.

Long term:

• Assess patients level of physical function and their previous capabilities to ensure
that they are treated in the most appropriate environment or discharged to the
most suitable location for their needs.

• Highlight patients’ on-going needs and refer to other community services that will
maximise recovery and prevent readmission.

• Prevent unnecessary hospital admissions while helping to successfully discharge

those who have received care and are clinically fit to go home.

Composition of Rehab team:

 - 142 -
• Physiatrists –

- Direct all aspects of the rehabilitation program, their broad medical expertise
allows them to diagnose and treat pain as a result of an injury, illness, or
disabiling conditions.

- Lead medical professionals, including physiotherapists, occupational therapists,

and physician extenders to optimize patient care. Work with other physicians,
which may include primary care physicians, neurologists, orthopaedic surgeons
and other specialists to treat patient as a whole.

- Depending upon the injury, illness or disabling condition, Physiatrists may use
procedures like EMG/ Nerve conduction velocities, ultrasound guided
procedures

- Injections of spine and joints, Discography, Disc decompression, Perpipheral

and Spinal nerve stimulators and blocks, spasticity treatment with injections,
nerve and muscle biopsy, orthotic and prosthetic prescription, disability/
impairment assessment, Medicolegal consulting.

• Physiotherapists

- They work to streghthen the muscles, prevent stiffness and to maintain good
range of movements to emphasize gait training and improved balance.

- They evaluate strength, endurance , coordination, and movement in order to

achieve the best outcome from therapy.

- They work closely with various orthopaedic, neurological, and cardiorespiratory

conditions with various assessment tools and specific protocols to improve
quality of life and to prevent the severity of the disability.

- Early mobilisations, active and passive exercises, free and resisted exercises,
weight bearing and functional exercises for musculoskeletal conditions,
including post operative and post immobilisation stages of fracture.

- They help and encourage patients to return to normal work to earn their living.

- Chest physiotherapy, Postural drainage set up, positioning, breathing exercises

with respirometer, chest expansion and mobilisation, breathing exercises,
cardiac endurance training, aerobic exercises as a advanced exercises for follow
up post operative rehabilitation protocol for CABG, and other cardiorespiratory
operative procedures.

- Assessment of sensory, motor and cranial nerve examination for neurological

interventions to provide quality treatment includes, Muscle inhibition and
 - 143 -
facilitation, stretching and strengthening exercises, proper shifting and teaching
transfer techniques, circuit class therapy includes ( balance exercises,
coordination, gait training, upperlimb strengthening, mirror therapy).
Functional task oriented exercises to engage the central nervous system.

- Assessment of disabled conditions and supporting orthotic and prosthetist to

teach about fitting, training and re training about the use of the devices and to
imnprove the activities of daily living.

• Occupational therapist

- work to improve activities of daily, which include bathing , dressing, toileting,

grooming, and eating. In addition, they may assesss cognitive and perceptual
skills. They work on various neurologicial, paediatric and post operative
conditions. Intervention may be needed in sub acute stages.

• Prosthetist and Orthotist

- Provides supportive devices for the instable joints and injured sites to stabilise
the joints to prevent further damage.

• Rehabilitation Nurse / Social worker

- Provide assistance to the patient and family with emotional. Financial, family
issues and coordination of family meetings.

Discharge

- If the patient has been declared medically fit for discharge by the medical
team, there are no further investigations pending and the patient has no
attachments (IV, catheter) and an immediate physiotherapy assessment would
facilitate a timely discharge. These assessments are a priority.
- The Emergency rehabilitation team can also refer patients onto the community
rehabilitation team or Primary health centres for the follow up sessions, which
works within the community and will meet any short-term care and therapy
needs the patient may have after discharge, such as providing additional home
support or help with domestic activities and ongoing therapy interventions.

Conclusion:
Patients will be :

- discharged safely having undertaken a full physiotherapy assessment to an

appropriate location.
 - 144 -
- referred to appropriate services that could maintain safety at home and/or
prevent further admissions.

- satisfied by the service they have been provided.

References:

I. World Health organisation – Rehabilitation in Emergency Medical teams

II. Communication from Chief Commissioner for Persons with Disabilities to Medical
Council of India and Indian Medical Association. No.9 – 3 / CCD / 2007.

III. Duties and Responsibilities for the post ‘Senior Physiotherapist’ and
‘Physiotherapist’ from Dr. Ram Manohar Lohia Hospital, New Delhi.

IV. ARTHRITIS RESEARCH UK

V. University of Massachusetts Lowell, USA

VI. Manual for participants: Emergency Triage Assessment and Treatment World
Health Organization

VII. Michael T. Lebec and Carleen E. Jogodka, The Physical Therapist as a

Musculoskeletal Expert in the Emergency Department, Journal of Orthopaedic &
Sports Physical Therapy

VIII. Farrell SF. Can physiotherapistscontribute to care in the emergency department?

AMJ 2014, 7, 7, 315–317 http//dx.doi.org/10.4066/AMJ.2014.2183

IX. The Value of Physiotherapy: Emergency Department, Canadian Physiotherapy

Association

X. S.A. Lefmann, L.A. Sheppard, Perception of emergency department staff of the

role of physiotherapists in the system: a qualitative investigation.
 - 145 -
XI. https://www.nth.nhs.uk/services/emergency-care-therapy

XII. https://www.myhealth.london.nhs.uk/sites/default/files/33.%20East%20Surry%20Hospit
al%20Emergency%20Department%20Therapy%20Team_0.pdf

XIII. http://www.sfh-tr.nhs.uk/index.php/king-s-mill-hospital/emergency-department-and-
emergency-assessment-unit-therapy-team

XIV. http://www.ipswichhospital.nhs.uk/news/emergency-therapy-team.htm

STANDARD XV -- ACUTE REHABILITATIVE SERVICES

A trauma service should provide for the rehabilitation of its patients, with the goal of returning to
society an individual who functions at the highest possible level consistent with his or her injuries.
Early rehabilitation minimizes the risk of secondary complications that may interfere with or limit
functional recovery. Members of the trauma service should also work with colleagues to prepare the
patient and family physically, psychosocially, and emotionally for the transition to rehabilitation and
ultimately for return to the community.

A. The trauma medical director shall establish injury categories to identify trauma patients as
candidates for rehabilitative services. At a minimum, the injury categories shall include trauma
patients with musculoskeletal, cognitive, and other neurological impairments.
B. The trauma medical director or trauma program manager shall ensure that trauma patients
meeting the criteria established above have an evaluation by any or all of the following (as
appropriate to the patient's injury) within 7 days of inpatient admission:
1. Attending trauma surgeon, neurosurgeon, neurologist, or orthopedic surgeon.
2. Neuropyschologist.
3. Nursing personnel may include the following:
a. Trauma program manager or designee.
b. Clinical nurse specialist.
c. Rehabilitation nurse.
4. Occupational therapist.
5. Physiatrist or medical director of the rehabilitation services department.
6. Physical therapist.
 - 146 -
7. Speech therapist.

C. The consultant shall document this evaluation in the patient's medical record. Documentation
shall include any short- or long-term rehabilitation goals and plan.
D. The physician with primary responsibility for the patient shall review the assessment and
recommendations within 48 hours and document the review in the patient's medical record.
E. The trauma center shall have one of the following for long-term rehabilitative services:
1. A designated rehabilitation unit
2. A rehabilitation unit designated by the Department of Health.
A written transfer agreement in place with one of the above stated facility types, and written medical
transfer policies and protocols for when to initiate a transfer to ensure the timely and safe transfer of
the trauma patient.

STANDARD XVI -- PSYCHOSOCIAL SUPPORT SYSTEMS

Post Traumatic Stress Disorder is a common feature of Trauma. The trauma center should assure that
qualified personnel are available to assess and support the patient and the patient's family or
significant others. This should include crisis intervention, acceptance and adaptation to the
repercussions of the injury, and facilitation of the transition from the hospital.

A. The trauma center shall have written policies and protocols to provide mental health services,
child protective services, and emotional support to trauma patients or their families. At a
minimum, the policies and protocols shall include qualified personnel to provide the services
and require that the personnel shall arrive promptly at the trauma center when summoned.
B. Qualified personnel may include, but are not be limited to, the following:
1. Nurses (in addition to resuscitation area personnel).
2. Spiritual care representatives.
3. Patient advocates or representatives.
4. Physician consultants.
5. Psychologists or psychiatrists.
6. Social service workers.
C. Drug and alcohol counseling and referral services shall be available for patients and their
families.
The personnel listed in B.1-6 shall document these interventions in the patient's medical record.
 - 147 -
Chapter 19
Policy for Mass Casualty and Disaster Management in TAEI

STANDARD XX – DISASTER PLANNING AND MANAGEMENT

• The trauma center shall meet the disaster related requirements

• As per the guidelines of National Disaster Management Authority (NDMA) the principles of MCM
need to be followed such as
• Notification, Verification, Activation, Response and Deactivation.
• They are time bound and provided by trained Health Care personnel as cited above.
 - 149 -
Chapter 20
Policy for Quality of Care, Monitoring & Evaluation in TAEI

TAEI ER Check List

 - 150 -

A
S.No. Activities Statues Remarks
Yes/No
1.OUTSIDE EMERGENCY DEPARTMENT
Signage in the city on
main roads to inform the
1 Location of TAEI Center
TAEI Boards & signage on
the boundary wall of the
2 hospital
3 TAEI – ED
One way entry and exit
to emergency- with
Exit/entrance signage
Boards
Adequate lighting along
the boundary wall and at
entry and exit of the TAEI
4 ED
Safe drinking water Port
near main exit of the
5 TAEI ED
Designated Ambulance
6 Bay
Parking facility for:
7 (a) Ambulance
(b) Staff Vehicles
(c) Public Vehicles
(d) Clear “no parking
zone” outside
emergency area to
ensure smooth inflow
of traffic for bringing
and taking emergency
cases

Signage for Stretchers/

8 Trolley/ wheelchair Bay.
How many:
(A) Wheelchairs
(B)Trolleys
(C)Stretchers
How many have safety
9 belts
Security staff to manage
the entrance of the
hospital and parking
10 facility and other vital
 - 151 -
areas (in all 3 shifts)

Helpers / attendant to
provide wheelchairs and
trolleys (May I Help You
11 Staff.) at entrance

Washing Area for Trolleys

12 and Wheelchairs

S.No. Activities Statues Remarks

Yes/No
1.INSIDE EMERGENCY DEPARTMENT
ER Floor Marking showing
location of emergency
services eg. Lab, ECG,
Pharmacy, Registration,
Injection Room, Minor OT
1 etc
TAEI One Stop Crisis
2 Management Room
3 Police Out Post
Has the ER been Re-
4 organized ?
Pre-arrival Desk with PAI
Register & TAEI centers
Phone number displayed
5 TAEI - Triage Area
(A) Public Address(PA) System
 - 152 -
Triage Forms
- No.of
Traige forms used till now
- Is there
adequate stock of TAEI
(B) Triage forms
(C) TAEI Triage Board
Stethoscope in Sizes to
Accommodate all Patients
- Paediatric
- Adult
(D) - Infant
Blood Pressure Cuffs in
Sizes to Accommodate all
Patients
- Paediatric
- Adult
(E) - Infant
( F) 2 Patient Care Flashlights
Thermometer(s) with Low
Temperature Capability
- Oral
thermometer
- Rectal
thermometer
- Biohazard
(G) thermometer
Scissors for Cutting
(H) Clothing, Belts, and Boots
(I) Broselows Tape
Pulse Oximeter with
- Adult and
- Pediatric
(J) Probes
Glucometer with Reagent
(K) strips and single use lancets
(L) Multi-paramonitor

(M) Pulse oximeter

Scoop Boards/ Spine Board
(N) with Head Rest and Belt(7)

(O) Sharps Container

Antiemetics, Analgesics,
(P) Antacids
 - 153 -

(Q) Triage Registers

5 TAEI - Red Zone
(A) Public Address (PA) System
One TAEI Mobile phone for
(B) PAI
(C) Alarm System (CART)
How many ER Resuscitation
Bay available
(1 ER Resuscitation Bay for
(D) 400 IP)
Does it have Foot markings
around the hydraulic ER
(E) bed/trolley
Adequate Illumination - 400
Lux
( F)
Hand washing area with:
- elbow tap
and
- Mirror
6 TAEI - Yellow Zone
(A) No.of Beds in Yellow zone
Hand washing area with:
- Elbow tap
and
(B) - Mirror
7 TAEI Green Zone
Stethoscope in Sizes to
Accommodate all Patients
- Paediatric
- Adult
(A) - Infant
Blood Pressure Cuffs in
Sizes to Accommodate all
Patients
- Paediatric
- Adult
(B) - Infant
© 2 Patient Care Flashlights
Thermometer(s) with Low
Temperature Capability
- Oral
thermometer
(D) - Rectal
 - 154 -
thermometer
- Biohazard
thermometer
Pulse Oximeter with
- Adult and
- Pediatric
(E) Probes
Glucometer with Reagent
(F) strips and single use lancets
(G) Multi-paramonitor
(H) Scoop Boards
(I) Sharps Container
Antiemetics, Analgesics,
(J) Antacids

Biomedical Waste
8 Management
List of PAI Phone numbers
9 displayed
List of TAEI Team members
with Phone numbers
10 displayed
TAEI App Board - Daily data
11 displayed
TAEI Protocol Display
Boards
12 Decontamination Bay
13 Mass Casualty Area
14 Doctors Consultation room
15 Nurses Station
16 Counselling Room
17 EOT
18 POP Room
19 Xray
20 CT Scan

Permanent Oxygen Unit,

Placed in a Permanent
Mounting, with a Minimum
Capacity of 1500 Liters and
Equipped with a Reduction
Gauge and Flow Meter
Equipped with Reduction
21 Gage and Flow Meter
 - 155 -

Portable Oxygen Unit, with a

Minimum Capacity of 300
Liters, Capable of Delivering
Oxygen Flows of at Least 15
Liters per Minute and
Equipped with a Yoke,
Pressure Gage, and Flow
22 Meter.
Spare Portable Oxygen Tank
of at Least 300 Liter
23 Capacity

24 Patient waiting area

25 Canteen / Food zone

Scroll outside /LCD

display Name and Phone
26 No. of
(A) Doctor on duty (EMO 1&2)
Specialist on call and second
(B) on call of each specialty

© In charge of ED Department
(D) RMO/ DTNO/ HTNO
(E) In charge of Police post
In charge of Transport/108
(F) Ambulance
Help line Hearse & Red
(G) Cross Number
Help line Women Cell (Rape
Victims/Violence against
(H) Women
(I) etc.)
(J) Police post In charge
Tertiary care centre (nearest
(K) to the Hospital)
Available range of services
(L) in TAEI ED
(M) Matron of Hospital
(N) DTNC
(O) TNC on duty
(P) TAEI Nurses on duty

(Q) MNA/ FNA/ OT / POP tech

(R) Security Guard on duty

 - 156 -

27 TAEI Equipment RED YELLOW GREEN

AED/ Defibrillator
Central Oxygen Supply
Suction Apparatus
Ventilator
Pulsoxymeter
POTC - Machine (incl Cartridges)
Volume Infusion Pump
Syringe Infusion Pump
Mobile X Ray
Oxygen Flow Meter And
Humidifier
ECG
Dressing Trolley
Stretchers/Multi Functional
Stretcher
Wheel Chair
Spine Board and Head rest with
Belt(7)
Scoop Board
IV Stand
Traction Splints (Hare, Sager,
Thomas Ring)
Crash Cart
- Adult
- Paediatric
Camera
Desktop
Printer
Flash Autoclave Machine
Auto Clave Machine
Spot Light
Cell Counter
EC Pulse (CPR Machine)
Video Laryngoscope

DDA Cupboard - Dangerous

Drug Act with Narcotic Register
28 CRASH CART LIST
Draw 1
 - 157 -
1 Adult laryngoscope
2 Paed laryngoscope
3 1,2,3,4 curved blade
4 1,2 straight blade
5 Battery
6 Bougie
7 Suction catheter
8 ET tube (7,7.5,8 No)
9 Stylet
10 Tie and Elastoplast
11 Torch with Batteries
12 magills forceps
13 oro pharyngeal airway
14 nasopharngeal airway 6,7
Draw 2
15 ECG leads 3
16 Jelly
17 Sterillium Hand sanitiser
Bag Valve Masks (BVM) in Adult,
Child, & Infant Sizes Equipped
with Operable Pressure Relief
Valves and Transparent Masks,
with Oxygen
18 Reservoir/Accumulator.
The Pediatric BVM Shall Have
Masks for Neonate, Infant, and
19 Child.
Single Use, Transparent, Non-
Rebreather Oxygen Masks in
20 Adult and Pediatric Sizes
Nasal Cannulae in Adult and
21 Pediatric Sizes
Draw 3 - Drugs
22 Adrenalin
23 Atropine 5 amps
24 Adenosin 5 amps
25 Amiodaron 6 amp
26 Dopamine 2 amp
27 Scoline( store in fridge)
Draw 4
28 ABG syringe 2
29 16-22 G Needle
30 IV set
31 Micropore
32 3 way
33 Needles
34 Syringe 50 cc
35 Syringe 2cc, 5cc, 10cc
 - 158 -
Draw 5
36 5% dextrose
37 RL
38 NS
39 Intraosseous Needle – 5
PPE -Personal Protection
40 Goggles
41 Surgical Masks
Disposable Synthetic Gloves for
42 all Attendants
Disposable Biohazard Bags For
43 Non-Sharp Waste
Standard Sharps Container Both
44 Fixed and Portable
Disinfectant For Solution for
Cleaning Contaminated
45 Equipment
Waterless Hand Cleaner,
Commercial Antimicrobial
46 (Towelette, Spray, or Liquid)
Plastic Aprons or Fluid Resistant
47 Gowns
Immobilsation devices
Philadelphia Collar/ C collar
Rigid Cervical Immobilization
Devices in Appropriate -
Adult,
Child, and
48 Infant Sizes
Head Immobilization Device
(NOT SANDBAGS) –
Firm Padding OR
49 Commercially Available Device
Upper and Lower Extremity
50 Immobilization Device(s):
Lower Extremity Traction Splint
in Appropriate-
Adult and
51 Child Sizes
52 Broad arm slings
53 Triangular slings
54 Roller gauze
55 Wooden piece to splint
56 Pelvic Binder
ICD Kit
57 Needle Holder straight 8''
58 Kellys Clamp- curved 8"
59 Tray with Lid
 - 159 -
60 Stainless steel cup
61 Artery forceps straight 6"
62 Artery forceps straight 8"
63 Toothed forceps
64 Gauze
65 Cotton Balls
66 Biopsy Towel
67 Scalpel Holder with blade
68 Suture scissor sharp
69 Chest Tube
Bleeding Control and Wound
Management
70 Abdominal Trauma Dressing
71 Sterile Gauze in Various Sizes
72 Gauze Rolls in Assorted Sizes
73 Triangular Bandages
Occlusive Dressings or
74 Equivalent
Sterile Water or Saline Solutions
75 for Irrigation
76 Arterial Tourniquet
Sterile Burn Sheets or Medical
Director Approved Burn Care
77 Supplies
78 Adhesive Tape
79 1” & 2” Hypoallergenic
80 1” & 2” Adhesive
Patient
Assessment/Diagnostic
Measurements
Stethoscope in Sizes to
81 Accommodate all Patients
82 - Paediatric
83 - Adult
84 - Infant
Blood Pressure Cuffs in Sizes to
85 Accommodate all Patients
86 - Paediatric
87 - Adult
88 - Infant
89 Thermometer(s)
- Oral
90 thermometer
- Rectal
91 thermometer
92 - Biohazard thermometer
Scissors for Cutting Clothing,
93 Belts, and Boots
 - 160 -
94 Broselows Tape
95 Pulse Oximeter with
96 - Adult and
97 - Pediatric Probes
Additional Equipment –
Glucometer with Reagent Strips
98 and Single-Use Lancets
99 CPAP Equipment
100 Nebulizer Equipment
Equipment to Capture Out-Of-
101 Hospital 12 Lead
Advanced Airway (Non-
Visualized Approved by Title 172
102 NAC 11)
If Monitoring IV Solutions,
Intravenous Fluid Bag Pole or
103 Roof Hook
Miscellaneous Equipment
Device Capable for Pediatric
104 Immobilization
105 Ocular Irrigation Device
106 Hot Pack(s)
107 Cold Pack(s)
108 Emesis Bags/Basin
109 Urinal
110 Bedpan
STOCK
111 Blankets
Sheets – At Least One Change
112 Per Cot
113 Pillows
114 Towels
115 Step Stool for CPR
Oro-gastric lavage tube (Boas
116 tube)
117 Foleys Catheter
118 Uro Bag
119 Knee Hammer
120 Cheatles Forceps
121 Catheterisation Tray
122 Central Venous Lines Tray
123 Fetal Scope
124 Hair Trimmer
125 Weight and Height Machine
126 Portable Oxygen Cylinder
127 Nail Cutter
128 Raizor set
129 Ophthalmoscope
 - 161 -
130 Colour Coded Dust Bins

Date of Reporting
Reference Date

SN TAEI Report Fields No.

1 Name of Hospital
2 Total no.of:
A Beds in Hospital
B Specialties in Hospital
C Red Beds
D Yellow Beds
E Green beds
F EOT
RTA
RTA Major
RTA Minor
RTA Admitted
RTA DUI
Major Surgeries
Minor Surgeries
Blood Transfusions
Major Head Injuries
Minor Head Injuries
No.of DAMA
No.of RTA deaths
FALL
Major
Minor
Admitted
DUI Fall
Major Surgeries
Minor Surgeries
Blood Transfusions
Major Head Injuries
Minor Head Injuries
CT Done
No.of DAMA
No.of deaths
Assault
Major
Minor
Admitted
DUI breath
Major Surgeries
Minor Surgeries
Blood Transfusions
Major Head Injuries
 - 162 -
Minor Head Injuries
CT Done
No.of DAMA
No.of deaths
Transportation
Arrival by 108
From Scene
IFT
Brought Dead
Arrival by Other means
Referred Out
Total cases referred out
Institute referred to
Referred through 108/Pvt/other
Referred In
From
No.of PAI for Red Case

SN Emergency Indicators
1 Total no.of Redcases
2 No.of PAI for Red Case
3 No.of Intubation done

4 No.of ICD Done

5 No.of C spine immobilised
6 No.of pericardiocentesis done
7 No.of Blood Transfusion
8 No.of Intraosseous Infusion Done
9 No.of EFAST done
10 GCS Assessment done
11 No.of cases splints and tractions used

REMARKS OF INSPECTING OFFICER:

SN ER Infrastructure
Outside ED
1 Signage in the city on main roads to
inform the whereabouts of TAEI Hospital

2 Designated Ambulance Bay

 - 163 -
3 stretchers, wheelchairs and trolleys with
signage Trolley/ wheelchair Bay.
4 How many Wheelchairs & Trolleys have
safety belts
5 Security staff to manage the entrance of
the hospital and parking facility and other
vital areas (in all 3 shifts)
6 Helpers / attendant to provide wheelchairs
and trolleys (May I Help You Staff.) at
entrance
7 Has the space identified for ER
reorganisation
8 Has the PWD Estimate prepared
Inside ED
1 ER Floor Marking showing location of
emergency services eg.Lab, ECG,
Pharmacy, Registration, Injection Room,
Minor OT etc
2 TAEI One Stop Crisis Management Room

3 Police Out Post

4 Has the ER been Reorganized ?
5 How many resuscitation beds available
6 No.of red beds in ER
7 Is there Cardiac arrest Alarm system
8 Hand washing area with elbow tap and
mirror
9 No.of Yellow beds
10 No.of Green beds
11 Display boards/ Sign Boards

PAI Mobile phone/Sim card

Received
PAI Desk
PAI Register
Total no.of Red cases thru PAI
of 108 until date
Total no.of red cases received
in ER (After Incetion of PAI)
Triage Triage Desk
 - 164 -
Triage Nurse posted in all 3
shifts
Total Red Triaged
Total Yellow triaged
Total Green Cases triaged
Total cases in ER after
installation of Triage
Average Time taken for
triaging a patient
No.of Traige forms printed till
now
Traige form used till now

TRR
TAEI ER Team (CMO, TNC, Triage nurse,
support workers)identified
Minimum of 5 members (Team leader,
CMO, TNC, ED Nurse) required for TRR
No.of members present at any point of
time during resuscitation
Office order to post trained staff
exclusively in ED
Resusciation as per ABCDE protocols
KAP of ER Team on ATLS Protocols
No.of C Collars applied
No.of Intubation Done
TRR
No.of ICD done
No.of CPR Done
No.of Blood Transfusion done
No.of GCS done
No.of ISS done
No.of Pelvic Binders applied
No.of POCT done(ABG, CBC, etc)
Emeregncy CT Scan done for head Injury
Emeregncy U/S Scan done
No.of Emergency surgey done
No.of DAMA
No.of Deaths in ER

No.of ER trained Doctors (EMTC) from CMC

HR Vellore under TAEI
training No.of ER trained Doctors (EMTC + MSEED) from
CMC Vellore under TAEI
 - 165 -
No.of ER trained Doctors (DHPT) from EMRI,
Chennai under TAEI
No.of ER Trained Nurses (EMTC) under TAEI
No.of ER Trained Nurses (10 days in Emergency
care) under TAEI
No.of ER Trained Nurses (30 days in Emergency
Department) CMC Vellore under TAEI
No.of ATLS certified trainers available in the
hospital
No.of BLS certified trainers available in the
hospital
No.of ACLS certified trainers available in the
hospital
No.of PALS certified trainers available in the
hospital
List of TAEI ED nurses given
List of ED Doctors given
FR trained in BLS under TAEI

Availability of MDCCU
No.of beds in MDCCU
MDDCU
Has the space been identified
Has the PWD Estimate prepared
Availability of 24*7 Xray
No.of X rays done with mobile X ray
Imaging Availability of 24*7 CT scan
Timings of CT scan availability
Availability of MRI
Tmings of MRI scan available
No.of X Ray technician available
No.of CT Technician available

Name of Equipment Available number Working status

Equipment
Multi-Para Monitor
E-Fast
Aed
Ventilators
Equipment
Central Oxygen Supply
Suction Apparatus
Pulsoxymeter
ABG Analyser
Volume Infusion Pump
Syringe Infusion Pump
 - 166 -
Mobile X Ray
Oxygen Flow Meter And
Humidifier
ECG
Trauma Cot (Hydraulic)
Dressing Trolley
Stretchers/Multi Functional
Stretcher
Wheel Chair
Spine Board
Scoop Board
Iv Stand
Traction Splints (Hare, Sager,
Thomas Ring)
Crash Cart: Adult
Crash Cart Paediatric
Camera
Desktop
Printer
Flash Autoclave Machine
Auto Clave Machine
Spot Light
Cell Counter
CT
MRI
E FAST

CRASH CART LIST Available numbers Working status

Draw 1
Adult laryngoscope
Paed laryngoscope
1,2,3,4 curved blade
1,2 straight blade
Battery
Bougie
Consumables ECG leads 3
Jelly
magills forceps
oro pharyngeal airway
nasopharngeal airway 6,7
Draw 2
Suction catheter
ET tube (7,7.5,8 No)
stillet
 - 167 -
Bag Valve Masks (BVM) in Adult, Child,
& Infant Sizes Equipped with Operable
Pressure Relief Valves and Transparent
Masks, with Oxygen
Reservoir/Accumulator.
The Pediatric BVM Shall Have Masks
for Neonate, Infant, and Child.
Single Use, Transparent, Non-
Rebreather Oxygen Masks in Adult and
Pediatric Sizes
Nasal Cannulae in Adult and Pediatric
Sizes
Draw 3
Medicines
Adrenalin
Atropine 5 amps
Adenosin 5 amps
Amiodaron 6 amp
Dopamine 2 amp
Scoline( store in fridge)
Draw 4
ABG syringe 2
16-22 G Needle
IV set
Micropore
3 way
Needles
Syringe 50 cc
Syringe 2cc, 5cc, 10cc
Draw 5
5% dextrose
RL
NS
Intraosseous Needle - 5
PPE -Personal Protection
Goggles
Surgical Masks
Disposable Synthetic Gloves for all
Attendants
Disposable Biohazard Bags For Non-
Sharp Waste
Standard Sharps Container Both Fixed
and Portable
Disinfectant For Solution for Cleaning
Contaminated Equipment
Waterless Hand Cleaner, Commercial
Antimicrobial (Towelette, Spray, or
Liquid)
Fluid Resistant Gowns
 - 168 -
Immobilsation devices
Philadelphia Collar/ C collar
Rigid Cervical Immobilization Devices
in Appropriate -
Adult,
Child, and
Infant Sizes
Head Immobilization Device (NOT
SANDBAGS) –
Firm Padding OR
Commercially Available Device
Upper and Lower Extremity
Immobilization Device(s):
Lower Extremity Traction Splint in
Appropriate-
Adult and
Child Sizes
Broad arm slings
Triangular slings
Roller gauze
Wooden piece to splint
Pelvic Binder
Bleeding Control and Wound
Management
Abdominal Trauma Dressing
Sterile Gauze in Various Sizes
Gauze Rolls in Assorted Sizes
Triangular Bandages
Occlusive Dressings or Equivalent
Sterile Water or Saline Solutions for
Irrigation
Arterial Tourniquet
Sterile Burn Sheets or Medical Director
Approved Burn Care Supplies
Adhesive Tape
1” & 2” Hypoallergenic
1” & 2” Adhesive
Patient Assessment/Diagnostic
Measurements
Stethoscope in Sizes to
Accommodate all Patients
- Paediatric
- Adult
- Infant
Blood Pressure Cuffs in Sizes to
Accommodate all Patients
- Paediatric
- Adult
 - 169 -
- Infant
Thermometer(s)
- Oral thermometer
- Rectal
thermometer
- Biohazard thermometer
Scissors for Cutting Clothing,
Belts, and Boots
Broselows Tape
Pulse Oximeter with
- Adult and
- Pediatric Probes
Additional Equipment –
Glucometer with Reagent Strips
and Single-Use Lancets
CPAP Equipment
Nebulizer Equipment
Equipment to Capture Out-Of-
Hospital 12 Lead
Advanced Airway (Non-
Visualized Approved by Title 172
NAC 11)
If Monitoring IV Solutions,
Intravenous Fluid Bag Pole or
Roof Hook
Miscellaneous Equipment
Device Capable for Pediatric
Immobilization
Ocular Irrigation Device
Hot Pack(s)
Cold Pack(s)
Emesis Bags/Basin
Urinal
Bedpan
STOCK
Blankets
Sheets – At Least One Change
Per Cot
Pillows
Towels

SN CRASH CART LIST

Draw 1
1 Adult laryngoscope
 - 170 -
2 Paed laryngoscope
3 1,2,3,4 curved blade
4 1,2 straight blade
5 Battery
6 Bougie
7 Suction catheter
8 ET tube (7,7.5,8 No)
9 Stylet
10 Tie and Elastoplast
11 Torch with Batteries
12 magills forceps
13 oro pharyngeal airway
14 nasopharngeal airway 6,7
Draw 2
15 ECG leads 3
16 Jelly
17 Sterillium Hand sanitiser
Bag Valve Masks (BVM) in Adult,
Child, & Infant Sizes Equipped with
Operable Pressure Relief Valves and
Transparent Masks, with Oxygen
18 Reservoir/Accumulator.
The Pediatric BVM Shall Have Masks
19 for Neonate, Infant, and Child.
Single Use, Transparent, Non-
Rebreather Oxygen Masks in Adult
20 and Pediatric Sizes
Nasal Cannulae in Adult and
21 Pediatric Sizes
Draw 3 - Drugs
22 Adrenalin
23 Atropine 5 amps
24 Adenosin 5 amps
25 Amiodaron 6 amp
26 Dopamine 2 amp
27 Scoline( store in fridge)
Draw 4
28 ABG syringe 2
29 16-22 G Needle
30 IV set
31 Micropore
32 3 way
33 Needles
34 Syringe 50 cc
35 Syringe 2cc, 5cc, 10cc
 - 171 -
Draw 5
36 5% dextrose
37 RL
38 NS
39 Intraosseous Needle – 5
PPE -Personal Protection
40 Goggles
41 Surgical Masks
Disposable Synthetic Gloves for all
42 Attendants
Disposable Biohazard Bags For Non-
43 Sharp Waste
Standard Sharps Container Both
44 Fixed and Portable
Disinfectant For Solution for
45 Cleaning Contaminated Equipment
Waterless Hand Cleaner,
Commercial Antimicrobial
46 (Towelette, Spray, or Liquid)
Plastic Aprons or Fluid Resistant
47 Gowns
Immobilsation devices
Philadelphia Collar/ C collar
Rigid Cervical Immobilization
Devices in Appropriate -
Adult,
Child, and
48 Infant Sizes
Head Immobilization Device (NOT
SANDBAGS) –
Firm Padding OR
49 Commercially Available Device
Upper and Lower Extremity
50 Immobilization Device(s):
Lower Extremity Traction Splint in
Appropriate-
Adult and
51 Child Sizes
52 Broad arm slings
53 Triangular slings
54 Roller gauze
55 Wooden piece to splint
56 Pelvic Binder
ICD Kit
57 Needle Holder straight 8''
58 Kellys Clamp- curved 8"
 - 172 -
59 Tray with Lid
60 Stainless steel cup
61 Artery forceps straight 6"
62 Artery forceps straight 8"
63 Toothed forceps
64 Gauze
65 Cotton Balls
66 Biopsy Towel
67 Scalpel Holder with blade
68 Suture scissor sharp
69 Chest Tube
Bleeding Control and Wound
Management
70 Abdominal Trauma Dressing
71 Sterile Gauze in Various Sizes
72 Gauze Rolls in Assorted Sizes
73 Triangular Bandages
74 Occlusive Dressings or Equivalent
Sterile Water or Saline Solutions for
75 Irrigation
76 Arterial Tourniquet
Sterile Burn Sheets or Medical
Director Approved Burn Care
77 Supplies
78 Adhesive Tape
79 1” & 2” Hypoallergenic
80 1” & 2” Adhesive
Patient Assessment/Diagnostic
Measurements
Stethoscope in Sizes to
81 Accommodate all Patients
82 - Paediatric
83 - Adult
84 - Infant
Blood Pressure Cuffs in Sizes to
85 Accommodate all Patients
86 - Paediatric
87 - Adult
88 - Infant
89 Thermometer(s)
90 - Oral thermometer
- Rectal
91 thermometer
92 - Biohazard thermometer
 - 173 -
Scissors for Cutting Clothing, Belts,
93 and Boots
94 Broselows Tape
95 Pulse Oximeter with
96 - Adult and
97 - Pediatric Probes
Additional Equipment –
Glucometer with Reagent Strips and
98 Single-Use Lancets
99 CPAP Equipment
100 Nebulizer Equipment
Equipment to Capture Out-Of-
101 Hospital 12 Lead
Advanced Airway (Non-Visualized
102 Approved by Title 172 NAC 11)
If Monitoring IV Solutions,
Intravenous Fluid Bag Pole or Roof
103 Hook
Miscellaneous Equipment
Device Capable for Pediatric
104 Immobilization
105 Ocular Irrigation Device
106 Hot Pack(s)
107 Cold Pack(s)
108 Emesis Bags/Basin
109 Urinal
110 Bedpan
STOCK
111 Blankets
Sheets – At Least One Change Per
112 Cot
113 Pillows
114 Towels
115 Step Stool for CPR

116 Oro-gastric lavage tube (Boas tube)

117 Foleys Catheter
118 Uro Bag
119 Knee Hammer
120 Cheatles Forceps
121 Catheterisation Tray
122 Central Venous Lines Tray
123 Fetal Scope
124 Hair Trimmer
125 Weight and Height Machine
 - 174 -
126 Portable Oxygen Cylinder
127 Nail Cutter
128 Raizor set
129 Ophthalmoscope
130 Colour Coded Dust Bins

Trauma Quality of Care Analysis:

Under TAEI, Quality of Care will be analysed. The following procedure will be adopted.
• Verbal autopsy or community based Analysis
• Facility based Analysis
• Video Conference at state level including all healthcare professionals involved in
patient care from EMT,Pilot in the ambulance to the doctors and nurses involved in
treating the casualty.

Quality of Care
No.of Deaths In ER
Critical Case review of Death cases audited
Is the TAEI Case sheet audited by HTNO/Msupdt

Finance
Presence of TAEI bank account
How much funds has been received from NHM
Utilisation status of funds
UC submission on periodic basis

Proposal for Critical Case Review of Trauma and Emergency cases

Introduction:
National Health Mission-Tamil Nadu has been involved in the development of Trauma
care network in Tamil Nadu in the name “Tamil Nadu Accident and Emergency Care
Initiative” (TAEI). Government of Tamil Nadu had issued necessary orders for its
implementation. The Mission Director-State Health Society has been designated as ex-
officio Commissioner of Trauma Care.
The main objectives of trauma care centre are
1. to provide comprehensive emergency care to the accident casualties
2. to treat major injuries like head injury, cardiothoracic injury etc, wherever the facilities
are available based on the level of trauma care centre
3. to stabilize the more serious injuries like head injury, cardiothoracic injury etc, before
transportation to the appropriate higher centres
 - 175 -
Levels of Trauma care centre
Based on the availability of trauma care services the health facilities will be designated
as level I, II and III trauma care centres.
Level I trauma care centre:
Highly specialised medical centres where the services of all major super specialities
associated with trauma care services are available 24X7 will be designated as Level I
trauma care centre
Level II trauma care centre:
Medical college hospitals/ hospitals with bed strength of 300 to 500 beds will be
designated as level II trauma care centre. Level II centres are equipped with emergency
department, intensive care unit, blood bank, rehabilitation services, etc

Level III trauma care centre:

District and Taluk hospitals with limited intensive care facility, blood bank and other
supportive services will function as level III trauma care centre.

Need for Quality in trauma care and Critical Case Reviews:

Injuries cause both disease and economic burden. Quality improvement programmes
yield better treatment outcomes and reduce the cost associated with the provision of
care.
Critical Case Reviews provide a means to monitor the quality of care provided through
TAEI centres. A comprehensive approach for monitoring and reviewing patient care
helps to identify problems in care and take corrective actions. These actions are
required to strengthen the process of care.
There is a need to develop a standardized approach for conducting review across all
TAEI centres. The case review method should not be merely a facility based one but also
include system level factors. It should include all phases of care like pre-hospital care,
hospital care, and factors like timeliness of care, appropriateness of care and other
human factors involved in the process of care.
An action plan for critical case review is described below.
Aim of the review:
The aim of a critical case review is to identify opportunities to improve care at the level
where care is provided and at all levels below
 - 176 -
Levels of Review:

The review will be at following four levels

1. Department
2. Institution
3. District
4. State
The following persons will be responsible to conduct the review at Department,
Institution, District and State levels respectively.

• Head of the Department

• Head of the Institution
• District Collector (Joint Director of Health Services)
• Commissioner of Trauma Care

Review Process:

Department level review

The Department level review is a technical Audit. All deaths will be audited and among
survivors five will be chosen randomly.

Institutional level review

The Institutional level review is also a technical Audit. The Head of the institution will
chair the review.
This review will identify opportunities for improvement in care. The number of cases
reviewed will be six, out of which four will be deaths and two will be review of survivors.
The survivors reviewed at the department level will not be included for institutional
review. The following death cases will be included for death reviews
1. Poly-trauma- 2 cases
2. Child/Pregnancy- 1 case
3. Death after 3rd Day- 1 Case
 - 177 -

District level review

District level review is a social Audit. The number of cases reviewed will be 10, five each
of deaths and survivors.

The Factors to be considered include Referring Hospital/Direct, Response time, Referral

time, EMT Management, Delay in care provision, and deficiency in the system

State level review

The state level review headed by Commissioner of Trauma Care is an administrative

audit. The number of cases reviewed will be 20. It includes 10 deaths and 10 survivors.
 - 178 -

Critical Case Review Form

Date of Review
Name of the Reviewer
Name of the facility
Nodal person
Contact number
1 General Information
1.1 Name of the patient
1.2 Age
1.3 Sex
1.4 Residence
1.5 In Patient ID

2 Patient Presentation
2.1 Referral  Self referral
 Inter facility transfer
2.2 Referring hospital  Public
 Private
2.3 Number of health facilities Public
visited prior to arrival Private

2.4 Interventions performed at

facility from where referred

2.5 Mode of arrival to the present  Public ambulance

facility
 Private ambulance
 Other (Specify)
2.6 Pre Arrival Intimation  Yes
 No
3 Triage (Red/Yellow/Green)

3.1 Pre-hospital
3.2 patient arrival
 - 179 -

4 Presenting problem
4.1 Injury place  Home
 School
 Street/Road/Highways
 Rails
 Work place
 Unknown
 Other(Specify)
4.2 Mechanism of Injury  Road Traffic Injury
 Fall
 Fire
 Stab/Cut
 Gun shot
 Poisoning
 Choking/Hanging
 Drowning
 Other (Specify)
4.3 Patient’s activity when  Work
injured
 Education
 Sport
 Travelling
 Other (Specify)
4.4 Nature of injury  Fracture
 Sprain/Strain
 Cuts/Bite/open wound
 Bruise
 Burn
 Concussion
 Organ system injury
 Other (Specify)
4 Presenting problem
4.5 Injury intent  Unintentional
 Self harm
 Intentional (assault)
 Other (Specify)
 - 180 -
4.6 Alcohol use within 6 hours of  Suspected by report/ confirmation
the incident
 No confirmation
4.7 Use of mood altering  Suspected by report/ confirmation
substance by patient
 No confirmation

5 Vital signs Patient Arrival At the time of Near

Miss
5.1 Systolic Blood
Pressure

5.2 Heart Rate

5.3 Respiratory Rate

5.4 Oxygen Saturation

5.5 GCS E V M /15 E V M /15

6 Timeline of events DD:MM:YYYY HH:MM

24 hrs
6.1 Injury Date Injury Time

6.2 Patient Arrival Date Patient Arrival

Time

6.3 Admission Date Admission

Time

6.4 Emergency Department Emergency

Disposition Date Department
Disposition
Time
 - 181 -
6.5 First In Hospital Operative First In
Procedure Date Hospital
Operative
Procedure
Time
6.6 Date when the patient Near Miss
turned Near Miss Time

6.7 Hospital Disposition Date Hospital

Disposition
Time

7 Interventions at the facility (Specify)

8 Hospital events
8.1 Wound infection  Yes
 No
8.2 Septic Shock  Yes
 No
8.3 Cardiac Arrest  Yes
 No
8.4 Renal Failure  Yes
 No
8.5 Pneumonia  Yes
 No
8.6 Ulcer  Yes
 No
8.7 Other specified 
 - 182 -
9 Patient Disposition  Treated and discharged
 Discharged against advice
 Transferred to other hospital
 Died
10 Duration of hospital stay
11 Duration of ICU stay
12 Duration Patient was on
Ventilation

13 Care could have been

improved during
None
Airway management
Haemorrhage control
Chest management
Fluid resuscitation
Other (Specify)

14 Potential areas for

improvement
Pre-hospital
Emergency department
Operating theatre
Intensive care unit
Ward
Inter-facility transfer
Other
None
15 Factors influencing care
15.1 Lack of medical equipment  Yes  No
15.2 Lack of medical supplies  Yes  No
15.3 Failure of medical equipment  Yes  No
15.4 Medical task failure  Yes  No
15.5 Delay in staff action  Yes  No
15.6 Delay in patient communication  Yes  No
15.7 Lack of trained staff  Yes  No
15.8 Other  Yes  No
15.9 Other Specified
 - 183 -
16 Description of outcome
Decision as to whether the death
was
Definitely preventable
Possibly preventable
Not preventable

14. Summary of review

15. Recommendations

Form filled by:

Name of the Medical Officer: Signature:

Name of the Nodal Officer: Signature:

 - 184 -

Critical Case Review Form

Section I. General information

District
Block
Name of the victim
Age
Sex
Place of death
Date & Time of Death

Section II. Death Review

1. Site of death a. Pre-hospital
b. PHC
c. CHC
d. District Hospital
e. Medical College Hospital
f. Private facility
g. Other (Specify)

2. Decision as to whether the a. Definitely preventable

death was b. Possibly preventable
c. Not preventable

3. Whether Public ambulance a. Yes

facility was used b. No

If No answer 4

4. If NO specify the reason for a. Not availed

not using b. No communication received
by service providers
c. Non availability of public
ambulance
d. Other (Specify)

5. Was definitive treatment a. Yes

initiated within Golden Hour? b. No

6. Number of facilities visited a. Public................

before reaching the facility b. Private..............
where death occurred

7. Distance of the nearest facility a. ≤50 km

 - 185 -
providing Accident & b. 50-100 km
Emergency care services from c. 101-200 km
the scene of injury d. Above 200 km

8. Time elapsed from injury to

presentation to hospital

9. Time elapsed from presentation

to hospital to death

10. Care could have been a. None

improved during b. Airway management
c. Haemorrhage control
d. Chest management
e. Fluid resuscitation
f. Other (Specify)

11. Potential areas for a. Pre-hospital

improvement b. Emergency department
c. Operating theatre
d. Intensive care unit
e. Ward
f. Inter-facility transfer
g. Other
h. None

12. Did any of the following a. Lack of medical equipments

factors influencing care present b. Lack of medical supplies
c. Equipment failure
d. Medical task failure
e. Delay in staff action
f. Lack of trained staff
g. None of the above

Section III. Summary and Recommendations

A. Pre-hospital care
1 Percentage of trauma cases transported by
108 ambulance to ER
 - 186 -
2 Proportion (%) of EMTs formally trained in
BTLS
B. Care in ER ( includes input and process indicators)
B 1. Input- Macro, infrastructure, equipment, drugs
3 Proportion of hospitals with trauma care
coordinator
4 Proportion of hospitals with a designated ER
with triage areas
5 Proportion of hospitals with portable X-ray
facility in ER
6 Proportion of hospitals with CT scan facility in
or closer to ER
7 Number of drug shortage days per month ( for
any emergency drug
B 2. Input- Human resources
8 Proportion of Nurses trained in BTLS or
equivalent certified courses
9 Proportion of doctors trained in BTLS/ ATLS or
equivalent certified courses.

10 Proportion of CMOs trained in BTLS/ ATLS or

equivalent certified courses

B 3. Process indicators
11 Proportion of ER cases undergoing triage

12 Proportion of hospitals with functioning triage

systems
13 Proportion of ER with a dedicated digital
trauma HMIS health information systems

C. Trauma care outcome indicators

14 Proportional trauma related mortality in
ER(trauma related deaths in ER per 100 ER
deaths )
15 Trauma mortality per 100 ER registrations

16 Hospital trauma mortality deaths trauma

related deaths in hospital per 100 hospital
deaths
17 Proportion of trauma cases admitted as in-
patient
18 Proportion of trauma cases referred out

Pre-hospital
 - 187 -
1. Percentage of trauma cases transported
to ER in an ambulance
2. Average transportation time from site of
injury to definitive trauma care facility ( in minutes)
Care in ER
Input and process
3. Doctors per 100 trauma registrations in ER
4. Nurses per 100 trauma registrations in ER
5. Number of training programmes
conducted per year for each level of health staff
6. Number of training programmes for para-
health staff conducted in a year
Process
7. Average time for triage completion in ER
8. Average time for assessment by specialist
in ER
Outcome
9. Percentage of ER trauma cases with
improved outcomes
10. Average time for completion of triage
11. Average duration of stay in ER – general
and for red triaged cases
12. Average time for specialist consultation
13. Percentage of red-triaged ER trauma
cases with improved outcomes

SN Status of Prearrival Intimation & Triage

1 Mobile phone Received
2 PAI desk Installed with Register maintainance
3 Reception of PAI Phone Calls
4 Traige Desk installed with Traige nurse posted
5 Traige register
6 Traige Forms Utilisation
 - 188 -

SN Trauma Reception and Resuscitation

HTNO
DTNC
TNC
ED Team identified
No.of helping hands during resuscitation at any point of time
Non- rotatory Policy -office order to post Nurses in ED only
ABCDE Approach to Resusciataion
AR entry to follow after Resusciattaion
Philadelphia Collar applied
Intubation Done
ICD done
CPR Done
Blood Transfusion done
GCS done
ISS done
Pelvic Binders applied
POCT done(ABG, CBC, etc)
Emeregncy CT Scan for head Injury
Emeregncy U/S Scan done
Emergency surgey done
No.of DAMA
No.of Deaths in ER

SN Capacity Building
1 Master Trainer Doctors
2 Master Trainer Nurses
3 First Responder Training
ABCDE skills practiced in ED
AR entry done after Resusciation
Internal Training Classes conducted by Master Trainers
For CMO's and nurses

SN Quality of Care
1 Critical Case review meetings
 - 189 -
2 TAEI steering committee meeting with District Collector
3 Case sheets audited
TAEI App daily reporting

SN Funding
1 Exclusive Bank Account for TAEI
2 Utilisation status of funds

Trauma Registry

The Trauma Registry will have data captured at each stage of the Patient Management

Data Captured for Registry

1. Name
2. Age
3. Gender
4. In Case of RTA
5. In case of Chest Pain
6. In Case of Stroke
7. In Case of Poison
8.

Data captured for Trauma Registry at Post Mortem

1. Age
2. Gender
a. Male / Female
3. Mode of Injury
a. RTA / TTA / Assault / Fault / Industrial Accident
4. Is there a Head Injury
a. Yes / No
i. If Yes, Choose all that apply
1. Fracture
2. EDH
3. SDH
4. SAH
5. Contusion
6. IVH
5. Is there as Chest Injury
a. Yes / No
i. If Yes, Choose all that apply
1. Lung Injury
2. Heart Injury
3. Great Vessel Injury
6. Is there a Abdominal Injury
a. Yes / No
 - 190 -
i. If Yes, Choose All that apply
1. Liver Injury
2. Spleen Injury
3. Great Vessel Injury
4. Others
7. Is there a Long Bone or Pelvic Injury
a. Yes / No
i. If Yes, Choose All that Apply
1. Femur
2. Tibia
3. Pelvis
8. Was there any surgical intervention
a. Yes / No
i. If Yes, Choose All that Apply
1. Intercostal Drainage
2. Laparotomy
3. External Fixation
4. Burr Hole / Craniotomy

OP Load

Number of visits: 130.4 million

Number of injury-related visits: 37.2 million
Number of visits per 100 persons: 41.9
Number of emergency department visits resulting in hospital admission: 12.2 million
Number of emergency department visits resulting in admission to critical care unit: 1.5 million
Percent of visits with patient seen in fewer than 15 minutes: 29.8%
Percent of visits resulting in hospital admission: 9.3%
Percent of visits resulting in transfer to a different (psychiatric or other) hospital: 2.2%
https://www.cdc.gov/nchs/fastats/emergency-department.htm

STANDARD XVIII -- QUALITY MANAGEMENT

The goals of a trauma quality improvement program are to monitor the process and outcome of
patient care, to ensure the quality and timely provision of such care, to improve the knowledge and
skills of the trauma care providers, and to provide institutional structure and organization to promote
quality improvement. The plan should contain these essential elements for successful
implementation: authority and accountability for the program,
a well-defined organizational structure for the committee composition and member responsibilities,
defined standards to determine quality of care, and explicit definitions for outcomes required by the
facility’s prescribed standards.

The trauma center shall demonstrate a clearly defined performance improvement program for the
trauma population that is integrated into the hospital-wide program. The trauma program’s
monitoring and evaluation process must show identification of process/outcome issues, corrective
actions taken, and loop closure, when applicable, for evaluations of the desired effects.
 - 191 -
The trauma service shall have written evidence on file indicating an active and effective trauma
quality improvement program. This evidence shall include procedures and mechanisms for at least
the following:
Population of cases for review -- The trauma medical director and trauma program manager shall
review all trauma patient records from the following categories:
• All trauma alert cases admitted to the hospital
• Critical or intensive care unit admissions for traumatic injury.
• All operating room admissions for traumatic injury (excluding same day discharges or
isolated, non-life threatening orthopedic injuries).
• Any critical trauma transfer into or out of the hospital.
• All in-hospital traumatic deaths, including deaths in the trauma resuscitation area.
a. Process/outcome indicators -- The facility shall monitor at least ten indicators
relevant to process or outcome measures.

b. The facility must monitor four state-required indicators relevant to process and
outcome. The initial four indicators shall be as follows:
(1) All deaths.
(2) Any trauma patient with an unplanned re-admittance to the hospital
within thirty days of discharge.
(3) Any trauma patient readmitted to ICU, or an unplanned admission to the
ICU from a medical/surgical unit.
(4) Percentage of all traumatic C1, C2 and/or C3 spinal cord injury patients
permanently dependent on mechanical ventilator support who were
admitted or transferred to the ICU during the quarter or who remained in
the ICU from the previous quarter; who received the diaphragm pacer
surgery and were discharged to a less restrictive facility, home or home-
health.
.

• The facility must identify and monitor six indicators relevant to its respective facility for
a period of six months and submit these indicators to the Department of Health.
• The identification of indicators shall be based on defined criteria (expectations) that can be determined
from consensus institutional guidelines and nationally derived evidence-based guidelines.
• As process and outcome issues are resolved through evidence of the implementation of an action plan,
evaluation, and closure when applicable, new indicators shall be introduced and monitored for a
minimum of at least six months. New indicators must be submitted to the Department of Health.
 - 192 -
• Evaluation of cases -- The trauma medical director or trauma program manager shall evaluate
each case identified by one of the indicators
• Committee discussion and action -- The members of the TQM committee shall review and
discuss each case referred by the trauma medical director or trauma program manager.
• Resolution and follow-up -- The TQM committee shall evaluate and document the effectiveness
of action taken to ensure problem resolution, improvements in patient care, or improved patient
outcomes.

C. The trauma quality management committee shall be composed of at least the following
persons:
1. Trauma medical director (as chairperson).
2. Trauma program manager.
3. Medical director of emergency department or emergency physician designee.
4. Trauma surgeon, other than the trauma medical director.
5. Surgical specialist other than trauma surgeon, such as neurosurgeon, orthopedic
surgeon, and pediatric surgeon.
6. Representative from administration.
7. Operating room nursing director or designee.
8. Emergency department nursing director or designee.
9. Intensive care unit nursing director or designee.
10. Trauma Nurse Coordinator
 - 193 -
Chapter 21
Policy for Research

STANDARD XIX -- TRAUMA RESEARCH

One of the major responsibilities of a Level I trauma center is to continually expand the body of
knowledge in the field of trauma through clinical and basic research programs. It is incumbent on the
full-time staff of the trauma center to apply this newly acquired knowledge to the treatment of the
injured patient and to disseminate the knowledge throughout the medical community.
A. The trauma service shall conduct ongoing clinical and research programs in trauma patient
care and a Level I trauma center program must have:
a. Peer-reviewed funding for trauma research. There should be demonstrated
evidence of funding of the center from a recognized government or private
agency or organization.

b. Evidence of dissemination of knowledge to include review articles, book

chapters, technical documents, Web-based publications, editorial comments,
training manuals, and trauma-related course material.

c. Display of scholarly application of knowledge as evidenced by case reports or

reports of clinical series in journals included in MEDLINE.

d. Participation as a visiting professor or invited lecturer at national or regional

trauma conferences.

e. Support of resident participation in institution-focused scholarly activity,

including laboratory experiences, clinical trials, or resident trauma paper
competitions at the state, regional, or national level.

f. Mentorship of residents and fellows, as evidenced by the development of a

trauma fellowship program or successful matriculation of graduating residents
into trauma fellowship programs.
 - 194 -
B. The institution will have a designated trauma research director and demonstrate current
involvement in and commitment to research in adult and pediatric trauma care.
 - 195 -
Chapter 22
Policy for Linkages to Safe Systems Approach (eg Road
Safety) in TAEI

20. Policy for Linkages to Safe Systems Approach (eg Road

Safety)

Global organizations like WHO, UN have been constantly cautioning the society,
the horrendous way in which RTA could become a public health emergency, as it is now
the ninth leading cause of mortality with 1.25 million deaths and is estimated to reach
up to be the 3rd leading cause of mortality by 2020.

The dedication of the 2011-2020 as the decade for road safety, the September 2015
Sustainable Development Goals-2030 Agenda, by United
nations which targets to halve the deaths due to RTA by the
year 2020 and the advocacy of World Bank that
promotes all countries to adopt Safe Systems Approach shows
that Road safety has become the global priority.

The Safe Systems Approach:

Safe Systems Approach has brought about substantial reduction in RTA in high income
countries.

It agrees with the Haddon’s Matrix regarding complexity and multi-causal nature of RTA
(several factors involving Agent - Vehicle factors/ Environment- Hot spot /Social/legal
environment , Host- Road user factors/ behavioral factors interact resulting in RTA)-
that focusing only on corrective action from the road user, or road lay out or the vehicle
factors can’t bring the desirable output.

It recognizes the fact that– Road crashes are inevitable as there will be some
component of human error attached to and the vulnerable nature of human body to
crashes. It emphasizes on Systems approach, promoting the concept of shared
responsibility reiterating the fact that the road safety responsibility not just rests on the
individual road user.
 - 196 -
Hence, Safe systems approach –

❖ Holistically addresses the issues of road safety

❖ Substantially reduces accidents/ injuries and deaths through effective management of

road infrastructure, vehicle and speeds;

❖ Aims for a forgiving system, that though the crashes occur ensuring it does not lead to
deaths/ serious injuries by bringing down the crash energies to levels tolerated by the
body.

Expanding on these principles of Safe System Approach, a much clearer picture was
drawn in 2010 by the UN Global plan for road safety that promotes the 5 pillar
approach, which is as follows:

❖ Pillar 1: Road Safety Management aims at building enabling political, financial,

legislative, legal, regulatory and institutional environments so that there is a lead agency
for road safety, which will ensure effective monitoring and evaluation of road safety
activities.

❖ Pillar 2: Safer Road Infrastructure aims at establishing safe roads and transport
environments through regular audits by the respective State and national road safety
agencies.

❖ Pillar 3: Safer Vehicle refers to incorporating better safety features in the design and
manufacture of vehicles and ensuring all vehicles have the minimal vehicle standards.

❖ Pillar 4: Safer Road Users refers mainly the vulnerable road users eg. Pedestrians,
cyclist, motorist etc. and aims at bringing about a behavioural change through community
participation in IEC activities, improved branding/ marketing.

❖ Pillar 5: Post Crash Response refers to strengthening the EMS, such that there is
immediate response to emergencies. Pre hospital, in hospital and rehabilitative phases are
ungraded and empowered.
 - 197 -

Major Challenges in Implementing Safe Systems Approach:

Components Barriers
 - 198 -
Road safety ❖ Administrative Framework is a Top down Approach – Reach to the

management end users /implementers is minimal

❖ Road safety is a shared responsibility of nearly 15–20 different

ministries. Challenge to co-ordinate.

❖ Law remains maim as it is not undertaken simultaneously with

other sectors.

❖ Lack of Child restraint laws

❖ Demographic Transition ignored – Unequipped to favour safety of

elderly folks

Safer Road ❖ Road safety is more of an urban phenomenon, neglecting the rural

Infrastructure folks

Safer Vehicles ❖ Existence of Poorly designed and maintained vehicles on roads

Safer Road Users ❖ Behaviour change strategies

❖ Lack of Community engagement and participation

Post Crash Care ❖ Challenges in developing Mutual synergies between Pre-hospital/In

Hospital and Rehab Components

❖ Lack of a Comprehensive Emergency Department with proper

access and linkage with OT/Blood Bank/ CT/Pharmacy etc

❖ Lack of Monitoring and evaluation Methods.

Data System / Data source is completely based on police records only.

Registry
Need for an Integrated Data system, linking Prehospital, In
hospital, Rehabilitative and Police Data base.

Need for Publically available road safety data.

No data on safety performance indicators (speeding, alcohol, and

 - 199 -
helmet use) in the NCRB database

Recommendation for effective Road safety through safe systems approach in

Tamil Nadu:

Safer Road Infrastructure

Road Design ➢ Cycle Tracks and lanes to be incorporated with protected

space on all major roads

➢ Highways to be designed to carry heavy traffic at high speed

with the lowest possible number of accidents in all main roads

➢ Bypasses or Overbridges to be designed to carry long

distances traffic outside towns and cities and helps to introduce
traffic calming measures on the main road through a town

➢ Full Channelization includes both side road channelization

and left turn lanes, possible also right turn lanes.

➢ Roundabouts: Converting intersections to roundabouts can

improve safety and traffic flow in several ways

➢ Median Barriers: Locations with a history of head on

collisions will be prioritized for providing median barriers.

➢ Median barrier should not restrict access for local population.

They need to be provided such that locations that require
access for pedestrians and small vehicles with properly
engineered median openings.

➢ Redesigning of junctions to improve sight conditions at

intersections, simplify turns and make the intersection more
visible to road users who are approaching it
 - 200 -
➢ Staggered junctions can be introduced to reduce the number
of conflict points at junctions and thus take the task of crossing
the junction simpler for road users.

➢ A grade separated junction can be built inorder to improve

traffic flow and reduces the changing traffic lanes for traffic in
the same direction.

➢ Black spot treatment aims at identifying, analysing and

improving roads at place with a concentration of accidents by
improving road design or traffic regulation at such spots

➢ Improving cross section of the road to give all road users

increased safety margins by making the road wider, by
constructing hard shoulders along the road and by increasing
the number of traffic lanes and by constructing central
reservation between carriage ways.

➢ Improvements of road alignment and visibility conditions aim

at reducing the demands on driver attention and driving skills,
improving the consistency and predictability of roads.

➢ Reconstruction, rehabilitation and resurfacing of roads

consists of altering the existing roads to bring it up to current
design standards and other improvements.

➢ Guardrails and crash cushions can be designed to reduce

the extent of damage and injury in the event of an accident.
Guardrails in medians on divided roads are intended to prevent
accidents

Road ➢ Game accident measures to be taken to reduce the number

Environment of game accidents and the severity of such accident. The most
effective measure seems to be fencing in combination with safe
crossing facilities, Reducing speed limits in the animal crossing
areas also help to detect the animals

➢ Road Side street lights are neglected in many rural areas.

Make sure Road lighting proper in all types of roads with
 - 201 -
regular maintenance

➢ Removing road side distractions like attractive banners,

Safety advertisement in signals should be rotated when Red
light is on

➢ Speed Reduction Device Usage: Speed breakers, Barricades

to be placed with reflector.

Road ➢ Improving road surface friction reduces the number of RTA.

Maintenance
The effects are greatest on wet roads, in sharp bends and
when friction initially low

➢ Correcting erroneous traffic signs (Eg placing Signs in

position that is not easily visible, wrong size, wrong text or
color or lack of road sign, orange clothes for road workers etc)

➢ Safeguarding road works – like temporary traffic control

such as temporary speed limit, Closing roads where road works

➢ Resurfacing the roads to prevent dangerous unevenness and

damage due to wear and tear of road surface, to increase
driver comfort, maintain the road’s loading capacity to reduce
wear and tear on vehicles.

➢ Improving the unevenness involves filling potholes in the

road surface, sealing large cracks, repairing damage following
frost heave, rut depths

➢ Landslide protection in hilly areas like Nilgiris to be

undertaken. Landslide protection measures includes re-routing
of roads, landslide superstructures, walls , embankments or
landslide screens, bolting rocks, converging rock faces with
nets or similar material, the controlled release of landslides
and warning of landslide hazard and closing exposed road in
periods of particularly high risk

➢
 - 202 -
Safe Speeds ➢ Speed limits will be set based on road type and prevailing
geometric and road environment conditions for all National
Highways, State Highways, District Roads, City Roads, Village
Roads, Residential Streets.

➢ GPS enabled speed limit information will be prepared for

the entire state. Awareness about new speed limits will be
spread to reach every driver of the state standardized signage
will be erected on roads.

➢ Strict enforcement of speed limits will ensure compliance.

Enforcement of speed limits must be based on automated
technology. The success of speed enforcement will be
measured not by the number of speeding challans, but rather
by random

➢ compliance checks.

Road Safety ➢ Road Safety audit to be taken care by corresponding District,

Audit City Road Safety council periodically( once in a month or in
quarter) to make sure all of the above safety measures
ensured in road

R& D for Safe ➢ Data collection of Black spots, Analysing RTA patten, RTA
Infrastructure which causes fatalities and latest technology for road
infrastructure to be researched and need to tested in trial and
error method periodicially

Traffic Control ➢ Area wide traffic calming in a large defined area in order to
improve road safety and environmental conditions like ban
traffic on residential street by using traffic signs or physical
closure, speed reducing devices in residential streets, one way
traffic, changing parking regulations in residential streets

➢ Pedestrian Streets: Converting high density commercial

street to pedestrian streets.

➢ Urban Play Street: Converting streets to urban play streets

to give the residents a safe and attractive outdoor
 - 203 -
environment. Urban play streets are planted with trees and
shrubs, sandpits, play equipment, tables and benches. The
road itself is not rectilinear and is not delineated using
kerbstones or anything else that create difference in levels
between the road other areas. primarily environmental
measure, even though it can also improve traffic safety

Driving in and out of urban play streets will be over

kerbstones.

➢ Access Control to reduce the number of private access roads

along public road to make each access point as safe as possible
and to distribute traffic between access roads in such a way
that the total accident rate is minimised. By following
measures to be take constructing roads without access points,
removing private access roads.

➢ Traffic signal to be incorporated all blackspot junctions

➢ To improve the safety at intersections, traffic signals with

Cameras, rumbling strips about 100 metres before
intersections need to be provided on all National Highway and
State Highway when the crossing roads have significant traffic.

➢ Signalised Pedestrian Crossing to be incorporated in

regular intervals in City Road.

➢ Better automatic warning systems to be incorporated for

crossing lanes, Crossing Stop lane in traffic signals

➢ Road marking to direct traffic by indicating the path of the

carriageway and marking the road in relation to the
surrounding and to warn road users about specific conditions
related to road alignment.

➢ Traffic control for pedestrian intended to separate traffic in

time or space from vehicular traffic, direct pedestrian and cycle
traffic to safe crossing locations and increase mobility of
pedestrians. It includes following measures Foot path, Raised
cross walk, Lighting at cross walk, Pedestrian guard rails,
 - 204 -
School crossing patrols.

➢ Stopping and parking controls are designed to remove or

reduce on street parking , transfer parking to marked parking
places or parking lotw away from the streets to prevent
vehicles from stopping and parking at places where this
severely obstructs vision or hinders movement for other road
users, including pedestrians

➢ One Way street: By creating one way streets, theoretically

the number of conflict points at intersections can be
considerable reduced., it becomes easier for pedestrains to
cross the road and the capacity of the road increases.

➢ Bus Lanes and Bus stop designs: Constructing up bus lanes

and protecting bus stop s are intended to separate buses from
other traffic and thus reduce the number of accidents and
helps to increase the mobility for public transport and shorten
journey times.

➢ Dynamic Route Guidance: The main objective of dynamic

route guidance is to utilise capacity of road system better by
preventing inappropriate choices of route. In principle, such a
system could also supply information about traffic accidents,
direct traffic system from an accident location and give
information about the accident rate on different street, so that
drivers can select the safest streets. This can be achieved by
two measures

1. Vehicle equipped with GPS that may guide the drivers on

the recommended or chosen route

2. Based on VMS that display information about events on

road or in road network can recommend alternate route.
VMS are to be installed at strategic point on the road
network. They may provide information and
recommendations in the case of capacity problems, road
closures, accidents or other events. Different kinds of
technology can be used like flip dot, lamp matrix, rotating
 - 205 -
prisms, fibre optics, light emitting diode.

➢ Protecting railways and highway level: Protecting railways

and highway level crossings, by removing level crossings and
equipping them with warning signals and barriers.

➢ Environmental Zone: Concept of environmental zone to

reduce traffic volumes or speed are that improve the condition
for vulnerable road users based on the local need. (Eg: Parking
Restriction, Increase Parking prices, Reserved parking spaces
for Residence, Restriction to motorized transport, speed
reducing measure

Safer Vehicles:

Vehicle Standards: Tyre tread depth: Setting up minimium permissible tyre tread depth

Anti-Lock Braking System and Disc Breaks:

ABS to regulate and control the break pressure and avoid break locking
simultaneously to give best possible breaking effort.

Mandatory ABS for large vehicle to improve stability while braking.

Disc Brakes in cars to improve the handling capability during braking.

o The Central Government has mandated the inclusion of ABS

(anti-lock brake system) and auto headlamp on (AHO) for
two wheelers (>125 CC) from April 2018. This will likely
reduce fatalities involving two wheeler riders who contribute
the maximum deaths in road accidents.

o Retrofit of vehicles (e.g. high-grill on the front bumper,

spoilers / wings, engine modifications) will require prior
permission from RTOs.

High Mounted Stop lamps: To reduce the number of accidents

 - 206 -
involving rear end collisions.

Pedestrian Reflectors: Use of pedestrian reflectors and retro reflective

materials on bicycles, number plates and back of cars

To reduce the roll over accidents of vulnerable vehicles like certain cars,
trailers, by securing unstable loads, lowering center of gravity, increasing
rigidity by a new type of trailer coupling, reinforcing suspension on
trailers, using a system that warns of overturning danger.

Vehicle Features Bicycle helmets: Mandatory wearing of hard shell bicycle helmets.

Bicycle safety equipment: To prevent bicycle accidents by increasing

visibility, , easier to manneuvre, and easier to stop.

Motorcycle helmets: Mandatory use of helmets for moped riders and

motorcyclist.

➢ Automatic setup to be researched and introduce so that one can

start bike if all occupants of motorcycle wear helmets.

Seat Belts: Use of seatbelts in Cars/Vans:Use of three point Seatbelts

for all seats and two-point seatbelts for center rear seats. Mandating use
of seatbelt to all irrespective of the seat being used or age of the person.

➢ Need to introduce seat belts in Buses and trucks

➢ Driver seats of Buses and trucks are to be designed more

comfortable and safety measure

➢ Automatic setup need to be incorporated so that one can start

driving after all occupants wear the seat belt.

Child restraints: Mandatory wearing of Child restraints.

Airbags in cars

Doors in Buses: All buses to have doors to ensure footboard travel is

not possible
 - 207 -
Addressing the demographic transition:

Introduction of Low floored buses / Ramped buses and allocation of more

seats for elderly.

Vehicle Testing crashworthiness of vehicles in crash tests . All new vehicles

roadworthiness to be assessed by a new car assessment programme that tests for adult
occupant protection in the car, pedestrian protection, child occupant
protection and safety assist(seat belt reminder/speed limitations)

Fire safety satandards, Electronic stability control

FC Renewal: The procedure and periodicity of issuing FC for

vehicles older than 10 years will be revised.

R&D for Vehicle 1. On board system to detect obstacles without distracted by other
Safety environment condition like weather system
Technologies
2. Road-Vehicle Cooperative Smart Cruise System

The basic concept of the Road-Vehicle Cooperative Smart Cruise

System is for automobiles and road infrastructure that have been
given intelligent capabilities to cooperate through road-to-vehicle
communications in order to support drivers in operating their
vehicles. Research to be taken to possibility of implementation of
such system

3. R & D for all latest Vehicle Safety technologies

Safer Road Users:

Driver Training and Regulation of Age: Strict Enforcing the existing regulation on age at
Regulation of which driving can be practiced
professional drivers
Fitness Check: Health requirements for drivers as per regulation to
 - 208 -
include visual acuity, history of epileptic seizures, locomotory tests and
other illness tests.

Setting up driver performance standards, which covers their

knowledge, awareness, skills and understanding of the different road
user ‘s limitation and risk factors like fatigue, age , alcohol illness
Knowledge on the way vehicle functions , decide on if vehicle is in good
condition, traffic signs and signals

Improvement courses for older drivers, to refresh driving skils.

Training Schools

o Driving Test : Rigorous testing procedure for licenses will

be implemented; use of technology to minimize biases in
the testing process will be explored by introducing
Computerised Testing Tracks.

Regulation on driving and rest hours by setting standard daily/

weekly driving time, longest driving time without a break, rest periods,
weekly break.

Tachnograph registering system to capture driving hours (driver

fatigue) not just based on trip sheet.

School transport : to be entiled for every student at a minmum

distance of 4km from home

Public Education Age relevant road safety education and information such that preschool
and Information children are also benefitted.

Introduction of organised road safety education for school children.

Conducting road user information campaigns to promote safe behaviour

in traffic like

• Establishment of traffic education parks

 - 209 -
• Preparing literature and educational materials such as road sign
charts, traffic rules, safe driving, etc., for distribution among
public including children

• Preparing and screening of short films on Road Safety on TV

channels and in various educational institutions

• Preparing slides on traffic rules and their public screening

• Training school pupil aged between 5 and 12 the right way to

cross the road.

Police Enforcement ➢ Stationary Speed enforcement using radars, lasers, that measure
and Sanctions: mean speed between 2 fixed points or at stopping sites staffed
uniformed police officer

➢ Composite speed enforcement with more than one speed

enforcement element

➢ Mobile enforcements using patrols with special focus on DUI,

speeding

➢ Seatbelt/ helmet enforcement in all parts of state

➢ Red light Cameras at signalised junctions takes photograph of

vehicle that jumps red light from front to identify the driver.

➢ Automatic alarms or bleeps to warn the road user while crossing

the stopping line at signals.

➢ Automatic Number Plate Reading (ANPR) system based on web

cameras will be installed on national/state highways to control
speed of vehicles and to record other traffic violations

➢ Demerit point system and license suspension; An online portal for

cancellation/suspension of driving licenses of violators involved in
drunken driving, over speeding, red light jumping, overloading,
carrying person in goods carriages, using mobile phone while
driving, non wearing of seat belt to be enforced strictly.

➢ The person whose licence has been suspended/cancelled for

 - 210 -
causing fatal accident will be asked to undergo refresher driving
training in government institutions and obtain a medical
certificate from government hospitals before making a request to
revoke the suspension/cancellation of his driving licence

➢ Fixed penalties for violations.

➢ DUI legislation:

➢ Dram Shop laws that impose civil liability on liquor stores that sell
alcoholic beverages to minors.

➢ Random breath testing laws : Random night checks and

technology-based solutions will be explored to check drowsy
driving.

➢ Fines and imprisonment : Driver distraction – use of mobile

devices while driving is emerging as a major cause for accidents.
Need awareness and enforcement against such practices. A
related problem is the use of headphones / hands free by
pedestrians.

➢ Unlicensed driving has to be handled very strictly. Aadhar number

to be incorporated in all Driving Licenses to curtail duplicate
licenses. Carrying of original driving licence while driving a vehicle
is to be made compulsory.

➢ Linking Aadhar Number with Vehicle Registaration process (RC

Book)
 - 211 -

➢ Illegal motor/bike races resulting in severe road accidents will be

curbed

➢ Motor Vehicle Insurance:

Insurance schemes to cover all personal injuries as well as property

damage. The Fault system standard follows proving the person who
caused the accident acted negligently

No fault system that brings in the concept of shared responsibility

Setting up medical expense limit in that case

4. Bonus system: to reduce the insurance premium by a given

percentage for each year when no claims are filed.But if a claim is
filed it increases the payment which is done by the insurance
company.

Post Accident Care

Emergency Medical Objective of Emergency Medical Response Service is to ensure fast and
Response Service adequate medical treatment and transport to a hospital in the event of
RTA in order to maximise the probability of survival and full recovery

To deliver the right patient to the right trauma center at the right time

EMS system to govern and audit sustainability

Pre- hospital time: Time from occurrence of RTA and arrival of

patient at hospital. Problems in high pre- hospital time due to delay in
notification time , Long distance,Delay in transport due to heavy traffic.
 - 212 -
GPS in all ambulance, better location of accident spot with Avasaram
108 app and better assignment of ambulance will reduce the response
time.

Better location, repositioning, assignment and routing of ambulance is

required.

➢ First aid training to all lay persons. By making mandatory

first aid training for teachers and students in schools, for
employees in public and private organizations and making
mandatory to take first aid course for taking driving license.

➢ Treatment Strategies in accident Scene:

1. ALS (Advanced life support) Providing professional medical

treatment including invasive treatments and medication, at
the accident scene by specially trained EMT or doctor.

2. BLS (Basic Life Support) aims at transporting patients as

fast as possible to a specialised Hospital. Medical treatment
involves only non invasive techniques and is provided only
to the degree that is necessary to keep the patient alive
during transport

These strategy to be decided by EMT based on type of

patients and injuries and distance of Specialized Hospital.
(Eg Cardiac arrest are more like to benefit by BLS while
blunt trauma patient from ALS)

➢ Telemedicine : Use of telecommunication technology for

medical diagnosis and patient care by EMT or using portable
devices with audio and video equipment for the communication
of lay persons with emergency physician while providing first aid

➢ Establishing Emergency Stabilization units in all Hot Spot

areas

➢ Rescue Trains: Most of the cases from Vellore, Kancheepuram,

Chengalpet districts referred to RGGGH, Chennai. But the traffic
in the city is very heavy so that ambulance find the way to
move. Using Rescue Trains can be tested.
 - 213 -
Automatic Crash ➢ Automatic Crash Notification will reduce notification time. ACN
Notification system can use air bag sensor in the car or advanced systems to
detect serious accidents

Hospital Care ➢ To establish inclusive integrated trauma care services

(Trauma care as a quaternary speciality.)such that Prehospital,
Emergency, Operative and rehab services are available in the
same premise such that timeliness of intervention , management
and co-ordination of resources is ensured.

➢ Devise an insurance scheme for post crash 48 hrs

stabilisation cover entire population of TN

➢ Workout a strategy for seamless integration of post

stabilization intervention with the existing CMCHIS
package

➢ Pre arrival Intimation/ Trauma Call out/ System of Triage,

Resuscitation Team/ Capacity Building/ standard Adult retrieval
system and Pediatric Infant Perinatal Emergency Retrieval
Service (PIPER) for patients less than 16 years.

➢ High compliance with major trauma guidelines and protocols

to be ensured uniformly across the state such that the right
patient is taken to the right level of care in the shortest time.

➢ Use of Tranexamic acid in the post crash treatment of road crash

casualty to reduce deaths due to hemorrhagic shock

➢ Continuing medical education courses in ATLS / PALS

➢ Introduction of Quality indicators for ER – Standardisation of ER

 - 214 -
➢ Implementation and Evaluation of Hospital Trauma Care
Service of selected 72 TAEI centres in the state

➢ Enhancing Trauma Care Service in other Taluk Hospitals and

Primary Health Care Centres in the Hot Spot region

➢ Monitoring and Evaluation of patient minimum of 30 days to

identify the effects of RTI and hospital care.

o Mobile Trauma Care Centre (MTCU) helps to mitigate

the challenges of transporting severely injured
trauma patients over long distances and help stabilize
these patients and facilitates transfer to a tertiary
care centre. The MTCU locations would be taken up in
a phased manner.

o A senior level position will be created to establish, co-

ordinate and monitor functioning of Trauma Care
Centres

o Separate expressway needs to be created in all toll

gates exclusively for ambulances and fire services.

o Trauma registry database to be created to merge

road accident database with trauma care database to
evolve better strategies.

o Data driven, real-time, and dynamic ambulance location,

allocation and routing to be enabled.

o An Integrated trauma care policy will be prepared to give

quick and right medical aids to the road accident victims
to save their lives

o A new insurance scheme will be worked out to provide

treatment, rehabilitation and to compensate the working
days loss of the accident victims.

➢ Multidisciplinary meetings,
 - 215 -

Rehabilitation ➢ Early rehabilitation and support of Injured patients

➢ Engaging psychologist and social workers in Emergency Room for

psychologic rehabilitation of Road crash casualty.

R & D in Emergency ➢ Monitoring casualties from the occurrence of RTA and until
Medical Service and complete recovery.
Hospital Care
➢ Linking of casualty record from RADMS, 108, Hospitals

➢ Generation of unique TAEI ID of casualties to get better

understanding

➢ Data analysis and Continue Improvements

➢ Research for emergency medical service and trauma care may

be advanced by facilitating the following: (1) developing
emergency trauma clinical research networks; (2) integrating
emergency trauma research into Clinical (3) involving acute
trauma and emergency specialists in grant review and research
advisory processes; (4) supporting learn-phase or small, clinical
trials; (5) performing research to address ethical and regulatory
issues; and (6) training emergency care investigators with
research training programs.

➢ Research for best evaluation methods for trauma care and

outcome

Road Safety Management

Components Policy Recommendations

Monitoring and • Review and Strengthening the functioning Road Safety Council, The
evaluation District Road Safety Committee, Road Safety Cell, Inter Department
teams.

• Reviewing those councils and committees recommendation and

implement the needful to give continuous improvement in state level,
 - 216 -
district level and local level

• Standardised data collection forms to be uniformly used across all

departments by police, highway, health dept such that correlation,
integration of data and analysis is better with few missing data

• Eg. Data collected by police to be in line with RADMS, 108 AS record,

Hospital data(TAEI app fields)

Funding • Identify measures for increasing road safety fund

• Funding for road safety will be adequate and need based.

• Agencies and districts that are able to demonstrate documented

success in achieving targets shall be allotted with greater budget
share in subsequent instalments.

• Funds will be allocated on priority basis by the government for road

safety works.

• To support the treatment need to set up separate commission

or under the control State Road Safety Council we need to
set up a commission (Based on Victorian Model, The Transport
Accident Commission (TAC) is the statutory insurer of third-party
personal liability for road accidents in the State )

Its purpose is to fund treatment and support services for people

injured in transport accidents. The commission support covers medical
and non-medical expenses incurred as a result of an accident, for
example income support for people whose injuries prevent them from
performing normal job duties, or return to work programs, and
equipment or aids, such as wheelchairs or crutches that are
recommended by a healthcare professional. Funding used by the
Commission to perform these functions comes from compulsory
payments made by motorists when they register their vehicles each
year
R&D Setting up a Road Accidents Research Centre
➢ To improve quality of accidents data collection, help in analysis,
 - 217 -
recommend optimal interventions, and monitor progress

➢ With dedicated staff comprising road safety experts, highway

engineers, and statistical analysts

➢ The Centre will coordinate the collection of road accident data

throughout the state in partnership with the Police, health and
transport department

➢ A lighter version of the existing RADMS version with fewer data

capturing fields.

➢ The Research Centre will release monthly reports on progress made

across the state, organize quarterly meetings with all district teams
for inviting inputs and sharing of experiences, and an annual
conference that will invite leading experts from the nation to share
best practices. The Research Centre will serve as a clearinghouse for
data related to accidents in the state.

➢ It will provide a strong impetus towards data-driven, evidence-based

policies.

Co-ordination ➢ The level of co-ordination and interaction among stakeholder

Mechanism department like transport, police, highways, health, education and
state transport undertakings will be enhanced.

➢ The Apex office of road safety in Police Department i.e. office of ADGP
(Traffic & Road Safety) will be assisted by the district level senior
police officers to monitor the road safety in the state.

➢ Road safety will be added as an indicator of performance in the

Annual Confidential Report of senior police officers including
District SP, Range DIG, Zonal IG, Commissioners of Police and all
other officers assigned the task of road safety.

Safe ➢ Systematic recording of accidents in the local community by the

Community hospitals
Programmes
➢ District level critical case reviews with collector as the chairperson and
 - 218 -
other steering committee members

➢ Frequent road safety council meeting, monitoring and evaluation

Exposure ➢ Measuring the traffic volume by Annual Average Daily Traffic (AADT),
Control hourly volumes, rush hour percentage,

➢ Land use plans: To locate roads, residential areas, work places to

reduce travel distances

Conclusion:

As the Road Traffic injuries and fatalities have been horrendously increasing in the
State, it definitely proves that when the systems are not planned properly or remain
unequipped to handle emergencies (either the road infra-structure or road user behavior
or motorization or pre-hospital care or health care delivery or data management
system), it retaliates with enormous direct and indirect cost on the society as a whole.
Hence, re-emphasis on ‘systems approach’ is required for better inter-sectorial
collaboration and preparedness at all levels such that there is more effective
implementation of legislation, policies (gender sensitive policy) at all levels.
This is the best possible way to tackle this transcending issue of RTA from occurring in
the future.
 - 219 -
Chapter 23
Health Care Finance for TAEI

OPERATIONAL COSTGUIDELINES:
The Tamil Nadu Accident and Emergency Care proposes to provide operational cost to
the TAEI centers. The following are the Operational Cost guidelines:
5. Formation of the Committee with a Nodal Officer for each of these Trauma care Centers
(Institutions under TAEI)
A committee shall be formed with a nodal officer (Hospital Trauma Nodal Officer) with the
following members

Sl.
Composition Medical Colleges Government Hospitals
No.

Hospital
Superintendent/ CMO
1 Chairman Dean

Hospital Trauma
Hospital Trauma Nodal
2 Member Nodal Officer
Officer (HTNO)
(HTNO)
Secretary

Hospital Resident Medical

3 Member Superintendent Officer

Trauma Nurse Co- Trauma Nurse Co-

4 Member ordinator (TNC) ordinator (TNC)

Administrative Administrative Officer

Officer (AO) (AO)

(In case of more (In case of more than

5 Member
than one AO the one AO the senior
senior most AO) most AO)
 - 220 -
6. The Committee can decide to spend the operational cost funds(Untied funds) for
the following:
Stationeries

Printing of TAEI Case sheets , forms & Registers

Colour Coding of ER

Designing and making/ printing of:

signage

Floor markings

Foot markings around resuscitation Bay

Display boards

TAEI protocols

TAEI Badges & Stickers

7. IEC materials,
8. Procurement of Crash cart consumables (list attached),
9. minor instruments & Emergency Drugs
10.Expenses for TAEI meetings , critical case reviews
11.Fuel for generators
12.Annual maintenance contract for emergency equipments if not available in M& R
13.Minor Repairs
14.Curtains,
15.Bed sheets for red , Yellow and Green zones with TAEI logo printed
16.Data Entry Charges
Any other item related to Emergency Care if otherwise not available

Bank Account :

• In case there is no separate Bank Account for TAEI ER activities , a new Bank account
shall be opened in a Nationalised bank with the head of institution and HTNO as joint
account holders (TAEI Account), Preferably IOB or Canara Bank
• During any emergency, funds may be spent with appropriate ratification provided in the
following committee meeting.
 - 221 -

TAEI Nurses ED Uniform Guidelines

As part of branding of the TAEI centers it is considered important to give a
standard uniform for the nurses in the ED. It is mandatory for all the nurses working in
the ED (Casualty/ zero delay/ Triage/ Red Yellow , Green areas) to be in the TAEI
uniform in all the shifts.
The Dean, the Joint director of Health services and HTNO are requested to co-
ordinate in this regard and get two Uniforms per staff to be stitched and issued as per
the guidelines.
The detailed guideline has been annexed. This cost may be met from the TAEI
operational cost.
TAEI Uniform Guidelines:
Female Nurses
Uniform Type 1. Pants and Shirt model
2. Half sleeved Shirt with Round
Collar and thin White piping
(Sleeve, Collar, Pocket mouth)
3. Pajamas with Nada
4. Cover Patti, side open, Liberty
cut
5. 2 Pockets below
Logo TAEI logo to be printed in the left
side ( chest)

3.5 by 3.5

Colour Royal Blue

Fabric Mayur Suiting

No.of sets per staff 2

Suggested Tailor RGGGH – 9884490146

 - 222 -
Cap

Shoes and Socks White cut shoes and white socks

Male Nurses
Uniform Type 1. Pants and Shirt
2. Regular Collar
3. Outside Patty
4. Liberty cut
5. Piping in collar and sleeve
6. Pants -One back pocket , 2
cross pockets

Logo TAEI logo to be printed in the left

side ( chest)

3.5 by 3.5 cm

Colour White shirt and Black Pants

Black Shoulder Flap (buttons)

Fabric Mayur Suiting

No.of sets per staff 2

Suggested Tailor RGGGH – 9884490146

Shoes Black Shoes and Black socks

Belt Black

The RGGGH uniforms were stitched by a tailor (9884490146), it is suggested that he

may be contacted for any queries on uniform.
The TAEI centers should provide the utilisation certificates for the TAEI operational cost
on a periodic basis.

Annexure:
 - 223 -
SN CRASH CART LIST
Draw 1
1 Adult laryngoscope
2 Paed laryngoscope
3 1,2,3,4 curved blade
4 1,2 straight blade
5 Battery
6 Bougie
7 Suction catheter
8 ET tube (7,7.5,8 No)
9 Stylet
10 Tie and Elastoplast
11 Torch with Batteries
12 magills forceps
13 oro pharyngeal airway
14 nasopharngeal airway 6,7
Draw 2
15 ECG leads 3
16 Jelly
17 Sterillium Hand sanitiser

Bag Valve Masks (BVM) in Adult, Child, & Infant Sizes Equipped with
Operable Pressure Relief Valves and Transparent Masks, with Oxygen
18 Reservoir/Accumulator.

19 The Pediatric BVM Shall Have Masks for Neonate, Infant, and Child.

Single Use, Transparent, Non-Rebreather Oxygen Masks in Adult and

20 Pediatric Sizes

21 Nasal Cannulae in Adult and Pediatric Sizes

Draw 3 - Drugs
22 Adrenalin
23 Atropine 5 amps
24 Adenosin 5 amps
25 Amiodaron 6 amp
26 Dopamine 2 amp
27 Scoline( store in fridge)
Draw 4
28 ABG syringe 2
29 16-22 G Needle
30 IV set
31 Micropore
32 3 way
33 Needles
34 Syringe 50 cc
35 Syringe 2cc, 5cc, 10cc
 - 224 -
Draw 5
36 5% dextrose
37 RL
38 NS
39 Intraosseous Needle – 5
PPE -Personal Protection
40 Goggles
41 Surgical Masks

42 Disposable Synthetic Gloves for all Attendants

43 Disposable Biohazard Bags For Non-Sharp Waste

44 Standard Sharps Container Both Fixed and Portable

45 Disinfectant For Solution for Cleaning Contaminated Equipment

Waterless Hand Cleaner, Commercial Antimicrobial (Towelette, Spray, or

46 Liquid)

47 Plastic Aprons or Fluid Resistant Gowns

Immobilsation devices

Philadelphia Collar/ C collar

Rigid Cervical Immobilization Devices in Appropriate -
Adult,
Child, and
48 Infant Sizes

Head Immobilization Device (NOT SANDBAGS) –

Firm Padding OR
49 Commercially Available Device

50 Upper and Lower Extremity Immobilization Device(s):

Lower Extremity Traction Splint in Appropriate-

Adult and
51 Child Sizes
52 Broad arm slings
53 Triangular slings
54 Roller gauze
55 Wooden piece to splint
56 Pelvic Binder
ICD Kit
57 Needle Holder straight 8''
58 Kellys Clamp- curved 8"
59 Tray with Lid
60 Stainless steel cup
61 Artery forceps straight 6"
 - 225 -
62 Artery forceps straight 8"
63 Toothed forceps
64 Gauze
65 Cotton Balls
66 Biopsy Towel
67 Scalpel Holder with blade
68 Suture scissor sharp
69 Chest Tube

Bleeding Control and Wound Management

70 Abdominal Trauma Dressing
71 Sterile Gauze in Various Sizes
72 Gauze Rolls in Assorted Sizes
73 Triangular Bandages
74 Occlusive Dressings or Equivalent

75 Sterile Water or Saline Solutions for Irrigation

76 Arterial Tourniquet

77 Sterile Burn Sheets or Medical Director Approved Burn Care Supplies

78 Adhesive Tape
79 1” & 2” Hypoallergenic
80 1” & 2” Adhesive

Patient Assessment/Diagnostic Measurements

81 Stethoscope in Sizes to Accommodate all Patients

82 - Paediatric
83 - Adult
84 - Infant

85 Blood Pressure Cuffs in Sizes to Accommodate all Patients

86 - Paediatric
87 - Adult
88 - Infant
89 Thermometer(s)
90 - Oral thermometer
91 - Rectal thermometer
92 - Biohazard thermometer

93 Scissors for Cutting Clothing, Belts, and Boots

94 Broselows Tape
95 Pulse Oximeter with
96 - Adult and
97 - Pediatric Probes
Additional Equipment –
 - 226 -

98 Glucometer with Reagent Strips and Single-Use Lancets

99 CPAP Equipment
100 Nebulizer Equipment

101 Equipment to Capture Out-Of-Hospital 12 Lead

102 Advanced Airway (Non-Visualized Approved by Title 172 NAC 11)

103 If Monitoring IV Solutions, Intravenous Fluid Bag Pole or Roof Hook

Miscellaneous Equipment

104 Device Capable for Pediatric Immobilization

105 Ocular Irrigation Device
106 Hot Pack(s)
107 Cold Pack(s)
108 Emesis Bags/Basin
109 Urinal
110 Bedpan
STOCK
111 Blankets

112 Sheets – At Least One Change Per Cot

113 Pillows
114 Towels
115 Step Stool for CPR
Oro-gastric lavage tube (Boas tube)

116
Foleys Catheter
117
Uro Bag
118
Knee Hammer
119
Cheatles Forceps
120
Catheterisation Tray
121
Central Venous Lines Tray
122
Fetal Scope
123
 - 227 -
Hair Trimmer
124
Weight and Height Machine
125
Portable Oxygen Cylinder
126
Nail Cutter
127
Raizor set
128
Ophthalmoscope
129
Colour Coded Dust Bins
130

Emergency Drugs List

II DRUGS in ER
1 Ns -500ml
2 Rl-500ml
3 D25%
4 Inj Atropine
5 Inj Adrenaline
6 Inj Amiodarone
7 Inj Soda Bicarb
8 Inj Midazolam
 - 228 -
9 Inj Adenosine
10 Inj Dopamine
11 Inj Dobutamine
12 Digoxin
13 Diltiazem
14 Heparin
15 Inj Mgso4
16 Inj Lasix
17 Inj Vasopressin
18 Beta Blockers
19 Calcium Channel Blockers
20 Inj Kcl
21 Inj Ca Gluconate
22 Inj Lidocaine
23 Inj Lorazepam
24 Barbiturates
25 Benzodiazepine
26 Sterile Water
27 Carbamazipine
28 Calcitonin
29 Scoline (To store in fridge)
30 Antisnake Venom(ASV)
31 Activated Charcoal
32 N-acetyl Cysteine
33 Nalaxone
34 Inj Ntg
35 Tetanus Toxoid
36 Inj. Tramadol
37 Inj. Paracetamol 1G- Iv
38 Paracetamol Suppository
39 Fentanyl
40 Ketamine
41 Anti Rabies Vaccine
42 Inj.Vit. K
43 Nor Adrenaline
44 Hydrocortisone
45 Pheniramine Maleate
46 Inj Avil
47 Inj Diazepam
48 Inj. Dexamethasone
49 Inj Morphine
50 Inj Largactil
51 Inj Mannitol
52 Inj Phenargan
53 Inj Insulin
54 Inj Ranitidine
55 Inj Dilantin
 - 229 -
56 Inj Tranexamic Acid
57 Inj Pantoprazole
58 Inj Haloperidol
57 Inj. Ondensetron
58 Inj Aminophylline
59 Inj Glycerl Tri Nitrate (GTN)
60 Inj Piperacillin Sodium
61 Inj. Quinine
62 Inj Streptokkinase
63 Inj Urokinase
64 Dulcolax Suppository

Transport Accident Commission

7. Health Care Finance for TAEI including Transport Accident

Commission
A. Financing Framework of TAEI
Sn Name of Funding Agency Amount Sanctioned Amount Released
GOI
TANII
Road Safety Funds (TNRSP)
Transport Commissioner
State Funds

B. Transport Accident Commission:

 - 230 -
In Government of Tamil Nadu, several post crash beneficiary schemes like the Social
Security Schemes, Motor Accident Claims Tribunal are present but they are devised to
provide compensation after death and disabilities. Also Spot fines remitted to
Government account is around Rs. 120 crores up to October 2017, but there is no
scheme like the Victorian Transport Accident Commission, which provides medical
benefits to an injured person regardless of who caused the accident.
There is a need for a similar 'no-fault' scheme which aims to provide the complete
package of care in the ER free of cost in the first 48 hr at any hospital across the State.
Hence, the TAEI 48 hour Cashless Insurance Scheme recognizes:
- The enormous RTA burden in the state

- The inability of the victim and the family to mobilise resources due to the sudden mishap,

• The denial of treatment in nearby appropriate facility ( private medical facility) and
multiple IFT which results in mortality and morbidity to a great extent
• The IIT, Chennai has done an analysis and arrived at the annualised value of the Income
lost due to RTA.

Loss of Income due to Fatal Accidents in year-2016

Total Road Accidents Death for 2016 17218
Analyzed Road Accident Deaths 1759
Income Lost due to Road Accident Deaths for 1759 Persons 396.85 Cr
Average Income Lost due to Accident Death Per Person 22.56 lakhs
Income Lost due to Road Accident Deaths for 17218 Persons 3884.57 Cr

• In addition to the hospital expenses, loss of income due to hospitalization and rehabilitation
pushes the family into a permanent debt trap.
Now under the TAEI 48 hour Cashless Insurance Scheme:
• As the Health Department already has the experience of implementing the CMCHIS, A
new TAEI Insurance scheme has to be formulated by covering the entire population of
Tamil Nadu for providing 48 hour cashless treatment to RTA victims and victims of fire
accidents in public places.
• A “Corpus Fund” by way of budgetary support from the State Government has to be
created , to implement the 48 hours Cashless Treatment scheme for RTA Victims and
victims of fire accident in public places. The corpus money may be used for paying the
Insurance premium.
 - 231 -
• IRDA accredited Insurance companies needs to be identified through a competitive
procedure to implement the scheme.
• Need to fix a ceiling of up to Rs. 2 lakhs per person to meet the immediate medical
expenses up to 48 hours of admission in a medical facility.
• The expenses would cover diagnostics, medicines, emergency surgeries etc for which
packages would be worked out.
• A system of empanelment of Government and Private Hospitals to be done on the same
lines as CMCHIS.
• Need to develop a strategy / Process to identify the third party vehicle Insurance Agency
to recoup the cost of 48 hour treatment provided to the victim by the Insurance agency.
This plough back mechanism will reduce the State’s burden towards financing the scheme
and will ensure sustainability. An exception may be provided for hit and run cases. This
may be combined as part of the scope of the Insurance agency.
• To work out a strategy to seamlessly integrate the 48 hour cashless Insurance scheme
with the existing CMCHIS scheme as per the eligibility of the victim for post 48 hour
treatment and follow up if any arising.
• Considering that grievous injuries take a longer period of rehabilitation and also resulting
in temporary or permanent disability to the victim, the scheme may incorporate the
appropriate packages as well.
• work out to Rs. 50 per person per annum. The total cost of premium to be paid to the
Insurance agency would be around Rs. 375 crores.

S.N Population Estimated premium per person Total Estimated

o. Covered per annum (Rs.) Cost (Rs. in crores
)

1. 7.5 Crores 50 375

The compensation awarded to the victim by the Motor Vehicle Accident Tribunal (MACT),
under the third party insurance claim which is fixed based on the extent of injury will be
remitted by the third party insurance agency to the corpus fund.
 - 233 -
Chapter 24
A Brief History of TAEI (Till Date)

The Government has initiated various measures to reduce the increasing

fatality due to RTA by establishing:

a) Accident and Emergency wards in all major hospitals located in its National and
State Highways.
(b) Specialized Trauma care centres in 22 hospitals located in the Golden
Quadrilateral highways with assistance from Government of India under the 11th five
year plan.

The list of hospitals under DME and DMS are as follows:

S.No Name of the hospitals under DME (GOI funded for non-recurring
cost)
1 Villupuram Medical College Hospital, Villupuram
2 Karur Medical College Hospital, Karur
3 Kilpauk Medical College Hospital, Chennai-10
4 Vellore Medical College and Hospital, Vellore
5 Government Rajaji Hospital, Madurai
6 Tirunelveli Medical College Hospital, Tirunelveli
7 Kanniyakumar Medical College Hospital, Nagercoil

SN Name of the hospitals under DMS (GOI funded for non-recurring

cost)
1 Govt. Taluk Hospital, Melur, Madurai district.
2 Dist. Head Quarters Hospital, Padhmanabhapuram
3 Dist. Head Quarters Hospital, Tenkasi
4 Dist. Head Quarters Hospital, Namakkal
5 Dist. Head Quarters Hospital, Kovilpatti
6 Dist. Head Quarters Hospital, Wallajah, Vellore
7 Dist. Head Quarters Hospital, Cuddalore
8 Dist. Head Quarters Hospital, Dindigul
9 Government Taluk Hospital, Omalur, Salem district
10 Dist. Head Quarters Hospital, Perambalur
11 Dist. Head Quarters Hospital, Krishnagiri
12 Govt. HospitalTambaram, Kanjeepuram
13 Dist.Head Quarters Hospital, Kancheepuram, (State Funded)
14 Dist,Head Quarters Hospital, Thiruvallur (State Funded)
15 Govt. Hospital Palani, Dindigul district (State Funded)

(C) State funded Trauma care centres are:

• Government Head Quarters Hospitsl, Tiruvallur
• Government Head Quarters Hospital, Kanchipuram and
• Government Hospital, Palani as per ref. cited 2,3,4 above
 - 234 -
(d) Seat belt and helmet laws in the State.

(e) Prehospital care component through 108 Emergency Ambulance Services

under a Public Private Partnership Scheme to transport road traffic accidents and
other emergency cases to the appropriate hospital within a short time period at
absolutely free of cost.

(f) Emergency Care Centers have been set up for early stabilization and care of the
Trauma casualties in case of long distance drive on the highways through EMRI. They
are:

SN Name of the Emergency Care Center :

1 Emergency Care center , Tambaram, Chennai
2 Emergency Care center , Padyanallur, Tiruvallur district
3 Emergency Care center ,Injambakkam, Kancheepuram district.

10 from state funds

2 from TANII
Existing is from State Funds

(g) “Road Safety Committee” under the chairmanship of the Principal Secretary, Home
department who is designated as Road Safety Commissioner of the State

(g) Administrative Approval for 24 hours comprehensive emergency Trauma care

centres in 59 hospitals as per G.O. cited under ref. no. 1 above

Thus the ultimate aim of the Government is to have one 24 Hours Comprehensive
Emergency Trauma Care Centre for every 50 to 60 kms stretch in the National and
major State Highways.

Challenges in providing Comprehensive Trauma care:

There are several pre-hospital and Health system challenges identified in the State.
(a) Pre hospital care

The “Scene to Hospital Time” which is the response time needs to be improved
and
Patients referred to Multiple Centres: No Standard Trauma Treatment Centres and
there is delay in accessing the Correct Centre therby Loss of Golden Hour
 - 235 -
(b) At the Institution level
There is a demand and Supply mismatch with more accidents. There is no
protocol for standard emergency care resulting in Low Quality of Care. Moreover there
is confusion in Hospitals over prioritisation of treatment as there is no proper system of
Triage and Patients relatives swarm inside ICUs because of apprehension and lack of
communication about the status of the Patient or the treatment being given.
Lack of Co Ordination between various Medical and Paramedical Staff involved in
Trauma Care aggravates the issue on hand. Moreover, lack of Standard Treatment
Protocols and Training for the Stake Holder results in poor outcomes for the victims.

Hence it is proposed to roll out a State level trauma care initiative called the Tamil
Nadu Accident and Emergency Care Initiative.
 - 237 -
Chapter 25
Inter Department, National and International
Collaborations in TAEI
 - 238 -
Chapter 26
Studies undertaken till now in TAEI

Title: Tamil Nadu Accident and Research Initiative (TAEI )- Baseline survey -2018

Copyright: State Health Mission, Government of Tamil Nadu

Year of Publication: 2018

Suggested Citation: Gururaj G . Gautham M S, Ahamed D, Shoba S, Bruno Mascarenhas JMA,

Selvakumar.M, Arthur Amit S, Sivagurunathan, Jeyalydia.J, Manikandan, Prabhakar, Neelakandan.
Tamil Nadu Accident and Research Initiative (TAEI)- Baseline survey -2018, State Health Mission,
Government of Tamil Nadu,2018

Report prepared by

Dr Gururaj G, Senior Professor, Department of Epidemiology, Centre for Public Health,

WHO Collaborating Centre for Injury Prevention and Safety Promotion
National Institute of Mental Health & Neuro Sciences
Bengaluru - 560 029, India
Email: epiguru@yahoo.com,guru@nimhans.ac.in

Dr Gautham M S, Associate Professor, Department of Epidemiology, Centre for Public Health,

WHO Collaborating Centre for Injury Prevention and Safety Promotion
National Institute of Mental Health & Neuro Sciences
Bengaluru - 560 029, India
Email: drgauthamnimhans@gmail.com, drgauthamms@nimhans.ac.in

Opinions expressed in this report are those of the authors alone and does not reflect views of participating institutions

TAEI TEAM
1. Smt.Shoba – Additional Director-108, State Program Manager TAEI
2. Prof. Venkatesh Balasubramaniam, Expert Advisor, TAEI
 - 239 -
3. Dr.J.Mariano Anto Bruno Mascarenhas, M.B.,B.S., M.Ch., (Neurosurgery) Nodal Officer & Technical
Head.
4. Dr.Arthur Amit Suryakumar – Assistant Program Officer
5. Ms Jeyalydia. J - Public Health Consultant
6. Mr. Manikandan -Consultant
7. Mr. Prabhakar MIS TAEI

EMRI TEAM
1. Mr. Selvakumar. M, Chief Operations Officer, State Head GVKEMRI
2. Dr. Sivagurunathan, State Head , EMLC, GVK EMRI
3. Mr.Neelakandan, Research Associate, TAEI Baseline Survey

NIMHANS TEAM
1. Dr Gururaj G, Senior Professor of Epidemiology and Dean, NIMHANS
2. Dr Gautham M S, Associate Professor of Epidemiology, NIMHANS
 - 240 -

TEAMS AT HOSPITALS
RGGGH-Chennai Tambaram GTH
Prof. Singaravadivelu HTNO Dr.C.Palanivel HTNO
Dr.Rajesh CMO
R.Shriraman Program Manager Rajesh Kumar Program Manager
S.Kumaran Emergency Care Paramedic(Data Dr.M.Inbavalli CMO
Collector)
M.Apsara Emergency Care Paramedic (Data S.Rajeshwari ECE
Collector)
Mani kandan EMT R.Anand ECC EMT
Ananthi ECC EMT
Villupuram MCH Cuddalore GH
Dr.Kannan HTNO Dr.M.V.Thambiah HTNO
Jaya Kumar program Manager Jayakumar Program Manager
K.Pugazhandhi RMO Dhayalan ECP
C.Madhan ECP(Data Collector) Prasanth ECP
G. Manikandan ECP(Data Collector) Priya Dharshini EMT
Eakkampara moorthy EMT
Perambalur GH Dindigul GH
Dr.M.Arjunan HTNO Dr.Vadivel HTNO
Kannan.R Program Manager Kumaran Program Manager
Dharmalingam Hospital Superintendent Dr.Sivakumar Hospial supernant
Shiek Abdulla A-EMT Anantha Kumar. A A-EMT
Murugesan A-EMT Karthikeyan A-EMT
Jaya Priya EMT Arun Kumar EMT
Melur GTH Madurai GRH
Dr.C.Shakthi Annamalai HTNO Dr.Thanappan HTNO
Kumaran Program Manager Kumaran Program Manger
Thirupathi A-EMT(Data Collectro) Rajkumar A-EMT
Senthil Kumar A-EMT(Data Collector) Venkatesan.T ECP
Sathya Chitra EMT Kaleeswari EMT
Theni MCH Tenkasi GH
Jaiganesh HNTO Dr.R.Jesline HTNO/RMO
Kumaran Program Manager Ranjith Viswanathan Program Manger
Radha RMO Selva Sakthivel A-EMT,ECP (Data
Collector)
Vijayan ECP(data Collector) Saravanan ECP
Sundar Rajan A-EMT (Data Collector) Selva Lakshmi EMT
Sugumar EMT

Message-1
 - 241 -

Message-2
 - 242 -
Acknowledgements
• Dr.Darez Ahamed – IAS, Mission Director and Commissioner of Trauma Care, State Health Mission-

Tamil Nadu

• Uma Maheswari IAS – Project Director, Tamil Nadu Health Systems Projects

• The Director – NIMHANS

• Mr Manjunath, FIO, NIMHANS

• Mr Mahantesh, Project Staff, NIMHANS

• Dean and Directors of all study hospitals

• All team members involved in data collection in various hospitals

 - 243 -
List of abbreviations
ER Emergency Room

EMRI Emergency Management and Research Institute

DALY Disability Adjusted Life Year

NCRB National Crime Records Bureau

RTI Road Traffic Injuries

TAEI Tamil Nadu Accident and Emergency Care Initiative

 - 244 -

CONTENTS
INTRODUCTION ................................................................................... Error! Bookmark not defined.
INJURIES IN TAMIL NADU ................................................................. Error! Bookmark not defined.
TRAUMA CARE SCENARIO IN TAMIL NADU .................................. Error! Bookmark not defined.
TAMIL NADU ACCIDENT AND EMERGENCY CARE INITIATIVE (TAEI)Error! Bookmark not defined.
TERMS OF REFERENCE FOR CURRENT REVIEW ........................... Error! Bookmark not defined.
METHODOLOGY .................................................................................. Error! Bookmark not defined.
RESULTS ............................................................................................... Error! Bookmark not defined.
A: DESCRIPTION OF STUDY HOSPITALS ......................................... Error! Bookmark not defined.
B – MACRO-VIEW OF CASUALTY / ER IN STUDY HOSPITALS ..... Error! Bookmark not defined.
C - INFRASTRUCTURE, HUMAN RESOURCES, EQUIPMENTS AND DRUGS IN THE ERError! Bookmark not
defined.
D: DESCRIPTION OF TRAUMA CASES IN ER ................................... Error! Bookmark not defined.
E: PATIENT SATISFACTION ASSESSMENT ...................................... Error! Bookmark not defined.
F: TIME-MOTION STUDY IN ER ......................................................... Error! Bookmark not defined.
G. KEY CHALLENGES IN IMPLEMENTING TRAUMA CARE SERVICESError! Bookmark not defined.
H. SUMMARY and IMPLICATIONS ..................................................... Error! Bookmark not defined.
I. RECOMENDATIONS ......................................................................... Error! Bookmark not defined.
J. INDICATORS ..................................................................................... Error! Bookmark not defined.
K. REFERENCES ................................................................................... Error! Bookmark not defined.
L. ANNEXURES .................................................................................... Error! Bookmark not defined.
 - 245 -

LIST OF TABLES
Table 1: Pre-hospital care in Tamil Nadu .........................Error! Bookmark not defined.
Table 2: Intervention and study sites in TAEI –Baseline surveyError! Bookmark not defined.
Table 3: Study methods ...................................................Error! Bookmark not defined.
Table 4: Description of study hospitals .............................Error! Bookmark not defined.
Table 5: Human Resources in study hospitals (Sanctioned and Working)Error! Bookmark not
defined.
Table 6: Macro level interventions in ER room .................Error! Bookmark not defined.
Table 7: Physical infrastructure in ER ..............................Error! Bookmark not defined.
Table 8: Human Resources in ER (Sanctioned and working)Error! Bookmark not defined.
Table 9: Routinely used drugs and equipment’s in study hospitalsError! Bookmark not defined.
Table 10: Routinely used equipments in ER (Available , functioning and %functioning)Error!
Bookmark not defined.
Table 11: Diagnostic facilities in ER .................................Error! Bookmark not defined.
Table 12:Socio-demographic characteristics of trauma patients in study hospitalsError! Bookmark
not defined.
Table 13: Profile of trauma cases in ER ...........................Error! Bookmark not defined.
Table 14: Type of injury by severity ..................................Error! Bookmark not defined.
Table 15: Injury severity by level of trauma care ..............Error! Bookmark not defined.
Table 16: First –aid related information among trauma patients in ERError! Bookmark not defined.
Table 17: Injury severity and triage code misclassificationError! Bookmark not defined.
Table 18: Procedures done in ER ....................................Error! Bookmark not defined.
Table 19: Disposition status of patients in ER ..................Error! Bookmark not defined.
Table 20: Treatment outcomes among patients with polytraumaError! Bookmark not defined.
Table 21: Patient included for time motion study ..............Error! Bookmark not defined.
Table 22: Activities in ER room- Triage to treatment ........Error! Bookmark not defined.
Table 23: Implementation status of primary TAEI objectivesError! Bookmark not defined.
Table 24: Comparison of intervention and control hospitals on primary TAEI objectivesError!
Bookmark not defined.
Table 25: Comparison of TAEI and control hospitals on ER interventionsError! Bookmark not
defined.

LIST OF FIGURES
 - 246 -
Figure 1: Change in top 15 causes for DALYs, both sexes, ranked by number of DALYs ( 1990-2016)
.........................................................................................Error! Bookmark not defined.
Figure 2: Type of unnatural causes of death (injuries) in Tamil Nadu ( 2015)Error! Bookmark not
defined.
Figure 3: Road deaths and motorization in Tamil Nadu ( 2012-2017)Error! Bookmark not defined.
Figure 4: Elements of effective trauma care system.........Error! Bookmark not defined.
Figure 5: Meeting with stakeholders and training of data collectors (29-30th Jan 2018)Error!
Bookmark not defined.
Figure 6: Trauma related in-patients in study hospitals ....Error! Bookmark not defined.
Figure 7: Hospital wise distribution of trauma patients in ER who had recieved prior first-aid (%)
.........................................................................................Error! Bookmark not defined.
Figure 8: Mode of transportation to ER (%) ......................Error! Bookmark not defined.
Figure 9: Proportion of patients by number of hospitals visited before reaching current hospital (%)
.........................................................................................Error! Bookmark not defined.
Figure 10: Median transportation and waiting time among patients seeking care in ER (in minutes)
.........................................................................................Error! Bookmark not defined.
Figure 11: Status of injured at time of admission in ER ....Error! Bookmark not defined.
Figure 12: Triage in intervention and control hospitals .....Error! Bookmark not defined.
Figure 13: Treatment outcome at end of stay in ER .........Error! Bookmark not defined.
Figure 14: Treatment outcome amongst patients who underwent triage in ER (%)Error! Bookmark
not defined.
Figure 15: Condition at time of admission in ER and treatment outcomesError! Bookmark not
defined.
Figure 16: Mean satisfaction scores .................................Error! Bookmark not defined.
Figure 17: Indicators for monitoring TAEI .........................Error! Bookmark not defined.
 - 247 -

EXECUTIVE SUMMARY
An estimated million deaths occur due to injuries yearly, accounting for 10.7% (95% UI 9.6-11.2) of all deaths
in India. Tamil Nadu, one of the leading states in India, accounted for 8.5% of all unnatural deaths in India
(NCRB 2015).Road Traffic Injuries (RTIs) accounted for nearly 40% of all injury deaths. Self-harm, Road
Injuries and Falls were among the leading causes for DALYs lost in Tamil Nadu accounting for 4.3%, 3.3%
and 2.7% of all total DALYs lost in year 2016. Efficient trauma care systems are essential for reducing injury
deaths in the state. Evidence worldwide also indicates that well coordinated trauma care systems helps to
achieve 25% reduction in mortality.
To strengthen ongoing response to decrease trauma related mortality and morbidity, the Government of Tamil
Nadu launched the Tamil Nadu Accident and Emergency Care Initiative (TAEI) on 22nd June 2017. TAEI aims
to provide quality trauma care services for the injured by strengthening pre-hospital in hospital and
rehabilitation care through a specific set of Interventions, referred to as TAEI-ER Model.
Interventions under TAEI include developing an Institutional Framework at the state- district and facility
levels, building an effective trauma communication system, augmenting human, technical and financial
resources in ER rooms , strengthening physical infrastructure -equipment’s-diagnostics , implementing an
effective triage system in all hospitals , introduction of trauma care protocols constitution of multi-disciplinary
trauma team in hospitals , , introducing Trauma Registry and Reporting Systems, mortality / Trauma care
Audits and strengthening research.
In each of the hospitals, the TAEI-ER model specifically envisages a six pillar approach which includes care of
patients with Stroke, MI, Trauma(including Road Traffic Injuries), Burns, Poison, Paediatric emergencies and
other life threatening conditions.
The term casualty is uniformly rechristened as Emergency Room across the State and is re-organised with a
system of triage, Pre-arrival Intimation(PAI), Trauma Reception and Resucitation which includes Primary
survey and Resusciattion following a standard emergency care manual with patient management protocols,
flow charts and checklist, , implementation of Advanced Trauma Life Support (ATLS) protocols, appropriate
linkage with trained multi disciplinary teams at hospital levels along with coordinated 108 Ambulance
Services, Color coding, floor marking, display boards and MIS systems for trauma care.

To examine the pace of implementation, between January-April 2018, a baseline assessment of TAEI was
undertaken with technical support from National Institute of Mental Health and Neuro Sciences (NIMHANS) to
identify the progress made in trauma care systems, services, care outcomes, perceptions of stakeholders and
client satisfaction.
This baseline survey, adopting mixed methodologies, covered 5 TAEI-intervened hospitals and 5 control
hospitals across the state and data was collected by trained investigators drawn from EMRI 108 using smart
phone technology. The intervention hospitals were located in Chennai, Villupuram, Cuddalore, Perambalur
and Tambaram. Control sites were located in Madurai, Theni, Dindigul, Tirunelveli and Melur.
Secondary data was collected on existing human resources, physical facilities, equipments and all essential
supplies for trauma care services from 10 hospitals primarily by a review of records using a specially designed
questionnaire. Patient level information was collected from ERs of all 10 hospitals to understand trauma care
outcomes (4647 patients), patient satisfaction (2792 patients) and time-motion for trauma care (511 patients).
In addition, key informant interviews were conducted with trauma nodal officers to understand challenges in
trauma care delivery and usefulness of TAEI to strengthen emergency services. Data collection was monitored
on a daily basis by NIMHANS and TAEI team.

Key observations
The study observed that TAEI had strengthened Triage, training and trauma treatment in the hospitals. Systems
building efforts in terms of designating the Mission Director, NHM as the commissioner of Trauma Care,
appointing trauma nodal officer sand Trauma Nurse co-ordinators each at the district and facility level,,
training of doctors nurses, MNA/FNA, hospital workers and security guards, developing SOPs for triage along
with protocols and manuals were key achievements by TAEI.
 - 248 -

Study observed that ‘Training, Triage and leveraging Treatment’ were core interventions in TAEI.
• Availability of trained manpower was reported to be better in TAEI-intervened hospitals. Nearly 53% of
CMOs and 46% of nurses in TAEI-intervened hospitals had undergone formal training in trauma care
in comparison to 24% CMOs and 12% nurses in control hospitals. To counter shortage of trained
medical professionals for trauma care in public sector ,TAEI focused on ‘nurse driven model’ to
catalyze capacity building and service delivery in ER. Two hospital trauma nurse co-ordinator (HTNC)
per TAEI center and 1 District Trauma Nurse Co-ordinators(DTNC) per district have been identified
and trained as master trainers across the State to co-ordinate the triage and ER activities, Recruitment
and training of other nurses were conducted in hospital level by the master trainers . District Trauma
Nurse Coordinator (in TAEI sites) facilitated training of nurses in TAEI intervened hospitals. The
findings and reports indicate the usefulness of this model and require a formal and total evaluation of
the same in the coming days.Similiar observations were echoed in key informant interviews as well.

• Triage system development in terms of a delineating triage area, colour coding, SOPs and training was
a major contribution by TAEI. Significantly higher number of patients (88% of ER patients) underwent
triage in TAEI-hospitals as against 45.7% in control hospitals. This has impacted care outcomes as
amongst patients who underwent triage process, 87.4% patients in TAEI-hospitals had improved
outcomes in ER as against 70.7% in control hospitals. Similiarly referred out percentage was lesser in
TAEI-intervened hospitals.

• Nearly 86% of all cases seeking care in ER in TAEI-intervened hospitals had ‘improved outcome’ as
against 74% in control hospitals, hinting at better and efficient trauma care services. TAEI had
facilitated better case management in ER as treatment outcomes were better for patients whose
condition was more serious at time of admission, as compared to control hospitals. Nearly 3.3% of
 - 249 -
unconscious patients and 11% of semi-conscious patients admitted in ER improved by the end of ER
stay in TAEI hospitals as against 1.7% and 6.4% in control hospitals. Improved outcomes were
observed to be better in TAEI hospitals for even for patients with polytrauma too. Trauma related
deaths in ER was slightly higher in intervention hospitals (0.6 per 100 trauma registrations) as against
control hospitals (0.4 per 100 trauma registrations). Higher mortality was attributed to higher severity
in intervention hospitals.

From a combination of observation and key informant interviews for assessment of systems and services it was
observed that TAEI facilitated improvements in manpower, funding, infrastructure, drugs and equipments
which has reflected in patient care process and ER functionality.
• Though availability of equipments and drugs was adequate in all study hospitals, proportion of
functioning equipments was higher in TAEI hospitals. Key informant interviews revealed the need for
more ventilators and multi-para monitors in ER. Infrastructure for trauma care was present but space
in proportion to case load was reported insufficient in most hospitals.

• Key informant interviews revealed a need for more trauma care nurses and exclusive specialist
availability in ER to provide uninterrupted and better quality care including reduced referral. Both
intervention and control hospitals expressed concern over inadequate security personnel in ER rooms
and limited number of hospital attendants to shift patients and samples.

A macro level assessment (trauma care policy, committee, nodal trauma person, and funding and information
management systems) of ER revealed that TAEI facilitated macro level system establishment.
• TAEI has contributed to ensuring availability of trauma nodal officers (doctor and nurse) at hospital,
trauma committees, SOPs for triage but specific clinical management guideline protocols for managing
different kinds of trauma cases were not present.

• Digitalized trauma care information systems (mobile application) to collect the trauma care data from
the TAEI network Hospitals on a daily basis was an unique TAEI intervention. However digitalization
of data at patient level was not yet undertaken. Trauma care policy was not present in all TAEI
intervened hospitals, which is a lacunae that needs to be addressed at macro level. Utilization of
available funding too was better in TAEI intervened hospitals.

As an off-shoot of systems level, capacity level and resource level TAEI functionality in ER and patient
satisfaction was affected.
• Time motion studies in ER observed that median time taken for entry to ER and first assessment
by nurse (4 minutes) was lesser in TAEI-intervened hospitals. Similiarly time for specialist
assessment (8 minutes) and subsequent time between assessment and treatment (6 minutes) was
significantly lesser in TAEI-intervened hospitals.
 - 250 -
• Patient satisfaction with trauma care services was higher in TAEI-intervention group. Mean
satisfaction rating was significantly higher in intervention group ( 7.6/ 10) as compared to
control sites ( 7.2/10).

Enquiry into pre-hospital care experiences of ER patients revealed that percentage of trauma victims
receiving first-aid was as well as being transported in an ambulance was higher in TAEI-sites. Time for
transportation from the trauma site to definitive trauma care hospital was higher in intervention hospitals
probably due to referral from far away places and urban areas , more with regard to RTIs..Proportion of
patients transported at an early time, specially within the golden hour was non-significantly higher in
intervention group (79.4%) compared to control group (75%).
Recommendations
The following recommendations are placed herewith based on the review of secondary data, analysis of
primary data, opinion of stake holders to strengthen TAEI programme in the state of Tamil Nadu.
On a larger macro and micro examination, The TAEI initiative builds on earlier efforts of the state to improve
trauma care towards reducing mortality, disability and other negative outcomes of injuries and reflects the
commitment as well as the importance given to this programme by the state.

Macro level initiatives

• The entire TAEI initiative needs to be largely strengthened with the development of an institutional
framework with a well – defined state trauma care policy, trauma care programme and a dedicated
nodal agency along with defined funding to strengthen all trauma care activities at all levels of the
health care system.

• Trauma care is a continuum of integrated activities and needs to be implemented in a continuous

manner. Towards this objective, a dedicated state trauma care action plan of defined elements, mode of
implementation, responsible agency to implement, funding for activities established and agreed time
lines and measurable indicators should be put in place.

• The strength of TAEI initiative is its coordinated - integrated approach that can be made sustainable
and cost effective at the same time. This would require strengthening capacity of policy makers and
programme officers involved in trauma care at state and district levels within the public health sphere
to incorporate and integrate activities at all levels from periphery to apex levels.

• The lessons learnt from this review indicate that – adequate human resources at level 1 - 3, building a
trauma team, training trauma care personnel , building an effective triage system, provision of drugs
and equipment’s and having management protocols in place reduces negative outcomes on ERs and
hospitals. These are also considered good practices at international levels and have been recognized as
essential elements of a trauma care programmes. These lessons need to be further strengthened,
integrated in state policy and programmes and scaled up to other hospitals in the state in a phased
manner.
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• All existing manuals, protocols, SOPs and guidelines should be reviewed by a technical team at the
state level and uniformity to be ensured in all training programmes to enhance quality and skills of
trauma teams at all levels . Uniform trauma care SOPs need to be developed for the state that clearly
define the nature and type of services to be provided at corresponding level of hospitals.

• The current manpower deficiency in trauma with specific regard to neurosurgeons, anesthetists,
radiology technicians and nurses should be seriously addressed specially in Level 2 and 3 hospitals.

• The state government should specifically encourage the establishment of emergency medicine
departments in all level 1 hospitals and in all medical colleges, promote training of interns and nurses
in trauma care on a mandatory basis, posting of DNB and MS trainees to district hospitals and develop
other innovative methods to bridge trauma care human resource deficiencies.

Specific hospital level initiatives

• All level 1 and 2 hospitals in the state should have a hospital level trauma care committee and a
designated trauma care coordinator who can manage all related activities.

• As TAEI-ER model is nurse-driven at hospital level, there is a need for increasing number of nurses to 5
ER nurses per shift in Level 2 and 3 nurses in level 3 hospitals. In this regard , transfer related
deficiencies may be reduced by developing statutory mechanisms to ‘station nurses for a minimum fixed
time of 3 years in each hospital . Furthermore, incentivisation of ER nurses in form of credit points or
other non-monetary benefits should be piloted in all Level 2 and level 3 hospitals

• Along with ER nurses (and in places where nurses are unavailable) , the possibility of having EMTs in
ER room to facilitate care delivery and help to maintain trauma care records should be seriously
examined.

• Casualty Medical Officers are a major component of trauma care teams. Thus, there is need to have
separate CMOs and also limit duality of roles by specialists. Ensure availability of at least 6 to 8 CMOs
in Level 2 hospitals.

• The triage system with its manuals, training modules and mode of implementation should be scaled up
to all level 1, 2 and 3 hospitals across the state in a phased manner during 2018 – 2020 and should be
strictly monitored for implementation.

• All professionals and personnel, in particular CMOs, doctors, nurses and technicians should be
systematically trained with BTLS and ATLS programmes over a period of time. A dedicated institution
may be continuously engaged for the purpose and provided requisite funding as well as guidelines from
the state administration towards the same.
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• All treatment and referral activities should be guided by the use and implementation of clinical
management guidelines and protocols (including referral guidelines) and should be a part of training
activities wherever ATLS /BTLS programmes are yet to be implemented.

• Trauma audits and mortality reviews, proposed under TAEI, should be systematically introduced in all
Level 1 and medical college hospitals as a systematic activity in a defined manner to identify
preventable causes of trauma mortality.

• In all the existing TAEI identified and other proposed hospitals, the requirement of drugs, supplies and
equipment’s should be addressed after prioritization on a continuous basis.

• The proposed set of indicators ( along with this report) should be examined and implemented in all
trauma care institutions and reported to the state level nodal agency to specifically strengthen critical
gaps that exist at varying levels in different institutions.

• The designated hospital nodal officer should be trained in mechanisms of data collection as well as
utilization of data for focused activities. Simultaneously, an essential “Emergency Trauma Care
Record” should be implemented in all ERs of Level 1 and 2 which would eliminate duplication of
documentation activities.

The study limitations were mainly paucity of time that resulted in reliance on secondary data (that was difficult
to validate in terms of completeness, accuracy and timeliness) in the absence of established reporting systems.
Control hospitals also had some TAEI interventions in place, though not to the complete range present in TAE-
intervened hospitals, hereby increasing likelihood of underestimation of differences between the two groups.
In summary, the TAEI model for meeting emergency needs in ERs of public sector institutions has shown that it
is a useful model resting on the principles of triage, training and treatment soon after arrival. The interventions
in ER are broadly supported at the hospital level with training, easy availability of supplies and diagnostics
along with the presence of a designated trauma care nodal officer. At the state level larger institutional
approaches are required to scale up these efforts as well as a formal evaluation of these efforts in 2020.
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Section II:
TAEI
Protocols
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Section II
TAEI Protocols

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“Incidence” and Importance of Time.
Chapter Outline
3. Introduction to Concept of Incidence
4. Need for Time management
Incident denotes the accident or event
(assault, snakebite etc) that led to the
emergency, or the first symptom (Chest
pain, Stomach pain, Breathlessness, Fits,
Weakness, Unconsciousness, Vomiting etc)
that has necessitated the visit to health
care facility.
Time is the most important factor in the
management of any medical or surgical
emergency. At time zero the
person/patient is at their normal
baseline. In case of Injuries, There is then
some interaction with an external factors
(mechanical forces or chemicals or heat)
leading to “injury”. In case conditions like
Stroke or Heart Attack, the disease process
may start spontaneously or facilitated by
factors like Dehydration, Hypertension,
Exertion etc. The subsequent development
of pathology, the response of the body by
way of compensation and healing, and the
external responses by health professionals
all have a timeline; that timeline originates
at time zero, the moment of “injury”. The
timeline may be used to compare and
consider the progress from time zero to
other significant events or deadlines that
follow.
Some problems tend to lead to earlier
death than others. An obstructed airway, a
tension pneumothorax, an extradural
haematoma or an ischaemic limb will all
tend to progress along a characteristic
time-line after the moment of initial injury.
This creates an ‘imperative of time’ that
shapes and provides a basis for the
hierarchy of our initial medical response to
the injured patient. Thus, an obstructed
airway will need emergency initial
management at the scene of the
accident. An ischaemic limb may be dealt
Chapter
with urgently once the patient has reached
a definitive treatment centre. The order
ABCD, that is airway, breathing, circulation
and disability (neurology), of the ATLS
(Advanced Trauma Life Support) system is
founded upon this time dependence.
Understanding and assessing the nature of
the problem usually hinges on diagnosing
the injury. An injury may be discoverable
by special investigation or careful physical
examination, or be very obvious at
different points on its timeline. An example
is an evolving extradural haematoma: the
initial skull fracture may be visible on
radiography or computerised tomography
(CT); as the haematoma develops it will
first be visible on CT; later, it will be
suspected on careful clinical examination;
and, finally, it will become clinically very
obvious.
.
The next feature to add to the timeline is
the response time. Once an obstructed
airway is identified the response time to
carry out a life-saving simple airway
manoeuvre may be a matter of seconds.
Thus, even at the stage when the diagnosis
is clinically obvious there may still be time
to resolve the problem before irretrievable
damage occurs.
However, when the diagnosis is an
extradural haemorrhage, the average
response time from identification of the
problem to surgical resolution may be
measured in hours. This may seem an
unduly long time, but bringing the patient
to an operating theatre with a
neurosurgeon takes time to arrange. If we
now combine the various features of a
timeline for the single condition of
extradural haematoma, difficulties become
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apparent. If the response is only initiated
once the diagnosis is very obvious there
may be insufficient time left to resolve the
problem before death.
This seems to suggest that we need to
initiate a response to a problem before
we are sure of its existence. It can be
likened to the need to identify a cancer at
an early stage to give the best chance of
successful treatment. A common approach
to such a problem is to screen the at-risk
population, and the same principle applies
in trauma.
As we will see, much of the medical
preparation and planning related to
trauma is aimed at reducing the diagnosis
time and the response time so that they
will fit into the time available before death
or irretrievable damage. To revise the
meanings of these terms, the diagnosis
time is the time between injury and
recognition of the problem and the
response time is the time that elapses
between identifying the problem and
the intervention required to deal with it
being completed. We can reduce these
times by using a practised approach to
the initial stages of the management of a
polytrauma patient. This does not absolve
us from thinking but it does mean that we
can (1) have a pre-existing structure
upon which to build. This allows us to
(2)move forward more rapidly. This
structured initial approach allows for
(3)more straightforward teamwork and
(4) standardisation of the equipment
required. This practised familiarity (5)
brings confidence to a difficult situation.
The pressure of time determines the
manner in which we deal with the multiply
injured patient. The normal sequence of
history, examination, provisional diagnosis,
special investigations, diagnosis and
management plan is not appropriate. When
dealing with the multiply injured a quite
different approach is needed. As will be
seen, the primary survey used in ATLS
combines the identification of life-
threatening problems with their
management. It has evolved to improve
the chances of the necessary actions
being taken within the available time to
save life and limb. The system has to
allow diagnosis and response within the
timeline for the injuries sustained.
The model of a timeline need not be
restricted to the multiply injured. The role
of time when dealing with an elderly
person who has been injured is still
present but is frequently ignored. There
may be hidden urgent issues. Thus, when
dealing with the elderly we too readily
label a patient with the most obvious
problem (such as a hip fracture) without
performing the vital initial physiological
triage. They may have a primary cardiac,
respiratory or neurological problem
that has resulted in a fall and the
response to this may be the most urgent
issue. Therefore, the timeline is not only
relevant to the acute and obviously urgent
clinical issues. As noted at the beginning of
this chapter a timeline may be used to
compare and consider the progress from
time zero to other significant events or
deadlines that follow.
The response time to arrange a discharge
from hospital for the elderly patient may
be protracted. With such a long response
time, to allow for discharge at the
appropriate clinical time the social
planning needs to commence almost at the
time of admission. This is well before it
would seem clinically reasonable but to
achieve an efficient system it is quite
necessary. This approach allows an
emergency unit to get as close as is
possible to the practice of effective elective
units where discharge plans are made
before the patient is admitted.
Time also plays a part in how we deal with
more minor injuries. There is a need and
expectation that these patients will be dealt
with rapidly; however, there is then a
danger, especially with inexperienced
doctors, that corners will be cut and key
258
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problems missed. Focusing on the
important issues without risking missing
problems is a difficult skill. However, the
risks can be reduced. Although not all
patients will be seen by more than one
doctor, another health professional, usually
a nurse, will see them and their insights
should not be ignored.
Timelines reveal that things change. As a
consequence, reassessment can be of vital
importance. An observation, a radiograph
or a blood test are only snapshots in time.
Repeated observation will reveal trends
that may make a diagnosis more
straightforward. Modern monitoring
allows this continuing vigilance to be
carried out more straightforwardly.
Graphical recording of results in the HMIS
Website as well as App makes trends easier
to follow.
Chapter Essence
In a Nutshell
5. Time is Money is World, Muscle in Heart and Neuron in Brain
6. “Golden Hour” Starts from the Time of “Incidence” and not from the time of admission
Nursing Alerts
1. Check Time of “Incidence”
Nursing Management
1. Act as per Time of “Incidence” and not the time patient was admitted in the war
Trainer’s Pearls
1. Inculcate the Concept of Time
After the Incident, the First Responder is
Usually a Non Medical Relative (in case of
home), Colleague (in case of Office) or by
stander (in case of public places). Hence it
is imperative that every one gets trained in
First Aid.
If 108 Ambulance is called, the Ambulance
Reaches the place of the patient by
following the steps of
1. Call
2. Reach
3. Transit
Of these, Protocols for Call and Reach are
well established by 108 Ambulance
Systems and hence are not covered here.
However, during the transit, the EMT of the
ambulance is expected to communicate
certain details to the receiving hospital.
These are dealt in the next chapter
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Chapter
Protocols for Pre Hospital Care
Chapter Outline
1. Concept of Pre Arrival Intimation
2. Concept of TAEI Case sheet

Pre Hospital Care includes the Care followed will be the same as those being
received by the Patient from the Moment of followed by 108 Ambulance Services
Onset of the Symptoms till he steps into or
is received into the ER in a Trauma Care The EMT in consultation with emergency
Centre physicians will
1. Triage the Patient into Red, Yellow
This Pre Hospital Care has the Following or Green
Stages 2. Will inform the DTNC of the hospital
(Pre Arrival Intimation) and alert
1. PH.1 Call : From the Time of them regarding the Correct Code, if
Accident / Onset of Symptom(s) to the Patient qualifies for one of the 5
the Time of Patient or Relative Sub Categories of Code Blue
Calling 108 a. Code Blue Brain – Head
2. PH.2 Reach : From the Time of Injuries and Stroke
First Call to 108 to “Picking Up” of b. Code Blue Heart – Chest
the Patient by 108 Ambulance Injuries, Chest Pain,
3. PH.3 Transit : From the Breathlessness
Time of Picking Up the Patient by c. Code Blue Abdomen –
108 Ambulance to Reception Abdominal Injuries (Blunt as
in Trauma Care Centre well as penetrating), Pain
Abdomen
If the patient does not use 108 Ambulance d. Code Blue Poison – Snake
Services, but reaches hospital by some Bite, Scorpion Sting,
other means, then PH.1, PH.2 and PH.3 can Poisoning
be considered as a single entity e. Code Blue Burns - Burns
3. Will inform the DTNC of the hospital
The Guidelines and Protocols to be (Pre Arrival Intimation) even if the
followed will be the same as those being Patient does not come under one of
followed by 108 Ambulance Services the above Codes, but comes under
any of the following Criteria which
Call are condered as “Critical Case”
The Guidelines and Protocols to be a. Conscious level
followed will be the same as those being i. V or P or U & Added
followed by 108 Ambulance Services airway sounds
(snoring, gurgling)
Reach b. Temperature
The Guidelines and Protocols to be i. >104 degree F
followed will be the same as those being c. Pulse rate
followed by 108 Ambulance Services i. > 120 or <60, Low
Volume, Irregular
Transit Rhythm
The Guidelines and Protocols to be d. Blood Pressure

261
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i. BP systolic >140 or < i. Pulse,
90 & BP Diastolic >90 ii. Respiratory Rate,
or <60 iii. BP,
e. Respiratory rate iv. SpO2,
i. < 8 or > 24 v. Temperature.
f. SPO2 f. Blood Loss(Y/N)
i. < 93% g. Expected time of Arrival to
g. Pupils Change In Gaze, the Hospital
Altered size/sluggish 5. Do Primary Survey
response to 6. Administer emergency care
light/dilated/lateralization 7. Start Filling the TAEI Case Sheet
h. GRBS 8. Continue Care as Directed by 108
i. >300 or < 80 mg/dl Call Centre or Doctor from the
i. Burns Receiving Hospital
i. >40% 9. Confirm the Correct Building to
j. Capillary refill which the patient needs to go
i. > 4 sec 10. Share the Information to EME/PM
k. Skin a. Daily report about PAI will
i. Cyanosis, cold be uploaded in TAEI group
clammy extremities by respective PM. And
ii. Uncontrolled bleeding b. All these Cases should be
l. Symptoms/Signs closed as “CRITICAL” during
i. Chest pain case closing in Emergency
ii. Difficulty vision Response Centre.
iii. Delivery c. All these cases will be flowed
iv. Facial droop (recent), by 48 Hours follow-up.
Arm drift, Slurred
speech (Any of them) TAEI Case Sheet.
v. Unbearable pain (> This 8 Page TAEI Case Sheet should travel
5/10) with the patient from EMRI till discharge
vi. Amputations and attached to the regular case sheet
vii. Crush injuries • The TAEI Case Sheet has to be filled
viii. Open fractures with Carbon Paper
ix. Deformities in > 1 • in Hospital
regions o They will have to fill with
x. Pelvic tenderness trauma case sheet and with
xi. Extrication > 20 min the carbon paper, and the
xii. Neonates and infants carbon copy will be in the
(i.e age 0 to 1 year) case sheet
xiii. Victims of • in Ambulance,
inaccessible incidents o The Entry will be made in
xiv. Snake bites Trauma Case sheet and the
xv. Continuous seizures Copy will be in the EMT
xvi. Survivors of MCI Register
4. Will Share the Following Details as • Hence there is no need of a separate
part of PAI referral form
a. Age
b. Sex The advantages are
c. Type of Emergency 1. Time delay that happens in
d. Cause of Emergency preparing the referral discharge
e. Vitals summary will be avoided.

262
 - 263 -
2. The entire treatment given in the
earlier centres will be available to The Case Sheet is given in the next 8 pages
the hospital which receives the
patient for further treatment

Chapter Essence
In a Nutshell
1. PAI Protocols
2. TAEI Case Sheets
Nursing Alerts
1. What to Ask from EMT
Nursing Management
1. Fill the TAEI Case Sheets
Trainer’s Pearls
1. Insist on the Concept of TAEI Case sheets to be filled with Carbon paper so that Separate
Referral Sheet is not needed

263

Patient Details
Name : _______________
Age : ____ Gender : ___
IP No : _______________
PIN : _______________
TAEI No : _______________
Aadhar No : _______________
Mobile No : _______________
TAEI Flow Chart
- 265 -
Chapter
TAEI Case Sheet
Page 1 of TAEI Case Sheet
Relative : _____________________________
Mobile No : _____________________________
Address : _____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Provisional Diagnosis
__________________________________________
__________________________________________
__________________________________________
Final Diagnosis
__________________________________________
__________________________________________
__________________________________________
__________________________________________
ICD
GCS : _____________________________
AIS : _____________________________
ISS : _____________________________
MHIPS : _____________________________
GOS : _____________________________
KPS : _____________________________
JOA : _____________________________
Management
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Outcome
Discharged / Discharged at Request / Discharged
Against Medical Advice / Left Against Medical
Advice / Absconded / Expired / Brain Stem
Death
On ___/___/201__ at ___:___ AM/PM
265
 - 266 -
Page 2 of TAEI Case Sheet

Triage Pulse : ____/min BP : ___ /____ mm Hg

Date ___/___/201_ Time ___:___ by SPO2 : __________ GCS : E V M
_________________ AVPU (Alert Voice Pain Unconsciousness)
Scale
Primary Survey

To Look for Findings_________________ Do as per Need

A Airway & Airway Airway Patent
Cervical Spine Airway Filled with Fluids or
Airway Obstructed
Cervical Cervical Spine Stable
Spine Cervical Spine Instable
Not Sure of Stability
B Breathing Breathing Spontaneous Breathing
and Ventilation
Abnormal Breathing (Type of
Abnormal Breathing)
No Spontaneous Breathing ?
Hemothorax ? Pneumothorax ?
Cardiac Tamponade ?
Check Cervical Spine
Head Tilt / Chin Lift / Jaw
Thrust / OPA / NPA /
Intubation / Tracheostomy
Check Breathing
Apply Philadelphia Collar
and Check Breathing
Check Circulation
AMBU
or
Ventilator Support
Mobile X Ray, eFAST and
ICD
Pericardiocentesis

C Circulation, Pulse ? Peripheral Venous Access,

Hemorrhage BP ? Central Venous Access,
control Intra Osseous Access,
Venous Cut Down

D Disability: LOC CT Brain Plain

Neurological Fits
status, Headache
Consciousness, ENT Bleed
Focal
Neurological
Deficit
Power, Spine Board X Ray Spine
Reflexes, MRI Spine
Sensation
E Exposure: ,
To Check for
Poisons,
Trauma

266
 - 267 -
Page 3 of TAEI Case Sheet
Check List after Triage Check List for Past History

S.No Step Responsibility ✓ on Yes No If Yes,

Completion H/o Last Meal
1. Triage ER Medical Officer H/o Drug Allergy
EMO H/o Diabetes Modify Prescriptions
Casualty Medical H/o Hypertension Modify Prescriptions
Officer H/o Asthma, COPD Modify Prescription
2. Entry in Accident Casualty Medical JUDICIOUS FLUIDS
Register Officer AVOID NSAID
3. Inj TT ½ cc IM Stat ER Staff Nurse H/o Heart Diseases
4. Starting intravenous ER Staff Nurse H/o Thyroid
Line Disorders
5. Intubation ER Medical Officer H/o Alcohol / Drug
(GCS < 10 must be EMO Abuse
intubated) Anaesthesiologist H/o HIV / TB
Advanced Paramedic Treatment
6 Investigations ER Staff Nurse H/o HBsAg
7 Injections / Tablets ER Staff Nurse H/o Bleeding
Disorders
Immunoglobulins H/o Headache Urgent CT Brain
H/o Vomiting Urgent CT Brain
Crush Injury : H/o Weakness Urgent Intervention
Dog Bite : H/o Seizures Start Anticonvulsants
H/o Bladder Urgent Intervention
eFAST Involvement
H/o Bowel Urgent Intervention
Done by : ____________________________ Involvement
H/o Previous
Findings : ____________________________ Surgeries
H/o Long term
Medical Treatment
H/o Amenorrhea
Investigation Check List Instructions Check List
For All Patients ✓ on Completion For All Patients ✓ on Completion
or write NA or Write NA
1. Urine (Dipstick) 1. Head Shave
2. ABG 2. Ryle’s Tube
3. CBC, Hematocrit 3. Urinary Catheter
4. Random Blood Sugar 4. ICD
5. RFT 5. EVD
6. Serum Electrolytes Check List for Surgery
7. HIV Pre and Per Op ✓on Completion
8. HBsAg
or Write NA
9. HCV
1. Insurance E Number
10. Blood Group / Typing
2. Implants
11. CT / BT
3. Consent Obtained
12. PT / aPTT / INR
4. Patient Confirmed
13. ECG
5. Diagnosis Confirmed
14. CXR PA View, X Rays
6. Side Confirmed
15. eFAST / USG
16. ECHO
17. CT Scan / MRI
18. Specialist Opinion 1/2/3

267
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Page 4 of TAEI Case Sheet

Detailed History
Alleged History of : RTA / TTA / Fall / Assault / _____________________
Chest Pain / Weakness, Paralysis / Burns / Poison / Bites
At :
On : ___/___/201__ at ___:____ AM/PM
Mode of Arrival : 108 / Private Ambulance / Public Transport /
Own Vehicle / Walk in
Pre Arrival Intimation : Received / Not Received / Not Applicable for this patient

(Please write a detailed Narrative History below. In Case of RTA, Specify the Vehicles involved
and whether the patient was driving. In case of Assault, specify the number of persons involved.)

268
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Page 5 of TAEI Case Sheet

Anaesthesiologist Opinion

General Surgeon / Ortho Surgeon Opinion

269
 - 270 -
Page 6 of TAEI Case Sheet
Neurosurgeon Opinion

Other Specialists (Diabetologist, Cadiologist, Cardiothoracic Surgeon, Plastic

Surgeon, Vascular Surgeon, etc) Opinion

270
 - 271 -
Page 7 of TAEI Case Sheet

Drug Chart
S.N B Drug________ Dos Rout Fre Day 1 Day 2 Day 3
o y __ e e q 7a 1p 7p 7p 7a 1p 7p 7p 7a 1p 7p 7p
m m m m m m m m m m m m

Monitoring / Investigation Chart

The Patient has to be in the Recovery Position

271
 - 272 -

Page 8 of TAEI Case Sheet

Triage Criteria
Red Criteria Yellow Criteria Green Criteria
Physiologica A : Noisy Breathing A : Patent Airway A : Patent Airway
l B : RR <10 or > 24/min B : RR 10 – 24 / min B : RR 10 – 24 / min
SPO2 > 95 % SPO2 > 95 %
C : Radial Pulse – Present / Absent C : Pulse 50 to 100 C : Pulse 50 to 100
Pulse < 50 or > 100/min SBP > 90 mm Hg SBP > 90 mm Hg
SBP < 90 mm Hg Capillary Refill < 2 Sec Capillary Refill < 2 Sec
Capillary Refill > 2 sec
D : Responding only to Pain on AVPU D : Responding to Verbal on AVPU D : Alert on AVPU Scale
GCS <13 GCS 13,14,15 GCS 15
Spine Injury with Single Breath count Spine Injury with Single Breath Count
More than 15 < 15
Injuries • Gun Shot • Open Fractures or Closed • Abrasions
Identified • Stab Fractures of Hand and feet • Lacerations
• Obvious Major Vascular • Isolated Long Bone Fracture • Bruises
Injuries • GCS 15 with • Isolated
• Open Fractures (excluding o Alcohol Fracture of
hand and feet) o Anti coagulant Small Bones of
• Two or More long bone o LOC / Vomiting Hand and feed
Fractures o Nasal / ENT Bleed
• Pelvic Fracture o Limb Weakness
• Flail Chest with paradoxical • Burns < 15 %
Respiration
• Chest trauma with
o Surgical
Emphysema
o Seat Belt Mark
o CCT Positive
• Traumatic Amputation
(Above Wrist or Ankle) Major
Crush or Degloving Injuries,
Extremities without pulse
• Multiple Injured
• Visible Neck Swelling
• Burns > 15% apart from
limbs
• Inconclusive
Mechanism • Suspected Sexual Assault • Suspected Child Abuse • Came for
of Injury • All Penetrating Injuries • Suspected Elderly Abuse Medicolegal
• Blunt Trauma Abdomen • Significant Assault examination
• Fall from more than three • Fall from more than double
times the height of the the height of the patient
patient • Fall from less than five steps
• Fall from more than five • Pregnancy
steps
• Struck between heavy
vehicles / Roll Over
• Railway Track
• Co Passenger Dead
• Ejected from Vehicle
• Steering Wheel
• Prolonged Extraction Time (>
5 minutes) from Vehicle
• Pedestrian vs Motor Vehicle
• Inhalational Injury ,
Drowning, Suicide Attempt

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• Mechanism of Injury Not
Known

273
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Chapter Outline
The Importance of Recovery Position
Position
The Patient has to be in the Recovery
Position
Recovery Position
• The recovery position refers to one of a
series of variations on a lateral
recumbent or three-quarters prone
position of the body, in to which an
unconscious but breathing casualty can
be placed as part of first aid treatment.
• An unconscious person, a person who is
assessed on the Glasgow Coma Scale
(GCS) at eight or below, in a supine
position (on the back) may not be able
to maintain an open airway as a
conscious person would.
• This can lead to an obstruction of the
airway, restricting the flow of air and
preventing gaseous exchange, which
then causes hypoxia, which is life-
threatening.
• Thousands of fatalities occur every year
in casualties where the cause of
unconsciousness was not fatal, but
where airway obstruction caused the
patient to suffocate.
• The cause of unconsciousness can be
any reason from trauma to intoxication
from alcohol.
• The recovery position is designed to
prevent suffocation through
obstruction of the airway, which can
occur in unconscious supine patients.
The supine patient is at risk of airway
obstruction from two routes:
o Mechanical obstruction: In this
instance, a physical object
obstructs the airway of the
patient. In most cases this is the
patient's own tongue, as the
unconsciousness leads to a loss
of control and muscle tone,
Chapter
Position during Transit
causing the tongue to fall to the
back of the pharynx, creating an
obstruction. This can be
controlled (to an extent) by a
trained person using airway
management techniques.
o Fluid obstruction: Fluids,
usually vomit, can collect in the
pharynx, effectively causing the
person to drown. The loss of
muscular control which causes
the tongue to block the throat
can also lead to the stomach
contents flowing into the throat,
called passive regurgitation.
Fluid which collects in the back
of the throat can also flow down
into the lungs. Another
complication can be stomach
acid burning the inner lining of
the lungs, causing aspiration
pneumonia.
• Placing a patient in the recovery
position gives gravity assistance to the
clearance of physical obstruction of the
airway by the tongue, and also gives a
clear route by which fluid can drain
from the airway.
• The International Liaison Committee on
Resuscitation does not recommend one
specific recovery position, but advises
on six key principles to be followed:
1. The Patient should be in as near
a true lateral position as
possible with the head
dependent to allow free
drainage of fluid.
2. The position should be stable.
3. Any pressure of the chest that
impairs breathing should be
avoided.
4. It should be possible to turn the
victim onto the side and return
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to the back easily and safely,
having particular regard to the
possibility of cervical spine
injury.
5. Good observation of and access
to the airway should be possible.
6. The position itself should not
give rise to any injury to the
casualty.

Chapter Essence
In a Nutshell
1. There is no Single Recovery Position
Nursing Alerts
1. Look for Airway Obstruction
Nursing Management
1. Make sure that Patient is in Optimal Position
Trainer’s Pearls
1. Recovery Position is not a “Position”, it is a concept

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Chapter
Protocols for Inter Hospital Transfer of patients for
Referral from one hospital to another
Chapter Outline
1. Step by Step Guide for Referral and Transfer of Patients from One Hospital to Another
2. The Protocols to be followed inside the Ambulance are not included as these are covered
by the EMRI 108 Ambulance Guidelines

RE.1. : Referral
Referral of Patients from One Hospital to Another should strictly done as given below
Process Flow Chart

277
 - 278 -
Key Personnel and their Duties and
Responsibilities
1. MO : Medical Officer of the Ward /
Medical Officer on Duty
a. Takes Decision for Referral
of a Patient
b. Takes Decision for Order of
Referral Out
2. SN : Staff Nurse of the Ward in
which the patient is being admitted
a. Informs the DTNC RO about
the referral
b. Fills Relevant Columns in the
Referral Slip
c. Empties “Output Bags” like
Urobag, Ryles Tube Bag,
Colostomy Bag, ICD Bag, EVD
Bag etc and enters the Values
in the Referral Slip and Case
Sheet
d. Gives the Tablets / Injections
/ Replenishes iv Fluids as per
need
e. Co Ordinates with DTNC RO
about the time of Transfer
f. Hands over the patient to the
EMT
3. DTNC : The Duty Trauma Nurse Co
Ordinator is the Senior Most Staff
Nurse of the ER / Trauma Ward. He
/ She will be the single point of
contact for TAEI activities. He /
She acts as DTNC RO or DTNC RI
based whether the patient is
transferred out form the hospital or
transferred into the hospital
a. He / She will be supervised
by the Hospital Trauma
Nurse Co Ordinator
b. He / She will be the single
point of contact for TAEI
activities / ER Activities and
Referral Activities
c. During his / her duty
timings, she will be in
possession of the Hospital
TAEI Mobile.
d. After completion of his / her
shift, he / she will handover
the mobile and charger to the
next person on shift.
e. It is his / her duty to ensure
that the mobile is charged
and reachable all the time.
f. He / She will liaison with the
Other Hospitals and
Ambulances for Transfer,
Referral and Reception of
patients
g. He / She will maintain a
Register of All Call Outs and
Pre Hospital Intimations
Received in the following
format
h. He / She Can Initiate All
Variants of Code Blue Herself
based on the Call from 108 or
Other Hospitals.
i. He / She will Receive Pre
Arrival Intimation from EMT
j. He / She will follow up the
survival status and recovery
of the cases in the referral
hospitals
k. He / She will alert the TAEI
Team during emergencies,
mass casualty incidents and
disasters
l. He / She will maintain a
Register of All Call Outs and
Pre Hospital Intimations
Received in the prescribed
format
m. He / She will furnish
everyday TAEI app details –
Daily Reporting
4. DTNC RO : Duty Trauma Nurse Co
Ordinator of the Hospital from
which the patient is referred out
a. Will Received Calls from
various wards regarding the
need to refer patients to
other hospitals
b. Will enter the Calls in the
Register and decide the
order of transfer in
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consultation with the a. He / She will Receive Pre
medical officer Arrival Intimation from EMT
c. Will Liase with 108 / EMT / or from the DTNC RO
Ward Staff Nurse b. He / She Can Initiate All
d. Will inform the DTNC RI Variants of Code Blue Herself
regarding the transfer based on the Call from 108 or
e. Will Follow up the case over Other Hospitals.
phone till the patient is taken c. He / She will follow up the
over by DTNC RI survival status and recovery
f. Will Inform the Medical of the cases in the referral
Officer in case of Problems / hospitals
unforeseen events d. He / She will alert the TAEI
Team during emergencies,
5. DTNC RI : Duty Trauma Nurse Co mass casualty incidents and
Ordinator of the Hospital to which disasters
the patient is being referred to 6. EMT : Emergency Medical
Technician of the Ambulance
Phone Numbers of DTNC of Various Hospitals
As per Flow Chart Diagram
Name of the Institution DTNC Directorate District Type
Phone
numbers
1 Ariyalur 7397489495 DMS Ariyalur DHQH
2 Rajiv Gandhi Government 7338745036 DME Chennai MCH
General Hospital, Madras
Medical College
3 Stanley Medical College 9384811223 DME Chennai MCH
Hospital
4 Kilpauk Medical College 9384811224 DME Chennai MCH
Hospital
5 Government Royapettah 9384811225 DME Chennai MCH
Hospital
6 Government Medical 9384811226 DME Chennai MCH
College Hospital,
Omandurar
7 Institute of Child Health 9384811227 DME Chennai MCH
8 Coimbatore Medical 7397489496 DME Coimbature MCH
College Hospital
9 Pollachi 7397489496 DMS Coimbature DHQH
10 Rajah Muthaih Medical 9384811229 Govt Cuddalore MCH
College, Chidambaram
11 Cuddalore 7338745038 DMS Cuddalore DHQH
12 Dharmapuri Medical 9384811230 DME Dharmapuri MCH
College Hospital
13 Pennagaram 7397489497 DMS Dharmapuri DHQH
14 Harur 7397489498 DMS Dharmapuri NonTaluk
15 Dindigul 7338959772 DMS Dindukal DHQH
16 Palani 7397489499 DMS Dindukal Taluk
17 IRT Perundurai 9384811231 Govt Erode MCH

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Name of the Institution DTNC Directorate District Type

Phone
numbers
18 Erode 7397489500 DMS Erode DHQH
19 Chengalpet Medical 9384811232 DME Kancheepuram MCH
College Hospital
20 Sri Ramachndra Medical Pvt Kancheepuram MCH
College Hospital
21 Kancheepuram 7397489501 DMS Kancheepuram DHQH
22 Tambaram 7338745040 DMS Kancheepuram Taluk
23 Kanyakumari Medical 9384811233 DME Kankayumari MCH
College Hospital
24 Padmanabapuram 7397489502 DMS Kanyakumari DHQH
25 Karur Medical College 9384811234 DME Karur MCH
Hospital
26 Kulithalai 7397489503 DMS Karur Taluk
27 Krishagiri 7397489505 DMS Krishnagiri DHQH
28 Hosur 7397489504 DMS Krishnagiri Non Taluk
29 Government Rajaji 7338959770 DME Madurai MCH
Hospital,Madurai
30 Usilampatti 7397489506 DMS Madurai DHQH
31 Melur 7338959774 DMS Madurai Taluk
32 Nagapattinam 7397489507 DMS Nagapattinam DHQH
33 Namakkal 7397489508 DMS Namakkal DHQH
34 Uthagamandalam 7397489509 DMS Nilgiris DHQH
35 Perambalur 7338745039 DMS Perambalur DHQH
36 Pudukottai Medical 9384811235 DME Pudukottai MCH
College Hospital
37 Aranthangi 7397489510 DMS Pudukottai DHQH
38 Viralimalai 9384811245 DMS Pudukottai Non Taluk
39 Ramanathapuram 7397489511 DMS Ramanathapuram DHQH
40 Government Mohan 9384811236 DME Salem MCH
Kumaramangalam
Medical College Hospital,
Salem
41 Mettur 7397489512 DMS Salem DHQH
42 Omalur 7397489513 DMS Salem Taluk
43 Athoor 7397489514 DMS Salem Taluk
44 Sivagangai Medical 9384811237 DME Sivagangai MCH
College Hospital
45 Karaikudi 7397489515 DMS Sivagangai DHQH
46 Thanjavur Medical College 9384811238 DME Thanjavur MCH
Hospital
47 Kumbakonam 7397489516 DMS Thanjavur DHQH
48 Theni Medical College 7338959771 DME Theni MCH
Hospital
49 Periyakulam 7397489517 DMS Theni DHQH
50 Thiruvallur 7397489518 DMS Thiruvallur DHQH

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Name of the Institution DTNC Directorate District Type

Phone
numbers
51 Thiruthani 7397489519 DMS Thiruvallur Taluk
52 Cheyyar 7397489520 DMS Thiruvannamalai DHQH
53 Thiruvarur Medical 984811240 DME Thiruvarur MCH
College Hospital
54 Mannargudi 7397489521 DMS Thiruvarur DHQH
55 Thoothukudi Medical 9384811241 DME Thoothukodi MCH
College Hospital
56 Kovilpatti 7397489522 DMS Thuthookudi DHQH
57 Tirunelveli Medical 9384811242 DME Tirunelveli MCH
College Hospital
58 Tenkasi 7338959773 DMS Tirunelveli DHQH
59 Tiruppur 7397489523 DMS Tiruppur DHQH
60 Tiruvannamalai Medical 9384811239 DME Tiruvannamalai MCH
College Hospital
61 Mahatma Gandhi 9384811243 DME Trichy MCH
Memorial Hospital, Trichy
62 Manapparai 7397489524 DMS Trichy DHQH
63 Thirupattur 7397489526 DMS Velllore Taluk
64 Vellore Medical College 9384811244 DME Vellore MCH
Hospital
65 Walajapet (Vellore) 7397489525 DMS Vellore DHQH
66 Villupuram Medical 7338745037 DME Villupuram MCH
College Hospital
67 Kallakurichi 7397489527 DMS Villupuram DHQH
68 Ulundurpet 7397489528 DMS Villupuram Taluk
69 Tindivanam 7397489529 DMS Villupuram Taluk
70 Aruppukottai 7397489532 DMS Virdhunagar Taluk
71 Virudunagar 7397489530 DMS Virudhunagar DHQH
72 Rajapalayam 7397489531 DMS Virudhunagar Taluk

Details of Steps
As per Flow Chart Diagram

Forms to be Used

S.No Name of the Form

1 Referral Out Form

Referral out Form

S.No Name of the Field To be Filled by
1 Name of the Patient SN
2 Age of the patient SN
3 Gender SN
4 IP Number SN
5 TAEI Number SN
6 PIN Number SN
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7 Aadhar Number SN
8 Hospital SN
9 Department SN
10 Ward SN
11 Provisional Diagnosis MO
Reasons for Referral
12 Drugs Given SN
13 I / O Chart SN
14 “Tubes” (Catheter, Ryles, ICD, EVD etc) SN
15 Contact Number of the Treating Doctor MO
16 Decision to Refer Taken on MO
17 Patient handed over to EMT on SN

Registers to be Maintained
S.No Name of the To be Maintained To be Checked To be To be
Register by at Each Shift by Checked Checked
Daily by Weekly by
1 Referral Out Duty Trauma Nursing Supdt RMO HTNO
Register Nurse Co
Ordinator
2 Referral in cum Duty Trauma Nursing Supdt RMO HTNO
Call Out Nurse Co
Register Ordinator

Referral Out Register

S.No Name of the Field
1 Decision to Refer Taken on and at
2 Ward
3 Department
4 Name of the Patient
5 Age of the patient
6 Gender
7 IP Number
8 TAEI Number
9 PIN Number
10 Provisional Diagnosis
11 Contact Number of the Treating Doctor
12 Hospital to which patient is to be referred
13 Department to which patient is to be referred
14 Call Received from Ward on and at
15 Informed 108 on and at
16 Number of Patients in waiting list for transfer
17 Tentative Time of Transfer
18 Patient handed over to EMT on
19 Patient received in Referral in Hospital on and at

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Referral in cum Call Out Register

S.No Name of the Field

1 Date and Time of Call
2 Patient Coming from Ambulance / Hospital
3 From Which Hospital
4 From Which Ward
5 From Which Department
6 Name of the Patient
7 Age of the patient
8 Gender
9 IP Number
10 TAEI Number
11 PIN Number
12 Provisional Diagnosis
13 Contact Number of the Treating Doctor
14 Patient Referred in for
CEmONC, NICU, ER
15 Whether Call Outs need to be activated
Which Call Out – Brain, Heart, Abdomen, Poison, Burns
Which Department to be informed
16 Had Department been informed
17 Expected Time of Transfer in
18 Call Out Alert Issued on and at
19 Call Out Standby Issued on and at
20 Patient Received on and at (Call Out response)
21 Call Out Stand down Issued on and at
22 Informed DTNC RO on and at

Chapter Essence
In a Nutshell
1. Transfer of Patients from one Hospital to Another has to Follow this Step by Step Protocol
Nursing Alerts
1. Check for the Tubes and Bags
Nursing Management
1. Fill the Full Transfer Form
Trainer’s Pearls
1. Insist of Maintenance of All Registers and Forms

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Chapter
Protocol for Inter Hospital Shifting of Patients for
Opinions and Investigations
Chapter Outline
1. Protocols for Shifting patients from One Hospital to Another and Returning the patient to
the same ward after getting Opinion or Doing Investigation

Shifting of Patients between hospitals for Respiration and ascertain that

investigations or Opinions have to be done
as per the following Protocol
1. Decision of Opinion / Investigation – by
the Medical Officer
2. Shifting
a. The Ward Staff Nurse Call the
Department to which the patient
is send or the Lab or the Scan
Centre and confirms that the
patient can be send at the
particular time and day
b. The Ward Staff Nurse measures
the BP, Check the Pulse and
the patient is stable to be shifted
c. The Ward Staff Nurse Empties
“Output Bags” like Urobag, Ryles
Tube Bag, Colostomy Bag, ICD
Bag, EVD Bag etc and enters the
Values in the Case Sheet
d. Gives the Tablets / Injections /
Replenishes iv Fluids as per
need
3. Patient is shifted
After the patient has been received back,
the Ward Staff Nurse again check the Pulse,
BP, Respiratory Rate and enters in the case
sheet

Check List for Inter Hospital Shifting of Patients for Opinions and Investigations
S.No Description ✓ on Completion or write NA
Check Whether Shifting is Needed
1 Decision of the Opinion / Investigation
2 Whether it has been already obtained
3 Whether it has to be done
4 Whether the Doctor / Time Slot is available
Check Whether Patient is fit to be shifted out
5 Pulse
6 BP
7 Respiratory Rate
8 Tablets Given ?
9 Injections Given ?
10 IV Fluids Filled ?
11 Bags Emptied
12 I/O Chart Updated ?
Check whether the shifting has been uneventful
13 Pulse
14 BP
15 Respiratory Rate
16 Any Complaints of Pain

Chapter Essence

285
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In a Nutshell
1. Follow these Checklist when patient is send out of the hospital to another hospital and
patient comes to the same ward
Nursing Alerts
1. Call the destination and confirm before shifting
Nursing Management
1. Call the ward doctor if needed after patient comes back
Trainer’s Pearls
1. Inculcate the habit of check lists

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Chapter
Protocols for Intra Hospital Transfer for Take Over
Chapter Outline
1. Protocols for Shifting patients from Ward to Another During Take Over

Shifting of Patients inside hospital from
one Ward to Another for Take Over has to
be done as per the following Protocol
1. The Medical Officer incharge of the
Ward / Unit in which the patient is
present requests for the patient to be
taken over and the Medical Officer
incharge of the Ward / Unit where the
patient has to be transferred writes
“Yes Please” OR The Medical Officer to
which the patient has to be transferred
writes “Please transfer to Ward ___
under Unit ___” and the Medical Officer
of the ward in which the patient is
getting treated concurs for the same
2. Shifting
a. The Ward Staff Nurse calls the
Staff Nurse of the Ward to which
patient has to be shifted and
confirms the availability of bed
b. The Ward Staff Nurse measures
the BP, Check the Pulse and
Respiration and ascertain that
the patient is stable to be shifted
c. The Ward Staff Nurse Empties
“Output Bags” like Urobag, Ryles
Tube Bag, Colostomy Bag, ICD
Bag, EVD Bag etc and enters the
Values in the Case Sheet
d. Gives the Tablets / Injections /
Replenishes iv Fluids as per
need
3. Patient is shifted
After the patient has been received, the
Ward Staff Nurse of the New Ward again
check the Pulse, BP, Respiratory Rate and
enters in the case sheet and informs the
Medical Officer that patient has been
received

Check List for Intra Hospital Transfer for Take Over

S.No Description ✓ on Completion or write NA
Check Whether Patient Can be Taken Over
1 Decision of the Medical Officer of the Present Ward
2 Decision of the Medical Officer of the New Ward
3 Whether Bed is available
Check Whether Patient is fit to be shifted out
5 Pulse
6 BP
7 Respiratory Rate
8 Tablets Given ?
9 Injections Given ?
10 IV Fluids Filled ?
11 Bags Emptied
12 I/O Chart Updated ?
Check whether the shifting has been uneventful
(to be filled in by the Staff Nurse of the New Ward)
13 Pulse
14 BP
15 Respiratory Rate
16 Any Complaints of Pain
17 Doctor Informed about Patient Coming in to the ward
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Chapter Essence
In a Nutshell
1. Follow these Checklist when patient is send out of the hospital
Nursing Alerts
1. Call the destination and confirm before shifting
Nursing Management
1. Call the ward doctor if needed after patient comes back
Trainer’s Pearls
1. Inculcate the habit of check lists

288
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Chapter
Protocol for Intra Hospital Shifting of Patients for
Opinions and Investigations
Chapter Outline
1. Protocols for Shifting patients from One Ward to Another in the same hospital and Returning
the patient to the same ward after getting Opinion or Doing Investigation

Shifting of Patients inside the same Respiration and ascertain that

hospital for investigations or Opinions
have to be done as per the following
Protocol
1. Decision of Opinion / Investigation
– by the Medical Officer
2. Shifting
e. The Ward Staff Nurse Call the
Department to which the patient
is send or the Lab or the Scan
Centre and confirms that the
patient can be send at the
particular time and day
f. The Ward Staff Nurse measures
the BP, Check the Pulse and
the patient is stable to be shifted
g. The Ward Staff Nurse Empties
“Output Bags” like Urobag, Ryles
Tube Bag, Colostomy Bag, ICD
Bag, EVD Bag etc and enters the
Values in the Case Sheet
h. Gives the Tablets / Injections /
Replenishes iv Fluids as per
need
3. Patient is shifted
4. After the patient has been received
back, the Ward Staff Nurse again
check the Pulse, BP, Respiratory
Rate and enters in the case sheet

Check List for Intra Hospital Shifting of Patients for Opinions and Investigations
S.No Description ✓ on Completion or write NA
Check Whether Shifting is Needed
1 Decision of the Opinion / Investigation
2 Whether it has been already obtained
3 Whether it has to be done
4 Whether the Doctor / Time Slot is available
Check Whether Patient is fit to be shifted out
5 Pulse
6 BP
7 Respiratory Rate
8 Tablets Given ?
9 Injections Given ?
10 IV Fluids Filled ?
11 Bags Emptied
12 I/O Chart Updated ?
Check whether the shifting has been uneventful
13 Pulse
14 BP
15 Respiratory Rate
16 Any Complaints of Pain

289
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Chapter Essence
In a Nutshell
1. Follow these Checklist when patient is send out of the hospital
Nursing Alerts
1. Call the destination and confirm before shifting
Nursing Management
1. Call the ward doctor if needed after patient comes back
Trainer’s Pearls
1. Inculcate the habit of check lists

290
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Chapter
Protocols for Pre Arrival Intimation and
Preparation
Chapter Outline
1. Components of Pre Arrival Preparation

Pre Arrival Intimation and Preparation to 2. Duty Trauma Nurse Co Ordinator of

Receive the Patient involves Two Steps
1. Information to the Hospital ie, Pre
Arrival Intimation
2. Preparation by the Hospital ie
Hospital Response
Pre Arrival Intimation is the Process of
Informing an hospital about the Arrival of a
Patient. It is done by the EMT or DTNC
1. EMT of the 108 Ambulance in case
of Patients picked up by the
Ambulance. The Protocols to be
Followed by EMT has been already
discussed in the Chapter on Transit
the Referral Out Hospital in case of
Referral from One Hospital to
Another. The Protocols to be
followed by the DTNC of the
Referral Out Hospital has been
discussed in the Chapter Protocols
for Inter Hospital Transfer of
patients for Referral from one
hospital to another
Hospital Response follow the call from 108
or DTNC of Referral Out Hospital. During
this phase, the Hospital which is receiving
the patient activates a Hospital Emergency
Code as given in the protocols below

Chapter Essence
In a Nutshell
1. The Hospital Gets Information from
a. EMT (Protocols for Transit)
b. DTNC (Protocols for Response
2. The Hospital Responds as per the Condition
a. Code Blue Brain for Head Injury and Stroke
b. Code Blue Heart for Cardiac Emergencies
c. Code Blue Abdomen for Acute Abdomen, Blunt Injury and Stab Injury
d. Code Blue Burns for Burns
e. Code Blue Poison for Poisons
f. Code Yellow for Mass Casualties
Nursing Alerts
1. Please ask whether the patient has single injury or multiple injuries
Nursing Management
1. DTNC RI has active the correct code
Trainer’s Pearls
1. Stress the Importance of Team Concept

291
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Chapter Outline
1. Golden Hour
Cases of severe trauma, especially internal
bleeding, require surgical intervention.
Complications such as shock may occur if
the patient is not managed appropriately
and expeditiously. In case of Head Injuries
with Hematomas which cause Mass Effect,
Rapid Decompression is needed. In case of
Ischemic Stroke and Myocardial Infarction
(MI), immediate restoration of Blood Flow
is required. Every Minute or in fact every
second delayed leads to more neurons or
myocardial cells getting damaged. Even if
the patient survives, the quality of life is
affected.
In emergency medicine, the golden hour
(also known as golden time) refers to a
time period lasting for one hour, or less,
following traumatic injury being sustained
by a casualty or medical emergency, during
which there is the highest likelihood that
prompt medical treatment will prevent
death and reduce residual deficit. It is well
established that the patient's chances of
survival are greatest if they receive care
within a short period of time after a severe
injury. The late Dr. R Adams Cowley is
Chapter Essence
In a Nutshell
1. Remember Time is Gold.
Nursing Alerts
1. Golden Hour starts from Incident. So Hospital has less time to act.
Nursing Management
1. Be Ready with all Equipments and Consumable
Trainer’s Pearls
1. Stress Importance of Time Management
Chapter
Golden Hour
credited with promoting this concept, first
in his capacity as a military surgeon and
later as head of the University of Maryland
Shock Trauma Center. The concept of the
"Golden Hour" may have been derived
from French military World War I data. The
R Adams Cowley Shock Trauma Center
section of the University of Maryland
Medical Center's website quotes Cowley as
saying, “There is a golden hour between life
and death. If you are critically injured you
have less than 60 minutes to survive. You
might not die right then; it may be three
days or two weeks later — but something
has happened in your body that is
irreparable.” [Tribute to R Adams Cowley,
M.D.," Archived 2005-12-24 at the
Wayback Machine. University of Maryland
Medical Center, R Adams Cowley Shock
Trauma Center]
It therefore becomes a priority to not just
transport patients suffering from severe
trauma as fast as possible to hospital, but
also for the hospital to be ready to
immediately start definition treatment of a
patient who is in the Golden Hour.
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Chapter
Hospital Emergency Codes
Chapter Outline
1. Description of Various Hospital Codes

-oOo-

Hospitals and health care facilities all over to phase the emergency in one of the
the world utilise a nationally recognised following four categories:
set of codes to prepare, plan, respond and 1. Alert: there is a possible emergency.
recover from internal and external 2. Standby: the emergency is
emergencies. TAEI proposes to introduce imminent.
such a standard set of Codes and Protocols 3. Response: the emergency exists and
Associated with the Codes a response is required.
4. Stand down: the emergency has
Phases of an Hospital Emergency Codes abated and recovery activities can
In some emergencies, such as a Code Blue begin.
following Cardiac Arrest in a Patient Further, Each of the Hospital Emergency
already in the hospital, an immediate Codes will be described under three
response is required and First two Stages headings, aka 3Ps
of Alert and Standby are byepassed. In 1. Purpose
other cases, consideration should be given 2. Policy
3. Procedures

Code Code Description Description of Emergency Authority Authority to

Colour to Activate Execute
Code Red Fire Fire or smoke emergency. Resident Duty Trauma
Medical Nurse Co
Officer Ordinator
RMO (DTNC)
Code Blue Collapsed Medical Emergency other DTNC DTNC
General Patients than Code Blue Brain. Code
Requiring Blue Heart, Code Blue
Resuscitation Abdomen, Code Blue Poison,
Code Blue Burs
Code Blue Patient with suspected Head DTNC DTNC
Brain Injury or Stroke
Code Blue Patient with Chest Pain, DTNC DTNC
Heart Breathlessness, ECG Changes
Code Blue Patients with Abdominal DTNC DTNC
Abdomen Injuries
Code Blue Patients with Snake Bite, DTNC DTNC
Poison Scorpion Sting or Other
Poisoning
Code Blue Patients with Burns DTNC DTNC
Burns
Code Mass Casualties A multi-casualty incident that DTNC DTNC

295
 - 296 -

Yellow stretches or overwhelms

the available health resources
like Bus Accidents, Building
Collapse
Code Pink Abducted Infants Abducted Neonates RMO DTNC
Code Violent Patients / Uncontrollable patients / RMO DTNC
Violet Bystanders bystanders
Code Hazardous Spills RMO DTNC
Orange

-oOo-

Chapter Essence
In a Nutshell
1. Co Ordinated action is needed to respond to emergencies.
Nursing Alerts
1. To Check whether an Emergency warrants a Code to be actives
Nursing Management
1. To Activate the relevant code or to inform the relevant authority
Trainer’s Pearls
1. This is a new concept in Tamil Nadu Medical Services. Needs extensive explanation

296
 - 297 -
Chapter Outline
1. Code Blue Brain – For Head Injuries and Chest Pain
-oOo-
Purpose
1. To Save As Many Neurons as
Possible following Stroke or Head
Injury or other causes of Raised
Intracranial Tension
2. The purpose of the “Code Blue
Brain” team is to assure the prompt
and skilled resuscitation of persons
3. The formation of a “Code Blue
Brain” team shall provide for
trained personnel and relieve other
hospital staff members of the
responsibilities of attending this
condition.
Policy
1. The “Code Blue Brain” Team of a
hospital shall respond to all “Code
Blue Brain” Calls that are called in
that hospital
Procedure
1. Initiation of Code Blue Brain
a. When ?
b. By Whom ?
2. Composition of the Team
a. Who ?
3. Procedures to be done
a. What ?
b. Where ?
4. Responsibilities of the Team
Members
a. How ?
5. Termination of Code Blue Brain
Initiation of Code Blue Brain
1. Code Blue Brain is initiated for
a. Head Injuries
b. Stroke
c. Patient is Not Conscious
2. It is initiated by
a. Duty Trauma Nurse Co
Ordinator. The Duty Trauma
Nurse Co Ordinator is the
Chapter
Code Blue Brain
Senior Most Staff Nurse of
the ER / Trauma Ward.
During her duty timings, she
will be in possession of the
Hospital TAEI Mobile. After
completion of her duty, she
will handover the mobile and
charger to the next person on
shift. It is her duty to ensure
that the mobile is charged
and reachable all the time.
The Hospitla Trauma Nurse
Co Ordinator will supervise
this
3. It is initiated for
a. Patients Brought by 108
b. Patients brought by other
ambulances when Prior
Hospital Intimation has been
given
c. Patients sustaining Injuries
inside hospital or suddenly
becoming unconscious inside
the hospital
Composition of the Code Blue Brain
Team
1. Duty Trauma Nurse Co Ordinator
2. Stretcher Bearers, Hospital Workers
3. CT Technician
4. DAP (Duty Assistant Physician) or
Resident
5. DANS (Duty Assistant
Neurosurgeon), DANP (Duty
Assistant Neurophysician) if
Available or Resident
6. Duty Assistant Anaesthesiologist
7. Duty Pharmacist
8. TAEI Nurses
9. Nurses from ER, Casualty, ICU
10. Emergency OT
Alert
297
 - 298 -
1. Calls
a. As soon as the DTNC
received the Possibility of a
patient for whom Code Blue
Brain is likely to be needed,
he or she will sound the First
Call over Public Address
System
b. The Code Blue Brain will be
given a Number. New
Numbers will start from 7
AM on that day (as per the
Shift timing of Staff Nurse)
Today’s First Code Blue
Brain, Today’s Second Code
Blue Brain etc
c. Second Call will be given 5
minutes after that
d. Third and Final Call will be
given five minutes before the
Ambulance reaches
e. If the emergency is inside the
Hospital, the First Call will be
mentioned as First and Final
Call for In Hospital
Emergency
Standby
2. Assembly
a. As soon as the Call is given
The Team will Assemble
b. Theatre Team will assemble
in theatre
c. ICU Team will assemble in
ICU
d. Cath Lab Team will assemble
in Cath Lab
e. Rest of Team will assemble
in the CT Scan Room
3. Incharge
a. The DANS, DANP, DAP will
be the person incharge of
Conduct of Code Blue Brain
Protocol
4. CT Scan
a. If the CT Machine is not in
use, it is to be Switched on
and kept ready
b. If it is being used, the
procedure is completed and
no fresh patients are
admitted and the gantry is
kept ready for the incoming
emergency
5. Drugs
a. Drugs for Thrombolysis are
brought to the CT Room /
ICU
b. Emergency Tray is brought
to the CT Room (or should
we maintain a tray there ? )
6. ICU
a. One Bed with Ventilator and
IV Fluids will be made ready
7. EOT
a. Table and Equipments will
be made ready
Response
8. Reception
a. The patient will be received
in the Ambulance Bay and
taken to CT Scan Room
immediately in the
AMBULANCE Stretcher
itself.
b. If Needed, the patient will
be intubated in the
Ambulance stretcher itself.
c. If Hemodynamically
unstable, IV Fluids and
Drugs will be given in the
Ambulance stretcher itself
d. The patient is shifted to the
Gantry from the
Ambulance Stretcher.
e. If the CT Scan is in some
other building, or some other
campus, instructions will be
given to the 108 Team by the
DTNC to directly bring the
patient to the CT Room
9. CT Scan
a. is taken using the EMRI
Number or TAEI Number.
b. Only After CT Scan is taken,
the patient is shifted from
the Gantry in the hospital
stretcher
10. Decisions :
298
 - 299 -
a. Once Scan is Done, the
following two questions are
to be answered
i. Does the Patient
Require Surgery
ii. Does the patient
require thrombolysis
iii. Can be patient be
managed
conservatively
11. Thrombolysis
a. If the Patient requires
Thrombolysis, the process is
initiated as per Stroke
Guidelines
12. If the patient requires surgery and if
surgery can be done at that hospital
a. The Patient is wheeled into
the EOT and Surgery done
with the EMRI Number
13. If the Patient requires surgery and if
surgery cannot be done at that
hospital
a. Patient is immediately
referred to the hospital
where surgery can be done
and Code Blue Brain is
activated in that hospital
-oOo-
14. If the patient is to be managed
conservatively, patient is shifted to
ICU
15. AR Entries and Admission
Procedures are done ONLY AFTER
the above steps are completed
Stand Down
16. The Code Blue Brain Stand Down is
done when
a. Patient is shifted to EOT
b. Thrombolysis is initiated
c. Patient is shifted to ICU
d. Patient is referred out to
another hospital
17. Anouncements are again made that
the Particular Code Blue Brain has
been stood down. Eg “Stand down of
Code Today’s Second Code Blue
Brain”
18. AR Entry and other admission
procedures can be made only after
Stand down is initiated
19. No AR Entry or other procedures
are to be done till the stand down is
initiated for a Code Blue Patient
299
- 300 -

300
 - 301 -

Chapter Essence
In a Nutshell
1. Co Ordinated action is needed to respond to emergencies.
Nursing Alerts
1. To Check whether an Emergency warrants a Code to be actives
Nursing Management
1. To Activate the relevant code or to inform the relevant authority
Trainer’s Pearls
1. This is a new concept in Tamil Nadu Medical Services. Needs extensive explanation

301
 - 303 -
Chapter Outline
1. Code Blue Heart – For Myocardial Infarction and other Causes of Chest Pain
-oOo-
Purpose
1. To Save As Much Myocardium as
Possible following Ischemia or
Infarction
2. To Maintain Oxygen Supply to the
Maximum Possible Extent
3. The purpose of the “Code Blue
Heart” team is to assure the prompt
and skilled resuscitation of persons
4. The formation of a “Code Blue
Heart” team shall provide for
trained personnel and relieve other
hospital staff members of the
responsibilities of attending this
condition.
Policy
1. The “Code Blue Heart” Team of a
hospital shall respond to all “Code
Blue Heart” Calls that are called in
that hospital
Procedure
1. Initiation of Code Blue Heart
a. When ?
b. By Whom ?
2. Composition of the Team
c. Who ?
3. Procedures to be done
d. What ?
e. Where ?
4. Responsibilities of the Team
Members
f. How ?
5. Termination of Code Blue Heart
Initiation of Code Blue Heart
1. Code Blue Brain is initiated for
a. Chest Pain (traumatic as well
as non traumatic)
b. Breathlessness (traumatic as
well as non traumatic)
Chapter
Code Blue Heart
2. It is initiated by
a. Duty Trauma Nurse Co
Ordinator. The Duty Trauma
Nurse Co Ordinator is the
Senior Most Staff Nurse of
the ER / Trauma Ward.
During her duty timings, she
will be in possession of the
Hospital TAEI Mobile. After
completion of her duty, she
will handover the mobile and
charger to the next person on
shift. It is her duty to ensure
that the mobile is charged
and reachable all the time.
The Hospitla Trauma Nurse
Co Ordinator will supervise
this
3. It is initiated for
b. Patients Brought by 108
c. Patients brought by other
ambulances when Prior
Hospital Intimation has been
given
d. Patients sustaining Injuries
inside hospital or suddenly
developing Chest Pain or
Breathlessness
Composition of the Code Blue Heart
Team
1. Duty Trauma Nurse Co Ordinator
2. Stretcher Bearers, Hospital Workers
3. ECG Technician
4. X Ray Technician
5. CT Technician
6. DAP (Duty Assistant Physician), DAS
(Duty Assistant Surgeon) or
Resident
7. DAC (Duty Assistant ardiologist),
DACTS (Duty Assistant
Cardiothoracic Surgeon) if Available
or Resident
303
 - 304 -
8. Duty Pharmacist
9. TAEI Nurses
10. Nurses from ER, Casualty, ICU
11. Emergency OT
Alert
1. Calls
a. As soon as the DTNC
received the Possibility of a
patient for whom Code Blue
Heart is likely to be needed,
he or she will sound the First
Call over Public Address
System
b. The Code Blue Heart will be
given a Number. New
Numbers will start from 7
AM on that day (as per the
Shift timing of Staff Nurse)
Today’s First Code Blue
Heart, Today’s Second Code
Blue Heart etc
c. Second Call will be given 5
minutes after that
d. Third and Final Call will be
given five minutes before the
Ambulance reaches
e. If the emergency is inside the
Hospital, the First Call will be
mentioned as First and Final
Call for In Hospital
Emergency
Standby
2. Assembly
a. As soon as the Call is given
The Team will Assemble
b. Cath Lab Team will assemble
in Cath Lab
c. Theatre Team will assemble
in theatre
d. ICU Team will assemble in
ICU
e. Rest of Team will assemble
in the ER
3. Incharge
a. The DAC, DAP, DACTS, DAS
will be the person incharge
of Conduct of Code Blue
Heart Protocol
4. X Ray
a. If the X Ray Machine is not in
use, it is to be Switched on
and kept ready
a. If it is being used, the
procedure is completed and
no fresh patients are
admitted and the gantry is
kept ready for the incoming
emergency
5. CT Scan
b. If the CT Machine is not in
use, it is to be Switched on
and kept ready
c. If it is being used, the
procedure is completed and
no fresh patients are
admitted and the gantry is
kept ready for the incoming
emergency
6. Drugs
a. Drugs for Thrombolysis are
brought to the CT Room /
ICU
b. Emergency Tray is brought
to the CT Room (or should
we maintain a tray there ? )
7. Cath Lab
a. Cath Lab will be made Ready
8. ICU
a. One Bed with Ventilator and
IV Fluids will be made ready
9. EOT
a. Table and Equipments will
be made ready
Response
10. Reception
b. The patient will be received
in the Ambulance Bay and
taken to ER immediately in
the AMBULANCE Stretcher
itself.
11. ECG
a. ECG will be done and
decision for thrombolysis
will be taken by the DAC /
DAP immediately
12. CT Scan
304
 - 305 -
c. In Case of Trauma, CT is initiated as per STEMI
taken using the EMRI Guidelines
Number or TAEI Number. 17. ICD
a. Patient is taken to CT Scan a. If the patient requires ICD, it
Room immediately in the is done in the ER itself in the
AMBULANCE Stretcher Resuscitation Bay
itself. 18. If the patient requires surgery and if
b. The patient is shifted to the surgery can be done at that hospital
Gantry from the a. The Patient is wheeled into
Ambulance Stretcher. the EOT and Surgery done
d. Only After CT Scan is taken, with the EMRI Number
the patient is shifted from 19. If the Patient requires surgery and if
the Gantry in the hospital surgery cannot be done at that
stretcher hospital
13. X Ray b. Patient is immediately
a. If CT Scan is not available, X referred to the hospital
Ray is taken where surgery can be done
b. Patient is taken to X Ray and Code Blue Heart is
Room immediately in the activated in that hospital
AMBULANCE Stretcher 20. If the patient is to be managed
itself. conservatively, patient is shifted to
c. The patient is shifted to the ICU
X Ray from the Ambulance 21. AR Entries and Admission
Stretcher. Procedures are done ONLY AFTER
14. Only After CT Scan or X Ray is the above steps are completed
taken, the patient is shifted from the
Gantry in the hospital stretcher Stand Down
15. Decisions : 22. The Code Blue Heart Stand Down is
e. Once Scan is Done, the done when
following two questions are c. Patient is shifted to EOT
to be answered d. Thrombolysis is initiated
i. Does the Patient e. Patient is shifted to ICU
Require Thrombolysis f. Patient is referred out to
ii. Does the patient another hospital
require ICD 23. Anouncements are again made that
iii. Does the patient the Particular Code Blue Heart has
require any other been stood down. Eg “Stand down of
surgery Today’s Second Code Blue Heart”
iv. Can be patient be 24. AR Entry and other admission
managed procedures can be made only after
conservatively Stand down is initiated
16. Thrombolysis 25. No AR Entry or other procedures
a. If the Patient requires are to be done till the stand down is
Thrombolysis, the process is initiated for a Code Blue Patient

-oOo-

Chapter Essence
In a Nutshell

305
 - 306 -

2. Co Ordinated action is needed to respond to emergencies.

Nursing Alerts
2. To Check whether an Emergency warrants a Code to be actives
Nursing Management
2. To Activate the relevant code or to inform the relevant authority
Trainer’s Pearls
2. This is a new concept in Tamil Nadu Medical Services. Needs extensive explanation

306
 - 307 -

Chapter
Code Blue Abdomen
Chapter Outline
1. Code Blue Abdomen

-oOo-

Purpose a. Duty Trauma Nurse Co

1. To Reduce Mortality and Morbidity
following Abdominal Trauma and
other Causes of “Acute Abdomen”
2. The purpose of the “Code Blue
Abdomen” team is to assure the
prompt and skilled resuscitation of
persons
3. The formation of a “Code Blue
Abdomen” team shall provide for
trained personnel and relieve other
hospital staff members of the
responsibilities of attending this
condition.
Policy
1. The “Code Blue Abdomen” Team of
a hospital shall respond to all “Code
Blue Abdomen” Calls that are called
in that hospital
Procedure
1. Initiation of Code Blue Abdomen
g. When ?
h. By Whom ?
2. Composition of the Team
i. Who ?
3. Procedures to be done
j. What ?
k. Where ?
4. Responsibilities of the Team
Members
l. How ?
5. Termination of Code Blue Abdomen
Initiation of Code Blue Abdomen
1. Code Blue Abdomen is initiated for
a. Abdominal and Pelvic
Trauma
b. Acute Abdomen
2. It is initiated by
Ordinator. The Duty Trauma
Nurse Co Ordinator is the
Senior Most Staff Nurse of
the ER / Trauma Ward.
During her duty timings, she
will be in possession of the
Hospital TAEI Mobile. After
completion of her duty, she
will handover the mobile and
charger to the next person on
shift. It is her duty to ensure
that the mobile is charged
and reachable all the time.
The Hospitla Trauma Nurse
Co Ordinator will supervise
this
3. It is initiated for
a. Patients Brought by 108
b. Patients brought by other
ambulances when Prior
Hospital Intimation has been
given
c. Patients sustaining Injuries
inside hospital or suddenly
developing Acute Abdoment
inside the hospital
Composition of the Code Blue Abdomen
Team
1. Duty Trauma Nurse Co Ordinator
2. Stretcher Bearers, Hospital Workers
3. Radiologist
4. CT Technician
5. DAS (Duty Assistant Surgeon) or
Resident
6. DAOG in case of Female Patient
7. TAEI Nurses
8. Nurses from ER, Casualty, ICU
9. Emergency OT
Alert

307
 - 308 -
1. Calls
a. As soon as the DTNC
received the Possibility of a
patient for whom Code Blue
Abdomen is likely to be
needed, he or she will sound
the First Call over Public
Address System
b. The Code Blue Abdomen will
be given a Number. New
Numbers will start from 7
AM on that day (as per the
Shift timing of Staff Nurse)
Today’s First Code Blue
Abdomen, Today’s Second
Code Blue Abdomen etc
c. Second Call will be given 5
minutes after that
d. Third and Final Call will be
given five minutes before the
Ambulance reaches
e. If the emergency is inside the
Hospital, the First Call will be
mentioned as First and Final
Call for In Hospital
Emergency
Standby
1. Assembly
a. As soon as the Call is given
The Team will Assemble
b. Theatre Team will assemble
in theatre
c. ICU Team will assemble in
ICU
d. Rest of Team will assemble
in the ER
2. Incharge
a. The DAS will be the person in
charge of Conduct of Code
Blue Abdomen Protocol
3. USG
a. If the USG Machine is not in
use, it is to be Switched on
and kept ready
b. If it is being used, the
procedure is completed and
no fresh patients are
admitted and the gantry is
kept ready for the incoming
emergency
4. X Ray
a. If the X Ray Machine is not in
use, it is to be Switched on
and kept ready
b. If it is being used, the
procedure is completed and
no fresh patients are
admitted and the gantry is
kept ready for the incoming
emergency
5. CT Scan
a. If the CT Machine is not in
use, it is to be Switched on
and kept ready
b. If it is being used, the
procedure is completed and
no fresh patients are
admitted and the gantry is
kept ready for the incoming
emergency
6. ICU
c. One Bed with Ventilator and
IV Fluids will be made ready
7. EOT
d. Table and Equipments will
be made ready
Response
8. Reception
e. The patient will be received
in the Ambulance Bay and
taken to ER Immediately and
eFAST will be done.
9. USG
a. If needed, USG will be done
by the Radiologist
10. Decisions :
f. Once Scan is Done, the
following two questions are
to be answered
v. Does the Patient
Require Surgery
vi. Can be patient be
managed
conservatively
11. If the patient requires surgery and if
surgery can be done at that hospital
308
 - 309 -
g. The Patient is wheeled into
the EOT and Surgery done
with the EMRI Number
12. If the Patient requires surgery and if
surgery cannot be done at that
hospital
h. Patient is immediately
referred to the hospital
where surgery can be done
and Code Blue Abdomen is
activated in that hospital
13. If the patient is to be managed
conservatively, patient is shifted to
ICU
14. AR Entries and Admission
Procedures are done ONLY AFTER
the above steps are completed
Stand Down
15. The Code Blue Abdomen Stand
Down is done when
i. Patient is shifted to EOT
j. Patient is shifted to ICU
k. Patient is referred out to
another hospital
16. Anouncements are again made that
the Particular Code Blue Abdomen
has been stood down. Eg “Stand
down of Code Today’s Second Code
Blue Abdomen”
17. AR Entry and other admission
procedures can be made only after
Stand down is initiated
18. No AR Entry or other procedures
are to be done till the stand down is
initiated for a Code Blue Patient

-oOo-

Chapter Essence
In a Nutshell
3. Co Ordinated action is needed to respond to emergencies.
Nursing Alerts
3. To Check whether an Emergency warrants a Code to be actives
Nursing Management
3. To Activate the relevant code or to inform the relevant authority
Trainer’s Pearls
3. This is a new concept in Tamil Nadu Medical Services. Needs extensive explanation

309
 - 311 -

Chapter
Code Blue Poison
Chapter Outline
1. Code Blue Poison

-oOo-

Purpose Senior Most Staff Nurse of

1. To Reduce Mortality and Morbidity
following Poisoning / Snake Bite /
Scorpion Sting
2. The purpose of the “Code Blue
Poison” team is to assure the
prompt and skilled resuscitation of
persons
3. The formation of a “Code Blue
Poison” team shall provide for
trained personnel and relieve other
hospital staff members of the
responsibilities of attending this
condition.
Policy
1. The “Code Blue Poison” Team of a
hospital shall respond to all “Code
Blue Poison” Calls that are called in
that hospital
Procedure
1. Initiation of Code Blue Poison
m. When ?
n. By Whom ?
2. Composition of the Team
o. Who ?
3. Procedures to be done
p. What ?
q. Where ?
4. Responsibilities of the Team
Members
r. How ?
5. Termination of Code Blue Poison
Initiation of Code Blue Poison
1. Code Blue Poison is initiated for
d. Poisons Intake
e. Snake Bite
f. Scorpion Sting
2. It is initiated by
g. Duty Trauma Nurse Co
Ordinator. The Duty Trauma
Nurse Co Ordinator is the
the ER / Trauma Ward.
During her duty timings, she
will be in possession of the
Hospital TAEI Mobile. After
completion of her duty, she
will handover the mobile and
charger to the next person on
shift. It is her duty to ensure
that the mobile is charged
and reachable all the time.
The Hospitla Trauma Nurse
Co Ordinator will supervise
this
3. It is initiated for
h. Patients Brought by 108
i. Patients brought by other
ambulances when Prior
Hospital Intimation has been
given
j. Envenomation or Poisoning
inside hospital
Composition of the Code Blue Poison
Team
1. Duty Trauma Nurse Co Ordinator
2. Stretcher Bearers, Hospital Workers
3. DAP (Duty Assistant Physician) or
Resident
4. Duty Pharmacist
5. TAEI Nurses
6. Nurses from ER, Casualty, ICU
7. Emergency OT
Alert
1. Calls
l. As soon as the DTNC
received the Possibility of a
patient for whom Code Blue
Poison is likely to be needed,
he or she will sound the First

311
 - 312 -
Call over Public Address
System 7. Reception
m. The Code Blue Poison will be y. The patient will be received
given a Number. New in the Ambulance Bay and
Numbers will start from 7 taken to ER immediately
AM on that day (as per the z.
Shift timing of Staff Nurse) 8. CT / BT
Today’s First Code Blue aa. is taken in the ER using the
Poison, Today’s Second Code EMRI Number or TAEI
Blue Poison etc Number.
n. Second Call will be given 5 9. ECG
minutes after that a. Is taken in the ER
o. Third and Final Call will be 10. Can be patient be managed
given five minutes before the conservatively
Ambulance reaches 11. ASV
p. If the emergency is inside the bb. If the Patient requires ADV, it
Hospital, the First Call will be is given
mentioned as First and Final 12. Stomach Wash
Call for In Hospital cc. Is given
Emergency 13. If the patient is to be managed
conservatively, patient is shifted to
Standby ICU
2. Assembly 14. AR Entries and Admission
q. As soon as the Call is given Procedures are done ONLY AFTER
The Team will Assemble the above steps are completed
r. ICU Team will assemble in
ICU Stand Down
s. Rest of Team will assemble 15. The Code Blue Poison Stand Down is
in the ER done when
3. Incharge dd. Patient is shifted to EOT
t. The DAP will be the person ee. Thrombolysis is initiated
incharge of Conduct of Code ff. Patient is shifted to ICU
Blue Poison Protocol gg. Patient is referred out to
4. CT/BT another hospital
u. Bed Site CT / BT are to be 16. Anouncements are again made that
done by the TAEI Nurse the Particular Code Blue Poison has
5. Drugs been stood down. Eg “Stand down of
v. ASV is brought to the ER / Code Today’s Second Code Blue
ICU Poison”
w. Emergency Tray is brought 17. AR Entry and other admission
to the ER Room procedures can be made only after
6. ICU Stand down is initiated
x. One Bed with Ventilator and 18. No AR Entry or other procedures
IV Fluids will be made ready are to be done till the stand down is
initiated for a Code Blue Patient
Response

-oOo-

Chapter Essence

312
 - 313 -

In a Nutshell
4. Co Ordinated action is needed to respond to emergencies.
Nursing Alerts
4. To Check whether an Emergency warrants a Code to be actives
Nursing Management
4. To Activate the relevant code or to inform the relevant authority
Trainer’s Pearls
4. This is a new concept in Tamil Nadu Medical Services. Needs extensive explanation

313
 - 315 -
Chapter Outline
1. Code Blue Burns
-oOo-
Purpose
1. To Reduce Mortality and Morbidity
following Burns
2. The purpose of the “Code Blue
Burns” team is to assure the prompt
and skilled resuscitation of persons
3. The formation of a “Code Blue
Burns” team shall provide for
trained personnel and relieve other
hospital staff members of the
responsibilities of attending this
condition.
Policy
1. The “Code Blue Burns” Team of a
hospital shall respond to all “Code
Blue Burns” Calls that are called in
that hospital
Procedure
1. Initiation of Code Blue Burns
s. When ?
t. By Whom ?
2. Composition of the Team
u. Who ?
3. Procedures to be done
v. What ?
w. Where ?
4. Responsibilities of the Team
Members
x. How ?
5. Termination of Code Blue Burns
Initiation of Code Blue Burns
1. Code Blue Burns is initiated for
k. Burns
2. It is initiated by
l. Duty Trauma Nurse Co
Ordinator. The Duty Trauma
Nurse Co Ordinator is the
Senior Most Staff Nurse of
the ER / Trauma Ward.
During her duty timings, she
will be in possession of the
Hospital TAEI Mobile. After
completion of her duty, she
Chapter
Code Blue Burns
will handover the mobile and
charger to the next person on
shift. It is her duty to ensure
that the mobile is charged
and reachable all the time.
The Hospitla Trauma Nurse
Co Ordinator will supervise
this
3. It is initiated for
m. Patients Brought by 108
n. Patients brought by other
ambulances when Prior
Hospital Intimation has been
given
o. Patients sustaining Burns
inside hospital
Composition of the Code Blue Burns
Team
1. Duty Trauma Nurse Co Ordinator
2. Stretcher Bearers, Hospital Workers
3. CT Technician
4. DAS (Duty Assistant Surgeon) or
Resident
5. TAEI Nurses
6. Nurses from ER, Casualty, ICU
Alert
1. Calls
hh. As soon as the DTNC
received the Possibility of a
patient for whom Code Blue
Burns is likely to be needed,
he or she will sound the First
Call over Public Address
System
ii. The Code Blue Burns will be
given a Number. New
Numbers will start from 7
AM on that day (as per the
Shift timing of Staff Nurse)
Today’s First Code Blue
Burns, Today’s Second Code
Blue Burns etc
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jj. Second Call will be given 5 qq.
minutes after that 6. Cut Down will be made
kk. Third and Final Call will be 7. Patient is shifted to Burns Ward
given five minutes before the 8. AR Entries and Admission
Ambulance reaches Procedures are done ONLY AFTER
ll. If the emergency is inside the the above steps are completed
Hospital, the First Call will be Stand Down
mentioned as First and Final 9. The Code Blue Burns Stand Down is
Call for In Hospital done when
Emergency rr. Patient is shifted to Burns
Standby Ward
2. Assembly ss. Patient is referred out to
mm. As soon as the Call is another hospital
given The Team will 10. Anouncements are again made that
Assemble in the ER the Particular Code Blue Burns has
3. Incharge been stood down. Eg “Stand down of
nn. The DAS will be the person Code Today’s Second Code Blue
incharge of Conduct of Code Burns”
Blue Burns Protocol 11. AR Entry and other admission
4. Burns Ward procedures can be made only after
oo. One Bed will be readied in Stand down is initiated
the Burns Ward 12. No AR Entry or other procedures
Response are to be done till the stand down is
5. Reception initiated for a Code Blue Patient
pp. The patient will be received
in the Ambulance Bay and
taken to ER
-oOo-

Chapter Essence
In a Nutshell
5. Co Ordinated action is needed to respond to emergencies.
Nursing Alerts
5. To Check whether an Emergency warrants a Code to be actives
Nursing Management
5. To Activate the relevant code or to inform the relevant authority
Trainer’s Pearls
5. This is a new concept in Tamil Nadu Medical Services. Needs extensive explanation

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Chapter
Code Yellow : Management of Mass Casualty and
Disaster
Chapter Outline
1. Natural Disasters and Mass Casualties
-oOo-
A mass casualty incident (often shortened
to MCI and sometimes called a multiple
casualty incident or multiple-casualty
situation) is any incident (ie Disaster) in
which emergency medical services
resources, such as personnel and
equipment, are overwhelmed by the
number and severity of casualties.
Hospital Disasters can be either Internal
Disasters or External Disasters
• Internal Disasters are those events
in which hospital resources
themselves are affected. Examples
fire, earthquake, loss of utilities,
worker strikes, release of chemicals
or radiation in the hospital premises
• External Disasters are those which
occur outside the hospitals. It is not
uncommon to have incidents where
more than one patients are brought
to the hospital at the same time.
This may be due to the same
accident where all have been
affected at the same time, or due to
some common event where
different persons are affected at
different times. The examples for
the former would include Bus
Accidents, Fire in Buildings etc
where as the classical example for
latter in our state is the Bull Gore
Injuries during “Jallikattu” or
Cracker Injuries during Festivals
When there is a Mass Casualty Incident,
Code Yellow is activated by the DTNC
Purpose
1. To Save As Many Lives as Possible
and to Reduce Morbidity as Much as
Possible Following a Mass Casualty
Incident
2. The purpose of the “Code Yellow”
team is to assure the prompt and
skilled resuscitation of persons
3. The formation of a “Code Yellow”
team shall provide for trained
personnel and relieve other hospital
staff members of the responsibilities
of attending this condition.
Policy
1. The “Code Yellow” Team of a
hospital shall respond to all “Code
Yellow” Calls that are called in that
hospital
Procedure
1. Initiation of Code Yellow
a. When ?
b. By Whom ?
2. Composition of the Team
c. Who ?
3. Procedures to be done
d. What ?
e. Where ?
4. Responsibilities of the Team
Members
f. How ?
5. Termination of Code Yellow
Initiation of Code Yellow
4. Code Yellow is initiated for
a. Head Injuries
b. Stroke
c. Patient is Not Conscious
5. It is initiated by
a. Duty Trauma Nurse Co
Ordinator. The Duty Trauma
Nurse Co Ordinator is the
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Senior Most Staff Nurse of
the ER / Trauma Ward.
During her duty timings, she
will be in possession of the
Hospital TAEI Mobile. After
completion of her duty, she
will handover the mobile and
charger to the next person on
shift. It is her duty to ensure
that the mobile is charged
and reachable all the time.
The Hospitla Trauma Nurse
Co Ordinator will supervise
this
6. It is initiated for
a. Disasters Inside Hospital,
Disasters Outside Hospitals
where more than 5 patients
are involved
b. Patients brought by other
ambulances when Prior
Hospital Intimation has been
given
c.
Composition of the Code Yellow Team
11. Duty Trauma Nurse Co Ordinator
12. Stretcher Bearers, Hospital Workers
13. CT Technician
14. DAS (Duty Assistant Surgeon ) or
Resident
15. DAOS (Duty Assistant
OrthoSurgeon) or Resident
16. Duty Assistant Anaesthesiologist or
Resident
17. DAP (Duty Assistant Physician) or
Resident
18. DANS (Duty Assistant
Neurosurgeon), DANP (Duty
Assistant Neurophysician) if
Available or Resident
19. Duty Pharmacist
20. TAEI Nurses
21. Nurses from ER, Casualty, ICU
22. Emergency OT
Alert
20. Calls
a. As soon as the DTNC
received the Possibility of
Code Yellow, he or she will
sound the First Call over
Public Address System
b. The Code Yellow will be
given a Number. New
Numbers will start from 7
AM on that day (as per the
Shift timing of Staff Nurse)
Today’s First Code Yellow,
Today’s Second Code Yellow
etc
c. Second Call will be given 5
minutes after that
d. Third and Final Call will be
given five minutes before the
Ambulance reaches
e. If the emergency is inside the
Hospital, the First Call will be
mentioned as First and Final
Call for In Hospital
Emergency
Standby
21. Assembly
a. As soon as the Call is given
The Team will Assemble
b. Theatre Team will assemble
in theatre
c. ICU Team will assemble in
ICU
d. Cath Lab Team will assemble
in Cath Lab
e. Rest of Team will assemble
in the CT Scan Room
22. Incharge
a. The DAS will be the person
incharge of Conduct of Code
Yellow Protocol
23. CT Scan
a. If the CT Machine is not in
use, it is to be Switched on
and kept ready
b. If it is being used, the
procedure is completed and
no fresh patients are
admitted and the gantry is
kept ready for the incoming
emergency
24. Drugs
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a. Drugs for Thrombolysis are
brought to the CT Room /
ICU
b. Emergency Tray is brought
to the CT Room (or should
we maintain a tray there ? )
25. ICU
a. One Bed with Ventilator and
IV Fluids will be made ready
26. EOT
a. Table and Equipments will
be made ready
Response
27. Reception
a. The patients will be received
in the Ambulance Bay and
taken to CT Scan Room
immediately in the
AMBULANCE Stretcher
itself.
b. If Needed, the patient will
be intubated in the
Ambulance stretcher itself.
c. If Hemodynamically
unstable, IV Fluids and
Drugs will be given in the
Ambulance stretcher itself
d. The patient is shifted to the
Gantry from the
Ambulance Stretcher.
e. If the CT Scan is in some
other building, or some other
campus, instructions will be
given to the 108 Team by the
DTNC to directly bring the
patient to the CT Room
28. CT Scan
a. is taken using the EMRI
Number or TAEI Number.
b. Only After CT Scan is taken,
the patient is shifted from
the Gantry in the hospital
stretcher
29. Decisions :
a. Once Scan is Done, the
following two questions are
to be answered
i. Does the Patient
Require Surgery
ii. Does the patient
require Ventilatory
Suppport
iii. Does the Patient
require Management
of Shock
iv. Can be patient be
managed
conservatively
30. If the patient requires surgery and if
surgery can be done at that hospital
a. The Patient is wheeled into
the EOT and Surgery done
with the EMRI Number
31. If the Patient requires surgery and if
surgery cannot be done at that
hospital
a. Patient is immediately
referred to the hospital
where surgery can be done
and Relevant Code for the
patient’s condition is
activated in that hospital
32. If the patient is to be managed
conservatively, patient is shifted to
ICU
33. AR Entries and Admission
Procedures are done ONLY AFTER
the above steps are completed
Stand Down
34. The Code Yellow Stand Down is
done when
a. All patients who need
surgery have been shifted to
EOT
b. All patients who need
ventilatory Support are
shifted to ICU
c. All patients who need
referral are referred out to
another hospital
35. Anouncements are again made that
the Particular Code Yellow has been
stood down. Eg “Stand down of
Code Today’s Second Code Yellow”
36. AR Entry and other admission
procedures can be made only after
Stand down is initiated
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 - 320 -
37. No AR Entry or other procedures initiated for all Code Yellow Patient
are to be done till the stand down is

-oOo-

Chapter Essence
In a Nutshell
1. .
Nursing Alerts
1. .
Nursing Management
1. .
Trainer’s Pearls
1. .

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Chapter Outline
Care in ER
Triage
-oOo-
The Hospital Care includes Care in
ER Room and Care in the Respective
Departments.
Care in ER Room
The action in the ER Room can be
broadly classified as assessment and
response. Although the two concepts
overlap and intertwine it is helpful to
explore them separately. They can be
further subdivided into following Stages
1. ER.1 Triage : Categorisation of
Patient into Red, Yellow or Green
Categories
2. ER.2 Primary Survey : Check
ABCDE
3. ER.3 Resuscitation : Manage
ABCDE
4. ER.4 AR Entry : eMLC
5. ER.5 Secondary Survey : Detailed
Examination
6. ER.6 Investigations : Imaging and
Blood Investigations
7. ER.7 Specialist Opinion : From
Specialists
8. ER.8 Definitive Care : Continuous
post resuscitation monitoring and
re evaluation
Of the above eight stages of Management in
ER,
• 1,2,5,6,7 are Assessment Events
• 3,8 are Responses
• 4 is Documentation
Triage
Triage is the process of determining
the priority of patients' treatments based
on the severity of their condition. This
rations patient treatment efficiently when
resources are insufficient for all to be
treated immediately. The term comes from
Chapter
Triage
the French verb trier, meaning to separate,
sift or select.
Triage is an important concept in
modern health-care systems, and three
essential phases have developed:
1. Pre-hospital triage – in order to
despatch ambulance and
prehospital care resources; (This is
done by the 108 Call Centre and
hence is not explained here)
2. At the scene of trauma;
3. On arrival at the receiving hospital.
The term triage may have
originated during the Napoleonic Wars
from the work of Dominique Jean Larrey.
The term was used further during World
War I by French doctors treating the
battlefield wounded at the aid stations
behind the front. The brief behind
establishing these systems focused on the
identification of those immediately at risk
of loss of life, then moving to the
management of urgent cases and
prioritising these into clinically stable but
seriously ill and into the most appropriate
order for evacuation, and identifying the
most appropriate receiving unit.
There are discrepancies in the local
availability of services such as
neurosurgery, vascular surgery, plastic
surgery, orthopaedic surgery and intensive
care facilities in various hospitals. We are
in the process of establishing Trauma Care
Centres and specialised trauma units that
cater for those seriously injured. Hence the
concept of triage is an important one and
should be understood, and it remains the
entry point to an organised system of care
to maximise outcome in any medical
framework.
In trauma, two types of triage
situation usually exist:
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1. Multiple casualties. Here, the The Following Parameters are used
number and severity of injuries do for sorting
not exceed the ability of the facility 1. Physiological Parameters like
to render care. Priority is given to a. Breathing / Airway
the life-threatening injuries b. Respiratory Rate
followed by those with polytrauma. c. Radial Pulse
2. Mass casualties. The number and d. BP
severity of the injuries exceed the e. Capillary Refilling Time
capability and facilities available to f. AVPU Scale
the staff. In this situation, those with g. GCS Scale
the greatest chance of survival and 2. Nature of Injuries (as found during
the least expenditure of time, Examination)
equipment and supplies are 3. Mechanism of Occurrence of Injuries
prioritised (from History)
All Patients coming to the ER are
at first “Triaged” and are sorted out into The Triage Criteria is Given in the Page 8 of
Red, Yellow or Green Categories as per TAEI Case Sheet in an earlier Chapter
the Guidelines Given Below. AR Entry
and Registration are made after Triage.
-oOo-

Chapter Essence
In a Nutshell
1. If carried out properly triage can achieve a lot for patient care and timely management and is
therefore a useful and important aspect of care in emergency department
Nursing Alerts
1. Triage Form need to be documented by TRIAGE Nurse.
Nursing Management
1. The qualities of a Triage Nurse
a. • Broad clinical experience and knowledge of Anatomy and physiology
b. • High degree of interpersonal skills.
c. • Mature personality and ability to cope with stress.
d. • Excellent communication skills.
e. • Broad knowledge of hospital and community resources.
f. • Awareness of legal responsibility.
g. • Quick decision making abilities.
h. • Ability to exercise sound judgment.
Trainer’s Pearls
1. All healthcare workers need to memorize the Triage Criteria by heart

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Chapter
30 Second Quick Primary Survey (QPS) for a
Conscious Patient
Chapter Outline
1. 30 Second Quick Primary Survey

-oOo-
Primary Survey involves Evaluation of Second Quick Primary Survey Consists of 2
ABCDE Questions + 2 Instruction + 4 Examination
ABCDE means • Questions to Patient
• A-Airway maintenance with cervical o Name ?
spine immobilisation o What happened ?
• B-Breathing, Oxygenation, Ventilation • Instructions to Patient
• C-Circulation with Hemorrhage control, o Lift Both Legs,
• D-Disability: Neurological status, o Move Both Arms.
Consciousness, Focal Neurological • Check for the Volumes of Bilateral
Deficit Radial and Bilateral Dorsalis Pedis
• E-Exposure: To Check for Poisons, Pulses
Occult Injuries.
If the Patient is Unconscious, the American
If the Patient is Conscious, The 30 Second Heart Association’s Adult Cardiac Arrest
Quick Primary Survey may be done. The 30 Algorithm (2015 Update) given in the next
chapter may be followed

Interpretation of QPS
Observation Interpretation Remarks
If Patient Answers Airway is Patent A
Both Questions
Promptly and Sufficient Air Reserve to Permit B
Coherently Speech
Sensorium Clear D
Volume of All 4 Peripheral Perfusion is Adequate C
Peripheral Pulses
Adequate
Moves All 4 Limbs No Focal Neurological Deficit D
If one of the above is not adequate, the respective protocols may be
followed
Physiological Variations can Occur in special populations like
• Elderly
• Infants and Children
• Pregnant Women
• Obese
• Athletes

-oOo-

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Chapter Essence
In a Nutshell
.
Nursing Alerts
1. .
Nursing Management
1. Documetation of QPS need to be added.
Trainer’s Pearls
1. .

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BLS for an Unconscious Patient
Chapter Outline
1. .
-oOo-
If the Patient is Conscious, The 30 Second
Quick Primary Survey given in the previous
chapter may be done and If the Patient is
Unconscious, the American Heart
Association’s Adult Cardiac Arrest
Algorithm (2015 Update) may be followed.
AED is described in a subsequent chapter
Points to Note
• High-quality CPR improves a victim’s
chance of survival. The critical
characteristics of highquality CPR
include:
o Start compressions within 10
seconds of recognition of cardiac
arrest.
o Push hard, push fast: Compress
at a rate of at least 100-120/min
with a depth of at least 5cm (2
inches) for adults,
approximately 5cm (2 inches)for
children, and approximately 4cm
(1 ½ inches) for infants. Allow
complete chest recoil after each
compression.
o Minimize interruptions in
compressions (try to limit
interruptions to <10 seconds).
o Give effective breaths that make
the chest rise. Avoid excessive
ventilation.
• The Chain of Survival : The chain of
survival refers to a series of actions
that, properly executed, reduce the
mortality associated with cardiac
arrest. Like any chain, the chain of
survival is only as strong as its weakest
link. The five links in the adult chain of
survival are:
o Immediate recognition of
cardiac arrest and activation of
the emergency response system.
Chapter
o Early cardiopulmonary
resuscitation (CPR) with an
emphasis on chest
compressions.
o Rapid defibrillation.
o Effective advanced life support.
o Integrated post cardiac arrest
care.
• Guidelines for CPR:
o Sequence: C-A-B.
o Emphasis on High-quality CPR
o Use of naloxone IM or intra-
nasal in suspected opioid
overdose.
o For witnessed cardiac arrest, use
of defibrillator as soon as
possible.
• BLS consists of these main parts:
o Chest compressions
o Airway
o Breathing
o Defibrillation
• Overview of initial BLS steps
o STEP 1 Assessment and scene
safety. Look for response and
normal or abnormal breathing. If
no response and no breathing or
no normal breathing, shout for
help.
o Activate the emergency
response system and get an AED
if available and return to the
patient.
o Check the victims pulse (take at
least 5 but no more than 10
seconds)
o If no pulse within 10 seconds,
perform 5 cycles of
compressions and breaths
(30:2), starting with
compressions (C-A-B sequence).
• Step 1: Assessment and scene safety:
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o The first rescuer who arrives at
the scene must quickly be sure
that the scene is safe. The
rescuer should then check the
victim for a response:
o Make sure that the scene is safe
for you and the victim.
o Tap the victims shoulder and
shout, “Are you all right?”
o Check to see if the victim is
breathing. If a victim is not
breathing or not breathing
normally (i.e. only gasping)
activate the emergency response
system.
• Step 2: Activate the Emergency
Response System and get an AED:
o If you are alone and find an
unresponsive victim not
breathing, shout for help. If no
one responds, activate the
emergency response system, get
an AED if available, return to the
victim to check a pulse and begin
CPR (C-A-B sequence).
• Step 3: Pulse Check:
o Take no more than 10 seconds
to check for a pulse.
-oOo-
o Locate the trachea using 2 or 3
fingers.
o Feel the carotid pulse between
trachea and the muscles of the
neck.
o Pulse check for at least 5 but no
more than 10 seconds. If no
pulse start CPR.
• Step 4: CPR with 30 chest compressions
and 2 breaths:
o Chest compression technique:
o Position yourself beside the
victim.
o Keep the victim in supine
position and on firm surface.
o Place the heel of one hand on the
center of the victim’s chest on
the lower half of the sternum.
o Place the heel of the other hand
on top of the first hand.
o Straighten your arms and
position your shoulders directly
over your hands.
o Push hard and fast.
o Allow for complete chest recoil.
o Minimize interruptions.
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327
 - 328 -

Chapter Essence
In a Nutshell
2. .
Nursing Alerts
2. .
Nursing Management
2. .BLS has to be documented

328
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Trainer’s Pearls
2. .

329
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Chapter
Primary Survey & Initial Assessment and
Management of Polytrauma
Chapter Outline
1. .

-oOo-
“Polytrauma” and “multiple traumata” are during Primary Survey itself and do the
terms often used to denote a patient with appropriate steps
multiple traumatic injuries, such as a o Head Injury
serious head injury in addition to Chest, o Intubate if GCS Less than 9
Abdominal or Extremity Injuries. However, o Urgent CT Scan
it is definedii as Injury Severity Score (ISS) o Face Injury
equal to, or greater than 16. o Intubate even if GCS is 15
because of risk of aspiration
In addition to the routine ABCDE, certain of Blood
extra attention is required in attending to a o Neck Injury
Patient with Polytrauma. These are o Philadelphia Collar
discussed in this chapter. The reader is o Spine Injury
requested to First Read the Subsequent o Use Spine Boards
Chapters dealing with ABCDE to have an o Thoracic Injury
easy understanding of this chapter. o Check for Oxygen Saturation
to Intervene
Preparation o Abdominal Injury
If Pre Arrival Intimation has been given, o eFAST and Prepare for
the Team has to assemble in the Laparotomy if needed
Resuscitation Bay with o Pelvic Injuries
o Airway Equipment o Pelvic Binder
o Warmed intravenous Crystalline o Long Bone Injuries
Solutions o Manage Hypovolemia and
o Monitors Anticipate Fat Embolism
Primary Survey : o Crush Injuries
Look for Injuries at Head, Face, Neck, Spine, o Inj Tetanus Immunoglobin
Thorax, Abdomen, Pelvis, Long Bones

-oOo-

331
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332
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Chapter Essence
In a Nutshell
3. .
Nursing Alerts
3. . Airway Ineffective Airway Clearance related to obstruction or actual injury
Immobilize cervical spine.
4. Look
5. • Is there obvious airway trauma, tachypnea, accessory muscle use, tracheal shift?
6. Listen
7. • Stridor, hyperresonance, dullness to percussion?
8. Feel
9. • For air exchange over the mouth; insert finger sweep to clear foreign bodies.
10. Secure airway.
11. • Oropharyngeal
12. • Nasopharyngeal
13. • Endotracheal tube
14. • Cricothyrotomy
15. Breathing Ineffective BreathingPattern related to actual injuryImpaired Gas Exchange
related to actual injury or disrupted tissue perfusion Assess for:
16. • Spontaneous breathing
17. • Respiratory rate, depth, symmetry
18. • Chest wall integrity
19. For absent breathing:
20. • Intubate, mechanical ventilation

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21. If breathing, but ineffective:

22. • Assess life-threatening conditions (e.g., tension pneumothorax, flail chest).
23. • Administer supplemental oxygen.
24. • Initiate pulse oximetry.
25. Circulation Decreased Cardiac Output related to actual injuryAlteration in Tissue
Perfusion related to actual injury or shockDeficient Fluid Volume related to actual loss of
circulating volume Assess pulse quality and rate.Use ECG monitoring.If no pulse:
26. • Initiate ACLS.
27. If pulse, but ineffective
28. • Assess and treat life-threatening conditions (uncontrolled bleeding, shock).
29. Initiate two large-bore IVs or central catheter; obtain serum samples for laboratory
tests.Provide fluid replacement.
30. Disability Ineffective Cerebral Tissue PerfusionRisk for Injury related to actual injury of
brain or spinal cord Determine Glasgow Coma Scale score.Assess pupil size and
reactivity.
31. Exposure or environmental control Risk for Imbalanced Body Temperature Remove
all clothing to inspect all body regions.Prevent hypothermia.
Nursing Management
3. .
Trainer’s Pearls
3. .

334
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Chapter
Airway & Cervical Spine Assessment
Chapter Outline
1. .

-oOo-
The First and Foremost Assessment should
be assessment of the Airway. The
Healthcare Professional should find out
whether the airway is patent or whether
there is obstruction. In case of Obstruction,
the next step is to find out whether the
obstruction is intraluminal or extra
luminal.
o By Intra Luminal Obstructions, we
mean obstructions inside the Airway.
This obstruction inside the respiratory
tract can be due to Secretions, Blood,
Foreign Bodies
o By Extra Luminal Obstructions, we
mean compression of the Airway by an
external force
The Reader is requested to pause reading
this chapter and go to the Chapter on
“Position during Transit” and then come
back and continue
Assessment of Patency of Airway is easily
done by
o Checking the Oxygen Saturation
o Breath Sounds.
-oOo-
Oxygen Saturation of 100 % and Normal
Vesicular Breath Sounds are signs that
airway is patent. If Airway is patent, We
proceed to Evaluation of Breathing. If
Airway is obstructed, we follow the
relevant protocols under Resuscitation to
are clear the airway
Assessment of Airway is always
accompanied by Assessment of Cervical
Spine Injuries and in case of doubt,
Philadelphia Collar has to be applied
immediately. One need not wait for a
confirmation of injury to apply
Philadelphia Collar. Even a Mild degree of
suspicion is enough for Philadelphia collar
in addition to the following Category of
Patients
o All Patients with H/o Trauma who are
triaged under Red
o Those who have Head Injury, Neck
Injury, Chest Injury
Those who complain of Neck Pain or
Stiffness of Neck

Chapter Essence
In a Nutshell
4. .
Nursing Alerts
. Nursing alert
Even brief periods of hypo-perfusion can significantly increase mortality and decrease recovery of
function from spinal cord insult. Therefore, avoid hypotension and hypoxia at all stages of patient
care.
Assume that all trauma victims have spinal column/cord injuries until proven otherwise. No spinal
segment can be mobilized until it has been specifically cleared.
32.
Nursing Management

335
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4.
.
Trainer’s Pearls
4. .

336
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Foreign Body in Airway & Choking
Chapter Outline
1. .
-oOo-
Choking (also known as foreign body
airway obstruction) is a life-threatening
medical emergency characterized by the
blockage of air passage into the lungs
secondary to the inhalation or ingestion of
food or another object. Choking is caused
by a mechanical obstruction of the airway
that prevents normal breathing. This
obstruction can be
o partial (allowing some air passage
into the lungs) or
o complete (no air passage into the
lungs).
The disruption of normal breathing by
choking deprives oxygen delivery to the
body, resulting in asphyxia. Although
oxygen stored in the blood and lungs can
keep a person alive for several minutes
after breathing stopsiii, this sequence of
events is potentially fatal.
Deaths from choking most often occur in
the very young (children under 1 years
old) and in the elderly (adults over 75
years)iv. Obstruction of the airway can
occur at the level of the pharynx or the
trachea. Foods that can adapt their shape
to that of the pharynx (such as bananas,
marshmallows, or gelatinous candies) can
be a danger not just for children but for
persons of any agev.
In case of ER
Choking is Often Characterised by
o History of playing with or eating
small objects
o Lack of signs of other illness
o Sudden onset respiratory distress,
coughing, gagging, stridor
The Management of Choking in ER for
Unconscious Patients will follow the BLS.
Chapter
The Following Protocol may be followed
for Conscious Patients
1. Check for Oxygen Saturation.
o If Oxygen Saturation is adequate,
Sent for Urgent Call Over to the
ENT Surgeon / Chest Physician
for Bronchoscopy and removal
o If Oxygen Saturation is adequate
and there are no facilities for
Bronchoscopy in the institution
and if the level of obstruction is
above Cricoid, perform a
tracheostomy and refer the
patient to the centre with
bronchoscopy
2. If Oxygen Saturation is inadequate,
the further management depends
on whether the Cough Reflex is
adequate or not
o If Cough is effective and
Adequate, the patient is
encouraged to Cough. Effective
cough : loud cough, breathes
between coughs, alert and
responsive, able to
verbalise/cry. Note that a child’s
effective cough is superior to
any external manoeuvre at
relieving obstruction so should
be encouraged
o If Cough is ineffective and not
adequate, then one of the
Following is performed.
Ineffective cough – quiet/silent
cough, cyanosis, decreasing level
of consciousness, unable to
breathe or speak/cry
1. Infants
o Back blows
o • infant prone and head down
across your lap
o • infant’s head supported with
your thumb at one angle of the
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jaw and fingers at the other,
taking care not to compress the
soft tissues beneath the jaw
o • deliver up to 5 back blows
with the heel of the hand to the
back between the scapulae
o Chest thrusts
o • turn the infant head down
and supine, lying supported
along your arm with your hand
supporting the occiput
o • deliver up to 5 chest thrusts
(deeper and slower than chest
compressions) with 2 fingers to
the lower sternum a finger’s
breadth above the xiphisternum
o Removal of foreign body (Infants
and Children)
o Foreign body is removed from
the mouth if it is visible.
Preferred method to remove
foreign body is chest thrust,
back thrust, or Hemlich’s
maneuver.
2. Heimlich’s Maneuver
3. • Stand behind the chid and
Adult
4. • Make a fist of dominant hand
and place on the child’s
umbilicus / Adult Umblicus
5. • Support the wrist with the
other hand
-oOo-
6. • Give compression as in and
up ward push for five times
7. • Ensure that the foreign
body has been expelled out
8.
9. Nursing care
10. 1. Assess the airway for patency,
presence of secretions or foreign
body
11. 2. Measure oxygen saturation
12. 3. Assist in removing the foreign
body by back blows/ chest
thrust for infants or abdominal
thrust for child > 1 yr
(Heimlich’s Maneuver)
13. 4. If child looses consciousness
initiate basic and advanced life
support appropriately
14.
15. Nursing alert
16. The signs of foreign body
aspiration such as wheezing and
respiratory distress is common
for various other respiratory
conditions .The nurse must
consider history collection of
suspected of foreign body
aspiration if child is admitted
with respiratory distress.
Foreign body removal by
sweeping out should be done
carefully, or it may be forced
into the trachea
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Chapter Essence
In a Nutshell
5. .
Nursing Alerts
33. .
Nursing Management
5. .
Trainer’s Pearls
5. .

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Chapter
Asthma.
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
6. .
Nursing Alerts
34. .
Nursing Management
6. .

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7.
Trainer’s Pearls
6. .

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Chapter Outline
1. .
-oOo-
Once Airway is secured, the attention is
diverted to Breathing and Ventilation
• Airway patency alone does not ensure
adequate ventilation.
• Adequate gas exchange is required to
maximize oxygenation and carbon
dioxide elimination.
• Ventilation requires adequate function
of the lungs, chest wall, and diaphragm.
• Each component must be rapidly
examined and evaluated.
• The patient’s neck and chest should be
exposed to adequately assess jugular
venous distention, position of the
trachea, and chest wall excursion.
• Auscultation should be performed to
ensure gas flow in the lungs.
• Visual inspection and palpation can
detect injuries to the chest wall that
may compromise ventilation.
• Percussion of the thorax can also
identify abnormalities, but during a
noisy resuscitation this may be difficult
or produce unreliable results.
• Assess
o Expose the neck and chest
o Jugular venous distension
o Position of trachea, Symmetrical
Chest Movement, Use of
Accessory Muscles, Signs of
Injury, Subcutaneous
Emphysema
o Respiratory rate and depth
o Percussion findings of chest
o Air entry
o Oxygen saturation
• Injuries that severely impair ventilation
in the short term include tension
pneumothorax, flail chest with
pulmonary contusion, massive
hemothorax, and open pneumothorax.
Chapter
Breathing
• These injuries should be identified
during the primary survey and may
require immediate attention for
ventilatory efforts to be effective.
• Simple pneumothorax or hemothorax,
fractured ribs, and pulmonary
contusion can compromise ventilation
to a lesser degree and are usually
identified during the secondary survey.
• Recognise and treat early –
o Tension pneumothorax
o Flail chest with pulmonary
contusion
o Massive haemothorax
o Open pneumothorax
• Immediate Chest decompression with
Oxygen delivery
• Remember that After excluding
tension pneumothorax, cause of
hypotension is hypovolemia until
proved otherwise
• Differentiating between ventilation
problems and airway compromise can
be difficult:
o Patients who have profound
dyspnea and tachypnea appear
as though their primary problem
is related to an inadequate
airway. However, if the
ventilation problem is caused by
a pneumothorax or tension
pneumothorax, intubation with
vigorous bag-mask ventilation
can rapidly lead to further
deterioration of the patient.
o When intubation and ventilation
are necessary in an unconscious
patient, the procedure itself can
unmask or aggravate a
pneumothorax, and the patient’s
chest must be reevaluated. Chest
x-rays should be obtained as
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soon after intubation and
initiation of ventilation as is
practical.
• Injuries that may acutely impair
ventilation and should be identified in
the Primary survey are
o Tension pneumothorax
o Flail chest with pulmonary
contussion
o Massive hemothorax
o Open pneumothorax
• In case of Problems in Air Exchange
o Administer high concentrations
of oxygen, Ventilate with Ambu
Bag, or Connect to Ventilator
• For Pneumothorax
o needle decompression / Place
chest tube
o Thoracotomy if Indicated
o Seal an open pneumothorax
• Check with Pulse oximeter even if there
is no obvious cyanosis
• Always check for one-lung intubation,
chest X-rays should be performed
• If the ventilation problem is produced
by a pneumothrax, intubation without
decompressing the pneumothorax may
lead to deterioration.
• In Case of Head Injuries, certain
abnormal types of breathing may be
encountered based on the level of
lesion. For All these types, the Protocol
Given in the next Chapter may be
followed
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-oOo-

Chapter Essence
In a Nutshell
7. .
Nursing Alerts
35. .
Nursing Management
8. .
Trainer’s Pearls
7. .

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Chapter 62
Role of Mechanical Ventilation for Head, Face &
Neck Injuries
Chapter Outline
• Introduction to Breathing (or Respiration or Ventilation)
• Hyperventilation and Intracranial Pressure (ICP)
• Indications of Mechanical Ventilation in Head, Neck & Face Injuries
• Protocol for Mechanical Ventilation in Head, Neck & Face Injuries
• (Ventilation is dealt in detail in a subsequent chapter along with Resuscitation)

-oOo-
Introduction
• Breathing (or respiration, or
ventilation) is the process of moving air
into and out of the lungs to facilitate gas
exchange with the internal
environment, mostly by bringing in
oxygen and flushing out carbon dioxide.
• All aerobic creatures need oxygen for
cellular respiration, which uses the
oxygen to break down foods for energy
and produces carbon dioxide as a waste
product. Breathing, or "external
respiration", brings air into the lungs
where gas exchange takes place in the
alveoli through diffusion. The body's
circulatory system transports these
gases to and from the cells, where
"cellular respiration" takes place.
• For a Normal gas Exchange (aka
Breathing, Ventilation, Respiration) in
the Lungs, the following factors are
needed
o An Inspiration and Expiration -
signals originate in brain stem
and come to the muscles of
respiration through spinal cord
and nerves
o Alveolar Function
o Presence of Adequate Oxygen in
the Alveoli
• The Normal Gas Exchange in the Lungs
can be affected due to various reasons
o Absence of Inspiration and
Expiration
▪ Can be due to Head Injury
leading to brain stem
dysfunction
▪ Can be due to Neck Injury
leading to cervical spinal
cord lesions
o Loss of Alveolar Functions due
to pulmonary pathology
o Inadequate Oxygen in the Alveoli
due to Obstruction in the airway
▪ Can be due to External
Compression to the
respiratory tract
▪ Can be due to Blood,
Fluids, Vomitus, Water
inside the respiratory
tract
• Ventilator is a device which is designed
to move breathable air into and out of
the lungs, to provide breathing for a
patient who is physically unable to
carry out a normal gas exchange in the
Lungs. It is utilizable in all conditions of
impaired ventilation mentioned above
• Mechanical Ventilation has twin
functions. It provides Oxygen to the
Blood and increases the oxygen in the
blood. It also removes the Carbon di
oxide from the blood. The latter
function is useful in cases where we
need to wash out CO2 from the blood
Hyperventilation and Intracranial
Pressure
• Intracranial pressure (ICP) is
determined by the volume of brain
parenchyma (80%), blood (12%), and
CSF (8%) within a rigid cranial vault.
Normal ICP ranges from 5-15mmHg.
Because the cranial compartment is
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enclosed by a rigid skull, it has a limited
ability to accommodate additional
volume. When intracranial contents
increase in volume (e.g., secondary to
tumor, blood, swelling, hydrocephalus),
initially, circulating blood and CSF are
displaced to offset the extra volume and
ICP remains unchanged. However,
beyond a certain threshold, if
intracranial contents continue to
increase in volume, then ICP will
quickly increase as there is diminished
compliance in the fixed intracranial
vault. This dynamic is critical in surgical
patients with already decreased
intracranial compliance from space
occupying lesions, who may be
extremely sensitive to ICP changes
associated with anesthetic effects (e.g.,
cerebral vasodilation from inhalation
anesthetics or vasodilation from
periods of
hypoventilation/hypercapnia).
• Hyperventilation is one known
method of rapidly lowering ICP.
Cerebral blood flow is largely
dependent on PaCO2.
Hyperventilation causes decreased
PaCO2 which subsequently leads to
arterial vasoconstriction thus
lowering cerebral blood flow (CBF),
cerebral blood volume, and ICP. This
effect is mediated my pH changes in
the extracellular fluid which cause
cerebral vasoconstriction or
vasodilation depending on the pH.
There is approximately a 2%
decrease in CBF for every 1 mmHg
decrease in PaCO2 levels. Although
the effects of hyperventilation are
almost immediate, these effects on CBF
diminish over 6-24 hours as the brain
adapts by changing bicarbonate levels
in the extracellular fluid to normalize
the pH. Additionally, if prolonged
hyperventilation is suddenly
discontinued and normocapnia is
restored too quickly, there is a resultant
rebound increase in CBF and thus ICP
which can be deleterious.
• Hyperventilation is commonly used to
facilitate intracranial surgery because it
is thought to quickly provide brain
“relaxation” in the surgical field. One
multicenter randomized trial found that
hyperventilation to moderate
hypocapnia (PaCO2= 25 ± 2mmHg) was
effective at reducing ICP and decreasing
the brain bulk in the surgical field
during craniotomy (Gelb et al., 2008).
On the other hand, hyperventilation can
also have adverse effects.
Hyperventilation to PaCO2 levels below
20mmHg has been shown to induce
cerebral ischemia. Cerebral ischemia
with extreme hyperventilation is likely
mediated by severe vasoconstriction of
cerebral vessels and alkalosis induced
leftward shift of the oxyhemoglobin
curve, thus decreasing oxygen delivery
to brain tissue. For this reason,
hyperventilation to moderate levels
(PaCO2 = 25-35) is generally
considered a short term temporizing
measure to decrease ICP, or to reduce
brain bulk during neurosurgery, and
overly aggressive hyperventilation
(PaCO2 <25mmHg) should be avoided.
Indications of Mechanical Ventilation in
Head, Neck & Face Injuries
• Head Injuries
o Patient with GCS 9 or Less than
9
o Patients with Diffuse Injuries
o Patients with Clinical or
Radiological signs of increased
ICT
• Maxillo Facial Injuries
o Irrespective of GCS, if there is
any bleeding
• Neck Injuries
o With features suggestive of
Respiratory insufficiency
Protocol for Mechanical Ventilation in
Head, Neck & Face Injuries
• For all cases of Head Injuries,
Maxillofacial Injuries and Neck Injuries,
Mechanical ventilation can be done as
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per the following Protocol 4. Daily Routine : Investigations: at 7
AM and repeat if necessary
1. Mode : CMV Mode a. Bedside Chest X Ray
2. FiO2 – 60 % (40 to 60 % depending b. Serum Electrolytes
on PaO2) c. ABG
3. Drugs 5. Daily Routine : Review
a. Paralysis : a. Morning Anaesthesiologist
i. Vecuronium 2mg / Review
hour via infusion b. Duty Resident Review Daily
pump. (Repeat SOS) Evening 7 PM
b. Sedation : c. Duty Anaesthesiologist
i. Fentanyl Review Daily Evening 7 PM
20microg/hour via 6. Monitoring
infusion pump. a. Central Line
(Stepup SOS) b. Arterial Line
ii. Midazolam 2 mg/hour c. ICP Monitoring
via infusion pump. 7. Supportive Measures
(Stepup SOS) a. Anti Embolic Stockings
c. NTG / Dopamine / Nor b. Chest Physiotherapy
adrenalin drips – Depending c. Limb Physiotherapy
on BP d. Bedside USG Abdomen On
Third Day and Repeat SOS

-oOo-

Chapter Essence
In a Nutshell
1. Intubation and mechanical ventilation is required even in Fully Conscious Patient with
Perfect Lungs if he has chance of aspiration (eg Facial Injuries).
Nursing Alerts
1. Check for Indications of Mechanical injuries even if patient is fully conscious with SpO 2 100
Nursing Management
1. Call for Anaesthesiologist for Intubation
Trainer’s Pearls
1. Stress the importance of Ventilation in conditions where lung is normal

Expert Review 1 :
First we have to distinguish between hyperventilation and supportive ventilation.
Hyperventilation has a role for a limited period only, say 48 hours maximum; after which it
may even be deleterious.In addition if possible it should be bolstered by CBF / cerebral
metabolism monitoring to make sure that brain is not subjected to risk of stroke.
When the intention is just to reduce the work of breathing/ to avoid aspiration with normal
central respiratory drive- as in facial injuries, a tracheostomy may be a better option than
mechanical ventilation; of course if there is central respiratory failure, there is no option but
to use ventilator.
I am not convinced about ventilating a normal lung in anticipation of aspiration because we all
have seen ventilator induced complications, more do if the patient is conscious with good
cough reflex..

Expert Review 2 :

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Chapter
Anaphylaxis.
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
2. .

353
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Nursing Alerts
2. .
Nursing Management
2. . Nursing Care Plan for Anaphylaxis
3.
4. Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. It
typically causes a number of symptoms including an itchy rash, throat swelling, and low
blood pressure. Common causes include insect bites and stings, foods, and medications.
5.
6. On a mechanistic level, anaphylaxis is caused by the release of mediators from certain
types of white blood cells triggered by either immunologic or non-immunologic
mechanisms. It is diagnosed on the basis of the presenting symptoms and signs. The
primary treatment is injection of epinephrine, the administration of intravenous fluids, and
positioning the person flat, with other measures being complementary.
7.
8. Anaphylaxis typically presents many different symptoms over minutes or hours with an
average onset of 5 to 30 minutes if exposure is intravenous and 2 hours for foods. The
most common areas affected include: skin (80–90%), respiratory (70%), gastrointestinal
(30–45%), heart and vasculature (10–45%), and central nervous system (10–15%)[5] with
usually two or more being involved.
Trainer’s Pearls
2. .

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Circulation & Assessment of Shock.
Chapter Outline
1. .
-oOo-
• Circulatory compromise in trauma
patients can result from many different
injuries.
• Blood volume, cardiac output, and
bleeding are major circulatory issues to
consider.
• Bilateral Carotid, Radial, Dorsalis
Pedis Pulse along with SpO2 and
Hematocrit can help in earlier
identification of Problems in
Circulation
• Blood Volume and Cardiac Output :
o Hemorrhage is the predominant
cause of preventable deaths
after injury.
o Identifying and stopping
hemorrhage are therefore
crucial steps in the assessment
and management of such
patients.
o Once tension pneumothorax has
been eliminated as a cause of
shock, hypotension following
injury must be considered to be
hypovolemic in origin until
proven otherwise.
o Rapid and accurate assessment
of an injured patient’s
hemodynamic status is essential.
• The elements of clinical observation
that yield important information within
seconds are level of consciousness, skin
color, and pulse
o Level of Consciousness When
circulating blood volume is
reduced, cerebral perfusion may
be critically impaired, resulting
in altered levels of
consciousness. However, a
conscious patient also may have
lost a significant amount of
blood.
Chapter
o Skin Color Skin color can be a
helpful sign in evaluating injured
hypovolemic patients. A patient
with pink skin, especially in the
face and extremities, rarely has
critical hypovolemia after injury.
Conversely, the patient with
hypovolemia may have ashen,
gray facial skin and pale
extremities.
o Pulse The pulse, typically an
easily accessible central pulse
(e.g., femoral or carotid artery),
should be assessed bilaterally
for quality, rate, and regularity.
Full, slow, and regular
peripheral pulses are usually
signs of relative normovolemia
in a patient who is not taking ß-
adrenergic blocking
medications. A rapid, thready
pulse is typically a sign of
hypovolemia, but the condition
may have other causes. A normal
pulse rate does not necessarily
indicate normovolemia, but an
irregular pulse does warn of
potential cardiac dysfunction.
o Absent central pulses that are
not attributable to local factors
signify the need for immediate
resuscitative action to restore
depleted blood volume and
effective cardiac output.
• Bleeding :
o The source of bleeding should be
identified as either external or
internal.
o External hemorrhage is
identified and controlled during
the primary survey.
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o Rapid, external blood loss is
managed by direct manual
pressure on the wound.
o Tourniquets are effective in
massive exsanguination from an
extremity, but carry a risk of
ischemic injury to that extremity
and should only be used when
direct pressure is not effective.
o The use of hemostats can result
in damage to nerves and veins.
o The major areas of internal
hemorrhage are the
▪ chest,
▪ abdomen,
▪ retroperitoneum,
▪ pelvis, and
▪ long bones.
o The source of the bleeding is
usually identified by physical
examination and imaging (e.g.,
chest x-ray, pelvic x-ray, or
focused assessment sonography
in trauma [FAST]).
o Management may include chest
decompression, pelvic binders,
splint application, and surgical
intervention.
• Trauma respects no patient population
barrier. The elderly, children, athletes,
and individuals with chronic medical
conditions do not respond to volume
loss in a similar or even in a “normal”
manner.
o Elderly patients have a limited
ability to increase their heart
rate in response to blood loss,
which obscures one of the
earliest signs of volume
depletion—tachycardia. Blood
pressure has little correlation
with cardiac output in older
patients. Anticoagulation
therapy for medical conditions
such as atrial fibrillation,
coronary artery disease, and
transient ischemic attacks can
increase blood loss.
o Children usually have abundant
physiologic reserve and often
have few signs of hypovolemia,
even after severe volume
depletion. When deterioration
does occur, it is precipitous and
catastrophic.
o Well-trained athletes have
similar compensatory
mechanisms, may have
bradycardia, and may not have
the usual level of tachycardia
with blood loss.
o Often, the AMPLE history is
helpful
▪ Allergies
▪ Medications currently
used
▪ Past illnesses/Pregnancy
▪ Last meal
▪ Events/Environment
related to the injury
o
• Anticipation and an attitude of
skepticism regarding the patient’s
“normal” hemodynamic status are
appropriate.
• To Remember
o The elements that provide the
information about the
hemodynamic status of the
injured patients.
▪ 1. Level of consciousness
▪ 2. Skin color
▪ 3. Pulse ( quality, rate,
regularity )
o The Approximate Systolic Blood
Pressure may be ascertained by
the presence of pulse at various
locations as below
▪ Presence of a Carotid
pulse is at SBP 60 mmHg
▪ Presence of a Femoral
pulse is at SBP 70 mmHg
▪ Presence of a Radial pulse
is at SBP80 mmHg
o External bleeding has to be
identified and controlled in the
primary survey stage itself and
Operative intervention for
internal bleeding control.
o Assessment has to be based on :
Source of external hemorrhage,
Potential source(s) of internal
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hemorrhage, Pulse / skin color,
capillary refill / Blood pressure
o Management:
▪ Apply direct pressure to
external bleeding site.
▪ Internal hemorrhage ?
Need for surgical
intervention ?
▪ Establish IV access /
central line / IO
▪ Fluid resuscitation /
blood replacement
o After excluding tension
pneumothorax, cause of
hypotension is hypovolemia
until proved otherwise
o The elderly, children, athletes
and others with chronic medical
conditions do not respond to
volume loss in similar manner
• Assessment of Shock can be done with
the following Table
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-oOo-

Chapter Essence
In a Nutshell
3. .
Nursing Alerts
3. .
Nursing Management
9. .
Trainer’s Pearls
3. .

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Chapter
Assessment of Chest Pain : Acute Coronary
Syndrome
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
4. .
Nursing Alerts
4. .
Nursing Management
10. .
Trainer’s Pearls
4. .

359
 - 361 -
Chapter Outline
1. .
-oOo-
The Focused Assessment
Sonography in Trauma (FAST) FAST exam
is a tool for the rapid assessment of a
trauma patient. In order to develop
proficiency with this assessment, more
time than is available in the ATLS skill
station is required. However, this skill sta-
tion will provide you with a basic
framework for iden-tifying the correct way
to perform the FAST exam, and to interpret
FAST images in the context of several
cases. FAST includes the following views:
o pericardial view
o right upper quadrant (RUQ) view to
include diaphragm-liver interface
and Morrison’s pouch
o left upper quadrant (LUQ) view to
include diaphragm-spleen interface
and spleen-kidney interface
o suprapubic view
The only equipment necessary to
perform a FAST exam is an ultrasound
machine and water-based gel . The FAST
exam is performed with a low frequency
(3.5 MHz) transducer, which allows the
depth of penetration necessary to obtain
appropri-ate images. Either the curved
array transducer or the phased array
cardiac transducer, with a smaller foot-
print that fits more easily between the ribs,
may be used. Higher frequency transducers
may be appropri- ate for children or
extremely thin adults. Even lower
frequency transducers may be necessary
for the mor-bidly obese.
-oOo-
Chapter
eFAST.
Start with the heart to ensure that
the gain is set appropriately—fluid within
the heart should be black. The heart can be
imaged using the subxiphoid or the
parasternal view.
o The RUQ view is a sagittal view in
the midaxillary line, at
approximately the 10th or 11th rib
space. Structures to visualize
include the diaphragm, liver, and
kidney. The entire hepatorenal fossa
(Morrison’s pouch) should be
visualized.
o The LUQ view is a sagittal view in
the midaxillary line, at
approximately the 8th or 9th rib
space. Structures to visualize
include the diaphragm, spleen, and
kidney . The entire splenorenal
fossa should be visualized. Air
artifacts from the stomach and
colon, in addition to the smaller
acous-tic window, make this the
most difficult view to obtain; it may
be necessary to move the
transducer posteriorly
o The suprapubic view is a transverse
view optimally obtained prior to
placement of a Foley catheter.
Artifacts may be introduced due to
posterior enhance-ment; if areas of
fluid disappear with side-to-side
movement of the transducer, they
are likely artifact.
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362
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Chapter Essence
In a Nutshell
5. .
Nursing Alerts
5. .
Nursing Management
11. .
Trainer’s Pearls
5. .

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Chapter
Compartmental Syndrome.
Chapter Outline
1. .

-oOo-
The extremities contain muscles compromised by the effect of the pressure
and other structures surrounded by tough and the lack of blood flow. Because these
membranes, known as fascia, that do not processes take some time, compartment
stretch, creating multiple closed spaces syndrome does not present immediately,
known as compartments. Crush injuries, as but several hours following the initial
well as closed (and some open) frac-tures injury.
can cause bleeding and swelling, which is Late signs and symptoms of
contained within the closed space by the compartment syndrome are the five Ps:
fascia. This condition is called pain, pallor, pulselessness, paresthesia, and
paralysis. The early symptoms are usually
compartment syndrome.
pain, typically described as pain out of
Lower leg injuries have the greatest
proportion to injury, and paresthesia.
risk of developing compartment syn-
drome, although it can occur in the
Treatment requires emergent surgical
forearm, thigh, hand, and foot as well. As
compartment decompression with fasci-
the injured area swells, pressure
otomy. As with shock, a high degree of
compresses all the structures within the
suspicion is important to consider this
com-partment, including arteries, veins,
diagnosis before the later symptoms
nerves, and muscle. At a certain point, the
develop and likely result in permanent
pressure prevents venous return. Then, as
damage.
pressure continues to increase, it cuts off
arterial circulation. The nerves also are

-oOo-

Chapter Essence
In a Nutshell
6. .
Nursing Alerts
6. .
Nursing Management
12. . Nursing Plan:
13.
14. Sterility will be maintained on left arm prior and post fasciotomy, to prevent infection.
15.
16. Interventions:
17.
18. - Keep a sterile environment (washing hands before entering the room and before exiting,
to reduce transmission of possible infection. Washing hands before assess wound).
19.
20. -Checking the IV flow rate, ordered by physician (this will help you monitor the patient's

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intake (what they eat/drink/IV fluids) and their output (their urine/emesis). Less than 30ml
of urine per hour can indicate decreased renal perfusion, the transfer of blood and oxygen
through the blood vessels within the kidney. This can be dangerous if not treated, it can
lead to renal failure.
21.
22. -Assess the color and smell of the wound every 2 hours (the wound should be red in color,
with no drainage, this implies good healing. if there is yellow tissue there could be an
infection and/or sloughing, which is when skin begins to fall off the wound. It may also
begin to turn black and become necrotic, which is when the tissue is dead and needs to be
debrided. Debridement is when a specialist come in and removes the dead black tissue
from the infected wound. Early detection is key).
23.
24. - Patient teaching (teach the patient about the wound site, signs and symptoms of
infection and to notify a nurse immediately if anything changes. teach the patient how to
keep the area sterile by keeping blankets and clothing out of reach of the wound, resting
the extremity, body part. Advising any visitors of the same factors. Teach the patient about
the expected drainage).
25.
26. - Monitor vitals every 15 minutes (adequate blood pressure should be <120 and <80.
Adequate respirations should be between 12-20 breaths per minute. Adequate pulse
should be between 60-100 beats per minute. Adequate temperature should be 37.5
degrees Celsius. If any of those numbers are different there could be an infection setting
in).
27.
28. - Keep the patient in supine position to ensure adequate blood flow throughout the body
(this will help ensure good arterial blood flow, the blood vessels carrying oxygenated blood
from the heart to the body. It will also ensure good venous blood flow, blood flow through
the veins, the vessels that carry deoxygenated blood back to the heart. It will also take
strain off of any extremity that is elevated).
Trainer’s Pearls
6. .

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Chapter
ECG.
Chapter Outline
1. .

-oOo-
BASICS OF ECG
The graphic representation of the heart’s electrical activity recorded through electrodes
positioned at strategic points on the body constitutes the electrocardiogram (ECG).
• Normal impulse conduction in the heart
o Sinoatrial node-- AV node-- Bundle of His -- Bundle Branches-- Purkinje fibers
• P wave
o Indicates atrial depolarization, or contraction of the atrium.
o Normal duration is not longer than 0.11 seconds (less than 3 small squares)
o Amplitude (height) is no more than 3 mm
o No notching or peaking
• QRS complex
o Indicates ventricular depolarization, or contraction of the ventricles.
o Normally not longer than .10 seconds in duration
o Amplitude is not less than 5 mm in lead II or 9 mm in V3 and V4
o R waves are deflected positively and the Q and S waves are negative
• T wave
o Indicates ventricular repolarization
o Not more that 5 mm in amplitude in standard leads and 10 mm in precordial
leads
o Rounded and asymmetrical
• ST segment
o Indicates early ventricular repolarization
o Normally not depressed more than 0.5 mm
o May be elevated slightly in some leads (no more than 1 mm)
• PR interval
o Indicates AV conduction time. Duration time is 0.12 to 0.20 seconds
• QT interval
o Indicates repolarization time. General rule: duration is less than half the
preceding R-R interval

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The ECG paper
• Horizontally – One small box - 0.04 s – One large box - 0.20 s
• Vertically – One large box – 5 mm
• Every 3 seconds (15 large boxes) is marked by a vertical line. This helps when
calculating the heart
– Reminder: all rhythm strips shown here are 6 seconds in length.

Rhythm analysis
Step 1: Calculate Rate
• Method #1: Count the no: of “R” waves in a 6 second rhythm strip, then multiply by 10
• Method # 2: Count the number of large squares between two consecutive “R” waves
and divide 300 by the number of large squares or divide 1500 by the number of small
squares between two” R” waves
• Method # 3: Count the number of BIG squares between two consecutive “R” waves in
descending order as 300,150,100,75,60,50...

Step 2: Determine regularity

• Look at the R-R distances (using a caliper or markings on a pen or paper).
• Regular (are they equidistant apart)? Occasionally irregular? Regularly irregular?
Irregularly irregular?

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Step 3: Assess P waves
• Are there P waves?
• Do the P waves all look alike?
• Do the P waves occur at a regular rate?
• Is there one P wave before each QRS?

Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds.(3 - 5 small boxes)

Step 5: Determine QRS duration

Normal: 0.04 - 0.12 seconds. (1 - 3 small boxes)

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Normal sinus rhythm
Etiology: the electrical impulse is formed in the SA node and conducted normally.
This is the normal rhythm of the heart; other rhythms that do not conduct via the typical
pathway are called arrhythmias.

Rate 60 - 100 bpm

Regularity Regular
P waves Normal
PR interval 0.12 - 0.20 s
QRS duration0.04 - 0.12 s
Any deviation from before mentioned characteristics of Normal Sinus Rhythm is sinus
tachycardia, sinus bradycardia or an arrhythmia.

An Arrhythmia can arise from

• Sinus node : Sinus bradycardia, Sinus tachycardia
• Atrial cells : Premature atrial contractions, atrial flutter, atrial fibrillation
• AV junction : Paroxysmal supraventricular tachycardia, AV junctional blocks
• Ventricular cells : Premature Ventricular Contractions (PVCs), Ventricular Fibrillation,
Ventricular Tachycardia

ECG: 1

ECG: 1 :
• Sinus Bradycardia (Rate < 60 bpm)
• Cause: SA node is depolarizing slower than normal, impulse is conducted normally (i.e.
normal PR and QRS interval).

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ECG: 2

ECG: 2 : Sinus Tachycardia (Rate > 100 bpm)

• Cause: SA node is depolarizing faster than normal, impulse is conducted normally.
• Remember: Sinus tachycardia is a response to physical or psychological stress, not a
primary arrhythmia.

ECG: 3

ECG: 3 : Interpretation: NSR (Normal Sinus Rhythm) with Premature Atrial Contractions
• These ectopic beats originate in the atria (but not in the SA node), therefore the
contour of the P wave, the PR interval, and the timing are different than a normally
generated pulse from the SA node.
• Cause: Excitation of an atrial cell forms an impulse that is then conducted normally
through the AV node and ventricles.
• When an impulse originates anywhere in the atria (SA node, atrial cells, AV node,
Bundle of His) and then is conducted normally through the ventricles, the QRS will be
narrow (0.04 - 0.12 s).

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ECG: 4

ECG: 4
• Ectopic beats originate in the ventricles resulting in wide and bizarre QRS complexes.
• When there are more than 1 premature beats and look alike, they are called “uniform”.
When they look different, they are called “multiform”.
• Cause: One or more ventricular cells are depolarizing and the impulses are abnormally
conducting through the ventricles.
ECG: 5

ECG: 5
• No organized atrial depolarization, so no normal P waves (impulses are not originating
from the sinus node).
• Atrial activity is chaotic (resulting in an irregularly irregular rate).
• Cause: Recent theories suggest that it is due to multiple re-entrant wavelets conducted
between the R & L atria. Either way, impulses are formed in a totally unpredictable
fashion. The AV node allows some of the impulses to pass through at variable intervals
(so rhythm is irregularly irregular).

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ECG: 6

ECG: 6
• No P waves. Instead flutter waves (note “sawtooth” pattern) are formed at a rate of
250 - 350 bpm.
• Only some impulses conduct through the AV node (usually every other impulse).
• Cause: Reentrant pathway in the right atrium with every 2nd, 3rd or 4th impulse
generating a QRS (others are blocked in the AV node as the node repolarizes).

ECG: 7

ECG: 7
• The heart rate suddenly speeds up, often triggered by a PAC (not seen here) and the P
waves are lost.
• Cause: There are several types of PSVT but all originate above the ventricles (therefore
the QRS is narrow).
• Most common: Abnormal conduction in the AV node (reentrant circuit looping in the
AV node).

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ECG: 8

ECG: 8
• Impulse is originating in the ventricles (no P waves, wide QRS). There is a re-entrant
pathway looping in a ventricle (most common cause). Ventricular tachycardia can
sometimes generate enough cardiac output to produce a pulse; at other times no pulse
can be felt.
ECG: 9

ECG: 9
• Completely abnormal and chaotic fibrillatory waves
• The ventricular cells are excitable and depolarizing randomly
• Rapid drop in cardiac output and death occurs if not quickly reversed

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SIMPLE METHOD FOR THE DIAGNOSIS OF VENTRICULAR ARRYTHMIAS

AV NODAL BLOCKS

ECG: 10

ECG: 10 :
• PR Interval > 0.20 s
• Cause: Prolonged conduction delay in the AV node or Bundle of His.

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ECG: 11

ECG: 11
• PR interval progressively lengthens, and then the impulse is completely blocked (P
wave not followed by QRS).
• Cause: Each successive atrial impulse encounters a longer and longer delay in the AV
node until one impulse (usually the 3rd or 4th) fails to make it through the AV node.

ECG: 12

ECG: 12
• Occasional P waves are completely blocked (P wave not followed by QRS).
• Cause: Conduction is all or nothing (no prolongation of PR interval); typically block
occurs in the Bundle of His.

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ECG: 13

ECG: 13
• The P waves are completely blocked in the AV junction; QRS complexes originate
independently from below the junction.
• There is complete block of conduction in the AV junction, so the atria and ventricles
form impulses independently of each other. Without impulses from the atria, the
ventricles own intrinsic pacemaker kicks in at around 30 - 45 beats/minute.

SIMPLE METHOD FOR DIAGNOSING HEART BLOCKS

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How to diagnose MYOCARDIAL INFARCTION (MI)
• To diagnose a myocardial infarction you need to go beyond looking at a rhythm strip
and obtain a 12-Lead ECG.

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Why 12 leads for ECG?
• The 12-Lead ECG sees the heart from 12 different views.
• Therefore, the 12-Lead ECG helps you see what is happening in different portions of
the heart.
• The rhythm strip is only 1 of these 12 views.

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ST segment Elevation

• Elevation of the ST segment (greater than 1 small box) in 2 anatomically contiguous

leads is consistent with a myocardial infarction.

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Anterior Wall MI
• The anterior portion of the heart is best viewed using leads V1- V4.
• If you see changes in leads V1 - V4 that are consistent with a myocardial infarction,
• you can conclude that it is an anterior wall myocardial infarction.
• Now can you identify where the infarction is?

Yes, this person is having an acute anterior wall myocardial infarction

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Inferior Wall MI
• Leads II, III and aVF represent the inferior wall of the heart. This is an inferior MI. Note
the ST elevation in leads II, III and aVF

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Anterolateral MI
• This person’s MI involves both the anterior wall (V2-V4) and the lateral wall (V5-V6, I,
and aVL)!

Can there be an MI even without ST ELEVATION?

• Yes! This is called the Non ST elevation MI (NSTEMI)
• ST segment depression ≥ 1 mm in two or more leads in a patient with chest discomfort
and an abnormal troponin or CK-MB is diagnostic of non–ST segment elevation MI
(non–Q wave MI)

• Note the ST depression and T-wave inversion in leads V2-V6

• This patient had an elevation of cardiac enzymes

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ALGORITHM FOR DIAGNOSING MI

oOo-

Chapter Essence
In a Nutshell
7. .
Nursing Alerts
7. . Nursing alert
8. Do not delay in initiating treatment
9. Administer drugs promptly
10. Monitor continuously for complications
11. Detect for occurrence of arrhythmias and other complications
12. Provide complete bed rest till hemodynamically stable
13. Increase activity progressively
Nursing Management

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29. .
Trainer’s Pearls
7. .

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Chapter Outline
1. .
-oOo
AVPU Score
The AVPU scale (an acronym from "Alert,
Voice, Pain, Unresponsive") is a system by
which a health care professional can
measure and record their level of
consciousnessvi. It is a simplification of the
Glasgow Coma Scale, which assesses a
patient response in three measures: Eyes,
Voice and Motor skills. The AVPU scale
should be assessed using these three
identifiable traits, looking for the best
response of eachvii.
The AVPU scale has four possible outcomes
for recording (as opposed to the 13
possible outcomes on the Glasgow Coma
Scale). The assessor should always work
from best (A) to worst (U) to avoid
unnecessary tests on patients who are
clearly conscious. The four possible
recordable outcomes are:
• Alert: The patient is fully awake
(although not necessarily oriented).
This patient will have
spontaneously open eyes, will
respond to voice (although may be
confused) and will have bodily
motor function.
-
-oOo-
Chapter Essence
In a Nutshell
8. .
Nursing Alerts
14. .
Nursing Management
30. .
Trainer’s Pearls
8. .
Chapter
AVPU Score.
• Verbal: The patient makes some
kind of response when you talk to
them, which could be in any of the
three component measures of eyes,
voice or motor - e.g. patient's eyes
open on being asked "Are you OK?".
The response could be as little as a
grunt, moan, or slight move of a
limb when prompted by the voice of
the rescuer.
• Pain: The patient makes a response
on any of the three component
measures on the application of pain
stimulus, such as a central pain
stimulus like a sternal rub or a
peripheral stimulus such as
squeezing the fingers. A patient with
some level of consciousness (a fully
conscious patient would not require
a pain stimulus) may respond by
using their voice, moving their eyes,
or moving part of their body
(including abnormal posturing).
• Unresponsive: Sometimes seen
noted as 'Unconscious', this
outcome is recorded if the patient
does not give any eye, voice or
motor response to voice or pain.
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Glasgow Coma Scale (GCS)
Chapter Outline
1. .
-oOo-
Glasgow Coma Scale
Glasgow Coma Scale was described in 1974
by Graham Teasdale and Bryan Jennett viii
as a way to communicate about the level of
consciousness of patients with an acute
brain injury.
The findings using the scale guide initial
decision making and monitor trends in
responsiveness that are important in
signalling the need for new actions.
Eyes
• 4: Spontaneous Eye Opening
• 3: To sound : Opens Eyes When
Called
• 2: To pressure : Does not Open Eyes
When Called. Opens Only to
pressure
• 1: None : Does not Open Eyes Even
to Pressure (pain)
Verbal
• 5: Orientated : Normal oriented
Conversation
• 4: Confused : Talks Full Sentences,
but is not Fully Oriented
• 3: Words : Able to Form Words, But
cannot talk a meaningful sentence
• 2: Sounds : Makes only sounds. Not
able to make words
• 1: None : No Sound
• Endotracheal Tube is Indicated as
ET, Nasotracheal Tube as NT and
Tracheostomy as T
-oOo-
Chapter Essence
In a Nutshell
9. .
Nursing Alerts
Chapter
Motor
• 6: Obey commands : Moves as
instructed
• 5: Localising : Does not Obey
Commands, but Brings the
Extremeties to the site of Painful
stimulus and tries to remove the
painful stimulus
• 4: Normal flexion : is not able to
bring the Extremity to the site of
painful stimulus, but just flexes
• 3: Abnormal flexion : Decortication
• 2: Extension : Decerebration
• 1: None : No Motor Movements even
to painful stimulus
The Maximum Score is 15 and Minimum
Score is 3 (or 2ET)
The Scale is Written as E4V5M6 or E1V1M1
or E1VETM1 or E4V4M6 or E1VETM2 etc
Disadvantages of GCS
• Cannot Identify Spinal Injuries
Advantages of GCS
• Does not Require any Equipment to
Measure
• Least Ambigous when discussed
over phone
• Can be measured by any one with
minimal training
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15. .
Nursing Management
31. .
Trainer’s Pearls
9. .

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Chapter
Paediatric Glasgow Coma Scale
Chapter Outline
1. .

-oOo-
The Paediatric Glasgow Coma Scale (BrE)
(also known as Pediatric Glasgow Coma
Score (AmE) or simply PGCS) is the
equivalent of the Glasgow Coma Scale
(GCS) used to assess the level of
consciousness of child patients. As many of
the assessments for an adult patient would
not be appropriate for infants, the Glascow
Coma Scale was modified slightly to form
the PGCS. As with the GCS, the PGCS
comprises three tests: eye, verbal and
motor responses. The three values
separately as well as their sum are
considered. The lowest possible PGCS (the
sum) is 3 (deep coma or death) whilst the
highest is 15 (fully awake and aware
person). The pediatric GCS is commonly
used in emergency medical services.
Eyes
• 4: Spontaneous Eye Opening
• 3: To sound : Opens Eyes When
Called
• 2: To pressure : Does not Open Eyes
When Called. Opens Only to
pressure
• 1: None : Does not Open Eyes Even
to Pressure (pain)
Verbal
• 5: Smiles, oriented to sounds,
follows objects, interacts.
• 4: Cries but consolable,
inappropriate interactions.
• 3: Inconsistently inconsolable,
moaning.
• 2: Inconsolable, agitated.
• 1: None : No Sound
• Endotracheal Tube is Indicated as
ET, Nasotracheal Tube as NT and
Tracheostomy as T
Motor
• 6: 6. Infant moves spontaneously or
purposefully
• 5: Infant withdraws from touch
• 4: Infant withdraws from pain
• 3: Abnormal flexion : Decortication
• 2: Extension : Decerebration
• 1: None : No Motor Movements even
to painful stimulus

-oOo-

Chapter Essence
In a Nutshell
10. .
Nursing Alerts
16. .
Nursing Management
32. .
Trainer’s Pearls
10. .

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Chapter
Examination of Pupils
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
11. .
Nursing Alerts
17. .
Nursing Management
33. .
Trainer’s Pearls
11. .

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Chapter
Examination of Reflexes
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
12. .
Nursing Alerts
18. .
Nursing Management
34. .
Trainer’s Pearls
12. .

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Chapter
Neurological Examination
Chapter Outline
1. .

-oOo
D-Disability: Neurological status, • Primary brain injury results from
Consciousness, Focal Neurological the structural effect of the injury to
Deficit the brain.
• Prevention of secondary brain
• A rapid neurologic evaluation is injury by maintaining adequate
performed at the end of the primary oxygenation and perfusion are the
survey. main goals of initial management.
• This neurologic evaluation • Other Neurological Examination
establishes the patient’s Includes
o level of consciousness, o 1. History of
o pupillary size and reaction, ▪ i. Loss of
o lateralizing signs, and Consciousness
o spinal cord injury level. ▪ ii. Headache
• The GCS is a quick, simple method ▪ iii. Vomiting
for determining the level of ▪ iv. ENT Bleed
consciousness that is predictive of o 2. History Related to
patient outcome, particularly the Higher Mental Functions
best motor response. o 3. History Related to
• A decrease in the level of Cranial Nerves
consciousness may indicate o 4. History Related to
decreased cerebral oxygenation Motor Power
and/or perfusion, or it may be o 5. History Related to
caused by direct cerebral injury. Sensory System
• An altered level of consciousness o 6. History Related to
indicates the need for immediate Bladder and Bowel
reevaluation of the patient’s o 7. Examination of
oxygenation, ventilation, and Higher Mental Functions
perfusion status. with Mini Mental State
• Hypoglycemia and alcohol, Examination
narcotics, and other drugs also can o 8. Examination of Motor
alter the patient’s level of Power
consciousness. o 9. Examination of
• However, if these factors are Reflexes (Already seen in
excluded, changes in the level of previous chapter)
consciousness should be considered o 10. Examination of
to be of traumatic central nervous Sensory System
system origin until proven
otherwise.
-
-oOo-

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Chapter Essence
In a Nutshell
13. .
Nursing Alerts
19. .
Nursing Management
35. . Nursing Management
36. Initial Acute Care Management
37. Early treatment of stroke is recognized as a key factor in optimizing outcomes. Care may be
rendered in neurological intensive care unit or special acute care unit. The current
approved window to opportunity to use rt-PA is 0-3 hours after onset of ischemic stroke.
The goals of nursing management include:
38. • Maintenance of an adequate airway and oxygenation support to prevent hypoxia
39. • Control of fever
40. • Ongoing assessment of cardiac arrhythmia and cardiac ischemia / infarction
41. • Blood pressure management to maximize cerebral perfusion
42. • Glycemia management to maintain glucose less than 150mg/dl to decrease the risk of
43. cerebral edema and hemorrhage
44. • Prevention of complications such as aspiration pneumonia, nosocomial infections and
45. device related infections (urinary tract and intravascular line infections)
46. • Prevention of deep vein thrombosis and pulmonary embolism
47. • Fall prevention and patient safety
Trainer’s Pearls
13. .

398
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Chapter Outline
1. .
-oOo-
E-Exposure: To Check for Poisons,
Trauma
• The patient should be completely
undressed, usually by cutting off his
or her garments to facilitate a
thorough examination and
assessment. After the patient’s
clothing has been removed and the
assessment is completed, the
patient should be covered with
Chapter
Hyperthermia
warm blankets or an external
warming device to prevent
hypothermia in the trauma
receiving area.
• Intravenous fluids should be
warmed before being infused, and a
warm environment (i.e., room
temperature) should be maintained.
The patient’s body temperature is more
important than the comfort of the
healthcare providers
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-oOo-

Chapter Essence
In a Nutshell
14.
Nursing Alerts
20. Provide Adequate Nutrition and Fluids to meet the increased metabolic demands and
prevent dehyrdration

400
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Nursing Management
48. Reduce Physical activity to limit heat production, especially during the flush stage
49. Provide a tepid sponge bath to increase the heat loss through conduction
50. Provide dry clothing and bed linens
Trainer’s Pearls
14. .

401
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Chapter
Heat Stroke.
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
15. .
Nursing Alerts
21. .
Nursing Management

403
 - 404 -

51. .
Trainer’s Pearls
15. .

404
 - 405 -

Chapter
Log Rolling and Pelvic Binder
Chapter Outline
1. .

-oOo-
The Log Roll not be log-rolled, but should be lifted
The log-roll technique is used for carefully onto a board by four or more
moving a patient onto a backboard. It is rescuers. The scoop stretcher also could be
com-monly used because it is easy to used to move patients with unstable pelvic
perform with a minimum number of fractures onto the backboard. At least one
rescuers. As yet, no technique has been model of scoop stretcher can be used in
devised that maintains complete spinal place of a backboard
immobiliza-tion while moving a patient Pelvic binder
onto a backboard. Properly performed, the Pelvic Binder Application
log-roll technique will minimize movement Function of Pelvic Binder
of the spinal column as safely and 1. To splint the bony pelvis to
efficiently as any other technique for reduce haemorrhage from bone ends and
moving a patient onto the backboard. venous disruption.
The log-roll technique moves the 2. To reduce pain and
spinal column as a single unit with the movement during transfers.
head and pelvis. It can be performed on 3. To provide some integrity to
patients lying prone or supine. Using three the pelvis when operative packing of the
or more rescuers—controlled by the pelvis is necessary.
rescuer at the patient’s head—the patient 4. To provide stabilization of
(with her arms at her side) is rolled onto the pelvis until definitive stabilization can
her uninjured side, a board is slid be achieved.
underneath her, and the patient is rolled
faceup onto the board. The log-roll Universal Precaution
technique is then completed when the Indications – High risk mechanism
patient’s chest, pelvis, and head are with:
secured to the board. • Pelvic, low back or groin pain
The log-roll may be modified for and SBP < 90 mmHg or pediatric age
patients with painful arm, leg, and chest specific hypotension
wounds who need to be rolled onto their • Application
uninjured side. The side to which you turn • Remove clothing
the patient during the log-roll procedure is • Identify greater trochanters
not critical and can be changed in
situations in which you can only place the 1. Place sheet or binder under
backboard on one side of the patient. the patient with center at the level of the
The log-roll technique is useful for greater trochanter o Tighten per
most trauma patients, but for patients with manufacturer instruction. With sheet
an unstable fractured pelvis, rolling their binder, tighten by twisting and secure to
weight onto the pelvis could aggravate the maintain tension
injury. If the pelvic fracture appears stable, Assess for distal pulse before and
the log-roll should be carefully performed, after application
turning the patient onto the uninjured side Contraindications:
(if it can be identified). Patients with • Isolated neck of femur
obviously unstable pelvic fractures should fracture

405
 - 406 -
• Suspected traumatic hip 2. Hypotension/shock
dislocation associated with pelvic injury
3. Deformity, bruising or
Pelvic fractures are associated with swelling over bony prominences, pubis,
high risk mechanisms of injury, including: perineum or scrotum
Motor vehicle collisions – especially
if the patient was in the front seat with a 4. Leg length
head-on or there was a lateral impact on discrepancies/rotations
the patient side 5. Wounds over the pelvis,
Auto vs pedestrian accidents bleeding from the rectum, vagina or
Motorcycle collisions urethra
Fall from heights It is a device used to compression
Patients ≥ 65 have a greater the pelvis in those with a pelvic fracture in
likelihood of pelvic fractures even with low an effort to stop bleeding. They are
energy mechanism specifically recommended for open book
Possible signs and symptoms of a pelvic fractures and might not be useful in
pelvic fracture: those with lateral compression fractures.
A bed sheet may be used as well.
1. Any pain at pelvis or lower The device should be placed over the upper
back/groin/hips femurs specifically the greater trochanters.
o DO NOT rock or “spring” the It should only be used short term.
pelvis Complications can include skin ulceration
o Use scoop or multi-person lift
when moving

-oOo-

Chapter Essence
In a Nutshell
16. .

406
 - 407 -

Nursing Alerts
22. .
Nursing Management
52. .
Trainer’s Pearls
16. .

407
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Chapter Outline
1. .
-oOo-
Resuscitation
As being stressed again and again,
Resuscitation is a part and parcel of
primary survey and again follows the same
ABCDE Pattern
Management of Pain
Nursing Management
Assessing- pain history, location,
pain intensity with pain scale, pattern,
precipitating factors, alleviating factors,
associated symptoms, effect on daily
activities, coping resources, affective
response. The nurse must also distinguish
whether it is acute or chronic pain. The
nurse must acknowledge and accept the
patients’ discomfort caused by pain, must
reduce the misconceptions about the pain,
reduce fear and prevent pain.
Pharmacological Management
Mild Pain
Paracetamol (acetaminophen) or an
NSAID such as aspirin/ibuprofen. NSAID’s
have analgesic, anti-pyretic and anti-
inflammatory properties. The anti
inflammatory effect relieves the pain by
interfering with cyclooxygenase.
Mild-Moderate pain
Chapter
Management of Pain
Paracetamol, an NSAID and/or
paracetamol in a combination product with
a weak opioid such as hydrocodone, may
provide greater relief that t heir separate
use. Also combination of opioid with
acetaminophen can be frequently used.
Moderate-Severe pain
Certain pain medications may work
better for acute pain, others for chronic
pain; hence it is important to distinguish
the duration of the pain. Drugs such as
morphine, fentanyl, pethdidine,
pentazocine, amitriptyline can be
considered as per the nature of the pain.
Patient has to be monitored throughout for
the adverse effect of the medication.
Non-Pharmacological Management
This category of pain management includes
the measures without the use of any drugs.
This method utilizes way to alter thoughts
and focus concentration to better manage
and reduce pain. Methods of non-
pharmacological pain include:- Bed rest,
manipulation and mobilization, traction,
therapeutic modalities, transcutaneous
electrical nerve stimulation, superficial
heat, cryotherapy, exercise etc…
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-oOo-

Chapter Essence
In a Nutshell
17. .
Nursing Alerts
23. . Nursing responsibilities for managing pain
24. The goal of pain management is to eliminate the cause of pain, provide analgesia, or both.
Avoid assuming that because a resident cannot express or respond to pain that it does not
exist. Manage pain by eliminating or controlling the source. Provide analgesia as needed
and appropriate.Nursing responsibilities for assessing, managing, and evaluating
effectiveness of pain management include the following:
25. Determining the nature of the pain and its impact on the resident
26. Identifying factors that affect the resident’s perception and expression of pain
27. Determining when to administer analgesics
28. Deciding which analgesic to administer, if more than one is ordered
29. Determining the dose of the analgesic medication to administer, if a range is
prescribed
30. Evaluating the effectiveness of the analgesic
31. Assessing for and managing side effects of the medication
32. Determining why the analgesic was ineffective, if applicable
33. Determining the need to change the dose, timing, or medication and reporting this
information to the healthcare provider
34. Using nursing interventions to promote comfort and relieve pain
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35. Making sure the plan of care describes pain assessment and management
36. Documenting pain assessment and intervention noted herein to reflect use of the
nursing process
37. Acute pain management:
Nursing Management
53. . Nursing Interventions Rationale
54. Perform a comprehensive assessment. Assess location, characteristics, onset, duration,
frequency, quality and severity of pain. Assessment is the first step in managing pain.
It helps ensure that the patient receives effective pain relief.
55. Observe for nonverbal indicators of pain: moaning, guarding, crying, facial grimace.
Some patients may deny the existence of pain. These behaviors can help with
proper evaluation of pain.
56. Accept patient’s description of pain. Pain is highly subjective.
57. Obtain vital signs. Vital signs are usually affected when pain is present.
58. Assess the client’s current use of medications. Aids in planning and in obtaining
medication history.
59. Anticipate the need for pain management. Early and timely intervention is key to effective
pain management. It can even reduce the total amount of analgesia required.
60. Provide a quiet environment. Additional stressors can intensify patient’s perception
and tolerance of pain.
61. Use nonpharmacological pain relief methods (relaxation exercises, breathing exercises,
music therapy). Works by increasing the release of endorphins, boosting the
therapeutic effects of pain relief medications.
62. Provide optimal pain relief by administering prescribed pain relief medication. Various
types of pain requires different analgesic approaches. Some responds well to non-opioid
pain relievers while others demand a combination of non-opioid and low dose opioid.
63. Review patient’s medication records and flow sheet. It helps determine the
effectiveness of the pain control measures. If the patient demands pain medications more
frequently, a higher dose may be needed.
64. Document patient’s response to pain management. It helps the entire healthcare team
evaluate their pain management strategy.
65.
66. Chronic Pain management:
67. Nursing Interventions Rationale
68. Perform a comprehensive assessment. Assess location, characteristics, onset, duration,
frequency, quality and severity of pain. Assessment is the first step in managing pain.
It helps ensure that the patient receives effective pain relief.
69. Check current and past analgesic/narcotic drug use. It helps obtain a medication history.
70. Review the patient’s expectation of pain relief. It’s possible that pain may not be
completely resolved but it can be lessened significantly.
71. Encourage patient to use breathing techniques and positive affirmations. This helps the
patient achieve generalized relaxation which aids in reduced perception of pain.
72. Explore the patient’s need for medications from the three classes of analgesics: NSAIDS,
opioids and nonopioids. Combinations of analgesics may enhance pain relief.
73. As much as possible, use tranquilizers, narcotics, and analgesics sparingly. These
medications promote addiction and can cause sleep disturbance.
74. Encourage use of nonpharmacological interventions (massage, guided imagergy, breathing
techniques). They help reinforce pharmacological interventions.
75. Determine the patient’s appetite, bowel elimination, and ability to rest and sleep.

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Side effects should be monitored and managed accordingly.

76. Evaluate effectiveness of pain medications and ask to decrease or increase dose and
frequency as necessary. Medications should be adjusted to achieve optimum pain
relief without causing severe adverse effects.
77.
78.
Trainer’s Pearls
17. .

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Chapter
Basic and Advanced Airways.
Chapter Outline
1. .

-oOo-
Opening up and maintaining an • Definitive airway (Cuffed, Secured
obstructed airway may require one or endotracheal tube)
more of the following measures: • Surgical airway
• Physical manoeuvres – like head
tilt-chin lift or jaw thrust Wide Bored Suction
• Suctioning – to remove debris and • First and Foremost, the Airway is
foreign bodies cleared with a wide bored suction
• Positioning and the secretions, and blood (if
• Airway adjuncts any) are removed.
• Endotracheal intubation
Head Tilt / Chin lift and Jaw thrust
Airway – Establishing Patent airway manoeuvre
with c-spine protection • The two most common methods for
GOAL : The Aim is to have Room Air opening the airway are the head-
Oxygen Saturation of 100 % and if that is tilt/chin-lift and jaw-thrust
not possible 100 % SpO2 with Oxygen maneuvers.
Supplementation
Head Tilt / Jaw Thrust
As well, immobilization of the cervical Chin Lift
spine is the accepted standard of care to Advantages Easy to do Can be
prevent secondary neurologic injury. The used in
most effective device for this purpose is the Case of
halo vest although it tends to be Cervical
inappropriate in the emergency setting. Spine
The most practical apparatus is a Injury
combination of a hard collar and sandbags Disadvantages Dangerous is Needs
on opposite sides of the head. Tape is then Patient has Training
extended from one side of the spine board Cervical
over the forehead of the patient to the Spine Injury
opposite side of the board. This provides
near complete cessation of movement. On Head Tilt / Chin Lift Manoeuvre
its own, a hard collar provides only • While the head-tilt/chin-lift is the
moderate protection and a soft collar offers preferred method, it can be
minimal benefit. dangerous to use on a patient who
may have a cervical spine injury.
STEPS : • To perform the head-tilt maneuver,
The following steps are to be followed approach the patient from the side
• Clear the airway using wide bore and place the palm of one hand on
suction the patient's forehead and push
• Chin lift / Jaw thrust manoeuvre down gently, rolling the patient's
• Oropharyngeal / nasopharyngeal head towards the top. Then, using
airway

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the fingers of your free hand, lightly
lift the chin even further up.
• The International Liaison
Committee on Resuscitation’s
"Treatment Recommendation"
under "Opening the Airway" says,
"Rescuers should open the airway
using the head tilt–chin lift
maneuver."
Oropharyngeal / nasopharyngeal
airway
Oropharyngeal Airway
Jaw thrust manoeuvre
• The jaw-thrust maneuver is a first
aid and medical procedure used to
prevent the tongue from obstructing
the upper airways.
• The maneuver is used on a supine
patient.
• It is performed by placing the index
and middle fingers to physically
push the posterior aspects of the
mandible upwards while their
thumbs push down on the chin to
open the mouth.
• When the mandible is displaced
forward, it pulls the tongue forward
and prevents it from obstructing the
entrance to the trachea.
• Traditionally, the jaw-thrust
maneuver has been considered the
better alternative (rather than the
head-tilt/chin-lift maneuver) when
a first aider suspects that the
patient may have a spinal injury
(especially one to the neck portion
of the spine).
• If the patient is in danger of
pulmonary aspiration, he or she
should be placed in the recovery
position, or advanced airway
management should be used.
• An oropharyngeal airway (also
known as an oral airway, OPA or
Guedel pattern airway) is a medical
device called an airway adjunct
used to maintain or open a patient's
airway. It does this by preventing
the tongue from covering the
epiglottis, which could prevent the
person from breathing. When a
person becomes unconscious, the
muscles in their jaw relax and allow
the tongue to obstruct the airway
• Oropharyngeal airways come in a
variety of sizes, from infant to adult,
and are used commonly in pre-
hospital emergency care and for
short term airway management
post anaesthetic or when manual
methods are inadequate to maintain
an open airway.
• This piece of equipment is utilized
when tracheal intubation is either
not available, not advisable or the
problem is of short term duration.
o Lifts the tongue off the
posterior pharyngeal wall to
prevent airway obstruction
o bite block
o assist oropharyngeal
suctioning
o promotes moulding of the
face of a mask for manual
ventilation
• Oropharyngeal airways are
indicated only in unconscious
people, because of the likelihood
that the device would stimulate a
gag reflex in conscious or semi-
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conscious persons. This could result
in vomit and potentially lead to an
obstructed airway. Nasopharyngeal
airways are mostly used instead as
they do not stimulate a gag reflex.
• In general, oropharyngeal airways
need to be sized and inserted
correctly to maximize effectiveness
and minimize possible
complications, such as oral trauma.
• Parts:
o flange to prevent
overinsertion
o reinforced bite section
o curved body to conform over
tongue/palate
o tubular air channel
• Sizes:
o equal to length in cm
o colour coded bite portions
can aid easy size
identification (children – 00,
1, 2; adults – 4, 5, 6)
o sized by measuring from the
center of the mouth between
the first incisors to the angle
of the mandible in an adult
• The correct size OPA is chosen by
measuring from the first incisors to
the angle of the jaw. The airway is
then inserted into the person's
mouth upside down. Once contact is
made with the back of the throat,
the airway is rotated 180 degrees,
allowing for easy insertion, and
assuring that the tongue is secured.
An alternative method for insertion,
the method that is recommended
for OPA use in children and infants,
involves holding the tongue forward
with a tongue depressor and
inserting the airway right side up.
• METHOD OF INSERTION/ USE
o Children – insert directly
over the tongue ideally with
aid of a tongue depressor (no
twisting through 180
degrees)
o Adults – rotate 180 degrees
from concave upwards
position as it is inserted over
the tongue
o Lubricant may aid insertion
o The device is removed when
the person regains swallow
reflex and can protect their
own airway, or it is
substituted for an advanced
airway. It is removed simply
by pulling on it without
rotation.
• Use of an OPA does not remove the
need for the recovery position and
ongoing assessment of the airway
and it does not prevent obstruction
by liquids (blood, saliva, food,
cerebrospinal fluid) or the closing of
the glottis. It can, however, facilitate
ventilation during CPR
(cardiopulmonary resuscitation)
and for persons with a large tongue.
• The main risks of its use are:
o if the person has a gag reflex,
they may vomit
o when it is too large, it can
close the glottis and thus
close the airway
o improper sizing can cause
bleeding in the airway
Nasopharyngeal Airway
• Nasopharyngeal airway, also known
as an NPA, nasal trumpet (because
of its flared end), or nose hose, a
type of airway adjunct, is a tube that
is designed to be inserted into the
nasal passageway to secure an open
airway. When a patient becomes
unconscious, the muscles in the jaw
commonly relax and can allow the
tongue to slide back and obstruct
the airway. This makes airway
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management necessary, and an NPA
is one of the available tools. The
purpose of the flared end is to
prevent the device from becoming
lost inside the patient's nose.
• Sizes : As with other catheters, NPAs
are measured using the French
catheter scale, but sizes are usually
also quoted in millimeters. Typical
sizes include: 6.5 mm/28FR, 7.0
mm/30FR, 7.5 mm/32FR, 8.0
mm/34FR, and 8.5 mm/36FR
• Indications
o where an artificial form of
airway maintenance is
necessary, but tracheal
intubation is impossible,
inadvisable, or outside the
practitioner's scope of
practice.
o An NPA is often used in
conscious patients where an
oropharyngeal airway would
trigger the gag reflex.
• Contraindications
o Nasal pharyngeal airways
are not recommended for
patients with possible head
injury.
• Insertion
o The correct size airway is
chosen by measuring the
device on the patient: the
device should reach from the
patient's nostril to the
earlobe or the angle of the
jaw. The outside of the tube
is lubricated with a water-
based lubricant so that it
enters the nose more easily.
The device is inserted until
the flared end rests against
the nostril. Some tubes
contain a safety pin to
prevent inserting the tube
too deeply. Care must be
taken to ensure the pin does
not stick into the nostril. In
the event that a pin is not
available, you may also stop
insertion just short of the
natural gag reflex and tape
the remaining exposed
portion of the NPA to the
surrounding facial tissue.
Definitive airway (Cuffed, Secured
endotracheal tube)
If Airways cannot be secured with the
methods mentioned above, Intubation is
needed
• Rapid Sequence of Intubation (RSI)
is the standard or care in emergency
airway management for intubations
not anticipated to be difficult
• RSI is virtually simultaneous
administration of a sedative and a
neuromuscular blocking agent to
render a patient rapidly
unconscious and flaccid in order to
facilitate urgent endotracheal
intubation and to minimize the risk
of aspiration
• RSI Protocol for Hemodynamically
Stable Patient
o Preoxygenate with 100 %
Oxygen
o Midazolam 5mg
(0.1mg/KBW)
o Fentanyl upto 100 μg (2
μg/KBW)
o SuccinylCholine 100 mg
(2mg/KBW)
o Wait for 60 seconds and then
intubate
• RSI Protocol for Hemodynamically
unstable Patient
o Preoxygenate with 100 %
Oxygen
o Ketamie 100 mg (1-2
mg/KBW)
o SuccinylCholine 100 mg
(2mg/KBW)
o Wait for 60 seconds and then
intubate
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 - 417 -
• Midazolam and Fentanyl can cause
hypotension and hence should be
avoided in hemodynamically
unstable patients
• SCh induces Rapid, Complete and
Predictable Paralysis with
Spontaneous Recovery in about 5
minutes. But, if can cause Potassium
release from muscles and hence
dangerous hyperkalemia, especially
in those with extensive burns and
soft tissues injuries. It is imperative
to Either Avoid SCh or Check K +
levels before using SCh with the
following conditions
o Known Case of CKD
o Extensive Burns (Can be
given if patient presents
within 24 hours)
o Spinal Shock after 24 hours
• If SCh is absolutely contraindicated
in hemodynamically unstable
patients, a small dose of midazolam
(2mg) can be given during RSI
Difficult Intubation
If Intubation is not possible, The plans for
Alternate Airway are considered. They are
1. Laryngeal Mask Airway
2. Intubating Laryngeal Mask Airway
3. Surgical Airway
Laryngeal Mask Airway
Intubating laryngeal Mask Airway
• The Laryngeal Mask Airway has
been developed further as
intubating Laryngeal Mask Airway
• The Steps are
a. Preoxygenation
b. Induction with Fentanyl 1
microgram / KBW and
Propofol 3 mg / KBW
4.
Surgical airway
If Intubation is not possible, Surgical
Airway can be done.
The inability to intubate the trachea is a
clear indication for an alternate airway
plan, including laryngeal mask airway,
intubating laryngeal mask airway, or a
surgical airway. A surgical airway (i.e.,
cricothyroidotomy or tracheostomy) is
established when edema of the glottis,
fracture of the larynx, or severe
oropharyngeal hemorrhage obstructs the
airway or an endotracheal tube cannot be
placed through the vocal cords. A surgical
cricothyroidotomy is preferable to a
tracheostomy for most patients who
require establishment of an emergency
surgical airway, because it is easier to
perform, associated with less bleeding, and
requires less time to perform than an
emergency tracheostomy.
Needle- Cricothyroidotomy Needle
cricothyroidotomy involves insertion of a
needle through the cricothyroid membrane
or into the trachea in an emergency
situation to provide oxygen on a short-
term basis until a definitive airway can be
placed. Needle cricothyroidotomy can
provide temporary, supplemental
oxygenation so that intubation can be
accomplished on an urgent rather than an
emergent basis. The jet insufflation
technique is performed by placing a large-
caliber plastic cannula, 12- to 14-gauge for
adults, and 16- to 18-gauge in children,
through the cricothyroid membrane into
the trachea below the level of the
obstruction
The cannula is then connected to oxygen at
15 L/min (40 to 50 psi) with a Y-connector
or a side hole cut in the tubing between the
oxygen source and the plastic cannula.
Intermittent insufflation, 1 second on and 4
seconds off, can then be achieved by
placing the thumb over the open end of the
Y-connector or the side hole. The patient
can be adequately oxygenated for 30 to 45
minutes using this technique, and only
patients with normal pulmonary function
who do not have a significant chest injury
may be oxygenated in this
manner
During the 4 seconds that the oxygen is not
being delivered under pressure, some
417
 - 418 -
exhalation occurs. Because of the
inadequate exhalation, CO2 slowly
accumulates, limiting the use of this
technique, especially in patients with head
injuries.
Jet insufflation must be used with caution
when complete foreign-body obstruction of
the glottic area is suspected. Although high
pressure can expel the impacted material
into the hypopharynx, where it can be
removed readily, significant barotrauma
can occur, including pulmonary rupture
with tension pneumothorax. Therefore,
particular attention must be paid to
effective airflow, and low flow rates (5 to 7
L/min) should be used when persistent
glottic obstruction is present.
The inability to intubate a patient
expediently, provide a temporary airway
with a supraglottic device, or establish a
surgical airway results in hypoxia and
patient deterioration. Remember
that performing a needle
cricothyroidotomy with jet insufflation
can provide the time necessary to establish
a definitive airway.
Surgical cricothyroidotomy is performed
by making a skin incision that extends
through the cricothyroid membrane. A
curved hemostat may be inserted to dilate
the opening, and a small endotracheal tube
or tracheostomy tube (preferably 5 to 7
mm OD) can be inserted.
When an endotracheal tube is used, the
cervical collar can be reapplied. It is
possible for the endotracheal tube to
become malpositioned and therefore easily
advanced into a bronchus. Care must be
taken, especially with children, to avoid
damage to the cricoid cartilage, which is
the only circumferential support for the
upper trachea. Therefore, surgical
cricothyroidotomy is not recommended for
children under 12 years of age.
Tracheostomy
1. Assemble the necessary Equipment
(tracheostomy tray, tube, suture,
cuffed disposable tracheostomy
tube)
2. Place the patient supine with the
next extended
3. Surgically prepare and anaesthetize
the area locally
4. Make a transverse skin incision over
the lower nect over the trachea –
preferably below the second
tracheal ring
5. Incise the deep cervical fascia,
retract the strap muscles laterally
6. Expose the trachea
7. beware of the thyroid isthmus,
retract is superiorly, ligate any
vessels carefully
8. Incise the tracheal cartilate after
confirming by aspiration of air,
removing a cuff of the trache
9. Insert a cuffed tracheostomy tube
10. Inflate the cuff and ventilate the
patient
11. Close the incision
12. Secure the tube to prevent
dislodgement
In recent years, percutaneous
tracheostomy has been reported as an
alternative to open tracheostomy. This is
not a safe procedure in the acute trauma
situation, because the patient’s neck must
be hyperextended to properly position the
head to perform the procedure safely.
Percutaneous tracheostomy requires the
use of a heavy guidewire and sharp dilator,
or a guidewire and multiple or single large-
bore dilators. This procedure can be
dangerous and time-consuming, depending
on the type of equipment used.
In any suspected caseed injury
• Airway with cervical spine control
o Upper airway (above vocal cords)
managed adjunctively with chin lift/jaw
thrust, suctioning, oral airway,
nasopharyngeal airway, and laryngeal
mask airway. The most common cause of
airway obstruction in the unconscious
patient is the tongue.
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o Lower airway managed definitively  Foreign bodies, facial /
with a cuffed tube in the trachea mandibular / tacheal /
(orotracheal intubation, nasotracheal larygeal fractures.
intubation, or surgical airway—  Management:
cricothyroidotomy)  Chin lift / jaw thrust
o Assume cervical spine injury in maneuver
patients sustaining any blunt injury or  Clear the airway of FB
penetrating injury above the chest.
 Insert an orotracheal /
o Intubation is indicated for airway
nasopharyngeal airway
protection (GCS < 9; severe maxillofacial
 Establish a definitive airway
fractures; laryngeal or tracheal injury;
1. Orotracheal / nasotracheal
evolving airway loss with neck hematoma
intubation
or inhalation injury) and as a conduit for
2. Surgical cricothyroidotomy
ventilation (apnea, respiratory distress--
tachypnea >30, hypoxia/hypercarbia).  Jet insufflation
 Maintain the cervical spine in a
Indications For Definite Airway neutral position with manual
Need for Need for immobilization as necessary
Airway Ventilation when establishing an airway
Protection  Immobilization of the c-spine
Unconscious Apnea with appropriate devices after
GCS ≤ 8 Neuromuscular establishing an airway.
paralysis  Important Notes:
Unconscious  NE does not exclude a
Severe Inadequate cervical spine injury
maxillofacial respiratory effort  Assume a cervical spine
fractures Tachypnea injury in any patient with
Hypoxia multisystem trauma,
Hypercarbia especially with an altered
Cyanosis level of consciousness or a
Risk for Severe closed blunt injury above the clavicle
aspiration head injury with  Pitfalls:
Bleeding need for  Equipment failure
Vomiting hyperventilation  Cannot be intubated after
Risk for paralysis and accompanied
obstruction with difficult surgical airway
 Assessment:  Unknown laryngeal fracture /
 Ascertain patency incomplete airway
 Rapidly assess for airway transection.
obstruction

-oOo-

Chapter Essence
In a Nutshell
18. .
Nursing Alerts
38. .
Nursing Management

419
 - 420 -

79. . Nursing Interventions

80. ________________________________________
81. The following are the therapeutic nursing interventions for Ineffective Airway Clearance:
82. Interventions Rationales
83. Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath,
hold for 2 seconds, and cough two or three times in succession). The most convenient
way to remove most secretions is coughing. So it is necessary to assist the patient during
this activity. Deep breathing, on the other hand, promotes oxygenation before controlled
coughing.
84. Educate the patient in the following:
85. • Optimal positioning (sitting position)
86. • Use of pillow or hand splints when coughing
87. • Use of abdominal muscles for more forceful cough
88. • Use of quad and huff techniques
89. • Use of incentive spirometry
90. • Importance of ambulation and frequent position changes The proper sitting
position and splinting of the abdomen promote effective coughing by increasing abdominal
pressure and upward diaphragmatic movement. Controlled coughing methods help
mobilize secretions from smaller airways to larger airways because the coughing is done at
varying times. Ambulation promotes lung expansion, mobilizes secretions, and lessens
atelectasis.
91. Position the patient upright if tolerated. Regularly check the patient’s position to prevent
sliding down in bed. Upright position limits abdominal contents from pushing upward and
inhibiting lung expansion. This position promotes better lung expansion and improved air
exchange.
92. Perform nasotracheal suctioning as necessary, especially if cough is ineffective.
Suctioning is needed when patients are unable to cough out secretions properly
due to weakness, thick mucus plugs, or excessive or tenacious mucus production.
93. • Explain procedure to patient This procedure can also stimulate a cough. Frequency
of suctioning should be based on patient’s present condition, not on preset routine, such
as every 2 hours. Over suctioning can cause hypoxia and injury to bronchial and lung tissue.
94. • Use well-lubricated soft catheters Using well-lubricated catheters reduces
irritation and prevents trauma to mucous membranes.
95. • Use curved-tip catheters and head positioning (if not contraindicated). These
facilitates secretion removal; from a specific side of the lung (left or right).
96. • Instruct the patient to take several deep breaths before and after nasotracheal
suctioning procedure and use supplemental oxygen, as appropriate.
Hyperoxygenation before, during, and after suctioning prevents hypoxia.
97. • Stop suctioning and provide supplemental oxygen if the patient experiences
bradycardia, an increase in ventricular ectopy, and/or significant desaturation. Oxygen
therapy is recommended to improve oxygen saturation and reduce possible complications.
98. • Use universal precautions: gloves, goggles, and mask, as appropriate. As
protection against the blood-related modes of transmission, health care workers should
use universal precautions when coming in contact with the blood of all patients, or bodily
fluids containing blood.
99. Maintain humidified oxygen as prescribed. Increasing humidity of inspired air will reduce
thickness of secretions and aid their removal.
100. Encourage patient to increase fluid intake to 3 liters per day within the limits of
cardiac reserve and renal function. Fluids help minimize mucosal drying and maximize

420
 - 421 -

ciliary action to move secretions.

101. Give medications as prescribed, such as antibiotics, mucolytic agents,
bronchodilators, expectorants, noting effectiveness and side effects. A variety of
medications are prepared to manage specific problems. Most promote clearance of airway
secretions and may reduce airway resistance.
102. Coordinate with a respiratory therapist for chest physiotherapy and nebulizer
management as indicated. Chest physiotherapy includes the techniques of postural
drainage and chest percussion to mobilize secretions from smaller airways that cannot be
eliminated by means of coughing or suctioning.
103. Provide postural drainage, percussion, and vibration as ordered. Chest physical
therapy helps mobilize bronchial secretions; it should be used only when prescribed
because it can cause harm if patient has underlying conditions such as cardiac disease or
increased intracranial pressure.
104. Provide oral care every 4 hours. Oral care freshens the mouth after respiratory
secretions have been expectorated.
105. Pace activities especially for patients with reduced energy. Maintain planned rest
periods. Promote energy-conservation methods. Fatigue is a contributing factor to
ineffective coughing. Effective coughing requires enough energy and may consume an
extra effort to the patient.
106. For acute problems, resort in bronchoscopy.Bronchoscopy acquires lavage samples
for culture and sensitivity, and eliminates mucous plugs.
107. If secretions cannot be cleared, consider the need for an intubation. Once
intubated: Readiness for an emergency helps prevent further complications. Intubation
may be needed to facilitate removal of tenacious and copious amounts of secretions and
provide source for augmenting oxygenation.
108. • Start suctioning airway as determined by the existence of adventitious
sounds. Suctioning clears mucus from the tube and is essential for proper breathing.
109. • Use sterile saline solution for the period of suctioning This promotes
elimination of viscous secretions.
110. Perform cardiopulmonary resuscitation (CPR) maneuvers for patients with
complete airway obstruction. This is used to relieve airway obstructions and to sustain life
until definitive treatment can be provided.
111. Educate patient on coughing, deep breathing, and splinting techniques. Patient
will understand the underlying principle and proper techniques to keep the airway clear of
secretions.
112. Provide patient understanding about the proper use of prescribed medications and
inhalers. Understanding prescriptions promote safe and effective medication
administration.
113. Consider the need of humidifiers in home care setting. This facilitates
liquefaction of secretions.
114. Instruct patient about the need for adequate fluid intake even after hospital
discharge. Hydration facilitates easy elimination of secretions.
115. Educate caregivers in suctioning techniques. Provide opportunity for return
demonstration. Modify techniques for home setting. This promotes safe and
effective removal of secretions from the airway.
116. Consider verbalization of feelings. Recognize reality of situation. Anxiety adds to
oxygen demand, and hypoxemia potentiates respiratory distress or cardiac symptoms,
which in turn increases anxiety.
117. Explain further the effects of smoking, including secondhand smoke. Chemical

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irritants and allergens can increase mucus production and bronchospasm.

118. Refer to the pulmonary clinical nurse specialist, home health nurse, or respiratory
therapist as indicated. Consultants may be helpful in ensuring that proper
treatments are met.
Trainer’s Pearls
18. .

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Chapter
Manual Inline Stabilisation.
Chapter Outline
1. .

-oOo-
Manual Inline Stabilisation

Maintenance of immobilization of the injured spine is of paramount importance. If a cervical

spine fracture is suspected, immobilization or manual inline stabilization of the neck is
necessary before the patient is moved

-oOo-

Chapter Essence
In a Nutshell
19. .
Nursing Alerts
39. .
Nursing Management

423
 - 424 -

119. Nursing alert

120. Even brief periods of hypo-perfusion can significantly increase mortality and
decrease recovery of function from spinal cord insult. Therefore, avoid hypotension and
hypoxia at all stages of patient care.
121. Assume that all trauma victims have spinal column/cord injuries until proven
otherwise. No spinal segment can be mobilized until it has been specifically cleared..
Trainer’s Pearls
19. .

424
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Chapter
Cervical Spine Stabilisation
Chapter Outline
1. .

-oOo-
Cervical spine stabilization is a phrase applied to a variety of different techniques used in the
cervical spine (the neck) to reduce or eliminate instability. Instability can be caused by
degenerative disc diseases, injury, trauma, herniated discs and more.

-oOo-

Chapter Essence
In a Nutshell
20. .
Nursing Alerts
40. .
Nursing Management
122. .
Trainer’s Pearls
20. .

425
 - 427 -

Chapter
Helmet Removal.
Chapter Outline
1. .

-oOo-

-oOo-

427
 - 428 -

Chapter Essence
In a Nutshell
21. .
Nursing Alerts
41. .
Nursing Management
123. .
Trainer’s Pearls
21. .

428
 - 429 -

Chapter
Head Tilt – Chin Lift – Jaw Thrust.
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
22. .
Nursing Alerts
42. .
Nursing Management
124. .
Trainer’s Pearls
22. .

429
 - 431 -

Chapter
.
Chapter Outline
1. .

-oOo-
Procedure 1 : Suction
Aim: To remove secretions from tracheo-bronchial tree.

Equipments Needed
1. Suction Apparatus
2. Central Suction (Vaccum Line)
Consumables Needed
1. Suction Cannula
2.
Drugs Needed
1. Sodium Bicarbonate
2. Normal Saline

Step Step Equipments Needed Consumables Needed Drugs

No Name Needed
1. High wall suction 1. Suction catheter 1.
of appropriate
size
2. Single sterile
glove
3. Pulse oximeter
to assess O2
saturation
(SaO2)
4. Goggles / Face
Shields
2. Wash hands. Aseptic technique 5. Soap 2.
will be used when suctioning. 6. Betadine

3. 7. 3.

4. 8. 4.

431
 - 432 -

5. Turn suction on, ensure that it is 9. 5.

functioning.
6. Pre oxygenate patient with 100%
oxygen for at least 2 minutes
before suctioning
7. Open sterile catheter.
8. Ensure that suction pressure does
not exceed 150mm Hg
9. Insert suction catheter into
tracheostomy or ET tube without
applying suction. Insert catheter
until the patient coughs o
resistance is felt and withdraw
slightly.
10. Apply suction whilst withdrawing
catheter. Suctioning should be for
no longer than 15 seconds per
time.
11. Curl suction catheter up in your
gloved hand and remove glove
keeping catheter inside for
disposal.
12. Suction oropharynx with Yankeur
sucker/suction catheter. The
patient should be monitored by
oximetry for O2 saturation
throughout the procedure. At the
end of procedure discard suction
13. catheter in trash bin. Rinse
suction tubing with water.Check
ventilator observations and air
entry to ensure adequate
ventilation.
14. Observe patient’s respiratory
status.
15. Document procedure and record
amount and type of secretions.

432
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433
 - 434 -
-oOo-

Chapter Essence
In a Nutshell
23. .
Nursing Alerts
43. . Complications:
44. o Infection
45. o Trauma to tracheo-bronchial mucosa
46. o Hypoxia
47. o Aggravation of pulmonary oedema
48. o Raised intracranial pressure
49. o Decreased lung compliance due to disconnection from ventilator and loss of PEEP
Nursing Management
125. . Points to Remember
126. o Clinical assessment of the patient through chest auscultation and the
previous amounts of secretion obtained through suctioning should guide our practice.
127. o For instance if the patient has copious amounts of secretions every 2nd hour
then they require more frequent suctioning.
128. o If the patient have scanty secretions every 2nd hour then the patient does
not require 2nd hourly suctioning.
129. o Besides auscultation and secretion quantity there are contraindications for
routine suctioning including patients with raised ICP, patients in Pulmonary oedema and
patients on 100% oxygen and requiring PEEP level > 10cmsH2O to maintain acceptable
SaO2 levels. Suctioning frequency should be judged according acceptable SaO2 monitoring
130. o Report any difficulty in inserting the suction catheter
131. o Report any alteration in the colour of sputum - eg from white to green or
blood stained/frothy.
Trainer’s Pearls
23. .

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Chapter
Nasal Prongs, Simple Face Mask, Venturi Mask, Non
Re Breathing Mask
Chapter Outline
1. .

-oOo-
1. Nasal Prongs
The nasal cannula is classified as a low-
flow oxygen administration system
designed to add oxygen to room air when
the patient inspires. The ultimate inspired
oxygen concentration is determined by the
oxygen flow rate through the cannula and
by how deeply and rapidly the patient
breathes (minute ventilation), but the nasal
cannula can provide up to 44% oxygen as
inspired air mixes with room air.
Increasing the oxygen flow by 1 L/min
(starting with 1 L/min and limited to about
6 L/min) will increase the inspired oxygen
concentration by approximately 4%.
Indication
• Patients with arterial oxyhemoglobin
saturation less than 94% (less than 90%
for acute coronary syndromes [ACS]
patients)
• Patients with minimal respiratory or
oxygenation problems
• Patients who cannot tolerate a face
mask
2. Simple Face Mask
The simple oxygen face mask delivers low-
flow oxygen to the patient’s nose and
mouth. It can supply up to 60% oxygen
with flow rates of 6 to 10 L/min, but the
final oxygen concentration is highly
dependent on the fit of the mask . Oxygen
flow rate of at least 6 L/min is needed to
prevent rebreathing of exhaled carbon
dioxide (CO2) and to maintain increased
inspired oxygen concentration.

Recent years have seen the advent of high-

flow nasal cannula systems, which allow
for flow rates up to (and sometimes
exceeding) 60 L/min. Inspired oxygen
concentration can be set up to 100%.
3. Venturi Mark
Note that the use of the nasal cannula
A Venturi mask enables a more reliable and
requires that the patient have adequate
controlled delivery of oxygen
spontaneous respiratory effort, airway
concentrations from 24% to 50%.
protective mechanism, and tidal volume.
Delivered oxygen concentrations can be

435
 - 436 -
adjusted to 24%, 28%, 35%, and 40% by
using a flow rate of 4 to 8 L/min and 40%
to 50% by using a flow rate of 10 to 12
L/min. Observe the patient closely for
respiratory depression. Use a pulse
oximeter to titrate quickly to the preferred
level of oxygen administration as long as
peripheral perfusion is adequate and no
shunting has occurred.
• Are seriously ill, responsive,
spontaneously breathing, have adequate
tidal volume, and require high oxygen
concentrations
• May avoid endotracheal (ET) intubation
if acute interventions produce a rapid
clinical effect (eg, patients with acute
pulmonary edema, COPD, or severe
asthma)
• Have relative indications for advanced
airway management but maintain intact
airway protective reflexes, such as gag
and cough
• Are being prepared for advanced airway
management

A Venturi mask can accurately control the

inspired oxygen concentration. Patients
with chronic obstructive pulmonary
disease (COPD), who usually have chronic
hypercarbia (high CO2) and mild to
Caution
moderate hypoxemia, may benefit from
The above patients may have a diminished
this device.
level of consciousness and be at risk for
Administration of high oxygen
nausea and vomiting. A tight-fitting mask
concentrations to patients with COPD may
always requires close monitoring.
produce respiratory depression because
Suctioning devices should be immediately
the increase in PaO2 eliminates the
available
stimulant effect of hypoxemia on the
respiratory centers.
Never withhold oxygen from patients
who have respiratory distress and severe
hypoxemia simply because you suspect a
hypoxic ventilatory drive. If oxygen
administration depresses respiration,
support ventilation.

4. Non Re Breathing Mask

The face mask below is a partial
rebreathing mask that consists of a face
mask with an attached oxygen reservoir
bag. A nonrebreathing face mask with an
oxygen reservoir provides up to 95% to
100% oxygen with flow rates of 10 to 15
L/min . In this system, a constant flow of
oxygen enters an attached reservoir.

Use of a face mask with a reservoir is

indicated for patients who

436
 - 437 -

-oOo-

Chapter Essence
In a Nutshell
24. .
Nursing Alerts
50. .
Nursing Management
132. .
Trainer’s Pearls
24. .

437
 - 439 -

Chapter
Nasopharyngeal Airway.
Chapter Outline
1. .

-oOo-

• The nasopharyngeal airway is a soft rubber
or plastic hollow tube that is passed
through the nose into the posterior
pharynx. The tubes come in sizes based on
the internal diameter (i.d.) of the tube. The
larger the internal diameter the longer the
tube. An 8.0 –9.0 i.d. is used for a large
adult, a 7.0 – 8.0 i.d. for a medium adult and
a 6.0 – 7.0 i.d. for a small adult.
• These tubes can be used when the use of an
oropharyngeal airway is difficult, such as
when a patient is clenching their jaw. As
well, the nasopharyngeal airway is
generally better tolerated than the
oropharyngeal airway in a semiconscious
patient.
Insertion technique
• To insert, the nasopharyngeal airway is
lubricated with water soluble lubricant or
anesthetic jelly along the floor of the nostril
into posterior pharynx behind the tongue.

-oOo-

Chapter Essence
In a Nutshell
25. .
Nursing Alerts
51. .
Nursing Management
133. .
Trainer’s Pearls
25. .

439
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Chapter
Oropharyngeal airway.
Chapter Outline
1. .

-oOo-
Oropharyngeal airway
• The oropharyngeal airway is essentially a
curved hollow tube that is used to create
an open conduit through the mouth and
posterior pharynx.
• A rough guide for choosing the correct size
is to hold the airway beside the patient's
mandible, orienting it with the flange at the
patient's mouth and the tip at the angle of
jaw. The tip should just reach the angle of
the jaw.
Insertion technique
• While inserting the airway pushing the
tongue into the posterior pharynx should
be avoided. This can be accomplished by
starting with the curve of the airway
inverted, and then rotate the airway as the
tip reaches the posterior pharynx.
Alternatively a tongue depressor can be
used to move.
• The oropharyngeal airway is essentially a
curved hollow tube that is used to create
an open conduit through the mouth and
posterior pharynx.

441
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442
 - 443 -
-oOo-

Chapter Essence
In a Nutshell
26. .
Nursing Alerts
52. .
Nursing Management
134. .
Trainer’s Pearls
26. .

443
 - 445 -

Chapter
SupraGlottic Devices : LMA and iGEL
Chapter Outline
1. .

-oOo-
Laryngeal Mask Airway (LMA) and pressed along the palato-pharyngeal
• It is supraglottic/extraglottic airway curve using the index finger. Many a time’s
Easy to insert Can be inserted quickly difficulties are encountered with the
Comes in various sizes and selection is classical technique. Various modifications
important as a smaller sized LMA will not have been evaluated.
cover the glottis and will result in
inadequate ventilation, while an oversized • 180o rotation (reverse technique):
one may cause injury In this technique the LMA is inserted with
Recommended Size guidelines: concavity facing the palate. On reaching
Size 1: under 5 kg oropharynx it is rotated 180o counter-
Size 1.5: 5 to 10 kg clockwise and pushed to its final position.
Size 2: 10 to 20 kg
Size 2.5: 20 to 30 kg
Size 3: 30 kg to
small adult Complications of LMA
Size 4: Adult • Aspiration
Size 5: Large • Gagging & laryngospasm
adult/poor seal with size 4 • Inability to achieve peak inspiratory
pressure
Insertion techniques
• Classical technique: Conventionally a. Igel Insertion
LMA is fully deflated and lubricated with
water based jelly on its posterior surface

445
- 446 -

446
 - 447 -

-oOo-

Chapter Essence

447
 - 448 -

In a Nutshell
27. .
Nursing Alerts
53. .
Nursing Management
135. .
Trainer’s Pearls
27. .

448
 - 449 -
Chapter
Combitube/Esophageao-tracheal double lumen
airway.
Chapter Outline
1. .
-oOo-
Combi Tubes / Esophageal Tracheal
Airway
• A double-lumen tube with one blind
end which functions as an esophageal
obturator airway and the other as a
“standard cuffed ET tube
• Inserted blindly and “seals” the oral and
nasal pharyngeal cavities Easy and
quick to insert
Insertion technique
• Inflate both balloons prior to insertion
to test the integrity of the balloons
(Should either balloon fail after
insertion, maintenance of the patient’s
airway cannot be assured)
• Insert the Combitube so that it curves
in the same direction as the natural
curvature of the pharynx. If resistance
is met, withdraw tube and attempt to
reinsert.
• Inflate the #1 blue pilot cuff with 100ml
of air from the large syringe
• Begin ventilation through the longer
blue tube labelled #1. If auscultation of
breath sounds is good and gastric
inflation is negative, continue.
• If the Combitube is placed in the
esophagus, the distal balloon will
occlude the esophagus. Ventilations are
provided through perforations in the
side of the pharyngeal tube. Stomach
contents can be safely expelled via the
hole in the end of the tube.
• If auscultation of breath sounds is
absent and gastric inflation is positive,
then begin ventilation through the
shorter clear tube labelled #2
• If placed in the trachea, it functions as
an endotracheal tube, with the distal
balloon preventing aspiration.
Ventilations are provided via the hole in
the end of the tube. Stomach contents
can be safely expelled via perforations
in the side of the pharyngeal tube.
Disadvantages of Combitube:
• Only adult and small adult sizes
• Potential for esophageal trauma
• Problems maintaining seal in some
patients
Cannot be used in:
• Intact gag reflex
• Under 4 feet of height
• Under 16 years of age
• Conscious, arousable patient
• Known esophageal disease (cancer,
varices)
449
- 450 -

450
 - 451 -
-oOo-

Chapter Essence
In a Nutshell
28. .
Nursing Alerts
54. .
Nursing Management
136. .
Trainer’s Pearls
28. .

451
 - 453 -
Chapter Outline
1. .
-oOo-
Intubation
Endotracheal Intubation
• Orotracheal intubation is the most
definitive advanced airway management
• 100% oxygen delivery can be
achieved
• Prevents aspiration
• Ensure the presence of a person
with skills to perform surgical airway in
the event of failed intubation.
• Ensure that suction and device to
ventilate the patient is readily available.
• Pre-oxygenate with 100% oxygen
and apply cricoid pressure (Sellick's
maneuver).
• Administer etomidate 0.3 mg/kg or
20 mg and then administer 1-2 mg/kg
succinylcholine intravenously.
• Avoid succinylcholine in patients
with severe crush injuries, major thermal
and electrical burns, pre-existing chronic
renal failure, chronic paralysis and chronic
neuromuscular disease as it has the
potential for severe hyperkalaemia.
• Thiopental and sedative drugs
(midazolam and diazepam) should be
avoided in patients with hypovolaemia.
• Perform intubation after the patient
relaxes.
• Inflate the cuff of the endotracheal
tube and confirm correct tracheal tube
placement by auscultation and presence of
CO2 in exhaled air.
Equipments Needed
3. Ambu Bag
4. Laryngoscope
5. Bougie
6. Stillette
Consumables Needed
3. ET Tube 7
Chapter
Intubation
• Release cricoid pressure.
• Ventilate the patient.
• Secure the tracheal tube firmly.
• Atlanto-occipital extension is
necessary to bring the vocal cords within
line-of-sight of the mouth. Thus patients
with unstable C1 or C2 injuries might be at
more risk from this technique.
• If possible, patients requiring
tracheal tube intubation should be
anaesthetised unless very cooperative. In
the obtunded head injured patient,
anaesthesia is vital to prevent pressor
responses to intubation increasing
intracranial pressure. Carbon dioxide
levels are also much better controlled in
the anaesthetised patient.
• Awake intubation is also a feasible
option and is favoured by some
practitioners. It has been shown to be safe
in the patient with cervical spine injury. It
may be performed via the nasotracheal
route, direct oral laryngoscopy or by
fibreoptic technique.
Failed Intubation
• Failed or difficult intubation is always a
problem. It is important not to waste time
with repeated attempts at intubation while
the patient is desaturating. Alternative
methods of securing the airway should be
instituted as soon as a problem is
recognized
453
 - 454 -
4. ET Tube 7.5
5. ET Tube 8
6. Laryngoscope Batteries
Drugs Needed
3. Atrophine
4. Fentanyl
5. Midazaolam
6. Vecuronium
7. Pancuronium
8. Propofol

Step No Step Name Equipments Needed Consumables Needed Drugs Needed

16. 10. 6.
17. 11. 7.

454
- 455 -

455
 - 456 -

-oOo-

Chapter Essence
In a Nutshell
29. .
Nursing Alerts
55. .
Nursing Management
137. .
Trainer’s Pearls
29. .

456
 - 457 -
Rapid Sequence Intubation
Chapter Outline
1. .
-oOo-
7 P’s in Rapid Sequence Intubation
1. Preparation
• Monitor oxygen saturation, blood
pressure (BP), and cardiac rhythm
Have at least one functioning (IV) line
(preferably two)
• Keep Bag Valve Mask (BVM),
Yankauer suction, and end tidal
carbon dioxide (CO₂) capnography
ready
• Ensure functioning laryngoscope with
blade of choice
• Ensure availability of endotracheal tube
[man: 8.0mm, woman 7.0mm internal
diameter (ID); pediatric: use length-
based (Broselow tape) system or rough
guide [four plus age (in years) divided
by 4] and 10cc syringe
• Check cuff, load and shape stylet
• Keep ready all the medications for rapid
sequence intubation
• Assess for possible difficult airway.
2. Preoxygenation
• Preoxygenate the patient by providing
three minutes of normal tidal volume
breathing or eight vital capacity breaths
with 100% oxygen (O₂) [use non-
rebreathing (NRB) oxygen mask if
100% O₂ source not available] to
prevent desaturation during intubation.
Chapter
3. Pretreatment
• Lidocaine 1.5 mg/kg IV - reduces
intracranial and bronchospastic
response to laryngoscopy in patients
with elevated intracranial pressure
(ICP) or reactive airway disease
• Fentanyl 3 μg/kg IV (over one minute) -
reduces sympathetic response [elevated
heart rate
• (HR) and blood pressure (BP)] to
intubation in patients with elevated
ICP, intracranial hemorrhage, cardiac
ischemia, or aortic dissection
• Vecuronium bromide 0.01 mg/kg IV (or
pancuronium bromide) - blunts ICP
elevation caused by succinylcholine in
patients with elevated ICP
• Atropine: Consider pretreatment with
atropine in children under age one.
4. Paralysis with induction
• One of the following induction agents
(or equivalent) to be given as rapid IV
push prior to paralysis:
1. i.Etomidate 0.3 mg/kg IV
2. ii.Midazolam 0.3 mg/kg IV
3. iii.Ketamine hydrochloride 1.5
mg/kg IV
4. iv.Propofol 1-2mg/kg IV
• Paralytic agent is given by IV push
immediately after induction agent.
Inj.Succinylcholine 1.5 mg/kg IV or Inj.
Rocuronium 1 mg/kg IV if
Succinylcholine is contraindicated
5. Protection
• Sellickmaneuver (firm pressure on
cricoid cartilage to prevent gastric
regurgitation) should be applied as
soon as consciousness lapses and to
457
 - 458 -
be maintained throughout intubation
until tube placement is confirmed
6. Placement
• Insert endotracheal tube with direct
visualization of the vocal cords
Inflate cuff
• Confirm endotracheal tube placement in
the trachea using end tidal CO₂
capnography
• Auscultate lungs bilaterally to ensure
right mainstem intubation has not
occurred
• Secure endotracheal tube with tape
• Release Sellickmaneuver
7. Post-intubation management
• Chest x-ray to be done to assess
placement of endotracheal tube (tip
should be at mid trachea)
• Ensure administration of long-acting
sedatives and, if necessary, use of
paralytics (Lorazepam 0.05 mg/kg IV)
for sedation and Vecuronium 0.1 mg/kg
IV for paralysis
• Initiate mechanical ventilation
• Administer infusion of Inj. Propofol
bolus/drip for sedation
458
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459
- 460 -

-oOo-

460
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Chapter Essence
In a Nutshell
30. .
Nursing Alerts
56. .
Nursing Management
138. .
Trainer’s Pearls
30. .

461
 - 463 -
Needle and Surgical Crico
Chapter Outline
1. .
-oOo-
Surgical Airway Management
• The need for a surgical airway
should be recognized quickly and
performed by an experienced person
without delay.
• As a primary airway, with injuries to
the pharynx, face, oral cavity, nasal cavity
After failure of orotracheal intubation
• Facial muscle spasms or
laryngospasm
• Uncontrollable emesis
• Upper airway stenosis
• Clenched teeth
• Tumor, cancer, or another disease
process or trauma causing mass effect
Oropharyngeal edema (eg, anaphylaxis)
• Foreign body obstruction
• Cervical spine immobilization
secondary to injury Maxillofacial injuries
Techniques
Needle Cricothyroidotomy
• Position the patient, apply lidocaine
(if indicated), and prepare a sterile field,
including cleansing with antiseptic
solution.
• Identify anatomic landmarks (see
the images). Palpate the thyroid cartilage
(the first prominent landmark on the
anterior neck), the cricoid cartilage (caudal
to the thyroid cartilage), and the area
between them, which is the cricothyroid
space that contains the membrane. With
the nondominant hand, stabilize the area
using the first and third digits to either side
of the thyroid cartilage, leaving the index
finger to palpate the membrane. With the
dominant hand, insert the angiographic
catheter, attached to the syringe filled with
normal saline, into the cricothyroid
Chapter
membrane, directing it caudally at a 45 o
angle.
• As the needle is advanced, apply
negative pressure to the syringe. A distinct
pop can be felt as the needle traverses the
membrane and enters the trachea. In
addition, air bubbles will appear in the
fluid-filled syringe.
• Advance the catheter, and retract
the needle.
• Attach the jet ventilation device, and
ventilate at 40-50 lb per square inch or 15
L/min. If this device is unavailable, attach
the barrel of a 3-mL syringe to the catheter,
and place an endotracheal tube adapter. A
bag valve mask (BVM) can then be attached
to deliver oxygen for ventilation.
Percutaneous Cricothyroidotomy
(Seldinger Technique)
• Follow first 4 steps from needle
cricothyroidotomy (see above),
substituting a finder needle attached to a
syringe for the angiographic
catheter.Remove the syringe from the
needle, and advance the guide wire
through the needle. Remove the needle
once the guide wire is in place.Use the
scalpel to make a small stab incision in the
skin close to the guide wire.Place the
dilator into the airway catheter, and insert
the 2 devices together over the wire.
Remove both the dilator and the guide wire
once the airway tube is secured in the
trachea. Secure the tube in place with
appropriate tape.
•
Surgical Cricothyroidotomy
• Follow steps 1-2 from needle
cricothyroidotomy (see above).With the
dominant hand, make a midline vertical
incision, approximately 3 cm long and skin
463
 - 464 -
deep, over the cricothyroid membrane. A
midline vertical incision may result in a
small amount of venous bleeding but
avoids the laterally located vasculature of
the neck.Palpate the cricothyroid
membrane through the incision, using the
index of the nondominant hand. Make a
horizontal stab incision through the
membrane. A distinct pop will be felt as the
scalpel pierces the membrane and enters
the trachea.An assistant should insert the
tracheal hook at the superior end of the
incision and retract the skin and
membrane cephalad. Keep the scalpel in
place until the tracheal hook is inserted. If
the incision is lost, the location can be
identified by means of air bubbles
produced during exhalation. If the patient
is apneic, apply pressure to the anterior
chest wall to simulate exhalation and
thereby produce air bubbles. Dilate the
incision vertically, using the Trousseau
dilator with the non dominant hand. With
the dominant hand, insert the
tracheostomy tube between the 2 blades of
the dilator, directing it initially to one side
of the patient. Once the tube is through the
membrane, rotate it 90o and insert
caudally. Remove the obturator, and insert
the inner cannula. Lock it into place.Inflate
the balloon with 5-10 mL of air. Attach the
tube to a BVM and ventilate. Confirm
placement through observation of chest
rise, auscultation, and assessment of end-
tidal CO2. Remove the tracheal hook, and
secure the tube in place
Complications
• Bleeding
• Incorrect placement, resulting in
possible creation of a false passage through
tissue Subcutaneous emphysema
Obstruction
• Esophageal or mediastinal
perforation Aspiration Vocal cord injury
Pneumothorax Laryngeal injury
• Posterior tracheal wall perforation
Thyroid perforation Hypercarbia (needle
cricothyroidotomy) Dysphonia
• Infections Hematoma
• Persistent stoma Scarring
• Glottic or subglottic stenosis
• Laryngeal stenosis
• Tracheoesophageal fistula
• Tracheomalacia
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Chapter Essence
In a Nutshell
31. .
Nursing Alerts
57. .
Nursing Management
139. .
Trainer’s Pearls
31. .

465
 - 467 -
Chapter Outline
1. .
-oOo-
A tracheostomy is a surgical procedure to
create an opening through the neck into
the trachea (windpipe). A tube is most
often placed through this opening to
provide an airway and to remove
secretions from the lungs. This tube is
called a tracheostomy tube or trach tube.
The technique described here is based on
Seldinger’s principle . The technique we
use was first described and later modified
by Ciaglia . The use of bronchoscopy was
first introduced by Marelli et al and has
subsequently been adopted by many
centers .
Positioning
1. The patient’s neck is extended over
a shoulder roll (unless there is a
contraindication).
2. The anesthesiologist stands at the
head end of the bed and under direct
laryngoscopy positions the endotracheal
tube (ETT) so that the cuff is midway at the
vocal cord level.
Incision
1. We routinely inject the skin with
1% lidocaine with 1:100,000 epinephrine
solution.
2. A horizontal or vertical incision
centered on the inferior border of the
cricoid cartilage may be used. We routinely
use a 3-4 cm vertical incision.
Placement of Introducer Needle
1. A minimal dissection is performed
onto the pretracheal tissue in order to push
the thyroid isthmus downward.
2. The larynx is stabilized and pulled
cephalad with the operator’s left hand.
Chapter
Tracheostomy
3. A bronchoscopy is then performed
and the light reflex is used to select the
best site for the introducer needle.
4. Placing the needle at the inferior
edge of the light reflex, the tip of the needle
is directed caudad into the tracheal lumen
avoiding the posterior tracheal wall at all
cost.
Introduction of Guide Wire, Stylet and
Initial Tract Dilatation
The needle is withdrawn while keeping the
cannula in the tracheal lumen. A J-tipped
guide wire is then place under vision. The
stylet is then placed with the safety ridge
directed towards the tip of the wire. The
tract is then dilated with the 8 FR dilator.
Dilatation with the Blue Rhino Dilator
The Blue Rhino dilator is loaded on the
stylet with the tip resting on the safety
ridge. The dilator is moved in and out to
optimally dilate the tissue between the skin
and the tracheal lumen. The Blue Rhino
dilator is never advanced beyond the point
where 40 FR mark disappears below the
skin level.
Placement of the Tracheostomy Tube
1. A tracheostomy tube is loaded onto
the dilator
- Females: a size 6 cuffed Shiley
tracheostomy tube is loaded on to the 26
FR dilator
- Males: a size 8 cuffed Shiley tracheostomy
tube is loaded on to the 28 FR dilator
2. The dilator is then loaded on the
safety ridge of the stylet and placed into
the tracheal lumen under direct
visualization.
Confirmation of Placement
467
 - 468 -

The bronchoscope is withdrawn from the Postoperative Consideration

ETT and introduced via the tracheostomy
tube. The placement is confirmed by
visualizing the carina.
Securing the Tube
We routinely secure the tube with 2
sutures of 2-0 nylon on each side of the
flange. In addition, a tracheostomy tape is
used to hold the tube in place. A flexible
extension tube is used to connect the tube
to the ventilator circuit to avoid undue
movement of the tube in the immediate
postoperative period.
A chest X-ray is not routinely required as
long as the entire procedure was done
under direct visualization and there were
no adverse events intraoperatively. The
postoperative care is same as for the open
procedure.
The tract between the skin and the tracheal
lumen takes a little longer (10-14 days) to
mature as there is no formal layer by layer
dissection involved. We, therefore, perform
the first tube change on Day 10-12
postoperatively

-oOo-

Chapter Essence
In a Nutshell
32. .
Nursing Alerts
58. .
Nursing Management
140. .
Trainer’s Pearls
32. .

468
 - 469 -

Chapter
Nebulisation.
Chapter Outline
1. .

-oOo-
Nebulization is the process of medication • Position the patient appropriately,
administration via inhalation. It utilizes a allowing optimal ventilation.
nebulizer which transports medications to • Assess and record breath sounds,
the lungs by means of mist inhalation. respiratory status, pulse rate and other
significant respiratory functions.
Indication • Teach patient the proper way of
Nebulization therapy is used to deliver inhalation:
medications along the respiratory tract and o Slow inhalation through the
is indicated to various respiratory mouth via the mouthpiece
problems and diseases such as: o Short pause after the
• Bronchospasms inspiration
• Chest tightness o Slow and complete
• Excessive and thick mucus secretions exhalation
• Respiratory congestions o Some resting breaths before
• Pneumonia another deep inhalation
• Atelectasis • Prepare equipments at hand
• Asthma • Check doctor’s orders for the
medication, prepare thereafter
Contraindications • Place the medication in the nebulizer
In some cases, nebulization is restricted or while adding the amount of saline
avoided due to possible untoward results solution ordered.
or rather decreased effectiveness such as: • Attach the nebulizer to the compressed
• Patients with unstable and increased gas source
blood pressure • Attach the connecting tubes and
• Individuals with cardiac irritability (may mouthpiece to the nebulizer
result to dysrhythmias) • Turn the machine on (notice the mist
• Persons with increased pulses produced by the nebulizer)
• Unconscious patients (inhalation may be • Offer the nebulizer to the patient, offer
done via mask but the therapeutic effect assistance until he is able to perform
may be significantly low) proper inhalation (if unable to hold the
nebulizer [pediatric/geriatric/special
Equipments cases], replace the mouthpiece with
• Nebulizer and nebulizer connecting mask
tubes • Continue until medication is consumed
• Compressor oxygen tank • Reassess patient status from breath
• Mouthpiece/mask sounds, respiratory status, pulse rate
• Respiratory medication to be and other significant respiratory
administered functions needed. Compare and record
• Normal saline solution significant changes and improvement.
Refer if necessary
Procedure • Attend to possible side effects and
inhalation reactions

469
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Teachings
Complications As nurses, it is important that we teach the
Possible effects and reactions after patients the proper way of doing the
nebulisation therapy are as follows: therapy to facilitate effective results and
• Palpitations prevent complications (demonstration is
• Tremors very useful). Emphasize compliance to
• Tachycardia therapy and to report untoward symptoms
• Headache immediately for apposite intervention.
• Nausea
• Bronchospasms (too much ventilation
may result or exacerbate
bronchospasms)

-oOo-

Chapter Essence
In a Nutshell
33. .
Nursing Alerts
59. .
Nursing Management
141. .
Trainer’s Pearls
33. .

470
 - 471 -
Breathing and Ventilation.
Chapter Outline
1. .
-oOo-
B-Breathing and ventilation
Once Airway is secured, the attention is
diverted to Breathing and Ventilation
• Airway patency alone does not ensure
adequate ventilation.
• A tension pneumothorax compromises
ventilation and circulation dramatically
and acutely; if one is suspected, chest
decompression should follow
immediately.
• Every injured patient should receive
supplemental oxygen.
• If not intubated, the patient should have
oxygen delivered by a mask-reservoir
device to achieve optimal oxygenation.
• The pulse oximeter should be used to
monitor adequacy of oxygen
hemoglobin saturation.
Needle Thoracentesis procedure is
appropriate for patients in critical
condition with rapid deterioration who
have a life-threatening tension
pneumothorax and in whom placement of
an expeditious chest tube is not possible.
Success rate in the presence of a tension
pneumothorax is 50–75% due to length of
needle and catheter, size of chest wall,and
kinking of the catheter. If this technique is
used and the patient does not have a
tension pneumothorax, a pneumothorax
and/or damage to the lung may occur.
• STEP 1. Assess the patient’s chest
and respiratory status.
• STEP 2. Administer high-flow oxygen
and apply ventilation as necessary.
• STEP 3. Identify the second
intercostal space, in the midclavicular
line on the side of the tension
pneumothorax.
• STEP 4. Surgically prepare the chest.
Chapter
• STEP 5. Locally anesthetize the area
if the patient is conscious and if time
permits.
• STEP 6. Place the patient in an
upright position if a cervical spine injury
has been excluded.
• STEP 7. Keeping the Luer-Lok in the
distal end of the catheter, insert an over-
the-needle catheter (2 in. [5 cm] long)
into the skin and direct the needle just
over (i.e., superior to) the rib into the
intercostal space
• STEP 8. Puncture the parietal pleura.
• STEP 9. Remove the Luer-Lok from
the catheter and listen for the sudden
escape of air when the needle enters the
parietal pleura, indicating that the
tension pneumothorax has been
relieved.
• STEP 10. Remove the needle and
replace the LuerLok in the distal end of
the catheter. Leave the plastic catheter
in place and apply a bandage or small
dressing over the insertion site.
• STEP 11. Prepare for a chest tube
insertion. The chest tube is typically
inserted at the nipple level just anterior
to the midaxillary line of the affected
hemithorax.
• STEP 12. Connect the chest tube to an
underwaterseal device or a flutter-type
valve apparatus and remove the
catheter used to relieve the tension
pneumothorax initially.
• STEP 13. Obtain a chest x-ray film.
COMPLICATIONS OF NEEDLE
THORACENTESIS
• Local hematoma
• Pneumothorax
• Lung laceration
471
 - 472 -
Chest Tube Insertion
• STEP 1. Determine the insertion site,
usually at the nipple level (fifth
intercostal space), just anterior to the
midaxillary line on the affected side. A
second chest tube may be used for a
hemothorax.
• STEP 2. Surgically prepare and drape
the chest at the predetermined site of
the tube insertion.
• STEP 3. Locally anesthetize the skin
and rib periosteum.
• STEP 4. Make a 2- to 3-cm transverse
(horizontal) incision at the
predetermined site and bluntly dissect
through the subcutaneous tissues, just
over the top of the rib.
• STEP 5. Puncture the parietal pleura
with the tip of a clamp and put a gloved
finger into the incision to avoid injury to
other organs and to clear any adhesions,
clots, and so on. Once the tube in the
proper place, remove the clamp from
the tube.
• STEP 6. Clamp the proximal end of
the thoracostomy tube and advance it
into the pleural space to the desired
length. The tube should be directed
posteriorly along the inside of the chest
wall.
• STEP 7. Look for “fogging” of the
chest tube with expiration or listen for
air movement.
• STEP 8. Connect the end of the
thoracostomy tube to an underwater-
seal apparatus.
• STEP 9. Suture the tube in place.
• STEP 10. Apply an occlusive dressing
and tape the tube to the chest.
• STEP 11. Obtain a chest x-ray film.
• STEP 12. Obtain arterial blood gas
values and/or institute pulse oximetry
monitoring as necessary.
COMPLICATIONS OF CHEST TUBE
INSERTION
• Laceration or puncture of intrathoracic
and/or abdominal organs, which can be
prevented by using the finger technique
before inserting the chest tube n
Introduction of pleural infection—for
example, thoracic empyema
• Damage to the intercostal nerve, artery,
or vein:
• Converting a pneumothorax to a
hemopneumothorax
• Resulting in intercostal neuritis/
neuralgia
• Incorrect tube position, extrathoracic or
intrathoracic
• Chest tube kinking, clogging, or
dislodging from the chest wall, or
disconnection from the underwater-seal
apparatus
• Persistent pneumothorax:
• Large primary leak
• Leak at the skin around the chest tube;
suction on tube too strong
• Leaky underwater-seal apparatus
• Subcutaneous emphysema, usually at
tube site n
• Recurrence of pneumothorax upon
removal of chest tube; seal of
thoracostomy wound not immediate
• Lung fails to expand because of plugged
bronchus; bronchoscopy required n
Anaphylactic or allergic reaction to
surgical preparation or anesthetic
Pericardiocentesis
• STEP 1. Monitor the patient’s vital
signs and electrocardiogram (ECG)
before, during, and after the procedure.
• STEP 2. Surgically prepare the
xiphoid and subxiphoid areas, if time
allows.
• STEP 3. Locally anesthetize the
puncture site, if necessary.
• STEP 4. Using a 16- to 18-gauge, 6-in.
(15-cm) or longer over-the-needle
catheter, attach a 35-mL empty syringe
with a three-way stopcock.
• STEP 5. Assess the patient for any
mediastinal shift that may have caused
the heart to shift significantly.
• STEP 6. Puncture the skin 1 to 2 cm
inferior to the left of the xiphochondral
472
 - 473 -
junction, at a 45-degree angle to the
skin.
• STEP 7. Carefully advance the needle
cephalad and aim toward the tip of the
left scapula.
• STEP 8. If the needle is advanced too
far (i.e., into the ventricular muscle), an
injury pattern known as the “current of
injury” appears on the ECG monitor (e.g.,
extreme ST-T wave changes or widened
and enlarged QRS complex). This
pattern indicates that the
pericardiocentesis needle should be
withdrawn until the previous baseline
ECG tracing reappears. Premature
ventricular contractions also can occur,
secondary to irritation of the ventricular
myocardium.
• STEP 9. When the needle tip enters
the blood-filled pericardial sac,
withdraw as much nonclotted blood as
possible.
• STEP 10. During the aspiration, the
epicardium approaches the inner
pericardial surface again, as does the
needle tip. Subsequently, an ECG current
of injury pattern may reappear. This
indicates that the pericardiocentesis
needle should be withdrawn slightly.
Should this injury pattern persist,
withdraw the needle completely.
• STEP 11. After aspiration is
completed, remove the syringe and
attach a three-way stopcock, leaving the
stopcock closed. Secure the catheter in
place.
• STEP 12. Option: Applying the
Seldinger technique, pass a flexible
guidewire through the needle into the
pericardial sac, remove the needle, and
pass a 14-gauge flexible catheter over
the guidewire. Remove the guidewire
and attach a three-way stopcock.
• STEP 13. Should the cardiac
tamponade symptoms persist, the
stopcock may be opened and the
pericardial sac reaspirated. This may be
repeated as the symptoms of tamponade
recur, prior to definitive treatment. The
plastic pericardiocentesis catheter can
be sutured or taped in place and covered
with a small dressing to allow for
continued decompression en route to
surgery or transfer to another care
facility.
COMPLICATIONS OF
PERICARDIOCENTESIS
• Aspiration of ventricular blood instead
of pericardial blood
• Laceration of ventricular epicardium/
myocardium
• Laceration of coronary artery or vein
• New hemopericardium, secondary to
lacerations of the coronary artery or
vein, and/or ventricular epicardium/
myocardium
• Ventricular fibrillation
• Pneumothorax, secondary to lung
puncture
• Puncture of great vessels with
worsening of pericardial tamponade
• Puncture of esophagus with subsequent
mediastinitis
• Puncture of peritoneum with
subsequent peritonitis or false positive
aspirate
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-oOo-

Chapter Essence
In a Nutshell
34. .
Nursing Alerts
60. .
Nursing Management
142. Pulmonar Embolisum
143.
144. Nursing management
145. • Prevent thrombus formation
146. • Ambulate
147. • Provide active and passive exercises
148. • Avoid constricting clothing
149. • Avoid dependant position
150. • Provide TED stockings/Sequential compressive devices
151. • Assess patients who are at risk
152. • Monitor thrombolytic therapy
153. • Administer oxygen therapy
154. • Relieve anxiety
155. • Monitor for complications- carcinogenic shock, right ventricular failure
156.
157.
158. Pnemothorax
159.
160. Nursing alert
161. •Traumatic open pneumothorax calls for emergency interventions.
162. Stopping the flow of air through the opening in the chest wall is a life-saving
measure.
163. •Relief of tension pneumothorax is considered an emergency
164. measure..
165.
166. Pulmonary Edema
167. Nursing management
168. • Position patient upright with legs dangling over the side of the bed to reduce the
venous return
169. • Provide psychological support to relieve anxiety
170. • Monitor for respiratory depression, hypotension, and vomiting when patient is
receiving
171. morphine
172. • Keep Naloxone ready at bedside
474
 - 475 -

173. • Meet the elimination needs and monitor urine output after diuretic therapy
174.
175. Nursing alert
176. • Monitor electrolyte levels, especially potassium and sodium, after administering
diuretics. • Monitor fluid balance as some patients may easily become hypovolemic or
hypervolemic
177. with small changes in the amount of circulating fluid.
178. • Falling blood pressure, increasing heart rate, and decreasing urine output
indicate that the
179. circulatory system is not tolerating diuresis and that measures must be taken to
reverse the
180. fluid imbalance that has occurred.
181. • Serum creatinine is monitored to assess renal function.
182. • Men with prostatic hyperplasia must be observed for signs of urinary retention.
183.
Trainer’s Pearls
34. .
35. ARDS
36. Nursing management
37. General measures
38. • Assess the respiratory rate, rhythm, and depth of respiration
39. • Assess for signs of respiratory distress- Intercostal retractions
40. • Auscultate the lungs for crackles/crepts
41. • Monitor vital signs closely - SpO2, ABG
42. • Administer oxygen as per order
43. • Provide chest physiotherapy
44. • Provide adequate rest
45. • Explain all procedures in a reassuring manner

475
 - 477 -
Chapter Outline
1. Mechanical Ventilation
2. Indications
3. Common Terms.
-oOo-
Mechanical ventilation
Mechanical ventilation is used to improve
pulmonary gas exchange during acute
hypoxemic or hypercapnic respiratory
failure with respiratory acidosis.
Mechanical ventilation also redistributes
blood flow from working respiratory
muscles to other vital organs and is
therefore a useful adjunct in the
management of shock from any cause.
Caring for a patient on mechanical
ventilation has become an integral part of
nursing care in critical care units. Nurses
must understand each patient’s specific
pulmonary needs and set realistic goals.
Positive patient outcomes depend on an
understanding of the principles of
mechanical ventilation and the patient’s
care needs as well as open communication
among members of the health care team
about the goals of therapy, weaning plans,
and the patient’s tolerance of changes in
ventilator settings.
Objectives
On completion of this unit, the learners will
be able to
• define mechanical ventilation
• state the indications for mechanical
ventilation
• classify the types of mechanical
ventilation
• explain the basic modes of the
mechanical ventilation
• demonstrate skills in setting up of a
ventilator and troubleshooting
ventilator alarms
• describe the complications of patients
on mechanical ventilation
Chapter
Ventilator
• discuss the role of nurses and provide
care to the patients on mechanical
ventilation
Indications of mechanical ventilation
• Respiratory failure
• Impending respiratory failure
• Apnea
• Acute hypoxemia with increased work
of breathing
Common terms used in mechanical
ventilation
• Negative pressure ventilation: A type of
ventilation, not requiring intubation
where a negative extra-thoracic
pressure is applied to the chest wall.
This causes a rise in the chest wall
resulting decreased intra-thoracic
pressure and creates a pressure
gradient from mouth to alveoli and
inspiration occurs
• Positive pressure ventilation: A positive
pressure greater than atmospheric
pressure is applied to the mouth
providing a positive pressure gradient
from mouth to alveoli resulting in
inspiration.
• Volume targeted ventilation: Tidal
volume set by the clinician is delivered
by ventilator during each mechanical
breath. Ventilating pressure is variable
depending upon the lung characteristics.
• Pressure targeted ventilation: Pressure
limit is set by the clinician. Lung
characteristics determine the volume
delivered to the lung.
• Triggering: Refers to initiation of breath,
it can be patient triggered (assisted),
477
 - 478 -
time triggered (controlled), pressure
triggered or flow triggered.
• Limit/ target: Refers to the variable
to maintain inspiration. Inspiration
can be pressure limited/flow limited
/volume limited.
• Cycling: Refers to termination of breath;
cycling parameters can be volume,
pressure time or flow.
Basic modes of ventilation
1. Control ventilation
Controlled breath implies that the entire
breathing is controlled by the ventilator
and the patient has no participation and is
incapable of initiating spontaneous breath.
If patient decides to take spontaneous
breath the ventilator will not allow since
every breath is time triggered. It should be
noted that when the patient is on
controlled mode he/ she should be deeply
paralyzed and sedated so that there will
not be any chance of dyssynchrony.
2. Assisted ventilation
Most common mode in volume ventilation.
Switching from controlled mode to assisted
mode involves simply activating the
sensitivity control. In assisted ventilation
every breath is initiated by the patient
delivering set tidal volume. The backup
frequency is set to ascertain the ventilation
in unforeseen situation like apnea. Patient
determines the total frequency.
3. Synchronized Intermittent Mandatory
Ventilation (SIMV)
In Intermittent mandatory ventilation
spontaneous breath is interposed between
controlled
mandatory breaths. In SIMV spontaneous
breaths are interposed between assisted
mandatory breaths. Currently all
ventilators use SIMV as one of the modes.
Not all breaths are positive pressure
breaths. Patient is doing partial work of
breathing. This is used as one of the
weaning mode and has minimal
cardiovascular side effects. One major
drawback of this mode is that patient is
permitted to take spontaneous breath
which can significantly increase the work
of breathing. Hence a pressure support
must be added to enhance spontaneous
breaths (generally 5 cm of H2O at
beginning point). Since SIMV involves two
types of breaths i.e. mandatory and
spontaneous breaths, minute ventilation is
the sum of mandatory minute ventilation
and spontaneous minute ventilation
4. Pressure Support Ventilation (PSV)
PSV is an integral part of mechanical
ventilation. This is one of the commonest
weaning mode or used as a stand- by mode
of ventilation. PSV provides inspiratory
flow in response to patients’ inspiratory
effort. Pressure support augments
spontaneous tidal volume. PSV only
enhances patient triggered spontaneous
breaths. This is a flow- cycled mode.
Expiration starts when the inspiratory flow
rate decreases to 25% of the peak flow.
Basic ventilator settings
• There are two basic ventilator settings -
volume ventilation and pressure
ventilation
Volume ventilation
• Mode -SIMV
• Tidal volume- 6-8 ml/kg(IBW)
• Respiratory rate- 10-15/breaths per
min Pressure support- 15 cm of H20
• PEEP- 5 cm H2O
• FiO2- 100%
• I: E ratio-1:2/Inspiratory time - 1.3
Pressure ventilation
• Mode -SIMV
• Pressure control - (Start at a lower
pressure =
15 cm H2O) and check the delivered
volume until the desired tidal volume is
attained (6-8 ml/IBW) Pressure control
< 30 cm H2O
• Respiratory rate- 10-15/breaths per
min Pressure support- 15 cm of H2O
• PEEP- 5 cm H2O
• FiO2- 100%
• I: E ratio-1:2/ Inspiratory time - 1.3
Trouble shooting ventilator alarms
478
 - 479 -
- Pain- analgesia
- Hypoxia- evaluate
and treat
- Metabolic acidosis-
correct acidosis
• Inappropriate or
incompatible ventilator
setting too high TV/ MV/
RR or alarm parameters not
set appropriate for
prescribed setting
Low minute • Leak in the system
ventilation • Decrease in the rate and
alarm the tidal volume
Settings should be adjusted
as per the patient’s clinical
Key alarms Significance and condition in consultation
intervention to be taken with the Physician.
High Increased airway resistance
pressure • Kink in the ventilator
alarm circuit- remove kink Complications of mechanical ventilation
• Kink in the tube- change • Ventilator associated lung injury
head position • Barotrauma - high pressure induced
• Water in the tube- lung damage
remove water • Volutrauma - damage caused by over-
• Clogging of filter - distension (high volume, high end
change filter inspiratory volume injury)
• Biting of the tube- apply • Biotrauma - pulmonary and systemic
bite block / OPA inflammation caused by the release of
• Increased airway mediators from the lung
secretions- perform • Atelectotrauma - caused by repeated
suctioning recruitment and collapse. Also called
• Decreased lung low volume or low end expiratory
compliance volume injury
• Bronchospasm - • Ventilator associated pneumonia
administer • Oxygen toxicity : Patients exposed to
bronchodilator FiO2 more than 50% may experience
(nebulizer) oxygen toxicity, particularly when the
Low Leak in the system exposure is prolonged. Oxygen may get
pressure • Leak in the circuit converted to free radicals which are
alarms • Disconnection toxic to alveolar and trachea-bronchial
• Major leak around the ET cells resulting in cell death
tube cuff
Leak should be identified
and intact connection needs
to be mantained
High minute • Increased RR
ventilation - Anxiety- reassure/
alarm sedate

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-oOo-

Chapter Essence
In a Nutshell
35. .
Nursing Alerts
1. Never ignore an alarm - even when you know the cause for the alarm and may not be fatal
2. Never mute the alarm
3. Ensure Alarm knobs/ switches are turned on and functional
4. Act appropriately to the alarm
5. If the reason for alarm is not known disconnect the patient from ventilator and start
manual bagging
Nursing Management : . Nursing care of patients on ventilator
1. 1. Trachea bronchial hygiene : Provide trachea bronchial hygiene to prevent VAP and
other infection in patients on ventilator. Essential elements include: Nebulization, chest
physiotherapy, suctioning and mouth care
2. Check the placement of ET tube : Check ET placement by ETCO2 monitoring, symmetrical
chest expansion, bilateral equal air entry on auscultation and post intubation Chest X ray
3. Secure the ET tube : The tube is usually fixed around 20-24 cm (ET tube size x 3). Check
the position of ET at teeth level frequently and document at least once a shift.
4. Maintain skin integrity : Prevent ET related skin sores on face, lips and earlobes. Inspect
the skin for excoriation or redness. Do not use too sticky items to secure the tube. Every
hourly oil massage to prevent pressure sores especially during NIV mask placement.
5. Monitor cuff pressure : Desired cuff pressure is 25-30 cm of H20. If the pressure is less it
can lead to displacement of tube, air leak and aspiration. High pressure can result in
tracheal stenosis. Monitor cuff pressure every 8 hrs.
6. Humidification : Ensure filling of water and regulate the temperature of the humidification
chamber. If inadequate, secretion would become thicker and may lead to tube block.
Increased humidification may lead to condensation and can block the tube. Ensure to
empty the water trap periodically
7. Prevent pain and discomfort : Pain may be associated with positioning of the tube, pulling
of the circuits. Discomfort may occur due to inappropriate flow rates, sensitivity setting
etc. Assess pain and provide appropriate analgesics and sedation
8. Prevent infection : Monitor color, consistency, and amount of secretions, temperature,
total counts, pulse rate. Follow sterile techniques and standard precautions.
9. Promote Nutrition : Ensure 20-30 kcal/kg/ day and protein 1-1.5/g/kg/day.
10. Prevent gastric ulcer : Administer proton pump inhibitor infusion or H2 receptor blocker to
prevent gastric ulcer.
11. Prevent aspiration : Elevate the head end by 30-45 degrees. Do not give anything orally.
Give feeds through enteral or parenteral route.
12. Sedation and analgesia : Administer appropriate sedation and analgesics. Muscle paralyzing
agents are not routinely used in ICU.
13. Eye care : Provide routine eye care with saline swabs and lubricating agents like moisol/
lacrigel eyedrops. Apply a goggle or the eyelids can be taped to prevent keratitis. Provide
eye care Q4H.
14. Thrombo embolic prophylaxis : Prevent Deep Vein Thrombosis (DVT) by periodic limb
exercises, application of TED stockings, sequential compression devices or administration
of injection Heparin.

480
 - 481 -

15. Communication : If conscious, orient to time, place and person, procedures, co-operation
expected etc. Use verbal and non verbal methods. Use paper and pen or provide calling
bell if necessary. Reassure and support the patient during the period of anxiety, frustration
and hopelessness. Include family in the care
Trainer’s Pearls
46. .

481
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Chapter
Ambu Bag.
Chapter Outline
1. .

-oOo-

Bag & Mask Ventilation

• The first step in bag-mask
ventilation is to select a mask that will
cover the mouth and nose of the patient
and create a tight seal. The mask is then
attached to the bag device, which should be
attached to high flow oxygen (15L/min.)
such that the reservoir of the bag is fully
inflated.

-oOo-

Chapter Essence
In a Nutshell
36. .
Nursing Alerts
6. .
Nursing Management
16. .
Trainer’s Pearls
47. .

483
 - 485 -
Chapter
Single Hand and Double Hand EC Technique.
Chapter Outline
1. .
-oOo-
Single Hand EC Technique
Generally, the bag device should be held
with the right hand and secure the mask to
the patient's face with their left hand.
While securing the mask to the patient's
face a tight seal should be created in
addition to elevating the mandible to
maintain an open airway. This is done by
hooking the fifth finger at the angle of the
jaw, holding the mandibular body with the
third and fourth fingers and holding the
mask between the index finger and thumb.
The physician must avoid the temptation to
push down on the mask in order to create a
tight seal as this will occlude the patient's
airway. The correct technique is to lift the
mandible up with the third, fourth and fifth
fingers while holding the mask tight
against the patient's face with the thumb
and index finger
It is worth repeating that the technique of
bag-mask ventilation is not easy under the
best of circumstances by even experienced
operators. The person who is performing
bag-mask ventilation must be carefully
monitoring the success of his/her efforts at
all times. The air should flow easily into the
patient, and the patient's chest should rise
and fall with each cycle of ventilation. If
there is obstruction to air flow or the chest
does not rise, the provider should check
that there is a tight seal to the face that the
mandible is being elevated to open the
airway if an artificial airway is being used,
that it is in place.
Double Hand EC Technique
Alternatively, two person technique can be
tried. The biggest challenge in bag-mask
ventilation is maintaining an open airway
and a tight seal using one hand. If a second
person is available, it is recommended that
one person manages the mask and the
airway, while the second person squeezes
the bag to ventilate the chest. The person
responsible for the mask stands at the head
of the bed and places his thumbs on the top
surface of the mask. The remaining fingers
are then used to grip the mandible on
either side. The mask is squeezed between
the thumbs and the fingers to create a seal
and at the same time the mandible is
elevated to open the airway. This technique
is considerably easier, but again, the
providers must be constantly checking that
air is flowing easily into the patient and
that the chest is rising and falling
485
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-oOo-

Chapter Essence
In a Nutshell
37. .
Nursing Alerts
7. .
Nursing Management
17. .
Trainer’s Pearls
48. .

486
 - 487 -

Chapter
Needle Decompression of Chest
Chapter Outline
1. .

-oOo-

Chest Decompression
For many years needle decompression of a Performing a Chest Decompression by
tension pneumothorax has been advo- the Lateral Approach
cated as a lifesaving procedure and the Assess the patient to make sure that his
anterior approach (second or third inter- condition is due to a tension
costal space, midclavicular line) has been pneumothorax. Signs of ten-sion
most commonly used by prehospital pneumothorax are
providers. In the last few years the lateral • Decreased level of consciousness (LOC)
approach has become popular with the • Open airway
military, who favor it because it can be • Rapid shallow respiration; respiratory
used to decompress the chest without distress
removing a soldier’s body armor. Multiple • Weak/thready pulses; possible absent
studies also have been published showing radial pulse e. Skin cool, clammy,
that the catheters being used were too diaphoretic; pale or cyanotic
short to decompress the chest in many • Neck vein distention (may not be
patients. It is recommended that for the present if there is associated severe
anterior approach the catheter needle hemorrhage) g. Possible tracheal
needs to be large bore (8 French or about deviation away from the side of the
14 gauge) and 6 to 9 cm long. Because injury (almost never present) h. Absent
there are advantages and disadvantages to or decreased breath sounds on the
each decompression site, this chapter will affected side
cover both of them. Follow your state • Tympany (hyperresonance) to
protocol or consult your serv-ice medical percussion on the affected side
director for guidance about which site to Give the patient high-flow oxygen and
use routinely. ventilatory assistance.

Indications to Perform Chest Determine that indications for emergency

Decompression decompression are present. Then, if
As with all advanced procedures, this required, obtain medical direction to
technique must be accepted local protocol perform the procedure.
or you must obtain medical direction
before performing it. The conservative Lateral site for decompression:
management of tension pneumothorax is Expose the side of the tension
oxygen, ventilatory assistance, and rapid pneumothorax and identify the
transport. The indication for performing intersection of the nipple (fourth rib) and
emergency decompression is the presence anterior axillary line on the same side as
of a tension pneumothorax with the pneumothorax .
decompensation as evidenced by more
than one of the following: Quickly prep the area.
• Respiratory distress and cyanosis Remove the plastic cap from a 14-gauge
• Loss of the radial pulse (late shock) catheter needle at least 2 inches or 5 cm
• Decreasing level of consciousness
487
 - 488 -
long and insert the needle into the
intercostal space at a 90-degree angle to
the superior border of the fourth rib to
avoid the neurovascular bundle . If the
patient is muscular or obese, you may need
to use a 6- to 9-cm catheter needle.
Direction of the bevel is irrelevant to
successful results. As the needle enters the
pleural space, there will be a “pop.” If a
tension pneumothorax is present, there
will be a hiss of air as the pneumothorax is
decompressed. If using an over-the-needle
catheter, advance the cath-eter into the
chest. Remove the needle and leave the
catheter in place. The catheter hub must be
stabilized to the chest with tape.
Place a one-way valve on or over the
decompressing needle. The Asherman
Chest Seal will go over the needle and
provide a one-way valve and will protect
the needle from accidently being dislodged.
Other one-way valves are available or can
be made but should be tested before using.
(A needle through the finger of a rubber
glove will not work as a one-way valve.)
Young healthy patients will tolerate having
no valve at all on the decompressing
needle.
Leave the plastic catheter in position until
it is replaced by a chest tube at the hospital.
Intubate the patient if indicated. Monitor
closely for recurrence of the tension
pneumothorax. If available monitor with
capnography. An increase in the CO2 is an
early sign the catheter is kinked or the
tension pneumothorax is worsening. (A 13-
or 14-gauge catheter may not be large
enough to decompress a large air leak
Advantages
The lateral chest wall is thinner than the
anterior chest wall (averages 2.6 cm), so
you are more likely to decompress the
pneumothorax with a shorter needle and
less likely to inadvertently cause
hemorrhage from vascular structures.
The military and tactical medics prefer the
lateral approach because in a tac-tical
situation it has the advantage of allowing
decompression while keeping body armor
in place.
Disadvantages and Complications
• The decompression catheter is more
likely to be dislodged when moving the
patient or if the patient moves his arm.
Using the Asherman Chest Seal for a
one-way valve also will provide some
protection against dislodgement of the
decompression catheter.
• It can be difficult to reach this area when
the patient is in the ambulance
(especially if the tension pneumothorax
is on the right).
• Laceration of the intercostal vessels may
cause hemorrhage. The intercostal
artery and vein run around the inferior
margin of each rib . Poor needle
placement can lacerate one of these
vessels.
• If performing the lateral approach,
inserting the needle too low may lacer-
ate the liver or spleen, and inserting the
needle too high may lacerate the axillary
artery, vein, or brachial plexus.
• Creation of a pneumothorax may occur
if not already present. If your
assessment was incorrect, you may give
the patient a pneumothorax when you
insert the needle into the chest.
• Laceration of the lung is possible. Poor
technique or inappropriate inser-tion
(no pneumothorax present) can cause
laceration of the lung, with sub-sequent
bleeding and an air leak.
• Risk of infection is a consideration.
Adequate skin preparation with an anti-
septic will usually prevent this.
Performing a Chest Decompression by
the Anterior Approach
Advantages
• The anterior site is preferred by many
because, in the supine patient, air in the
pleural space tends to accumulate
anteriorly. Thus, there is a better chance
of having the air in the pleural space
488

removed when decompressing at the
midclavicular area.
• Monitoring of the site is easier if
performed in the anterior site because
the catheter is not as likely to be
unintentionally dislodged when the
patient is moved or if the patient moves
his arm.
Disadvantages and Complications
• Unless a needle of proper length is used,
it is likely that the needle will not reach
the pleural space, and the tension
pneumothorax will not
decompressed. The recommended
catheter length is 6 to 9 cm (2.5 to 3.5
inches) .
• If the insertion of the needle is medial to
the midclavicular line (nipple line),
there is danger of cardiac puncture or
great vessel laceration.
• Laceration of the intercostal vessels may
cause hemorrhage. The intercostal
artery and vein run around the inferior
margin of each rib. Poor needle
placement can lacerate one of these
vessels.
• Creation of a pneumothorax may occur
if not already present. If your
assessment was incorrect, you may give
the patient a pneumothorax when you
insert the needle into the chest.
• Laceration of the lung is possible. Poor
technique or inappropriate inser-tion
(no pneumothorax present) can cause
laceration of the lung, with sub-sequent
bleeding and an air leak.
• Risk of infection is a consideration.
Adequate skin preparation with an anti-
septic will usually prevent this.
Decompression by the Anterior
Approach
Assess the patient to make sure that his
condition is due to a tension pneu-
mothorax. Signs of tension pneumothorax
are
• Decreased level of consciousness (LOC)
• Open airway
- 489 -
• Rapid shallow respiration; respiratory
distress
• Weak/thready pulses; possible absent
radial pulse e. Skin cool, clammy,
diaphoretic; pale or cyanotic
• Neck vein distention (may not be
present if there is associated severe
hemorrhage)
• Possible tracheal deviation away from
the side of the injury (almost never
present)
• Absent or decreased breath sounds on
the affected side
be • Tympany (hyperresonance) to
percussion on the affected side
Give the patient high-flow oxygen and
ventilatory assistance.
Determine that indications for emergency
decompression are present. Then, if
required, obtain medical direction to
perform the procedure.
Anterior site for decompression:
Expose the side of the tension pneumotho-
rax and identify the second or third
intercostal space on the anterior chest at
the midclavicular line on the same side as
the pneumothorax. This may be done by
feeling for “angle of Louis,” the bump
located on the sternum about a quarter of
the way from the suprasternal notch . The
insertion site should be slightly lateral to
the midclavicular line (nipple line) to avoid
cardiac or major vascular complications in
the mediastinum.
Quickly prepare the area with an
antiseptic.
Remove the plastic cap from a 14 gauge or
larger catheter 6 to 9 cm long (8 French, 9-
cm Turkel Safety Needle, 14-gauge, 8.25-
cm ARS decompression needle, 8.5 French,
6-cm Cook pneumothorax needle, or 14-
gauge, 8-cm angiocath) and insert the
needle into the intercostal space at a 90-
degree angle to the superior border of the
third rib to avoid the neurovascular bundle
.
489
 - 490 -
Direction of the bevel of the needle is
irrelevant to successful results. Be very
careful not to angle the needle toward the
mediastinum. As the needle enters the
pleural space, there will be a “pop.” If a
tension pneu-mothorax is present, there
will be a hiss of air as the pneumothorax is
decom-pressed. If using an over-the-needle
catheter, advance the catheter into the
chest. Remove the needle and leave the
catheter in place. The catheter hub must be
stabilized to the chest with tape.
Place a one-way valve on or over the
decompressing needle. The Asherman
Chest Seal will go over the needle to
provide a one-way valve and to protect the
needle from accidental dislodgment. Other
one-way valves are available or can be
made but should be tested before using. (A
needle through the finger of a rubber glove
will not work as a one-way valve.) Young
healthy patients will tolerate having no
valve at all on the decompressing needle.
Leave the plastic catheter in position until
it is replaced by a chest tube at the hospital.
Intubate the patient if indicated. Monitor
closely for recurrence of the tension
pneumothorax.
490
 - 491 -

-oOo-

Chapter Essence
In a Nutshell
38. .
Nursing Alerts
8. .
Nursing Management
18. .
Trainer’s Pearls
49. .

491
 - 493 -
Chapter Outline
1. .
-oOo-
Chest drains, also referred to as chest
tubes, under water sealed drainage
(UWSD), thoracic catheter, tube
thoracostomy, or intercostal drain. Chest
drains provide a method of removing air &
fluid substances from the pleural space.
The idea is to create a one-way mechanism
that will let air/fluid out of the pleural
space and prevent outside air/fluid from
entering into the pleural space. This is
accomplished by the use of an underwater
seal. The distal end of the drainage tube is
submerged in 2cm of H2O. They use
flexible plastic tubes which are inserted
through the chest wall and into the pleural
space between the 5th and 6th intercostal
space in the mid-axillary line, venting the
space which allows air back out.
Fluid or air that accumulates in the pleural
space will reduce lung expansion and lead
to respiratory compromise and hypoxia
Insertion of an intercostal catheter (ICC)
enables drainage of air or fluid from the
pleural space, allowing negative intra-
thoracic pressures to be re-established
leading to lung re-expansion
Indications
• Pnemothorax
• Heamothorax
• Pleural effusion
Contra Indication:
• Need for immediate thoracotomy
Equipments:
• Special procedures tray
• Under water sealed drain system
(UWSD)
Chapter
Intercostal Drain (ICD)
• use cell saver UWSD for massive
haemothorax
• Intercostal Catheter (guide sizes only)
• use smaller size for draining air
• larger size for draining blood/fluid
• Newborn 8-12 FG
• Infant 12-16 FG
• Child 16-24 FG
• Adolescent 20-32 FG
• Spigot connector / tube adaptor - 2 sizes
• Suction must be available and working
• Sterile gloves & gown
• Mask
• Sterile towels x 2
• 500ml bottle of sterile water
• Antiseptic solution
• 1% lignocaine + 1:100,000 adrenaline
5mL ampoule
• 5ml/10ml syringe and needle
• Scalpel blade
• Suture material - black silk or nylon
with needle size 3.0 x 2
• Sleek and Tegaderm x 2
Analgesia, Anaesthesia, Sedation
• Local anaesthetic and intravenous
analgesia are mandatory, as ICC
placement is a painful procedure. The
use of sedation should always be
discussed with a senior emergency
doctor, as it can potentially worsen the
patient's clinical condition.
Procedure
• Establish patient on continuous cardiac
monitoring and pulse oximetry
• Place conscious patient in a sitting
position at 45 degrees with arm of same
side placed above head
• Palpate the fourth or fifth intercostal
space just anterior to the mid-axillary
line
493
 - 494 -
• Surgically prepare the area
• Ensure local anaesthetic is infiltrated
from subcutaneous tissue down to
pleura.
• Select the appropriate size I.C.C.
and remove stylet.
• Incise the skin parallel to the upper
border of the rib below the chosen
intercostal space. Incise down to the
fascia.
• "Blunt dissect" (using an artery forcep)
down to the pleura, enter the pleural
space, and then widen the hole by
opening the forceps.
• Sweep the pleural space with a gloved
finger to widen the hole and push the
lung away from the hole (only possible
in older children, beware of rib fractures
in injured child).
• Hold the tip of the catheter with a
curved artery clamp and advance it into
the pleural space, directing the catheter
posteriorly and superiorly.
• Advance so that all apertures of the tube
are in the chest and not visible
• Attach the tube to UWSD below the
patient's chest level
• Anchor the drain and suture the wound.
Tape in place with tegaderm sandwich
and anchor the tube to the patient's side.
• Connect to the UWSD.
• Watch for "swinging" of water in tube
connection
Post-procedure care
• Reassess ABCs and ensure ICC is
functioning
• Reassess need for analgesia.
• In children following the removal of the
tube coverage with a large tegaderm is
sufficient for closure rather than a
formal purse string suture.
494
 - 495 -
Equipments Needed
1. ICD Tray
a. Curved Forceps
b. Straight Forceps
c. 11” Blade Holder – BP handle 3
d. Straight Scissors
e. Towel Clips
f. Babcocks
2. Ambu Bag
Consumables Needed
1. ICD Tube with Bag
2. Sterile Drapes
3. Silk or Prolene
4. Betadine
5. Gauzes
Drugs Needed
1. Local Anaesthetic Agent
a. Lignocaine
2. Atrophine

Step No Step Name Equipments Needed Consumables Needed Drugs Needed

Paint 18. Babcocks 12. Betadine 8.
13. Gauze
Drape 19. Towel Clips 14. 9.
Local Anaesthesia 20. 15. Disposable Syringe 10. Lignocaine

Incision 21. 3 BP Handle 16. 11 Blade 11.

22. 17. 12.

-oOo-

Chapter Essence
In a Nutshell
39. .
Nursing Alerts
9. . • Nurses have the responsibility to care for their patients’ chest tubes after they have
been properly inserted so that the pleural drainage system remains clear and intact. The
following are steps to care for chest tubes.
10. • Wash hands thoroughly with soap and warm water and don sterile gloves before
coming in contact with the patient.
11. • The chest tube should contain approximately 6 feet of tubing that connects to a
collection device located several feet below the patient’s chest. Instruct the patient not to
rest the body on the tubing. The nurse should take this time to check the patient’s tubing
for twists and kinks in the tubing line. The nurse should also tape the tubing connections to

495
 - 496 -

prevent air from leaking out of the tube.

12. • The drainage system has a water seal that operates as a one-way valve. The nurse
must add the required amount of saline into the patient’s separate water chamber while
ensuring the end of the patient’s tubing remains in the fluid.
13. • Add suctioning to the chest drainage system if necessary, but remember that the
amount of suctioning depends of the saline solution’s depth.
14. • The nurse should make a note of the level of drainage at the end of his or her shift.
Also, document the color and amount of the drainage in the patient’s notes.
15. • The respiratory status of the patient requires frequent assessment to maintain the
patient’s health. Nurses should also make note of decreased breathing sounds near the
side of the patient’s chest tube.
16. • To maintain the care of the chest tube, nurses should encourage the patient to
perform deep-breathing exercises or coughing.
17. Chest tubes may also serve the purpose of preventing or mitigating postoperative
complications, and may also be used to instill fluids into the pleural space (chemotherapy
drugs or sclerosing agents to treat recurrent pleural effusions). Also, blood collected from
the chest tubes may be used for auto transfusion.
18. Role of nurses
19. Pre-procedure
20. Confirm the procedure
21. Inform the patient
22. Check for consent
23. Prepare needed equipment (thoracotomy tray and one or more chest tubes of
appropriate size)
24. Prepare X-ray
25. Position patient
26. Monitor patient’s vital signs including patient’s breath sounds, heart rate, blood
pressure, temperature, respiratory rate and rhythm and O2 saturation.
27. Assess for allergies
28. Make sure that O2 and suction are available at the bedside
29. Reduce patient’s anxiety, instruct the patient regarding the purpose of the
procedure, what to expect, and signs and symptoms to report.
30. Analgesia may be given as ordered and as needed.
31. Prepare the underwater seal and connect the closed system fast
32. Post procedure
33. Check respiratory status, auscultate lungs to assess air exchange in affected lung
34. Immediately after insertion and q 4 hours while chest tube is in place assess
drainage collection system for fluctuations and air bubbles in the leak indicator, and
suction set at ordered level.
35. Place patient in semi fowler’s position
36. While chest tube is in place and drainage collection system is in use, mark volume
of drainage (date, time and initial)
37. Change the gauze when necessary observing strict aseptic technique when dressing
38. Check skin integrity for redness, swelling and loose suture
39. Maintain tube patency, check for obstructions
40. Reposition patient every two hours
41. Make sure that the drainage system is in an upright position, below level of the
heart at all times
42. Document assessment and interventions

496
 - 497 -

43. Nurses who encounter patients with a chest tube for the first time tend to panic and get all
worried. However, once one gets to know and understand the basics in CTT, he/she may be
able to gain the confidence in rendering appropriate nursing care to patients with test
tube.
44. Sources:
45. http://www.americannursetoday.com/Article.aspx?id=8256&fid=8172
46. https://www.thoracic.org/clinical/critical-care/patient-information/icu-devices-
and-procedures/chest-tube-thoracostomy.php
47. http://micunursing.com/chesttubecare.htm
48. http://www.slideshare.net/hanasheque/care-of-client-with-chest-tube
Nursing Management
19. .
Trainer’s Pearls
50. .

497
 - 499 -
Chapter Outline
1. .
-oOo-
EtCO2 Monitoring (capnography)
Capnography monitors ventilation. It
tracks respiratory rate as well as a breath-
by-breath trend of CO2 as it is eliminated
from the lungs.
Why do we need to know the EtCO2?
The EtCO2 monitor can provide an EARLY
WARNING of an impending respiratory
crisis. Elevations in CO2 (for example: due
to oversedation and subsequent
hypoventilation) can be identified HOURS
before changes in oxygen saturation are
identified by a pulse oximeter.
When is EtCO2 monitoring indicated?
EtCO2 should be monitored (in addition to
pulse oximetry) whenever respiratory
depression is a possibility (examples: pain
management and sedation issues, history
of sleep apnea).
Normal Values:
EtCO2 35-45 mm Hg
If respiratory rate falls below 7 per minute:
(whether ETC02 is normal or not)
1. Evaluate patient for sleep apnea. Sleep
apnea patients are encouraged to remain
non-supine.
2. Patients can potentially have a normal
EtC02 and low respiratory rate. In these
instances it is appropriate to monitor,
contact respiratory therapy or RRT if there
is any question regarding accuracy of
EtC02 measurement.
Abnormal Values:
EtCO2 < 35 mmHg = b. 6 hours after continuous epidural
"Hyperventilation/Hypocapnia"
EtCO2 > 45 mmHg = c. IV narcotics discontinued
Hypoventilation/Hypercapnia"
Chapter
ETCO2.
Documentation
1. During acute pain management, monitor
and document ETC02 every 1 hour until
satisfactory pain control is achieved.
2. Once patient comfort is achieved,
monitor and document ETC02 (and
displayed respiratory rate) every four (4)
hours, and more frequently as patient
condition warrants.
3. Some conditions may suggest a need for
increased monitoring and documentation.
Examples of conditions that require
increased monitoring are:
a. Additional boluses
b. Continuous IV or PCA basal rate
c. Risk factors for complications associated
with narcotic administration such as
advanced age or obesity
d. Pre-existing conditions including
allergies or sleep apnea e.
Current medication use
1. Document all interventions performed
as a result of changes in ETC02 and
respiratory rate.
2. ETCO2 values should be trended,
monitored and documented more
frequently if values fall outside the normal
range of 35 to 45mmHg.
3. All reports to physicians, respiratory
therapy or RRT must be documented in the
EMR.
Discontinuation
ETC02 monitoring may be discontinued
when:
a. PCA pump is discontinued
infusion is discontinued
d. Per moderate sedation monitoring policy
499
 - 500 -

-oOo-

Chapter Essence
In a Nutshell
40. .
Nursing Alerts
49. . Nursing Interventions:
50. If EtCO2 is 45 to 50mmHg:
51. 1. Attempt to stimulate and arouse the patient. If patient is immediately aroused and
breathing normally, monitor every 15 minutes x 1 hour.
52. 2. Assess vital signs for decompensation (02 sat, BP, HR, RR, and LOC)
53. 3. Check patient for normal signs of ventilation and assess for hypoventilation via
assessment of RR, quality and depth
54. 4. Assess pain, level of sedation, and consider decreasing narcotic dose and/or frequency
55. 5. Reposition the Smart CapnoLine® if necessary
56. 6. If EtC02 remains > 45 mmHg
57.
58. in spite of interventions, contact physician If ETC02 is >50 mmHg or greater:
59. (In addition to the interventions above)
60. 1. If EtC02 does not return to normal within 5 minutes, call Rapid Response Team and
notify MD immediately to report patient condition
61. 2. Consider obtaining ABG (RT or RRT can also be consulted during this process)
62. 3. If the patient does not immediately arouse, evaluate the appropriateness of
administering Narcan to partially OR completely reverse sedation
63. 4. Patients may be referred to an intensive care unit when nursing staff has concerns
about possible respiratory compromise.
Nursing Management
20. .

500
 - 501 -

Trainer’s Pearls
51. .

501
 - 503 -

Chapter
Cardiac Arrest
Chapter Outline
1. .

-oOo-

503
 - 504 -

-oOo-

Chapter Essence
In a Nutshell
41. .
Nursing Alerts
64. .
Nursing Management
21. .
Trainer’s Pearls
52. .

504
 - 505 -

Chapter
Pregnancy Cardiac Arrest

Chapter Outline
1. .

-oOo-

505
 - 506 -

-oOo-

Chapter Essence
In a Nutshell
42. .
Nursing Alerts
65. .
Nursing Management
22. .
Trainer’s Pearls
53. .

506
- 507 -

507
 - 509 -

Chapter
Paediatric Cardiac Arrest
Chapter Outline
1. .

-oOo-

509
 - 510 -

-oOo-

Chapter Essence
In a Nutshell

510
 - 511 -

43. .
Nursing Alerts
66. .
Nursing Management
23. .
Trainer’s Pearls
54. .

511
 - 513 -

Chapter
Management of Shock
Chapter Outline
1. .

-oOo-

513
 - 514 -

-oOo-

Chapter Essence
In a Nutshell
44. .
Nursing Alerts
67. .
Nursing Management
24. . Types of Shock Nursing Management in ED
25. STEP 1
26. • Place the patient in trendelenburg position, Start nasal oxygen
27. • Secure IV line using large bore IV cannula.
28. • Take blood samples for blood grouping and cross matching.
29. • Once IV access is obtained, initial fluid resuscitation is with isotonic crystalloid such
as lactated ringer’s solution (RL) or normal saline (NS). An initial bolus of one to two liters is
given for an adult or 20 ml/kg for a pediatric patient, and then the patient response os
assessed. If vital sings returns to normal, the patient may be monitored to ensure stability,
and blood Samples should be send for type and cross match. If vital sings transiently
improve, crystalloid infusion should continue, and type specific blood obtained.
30. • According to the types of shock, If there is no response within 30 minutes start a
colloid like haemaccel. Plan for blood transfusion.
31. • catheterize the bladder and assess urine output
32. STEP 2
33. • monitor pulse rate, Blood Pressure, Respiration Rate continuously

514
 - 515 -

34. • Replace the blood if the shock is because of blood loss

35. • If there is oliguria start dopamine infusion (2-4 micrograms/kg/mt)
36. • All female patients of child bearing years should have a pregnancy test done. if the
patient is pregnant and shock. A pelvic Ultra Sonography S should be performed
immediately in the emergency department. A culdocentesis may be performed, although in
most places, ultrasound can be done in the ED, and yields more information on the source
of bleeding
Trainer’s Pearls
55. .

515
 - 517 -
Chapter
Bleeding and Hypovolemia, management of Shock,
Hemorrhage Control.
Chapter Outline
1. .
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C-Circulation, Hemorrhage control
• Circulatory compromise in trauma
patients can result from many different
injuries.
• Definitive bleeding control is essential
along with appropriate replacement of
intravascular volume. A minimum
• of two large-caliber intravenous (IV)
catheters should be introduced.
• The maximum rate of fluid
administration is determined by the
internal diameter of the catheter and
inversely by its length—not by the size
of the vein in which the catheter is
placed.
• Establishment of upper-extremity
peripheral IV access is preferred.
• Other peripheral lines, cutdowns, and
central venous lines should be used as
necessary in accordance with the skill
level of the clinician who is caring for
the patient.
• At the time of IV insertion, blood should
be drawn for type and crossmatch and
baseline hematologic studies, including
a pregnancy test for all females of
childbearing age.
• Blood gases and/or lactate level should
be obtained to assess the presence and
degree of shock.
• Aggressive and continued volume
resuscitation is not a substitute for
definitive control of hemorrhage.
• Definitive control includes surgery,
angioembolization, and pelvic
stabilization.
• IV fluid therapy with crystalloids
should be initiated.
• A bolus of 1 to 2 L of an isotonic
solution may be required to achieve an
appropriate response in the adult
patient.
• All IV solutions should be warmed
either by storage in a warm
environment (i.e., 37°C to 40°C, or
98.6°F to 104°F) or fluid-warming
devices.
• Shock associated with injury is most
often hypovolemic in origin.
• If the patient is unresponsive to initial
crystalloid therapy, blood transfusion
should be given.
• Hypothermia may be present when the
patient arrives, or it may develop
quickly in the ED if the patient is
uncovered and undergoes rapid
administration of room-temperature
fluids or refrigerated blood.
• Hypothermia is a potentially lethal
complication in injured patients, and
aggressive measures should be taken to
prevent the loss of body heat and
restore body temperature to normal.
• The temperature of the resuscitation
area should be increased to minimize
the loss of body heat.
• The use of a high-flow fluid warmer or
microwave oven to heat crystalloid
fluids to 39°C (102.2°F) is
recommended.
• However blood products should not be
warmed in a microwave oven.
• Injured patients can arrive in the ED
with hypothermia, and hypothermia
can develop in some patients who
require massive transfusions and
crystalloid resuscitation despite
aggressive efforts to maintain body
heat.
• The problem is best minimized by early
control of hemorrhage.
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• This can require operative intervention
or the application of an external
compression device to reduce the pelvic
volume in patients with certain types of
pelvic fractures.
• Efforts to rewarm the patient and
prevent hypothermia should be
considered as important as any other
component of the primary survey and
resuscitation phase.
Peripheral Venous Access
• STEP 1. Select an appropriate site
on an extremity (antecubital,
forearm, or saphenous vein).
• STEP 2. Apply an elastic tourniquet
above the proposed puncture site.
• STEP 3. Clean the site with
antiseptic solution.
• STEP 4. Puncture the vein with a
large-caliber, plastic,
over-the-needle catheter. Observe
for blood return.
• STEP 5. Thread the catheter into
the vein over the needle.
• STEP 6. Remove the needle and
tourniquet.
• STEP 7. If appropriate, obtain
blood samples for laboratory tests.
• STEP 8. Connect the catheter to the
intravenous infusion tubing and
begin the infusion of warmed
crystalloid solution.
• STEP 9. Observe for possible
infiltration of fluids into the tissues.
• STEP 10. Secure the catheter and
tubing to the skin of the extremity.
Femoral Venipuncture: Seldinger
Technique
Note: Sterile technique should be used
when performing this procedure.
• STEP 1. Place the patient in the
supine position.
• STEP 2. Cleanse the skin around
the venipuncture site well and
drape the area.
• STEP 3. Locate the femoral vein by
palpating the femoral artery. The
vein lies directly medial to the
femoral artery (remember the
mnemonic NAVEL, from lateral to
medial: nerve, artery, vein, empty
space, lymphatic). Keep a finger on
the artery to facilitate anatomical
location and avoid insertion of the
catheter into the artery. Ultrasound
can be used as an adjunct for
placement of central venous lines.
• STEP 4. If the patient is awake, use
a local anesthetic at the
venipuncture site.
• STEP 5. Make a small skin incision
at the entry point of wire or
dilatation of central vein to insert
large bore catheter.
• STEP 6. Introduce a large-caliber
needle attached to a 12-mL syringe
with 0.5 to 1 mL of saline. The
needle, directed toward the
patient’s head, should enter the skin
directly over the femoral vein
(n-FIGURE-IV-1A). Hold the needle
and syringe parallel to the frontal
plane.
• STEP 7. Directing the needle
cephalad and posteriorly, slowly
advance it while gently withdrawing
the plunger of the syringe.
• STEP 8. When a free flow of blood
appears in the syringe, remove the
syringe and occlude the needle with
a finger to prevent air embolism. If
the vein is not entered, withdraw
the needle and redirect it. If two
attempts are unsuccessful, a more
experienced clinician should
attempt the procedure, if available.
• STEP 9. Insert the guidewire and
remove the needle. Use an
introducer if required
• STEP 10. Insert the catheter over
the guidewire
• STEP 11. Remove the guidewire
and connect the catheter to the
intravenous tubing.
• STEP 12. Affix the catheter in place
(with a suture), apply antibiotic
ointment, and dress the area.
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• STEP 13. Tape the intravenous
tubing in place.
• STEP 14. Obtain chest and
abdominal x-ray films to confirm
the position and placement of the
intravenous catheter.
• STEP 15. Change the catheter as
soon as it is practical.
MAJOR COMPLICATIONS OF FEMORAL
VENOUS ACCESS
• Deep-vein thrombosis n Arterial or
neurologic injury
• Infection n Arteriovenous fistula
Subclavian Venipuncture:
Infraclavicular Approach
Note: Sterile technique should be used
when performing this procedure.
• STEP 1. Place the patient in the
supine position, with the head at
least 15 degrees down to distend
the neck veins and prevent air
embolism. Only if a cervical spine
injury has been excluded can the
patient’s head be turned away from
the venipuncture site.
• STEP 2. Cleanse the skin around
the venipuncture site well and
drape the area.
• STEP 3. If the patient is awake, use
a local anesthetic at the
venipuncture site.
• STEP 4. Introduce a large-caliber
needle, attached to a 12-mL syringe
with 0.5 to 1 mL of saline, 1 cm
below the junction of the middle
and medial one-third of the clavicle.
Ultrasound can be used as an
adjunct for the placement of central
venous lines
• STEP 5. After the skin has been
punctured, with the bevel of the
needle upward, expel the skin plug
that can occlude the needle.
• STEP 6. Hold the needle and
syringe parallel to the frontal plane.
• STEP 7. Direct the needle medially,
slightly cephalad, and posteriorly
behind the clavicle toward the
posterior, superior angle of the
sternal end of the clavicle (toward
the finger placed in the suprasternal
notch).
• STEP 8. Slowly advance the needle
while gently withdrawing the
plunger of the syringe.
• STEP 9. When a free flow of blood
appears in the syringe, rotate the
bevel of the needle caudally, remove
the syringe, and occlude the needle
with a finger to prevent air
embolism. If the vein is not entered,
withdraw the needle and redirect it.
If two attempts are unsuccessful, a
more experienced clinician should
attempt the procedure, if available.
• STEP 10. Insert the guidewire
while monitoring the
electrocardiogram for rhythm
abnormalities.
• STEP 11. Remove the needle while
holding the guidewire in place.
• STEP 12. Insert the catheter over
the guidewire to a predetermined
depth (the tip of the catheter should
be above the right atrium for fluid
administration).
• STEP 13. Connect the catheter to
the intravenous tubing.
• STEP 14. Affix the catheter
securely to the skin (with a suture),
apply antibiotic ointment, and dress
the area.
• STEP 15. Tape the intravenous
tubing in place.
• STEP 16. Obtain a chest x-ray film
to confirm the position of the
intravenous line and identify a
possible pneumothorax.
Internal Jugular Venipuncture: Middle or
Central Route
Note: This procedure is frequently difficult
to perform in injured patients because they
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are often immobilized to protect the
cervical spine. Sterile technique should be
used when performing this procedure.
• STEP 1. Place the patient in the
supine position, with the head at
least 15 degrees down to distend
the neck veins and prevent an air
embolism. Only if the cervical spine
has been cleared radiographically
can the patient’s head be turned
away from the venipuncture site.
• STEP 2. Cleanse the skin around
the venipuncture site well and
drape the area.
• STEP 3. If the patient is awake, use
a local anesthetic at the
venipuncture site.
• STEP 4. Introduce a large-caliber
needle, attached to a 12-mL syringe
with 0.5 to 1 mL of saline, into the
center of the triangle formed by the
two lower heads of the
sternomastoid and the clavicle.
Ultrasound can be used as an
adjunct for the placement of central
venous lines.
• STEP 5. After the skin has been
punctured, with the bevel of the
needle upward, expel the skin plug
that can occlude the needle.
• STEP 6. Direct the needle caudally,
parallel to the sagittal plane, at an
angle 30 degrees posterior to the
frontal plane.
• STEP 7. Slowly advance the needle
while gently withdrawing the
plunger of the syringe.
• STEP 8. When a free flow of blood
appears in the syringe, remove the
syringe and occlude the needle with
a finger to prevent air embolism. If
the vein is not entered, withdraw
the needle and redirect it 5 to 10
degrees laterally.
• STEP 9. Insert the guidewire while
monitoring the electrocardiogram
(ECG) for rhythm abnormalities.
• STEP 10. Remove the needle while
securing the guidewire and advance
the catheter over the wire. Connect
the catheter to the intravenous
tubing.
• STEP 11. Affix the catheter in place
to the skin with suture, apply
antibiotic ointment, and dress the
area.
• STEP 12. Tape the intravenous
tubing in place.
• STEP 13. Obtain a chest film to
confirm the position of the
intravenous line and identify a
possible pneumothorax.
COMPLICATIONS OF CENTRAL VENOUS
PUNCTURE
• Pneumothorax or hemothorax
• Venous thrombosis
• Arterial or neurologic injury
• Arteriovenous fistula
• Chylothorax
• Infection
• Air embolism
Intraosseous Puncture/Infusion:
Proximal Tibial Route
Note: Sterile technique should be used
when performing this procedure. This
procedure is appropriate for all ages when
venous access is impossible because of
circulatory collapse or when percutaneous
peripheral venous cannulation has failed
on two attempts. Intraosseous infusions
(blood and crystalloids) should be limited
to emergency resuscitation discontinued as
soon as other venous access has been
obtained.
Swelling around the intraosseous needle
should prompt discontinuation of fluid
infusion and removal of the intraosseous
device.
• STEP 1. Place the patient in the
supine position. Select an uninjured
lower extremity, place sufficient
padding under the knee to effect
approximate 30-degree flexion of
the knee, and allow the patient’s
heel to rest comfortably on the
gurney or stretcher.
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• STEP 2. Identify the puncture
site—the anteromedial surface of
the proximal tibia, approximately
one fingerbreadth (1 to 3 cm) below
the tubercle.
• STEP 3. Cleanse the skin around
the puncture site well and drape the
area.
• STEP 4. If the patient is awake, use
a local anesthetic at the puncture
site.
• STEP 5. Initially at a 90-degree
angle, introduce a short (threaded
or smooth), large-caliber,
bone-marrow aspiration needle (or
a short, 18-gauge spinal needle with
stylet) into the skin and periosteum,
with the needle bevel directed
toward the foot and away from the
epiphyseal plate.
• STEP 6. After gaining purchase in
the bone, direct the needle 45 to 60
degrees away from the epiphyseal
plate. Using a gentle twisting or
boring motion, advance the needle
through the bone cortex and into
the bone marrow.
• STEP 7. Remove the stylet and
attach to the needle a 12-mL syringe
with approximately 6 mL of sterile
saline. Gently draw on the plunger
of the syringe. Aspiration of bone
marrow into the syringe signifies
entrance into the medullary cavity.
• STEP 8. Inject the saline into the
needle to expel any clot that can
occlude the needle. If the saline
flushes through the needle easily
and there is no evidence of swelling,
the needle is likely located in the
appropriate place. If bone marrow
was not aspirated as outlined in
Step 7, but the needle flushes easily
when injecting the saline and there
is no evidence of swelling, the
needle is likely in the appropriate
Management of Shock : Fluid Resuscitation
 Estimated Fluid and Blood Losses: ( For a 70-kg man )
place. In addition, proper placement
of the needle is indicated if the
needle remains upright without
support and intravenous solution
flows freely without evidence of
subcutaneous infiltration.
• STEP 9. Connect the needle to the
large-caliber intravenous tubing
and begin fluid infusion. Carefully
screw the needle further into the
medullary cavity until the needle
hub rests on the patient’s skin and
free flow continues. If a smooth
needle is used, it should be
stabilized at a 45- to 60-degree
angle to the anteromedial surface of
the patient’s leg.
• STEP 10. Apply antibiotic ointment
and a 3 3 sterile dressing. Secure
the needle and tubing in place.
• STEP 11. Routinely reevaluate the
placement of the intraosseous
needle, ensuring that it remains
through the bone cortex and in the
medullary canal. Remember,
intraosseous infusion should be
limited to emergency resuscitation
of the patient and discontinued as
soon as other venous access has
been obtained.
COMPLICATIONS OF INTRAOSSEOUS
PUNCTURE
• Infection
• Through-and-through penetration
of the bone
• Subcutaneous or subperiosteal
infiltration
• Pressure necrosis of the skin
• Physeal plate injury n Hematoma
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Class I Class II Class III Class IV

Blood Loss (ml) Up to 750 750-1500 1500-2000 >2000
Blood Loss Up to 15 % 15-30 % 30-40 % >40 %
(% Blood Volume)
Pulse Rate <100 >100 >120 >140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure Normal or Decreased Decreased Decreased
(mmHg) increased
Respiratory Rate 14-20 20-30 30-40 > 35
Urine Output >30 20-30 5-15 Negligible
(mL/hr)
CNS/Mental status Slightly Mildly Anxious, Confused,
anxious anxious Confused lethargy
Fluid Repacement Crystalloid Crystalloid Crystalloid Crystalloid
(3:1 rule) and blood and blood

 Fluid Therapy:
 Fluid bolus: 1-2 liters for an adult and 20mL/kg for a pediatric patient
 3:1 rule
 39 C ( 1 liter fluid, microwave, high power, 2 minutes )

 Blood Replacement:
 PRBC/Whole blood
 Crossmatched/type-specific/ type O blood
 FFP ( 1U FFP for every 5 U PRBC)

 CVP monitoring

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Chapter Essence
In a Nutshell
45. .
Nursing Alerts
68. . Nursing Care Planning & Goals
69. The major goals for the patient are:
70. • Maintain fluid volume at a functional level.
71. • Report understanding of the causative factors of fluid volume deficit.
72. • Maintain normal blood pressure, temperature, and pulse.
73. • Maintain elastic skin turgor, most tongue and mucous membranes, and orientation
to person, place, and time.
Nursing Management
37. . Nursing Interventions
38. Nursing care focuses on assisting with treatment targeted at the cause of the shock and
restoring intravascular volume.
39. • Safe administration of blood. It is important to acquire blood specimens quickly, to
obtain baseline complete blood count, and to type and crossmatch the blood in
anticipation of blood transfusions.

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40. • Safe administration of fluids. The nurse should monitor the patient closely for
cardiovascular overload, signs of difficulty of breathing, pulmonary edema, jugular vein
distention, and laboratory results.
41. • Monitor weight. Monitor daily weight for sudden decreases, especially in the
presence of decreasing urine output or active fluid loss.
42. • Monitor vital signs. Monitor vital signs of patients with deficient fluid volume every
15 minutes to 1 hour for the unstable patient, and every 4 hours for the stable patient.
43. • Oxygen administration. Oxygen is administered to increase the amount of oxygen
carried by available hemoglobin in the blood.
44. Evaluation
45. Expected outcomes for the patient include:
46. • Maintained fluid volume at a functional level.
47. • Reported understanding of the causative factors of fluid volume deficit.
48. • Maintained normal blood pressure, temperature, and pulse.
49. • Maintained elastic skin turgor, most tongue and mucous membranes, and
orientation to person, place, and time.
50. Documentation Guidelines
51. The focus of documentation include:
52. • Degree of deficit and current sources of fluid intake.
53. • I&O, fluid balance, changes in weight, presence of edema, urine specific gravity, and
vital signs.
54. • Results of diagnostic studies.
55. • Functional level and specifics of limitations.
56. • Needed resources and adaptive devices.
57. • Availability and use of community resources.
58. • Plan of care.
59. • Teaching plan.
60. • Client’s responses to interventions, teachings, and actions performed
61. • Attainment or progress towards desired outcomes.
62. • Modifications to plan of care.
Trainer’s Pearls
56. .

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Chapter
“Chest Pain” - Acute Coronary Syndrome ACS.
Chapter Outline
1. .

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Chapter Essence

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In a Nutshell
46. .
Nursing Alerts
74. .
75. Nursing Diagnosis for Chest Pain
76.
77. 1. Acute pain r / t tissue ischemia secondary to arterial occlusion, tissue
inflammation.
78. 2. Ineffective Tissue perfusion (heart muscle) r / t decrease in blood flow.
79. 3. Activity intolerance r / t imbalance between oxygen supply and tissue metabolic
needs.
80.
81. Interventions:
82.
83. • Bed rest with Fowler position / semi-Fowler.
84. • Perform a 12 lead ECG, 24-lead if necessary.
85. • Observing vital signs.
86. • Collaboration of O2 and administration of analgesic medications, tranquilizers,
nitroglycerin, calcium antagonists and observation of drug side effects.
87. • Installing a drip and give peace to the client.
88. • Taking blood samples.
89. • Reduce environmental stimuli.
90. • Calm in the works.
91. • Observing signs of complications.
Nursing Management
63. . Nursing Management
64. The nursing management involved in MI is critical and systematic, and efficiency is needed
to implement the care for a patient with MI.
65. Nursing Assessment
66. One of the most important aspects of care of the patient with MI is the assessment.
67. • Assess for chest pain not relieved by rest or medications.
68. • Monitor vital signs, especially the blood pressure and pulse rate.
69. • Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles.
70. • Assess for nausea and vomiting.
71. • Assess for decreased urinary output.
72. • Assess for the history of illnesses.
73. • Perform a precise and complete physical assessment to detect complications and
changes in the patient’s status.
74. • Assess IV sites frequently.
75. Diagnosis
76. Based on the clinical manifestations, history, and diagnostic assessment data, major
nursing diagnoses may include.
77. • Ineffective cardiac tissue perfusion related to reduced coronary blood flow.
78. • Risk for ineffective peripheral tissue perfusion related to decreased cardiac output
from left ventricular dysfunction.
79. • Deficient knowledge related to post-MI self-care.
80. Planning & Goals
81. To establish a plan of care, the focus should be on the following:
82. • Relief of pain or ischemic signs and symptoms.

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83. • Prevention of myocardial damage.

84. • Absence of respiratory dysfunction.
85. • Maintenance or attainment of adequate tissue perfusion.
86. • Reduced anxiety.
87. • Absence or early detection of complications.
88. • Chest pain absent/controlled.
89. • Heart rate/rhythm sufficient to sustain adequate cardiac output/tissue perfusion.
90. • Achievement of activity level sufficient for basic self-care.
91. • Anxiety reduced/managed.
92. • Disease process, treatment plan, and prognosis understood.
93. • Plan in place to meet needs after discharge.
94. Nursing Priorities
95. 1. Relieve pain, anxiety.
96. 2. Reduce myocardial workload.
97. 3. Prevent/detect and assist in treatment of life-threatening dysrhythmias or
complications.
98. 4. Promote cardiac health, self-care.
99. Nursing Interventions
100. Nursing interventions should be anchored on the goals in the nursing care plan.
101. • Administer oxygen along with medication therapy to assist with relief of
symptoms.
102. • Encourage bed rest with the back rest elevated to help decrease chest
discomfort and dyspnea.
103. • Encourage changing of positions frequently to help keep fluid from pooling
in the bases of the lungs.
104. • Check skin temperature and peripheral pulses frequently to monitor tissue
perfusion.
105. • Provide information in an honest and supportive manner.
106. • Monitor the patient closely for changes in cardiac rate and rhythm, heart
sounds, blood pressure, chest pain, respiratory status, urinary output, changes in skin
color, and laboratory values.
107. Evaluation
108. After the implementation of the interventions within the time specified, the nurse
should check if:
109. • There is an absence of pain or ischemic signs and symptoms.
110. • Myocardial damage is prevented.
111. • Absence of respiratory dysfunction.
112. • Adequate tissue perfusion maintained.
113. • Anxiety is reduced.
114. Discharge and Home Care Guidelines
115. The most effective way to increase the probability that the patient will implement a
self-care regimen after discharge is to identify the patient’s priorities.
116. • Education. This is one of the priorities that the nurse must teach the patient
about heart-healthy living.
117. • Home care. The home care nurse assists the patient with scheduling and
keeping up with the follow-up appointments and with adhering to the prescribed cardiac
rehabilitation management.
118. • Follow-up monitoring. The patient may need reminders about follow-up
monitoring including periodic laboratory testing and ECGs, as well as general health

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screening.
119. • Adherence. The nurse should also monitor the patient’s adherence to
dietary restrictions and prescribed medications.
120. Documentation Guidelines
121. To ensure that every action documented is an action done, documentation must be
secured. The following should be documented:
122. • Individual findings.
123. • Vital signs, cardiac rhythm, presence of dysrhythmias.
124. • Plan of care and those involved in planning.
125. • Teaching plan.
126. • Response to interventions, teaching, and actions performed.
127. • Attainment or progress towards desired outcomes.
128. • Modifications to plan of care.
Trainer’s Pearls
57. . Nursing Management
58. 1. Early identification of myocardial ischemia
59. • Apply ‘ SOCRATES’ to assess pain and its characteristics Immediate
60. • Administer Tab. Aspirin to prevent platelet aggregation
61. • Administer intravenous anti-platelet agents such as Tirofiban, and unfractionated
heparin to prevent new thrombus formation.
62. •Administer Nitroglycerin for vasodilatation
63. • Monitor patients for hemodynamic stability
64.
65. STEMI
66. • Collect accurate history of symptoms and perform 12-lead ECG to determine initially the
diagnosis of MI.
67. • The ECG is examined for the presence of ST segment elevations of 1 mV or greater in at
least two contiguous leads.
68. • Administer chewable Aspirin, 160 to 325 mg, Tab. Clopidogrel 300 mg and Tab.
Atorvastatin 80mg to prevent new clot formation.
69. • Place the patient on a cardiac monitor and assess for arrhythmias
70. . • Monitor patients for hemodynamic stability
71. • Administer oxygen if SPO2 is less than 94%/ or patient has dyspnoea.
72. • Administer sublingual Nitroglycerin (Angised/Sorbitrate). Omit if BP (systolic blood
pressure) is less than 90 mm Hg or the heart rate is less than 50 or greater than 100
beats/minute.
73. • Provide adequate analgesia with morphine sulfate to reduce chest pain.
74. • Administer other drugs such as LMW heparin, Statins, Beta blocker and ACE inhibitor
depending upon the condition of patient
75. • Prepare the patient for thrombolysis or primary Percutaneous Transluminal
Coronary Angioplasty
76. • Monitor the patient for lethal arrhythmias such as ventricular tachycardia or
ventricular fibrillation
77. Thrombolytic Therapy - The drugs used to thrombolyse include Inj.Streptokinase/ Ateplase/
Tissue Plasminogen activator. The purpose is to dissolve the thrombus in coronary artery
so that the perfusion to the damaged myocardium can be improved. Thrombolytic
therapy provides maximal benefit if given within the first 3 hours after the onset of
symptoms. Significant benefit still occurs if therapy is given up to 12 hours after onset of
symptoms. Pain relief, resolution of acute ST elevation, and transient arrhythmias are the

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signs of successful reperfusion. The greatest benefit in mortality reduction was observed
when Streptokinase was administered within four hours, but benefit has been reported up
to 24 hours
78. Nursing alert
79. • Do not delay in initiating treatment
80. • Administer drugs promptly
81. • Monitor continuously for complications
82. • Detect for occurrence of arrhythmias and other complications
83. • Provide complete bed rest till hemodynamically stable
84. • Increase activity progressively

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Chapter
Return of Spontaneous Circulation (Adult)
Chapter Outline
1. .

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The strategies in adult immediate post-cardiac arrest care

Strategy Doses/details
Airway Consider tracheal intubation and waveform capnography
Breathing- Avoid hypoxemia
oxygenation Goal: titrate FiO2 to achieve SpO2 94% to 98%
Breathing- Avoid excessive ventilation
ventilation Goal: titrate to target PaCO2 35 to 45 mmHg or PETCO2 30 to 40 mmHg
Circulation- Avoiding and immediately correcting hypotension (systolic blood
hemodynamics pressure <90 mmHg, mean arterial pressure <65 mmHg)
Goal: systolic blood pressure ≥100 mmHg
Circulation- Norepinephrine: 0.1 to 0.5 mcg/kg/min
vasoactive drugs Dopamine: 5 to 10 mcg/kg/min

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Strategy Doses/details
Epinephrine: 0.1 to 0.5 mcg/kg/min
Correct the Hypovolemia, hypoxia, hydrogen ion (acidosis),
reversible causes hypokalemia/hyperkalemia, hypothermia, tension pneumothorax, cardiac
tamponade, toxins, pulmonary thrombosis, coronary thrombosis
FiO2, fraction of inspired oxygen; SpO2, oxygen saturation; PaCO2, arterial oxygen tension;
PETCO2, Partial pressure of end-tidal carbon dioxide.

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Chapter Essence
In a Nutshell
47. .
Nursing Alerts
92. .
Nursing Management
129. .
Trainer’s Pearls
85. .

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Chapter
Return of Spontaneous Circulation – Children
Chapter Outline
1. .

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535
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536
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Chapter Essence
In a Nutshell
48. .
Nursing Alerts
93. .
Nursing Management
130. .
Trainer’s Pearls
86. .

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Chapter
Tachy Cardia & Brady Cardia Protocol - Adult
Chapter Outline
1. .

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539
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-oOo-

Chapter Essence
In a Nutshell
49. .
Nursing Alerts
94. .
Nursing Management
131. .
Trainer’s Pearls
87. .

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Chapter
Tachy Cardia & Brady Cardia Protocol - Children
Chapter Outline
1. .

-oOo-

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-oOo-

Chapter Essence
In a Nutshell
50. .
Nursing Alerts
95. .
Nursing Management
132. .

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Trainer’s Pearls
88. .

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Chapter
CPR and “DC Shock” – BLS and AED Defibrillation
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
51. .
Nursing Alerts
96. .
Nursing Management
133. .
Trainer’s Pearls
89. .

547
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Chapter
Advanced Cardiac Life Support : Synchronised
Electrical Cardioversion
Chapter Outline
1. .
-oOo-
CPR and “DC Shock” – BLS and AED
Defibrillation
Cardiopulmonary resuscitation (CPR) is an
emergency procedure that combines chest
compressions often with artificial
ventilation in an effort to manually
preserve intact brain function until further
measures are taken to restore spontaneous
blood circulation and breathing in a person
who is in cardiac arrest. It is recommended
in those who are unresponsive with no
breathing or abnormal breathing, for
example, agonal respirations.
CPR involves chest compressions for adults
between 5 cm (2.0 in) and 6 cm (2.4 in)
deep and at a rate of at least 100 to 120 per
minute. The rescuer may also provide
artificial ventilation by either exhaling air
into the subject's mouth or nose (mouth-
to-mouth resuscitation) or using a device
that pushes air into the subject's lungs
(mechanical ventilation). Current
recommendations place emphasis on early
and high-quality chest compressions over
artificial ventilation; a simplified CPR
method involving chest compressions only
is recommended for untrained rescuers. In
children, however, only doing
compressions may result in worse
outcomes. Chest compression to breathing
ratios is set at 30 to 2 in adults.
CPR alone is unlikely to restart the heart.
Its main purpose is to restore partial flow
of oxygenated blood to the brain and heart.
The objective is to delay tissue death and to
extend the brief window of opportunity for
a successful resuscitation without
permanent brain damage. Administration
of an electric shock to the subject's heart,
termed defibrillation, is usually needed in
order to restore a viable or "perfusing"
heart rhythm. Defibrillation is effective
only for certain heart rhythms, namely
ventricular fibrillation or pulseless
ventricular tachycardia, rather than
asystole or pulseless electrical activity.
Early shock when appropriate is
recommended. CPR may succeed in
inducing a heart rhythm that may be
shockable. In general, CPR is continued
until the person has a return of
spontaneous circulation (ROSC) or is
declared dead.
In their 2015 Guidelines, the AHA
describes high-quality CPR as the
combined impact of 5 factors:
• Depth: 2–2.4 inches (5–6 centimeters)
• Compression rate: 100–120/minute
• Recoil: Allow for full recoil after each
compression. No leaning.
• Minimize pauses. Get the chest
compression fraction (CCF), the
percentage of time CPR is being
delivered, as high as possible, with a
target of at least 60%. It may be
reasonable with a sufficient number of
rescuers to achieve a CCF greater than
80%.
• Ventilation: 2 breaths after 30
compressions without an advanced
airway; 1 breath every 6 seconds with
an advanced airway & continue CPR for
2 minutes.
AED (Automated External Defibrillator)
Definition
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Defibrillation is a process in which an
electronic device sends an electric shock to
the heart to stop an extremely rapid,
irregular heartbeat, and restore the normal
heart rhythm if the heart is viable.
Purpose
Defibrillation is performed to correct life-
threatening fibrillations of the heart and to
be followed by an effective CPR to restore
the normal cardiac activity.
Precautions
Defibrillation should not be performed on a
patient who has a pulse or is alert, as this
could cause a lethal heart rhythm
disturbance or cardiac arrest.
The paddles used in the procedure should
not be placed on a woman's breasts or over
a pacemaker.
Quickly wipe the chest for excessive sweat
or water on the victims chest
Paddles should not be placed on top of any
medicine patch
Steps of AED
Steps to operate AED :
P→ Power on
A → Attach pads
A → Analyze heart rhythm of the patient
(Clear the patient before analyzing)
S → Shock (Clear the patient before giving
shock)
MANUAL DEFIBRILLATION
Initiate CPR until defibrillator available to
maintain oxygenation/circulation to brain
and heart. Prepare and plan for crash
intubation. Defibrillate as soon as possible.
Preparing the patient for defibrillation:
• Bring the side railings down
• Make the bed and patient flat
• Prepare the machine for defibrillation:
• Turn defibrillator on and ensure the
machine is defib model
• Set charge at 360 joules monophasic/
200 J biphasic.
• Hold paddles firmly to chest until charge
is complete.
• Ensure that paddles do not come in
contact with ECG leads.
• Command, I am Clear, Are You Clear,
Every Body Clear to ensure safety of
team and patient or simply command “
CLEAR”Apply gel on to paddles and
press paddles firmly applying 25-30 lbs
pressure
• Ensure that the whole surface of the
paddle is in contact with the victim’s
skin
• Discharge by simultaneously depressing
buttons on both the paddles.
• Be sure to depress buttons firmly and
hold for 2 seconds.
• The shock delivered is indicated by
sudden jerky contraction of muscles
• Immediately resume CPR for two
minutes followed by reassessment.
Points to remember
In order to give the victim in cardiac arrest,
the best chance of survival, CPR has to be
integrated with defibrillation
Endotracheal intubation is not always
mandatory for successful cardiac arrest
resuscitation. But if situations warrants, do
an early advanced airway insertion.
Effective ventilation can also be achieved
by bag-valve mask ventilation.
When VF/ pulse less ventricular
tachycardia (pVT) are present, the rescuer
should deliver 1 shock and should then
immediately resume CPR. The rescuer
should not delay resumption of chest
compressions to recheck the rhythm or
pulse.
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If a non shockable rhythm is detected, the
AED would instruct the rescuer to resume
CPR immediately, beginning with chest
compressions.
The health care provider should be aware
of the rhythm being displayed on the
defibrillator screen and judge whether
subsequent shocks will be necessary or
not.
For adult defibrillation, both handheld
paddle electrodes and self-adhesive pad
electrodes 8 to 12 cm in diameter perform
well rather than the small paddles (4.3cm)
which may cause myocardial necrosis.
Equipment required for
defibrillation/cardioversion
• Defibrillator unit
• Functioning oxygen
• suction source
• Hand - ventilation equipment connected
to oxygen with appropriate size mask
and oro - pharyngeal airway
• Suction catheter
• Emergency drugs Atropine,
Adrenaline,Vasopressin
• Intubation equipment
• Conduction jelly
Preparing for emergency defibrillation
• Move bed away from wall and remove
head of bed
• Ensure effective CPR is being performed
Position the patient in supine without
any pillow
• Take the defibrillator to the left side of
patient
• Turn on the 0defibrillator
• Select the joules(200J-BIPHASIC,200-
360J-MONOPHASIC)
• Select paddles mode and asynchronized
mode and ensure patient is off oxygen
• Apply gel to the paddle and place the
paddles on the chest
• Apply 10kg of pressure over the paddles
• Check the rhythm and confirm the
arrhythmia
• Charge the defibrillator to the selected
joules
• Loudly say ALL CLEAR
• Recheck the rhythm and confirm the
arrhythmia
• Defibrillate by pressing the discharge
buttons
• Reassess cardiac monitor to determine
the rhythm and leave the paddles in
place
Reasons for failed defibrillation
• Equipment
• -failing to charge, low battery, no Ac
power, synchronizing mode off
• -paddles disconnected from main unit
• Ineffective shock and arrhythmias
• Ineffective cardiac massage and oxygen
• Situation that requires repeat
defibrillation at higher setting
• Drug toxicities

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Chapter Essence
In a Nutshell
52. .
Nursing Alerts
97. . Nursing
98. When defibrillation fails
99. Deliver three successive discharge of increasing joules
100. Assess techniques

551
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101. Assess patient status

Nursing Management
134. .
Trainer’s Pearls
90. .

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Chapter
Advanced Cardiac Life Support : Synchronised
Electrical Cardioversion
Chapter Outline
1. .
-oOo-
SYNCHRONIZED ELECTRICAL
CARDIOVERSION
Delivery of direct current (DC) shocks to
the heart has long been used successfully
to convert abnormal heart rhythms back to
normal sinus rhythm
The DC electrical discharge is synchronized
with the R or S wave of the QRS complex.
Synchronization in the early part of the
QRS complex avoids energy delivery near
the apex of the T wave in the surface ECG,
which coincides with a vulnerable period
for induction of ventricular fibrillation.
Based on advanced cardiac life support
(AHA ACLS) guidelines, any patient with
narrow or wide QRS complex tachycardia
(ventricular rate >150) who is unstable
(e.g., chest pain, pulmonary edema, acutely
altered mental status, hypotension) should
be immediately treated with synchronized
electrical cardioversion
Synchronized electrical cardioversion may
be used to treat stable VT that does not
respond to a trial of intravenous
medications.
In hemodynamically stable patients with
atrial fibrillation, atrial flutter, or other
supraventricular tachycardia (SVT),
synchronized electrical cardioversion can
also be used electively after using chemical
ways to restore sinus rhythm.
Because DC delivery is painful, it is usually
performed after the patient has received
sufficient intravenous sedation from an
Emergency Physician or Anesthesiologist
or trained Nurse to produce an analgesic
effect.
Contraindications
Contraindications include patients with
known digitalis toxicity–associated
tachycardia, patients with sinus
tachycardia caused by various clinical
conditions, or patients with multifocal
atrial tachycardia.
In addition, patients with atrial fibrillation
are at risk to develop stroke. As a result,
patients who are not anticoagulated should
not undergo cardioversion without a
transesophageal echo that can assess the
presence of left atrial thrombus. But if the
patient is unstable, synchronized
cardioversion must be performed.
Procedure
• Equipment required are intravenous
access, airway management equipment,
sedative drugs, and a cardioverter /
defibrillator monitoring device.
• Patient should be adequately sedated
with a short-acting agent such as
Midazolam or Propofol.
• Defibrillator should be placed in the
synchronized mode, which permits a
search for a large R or S wave.
• Ensure that cardioversion marker
correctly picks on just before R wave
The energy to belivered is selected.
• One paddle is placed on the left fourth or
fifth intercostal space on the midaxillary
line; the other paddle is placed just to
the right of the sternal edge on the
second or third intercostal space.
• Paddles should be placed firmly against
the chest wall to avoid arcing and skin
burns.
• Pacemakers and Implanted Cardio
Defibrillator should be at least 10 cm
from direct contact with paddles
• Recommended initial monophasic
energy dose for cardioversion of atrial
fibrillation is 120 j to 200 j.
Cardioversion of atrial flutter and other
supraventricular tachycardias generally
553
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requires less energy; an initial energy of recommended. In subsequent attempts,
50 j to 100 j is often sufficient. If the the energy is increased.
initial 50-j shock fails, providers should • During pregnancy, recommendations as
increase the dose in a stepwise fashion for other adults are applicable.
• Monomorphic VT (regular form and Complications
rate) with a pulse responds well to • Inducible arrhythmias include
monophasic waveform cardioversion bradycardia, atrioventricular (AV) block,
(synchronized) shocks at initial energies asystole, pVT and VF.
of 100 j. • In patients with acute coronary
• If there is no response to the first shock, syndromes or acute myocardial
increase the dose in a stepwise fashion infarction, bradycardia or AV blocks can
(eg, 100 j, 200 j, 300 j, 360 j). be induced
Special conditions
• In pediatric patients with PSVT or VT
who are not hemodynamically stable, an
initial synchronized shock of 0.5 J/kg is

-oOo-

Chapter Essence
In a Nutshell
53. .
Nursing Alerts
102. .
Nursing Management
135. .
Trainer’s Pearls
91. .

554
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Chapter
“Venflons” and “Butterflies” - Peripheral
Intravenous Cannula Insertion.
Chapter Outline
1. .

-oOo-
PERIPHERAL VENOUS ACCESS 5. Insert the catheter-over-the-needle
Introduction: through the skin and into the vein at 45
Peripheral venous cannulation is a degree angle.
procedure of gaining venous access for the 6. A flash of blood in the hub of the
purpose of administrating intravenous needle confirms that the tip of the needle is
fluids and intravenous medications. within the vein.
Necessary equipments for the procedure: 7. Advance the catheter-over-the-
Venous catheter of various sizes needle an additional 1 to 2 mm to ensure
1. Spirit or suitable antiseptic agents that the catheter is completely within the
2. Cotton vein.
3. Adhesive e plaster (Dynaplast) to fix 8. An alternative is to drop the hub of
the catheter the needle nearly parallel to the skin before
4. Hepsaline for flush advancing the catheter-over-the-needle.
5. 3 way adaptor This will prevent the needle from
6. Gloves puncturing the far wall of the vein and the
7. Tourniquet catheter from pushing the vein away from
Indications: the needle.
Administration of Intravenous fluids and 9. Hold the hub of the needle securely
intravenous medications. A 14G Cannula is and advance the catheter over the needle
more effective in fluid resuscitation than a until its hub is against the skin. Never pull
central line triple lumen catheter. Whereas out the needle without inserting the
even 20 G cannula is enough if the purpose cannula.
is only to administer drugs. 10. Applying digital pressure over the
Contraindications: tip of the catheter, to prevent blood leak
• Distal to limb injury while withdrawing the needle.
• Infection of the local area 11. Connect stopcock to the hub of the
• No visible peripheral vein cannula and flush with saline.
• Thrombophelebitis / Thrombosis of 12. When the cannula is inserted collect
the vein the blood samples, if needed ( refer to the
Procedure: hospital protocol)
1. Explain the need and nature of the 13. Intravenous tubing can be attached
procedure. to the catheter to begin a fluid infusion.
2. Select non hairy, distal part of the Always fix the tubing along with the limb to
upper limb and preferably where the two prevent accidental disconnection.
tributaries of the veins joints Complications:
3. Clean the area with antiseptic Thrombophelebitis, Thrombosis,
4. Stretch the skin with slight pressure Pulmonary embolism, Extravasations,
to fix the underlying vein while Cellulites, Gangrene.
cannulation. Post procedure care:
• Flush with hepsaline,
• Change sterile dressing,

555
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• Change the cannula after 48 to 72 Connect to maintenance fluid in order to
hrs or whenever the early signs of phlebitis maintain the patency of the cannula Watch
or extravasations appear, for bulge or extravasations.

-oOo-

556
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Chapter Essence
In a Nutshell
54. .
Nursing Alerts
103. .
Nursing Management
136. .
Trainer’s Pearls
92. .

557
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Chapter
“Central Line” aka (Subclavian, Jugular, Femoral)
Central Venous Access.
Chapter Outline
1. .

-oOo-

Practical Procedures: Central Line • Avoid in raised intracranial

Insertion - Internal Jugular approach pressure- aim for a femoral approach if
Central line insertion should be real-time required
ultrasound guided • Patient non compliance
Internal jugular is preferred to subclavian
where possible as it is less likely to lead to Pre Procedure:
pneumothorax • Consent patient if conscious
otherwise document why the procedure is
Indications for central line Insertion: in the patients best interests
• Administration of medications that • Consent should include:
require central access e.g. amiodarone, o Infection, bleeding (arterial
inotropes, high concentration electrolytes puncture, haematoma, haemothorax), pain,
• Fluid balance monitoring with CVP failure, damage to surrounding structres
• Intravenous access (long term or (including pneumothorax), thrombosis.
difficult peripherally) • Set up sterile trolley
• Position patient with head down if
Complications associated with insertion: they can tolerate it, with head facing away
• Haemothorax from side of insertion
• Pneumothorax o This ensures maximum venous
• Haematoma filling
• Inadvertant arterial puncture • Ultrasound area to define anatomy
• Having a nurse or assistant is
Equipment required: helpful
• Ultrasound and sterile ultrasound
sheath The Procedure:
• Sterile trolley • Wash hands and don sterile gown
• Sterile field, gloves, gown and mask and gloves
• Seldinger central line kit • Clean the area and apply sterile field
• Saline flush • Apply sterile sheath to the
• Chlorhexidine ultrasound probe
• Lignocaine • Confirm anatomy
• Suture • Under ultrasound guidance insert
• Scalpel lignocaine cutaneously, subcutaneously
• Sterile dressing and around internal jugular.
• Pressure bag to attach to • Whilst lignocaine has time to work
monitoring flush all lumens of the line and then clamp
all lumens except the Seldinger port
Contraindications to procedure: • Ensure caps are available for the
• Coagulopathy lumens
• Local infection

559
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• Under ultrasound guidance take
Seldinger needle attached to syringe and
insert into the internal jugular vein.
• When blood is freely aspirated
remove syringe and inset Seldinger wire.
This should pass easily.
• Use scalpel to make an incision in
the skin
• Pass the dilator over the wire and
gently but firmly dilate a tract through to
the internal jugular.
• Remove the dilator and pass the
central line over the Seldinger wire, do not
advance the line until you have hold of the
end of the wire.
• Remove the wire
• Aspirate and flush all lumens and re
clamp and apply lumen caps
• Suture the line to allow 4 points of
fixation
• Dress with a clear dressing so the
insertion point can be clearly seen
Post Procedure:
• Attach central line to pressure bag
to allow CVP monitoring
o Nursing staff can show you how to
do this or will do it for you
• Run a blood gas to ensure a venous
sample
• Chest x-ray to confirm placement
and to check for pneumothorax
• Clear documentation of date of
insertion and monitor for infection
In the event of failure:
• Stop procedure
• Seek senior help
Top Tips for central line insertion:
• Central lines can have multiple
lumens. Most commonly 3,4 and 5 lumen
lines are inserted. Confirm what the line
will be used for and how many infusions a
patient has to aid your selection of the line
with the correct amount of lumens
• Always ensure you are happy with
your anatomy before commencing the
procedure
• Ensure your sterile trolley is well
set up with the kit lined up in the order you
will use things and a clear area for sharps.
This will make your life easier.
• NEVER LET GO OF THE SELDINGER
WIRE!
N.B. The Seldinger central line kit should
contain the line, Seldinger wire, dilator,
Seldinger needle and syringe, scalpel and
suture point fixation.
(End of Chapter)
560
 - 561 -

-oOo-

Chapter Essence
In a Nutshell
55. .
Nursing Alerts
104. .

561
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Nursing Management
137. .
Trainer’s Pearls
93. .

562
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Chapter
Intraosseous Access.
Chapter Outline
1. .

-oOo-
Intra Osseous Access tibia at the junction of the medial malleolus
Introduction: and the shaft of the tibia, posterior to the
In situations where it is difficult to obtain greater saphenous vein. The needle is
rapid vascular access, the IO route is directed cephalad, away from the growth
indicated. plate.
Informed consent: 3.Distal femur: The IO needle is inserted 2
As any other procedure, it is mandatory to to 3 cm above the external condyles in the
get an informed consent from the patient midline and directed cephalad away from
or the patient attenders. the growth plate.
Pre requisites for the procedure:
• IO access needle with a stylet and a Technique:
syringe for aspiration. 1. The fingers and thumb are wrapped
• Needles range in size from 13 to 20 around the proximal tibia to stabilize it.
G. 2. A towel may be placed behind the
Needles used for intraosseous (IO) knee for support.
infusion. 3. The needle is grasped firmly in the
a. Left to right, Illinois bone marrow palm, and a rotary motion is applied with
aspiration needle moderate pressure
b. Illinois sternal/iliac aspiration 4. The plastic sleeve can be adjusted to
needle prevent it from being forced too deeply
c. Jamshidi disposable sternal/iliac into the bone or through the bone.
aspiration needle 5. Note that the needle is directed
d. Cook IO needle with 45° trocar away from the joint space.
e. Sur-Fast IO needle. 6. The metal tip is now positioned in
the cortex-medullary junction.
Indications: 7. The needle and tubing are secured
When venous access is not readily with tape and the extremity is immobilized
available. Cardiac arrest in an infant or on a leg board.
child,in adult patients with shock, trauma, 8. After the needle is placed in position
extensive burns, severe dehydration, status it is secured by using inverted T shaped
epilepticus, or any situation in which the dressing
emergency administration of fluids or Complications:
drugs is necessary but not feasible by other Immediate:
routes. 1. Incomplete penetration of the bone
Procedure details 2. Fluid extravasations
Sites: 3. The needle may be blocked
1. Proximal tibia: The IO needle is periodically by clots.
inserted 1 to 3 cm distal to the tibial Late:
tuberosity and over the medial aspect of 1. Necrosis and sloughing of the skin
the tibia. The bevel of the needle is directed at the site of infusion.
away from the joint space. 2. Injury of the growth plate and
2. Distal tibia: The IO needle is developmental abnormalities
inserted on the medial surface of the distal 3. Fat embolism

563
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4. Compartment syndrome. It is important to maintain the patency and
Post Procedure Care position of the needle

564
- 565 -

565
 - 566 -
-oOo-

Chapter Essence
In a Nutshell
56. .
Nursing Alerts
105. .
Nursing Management
138. .
Trainer’s Pearls
94. .

566
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Chapter
Pericardiocentesis.
Chapter Outline
1. .

-oOo-
Pericardiocentesis injury pattern, persist, withdraw the
A. Monitor the patient's vital signs, CVP, needle completely.
and ECG before, during, and after the K. After aspiration is completed, remove
procedure. the syringe, and attach a three-way
B. Surgically prepare the xiphoid and stopcock, leaving the stopcock closed.
subxiphoid areas, if time allows. Secure the catheter in place.
C. Locally anesthetize the puncture site, if L. Should the cardiac tamponade symptoms
necessary. persist, the stopcock may be opened and
D. Using a #16- to #18-gauge, 6-inch (15 the pericardial sac reaspirated. The plastic
cm) or longer over-the-needle catheter, pericardiocentesis needle can be sutured
attach a 35-mL empty syringe with a three- or taped in place and covered with a small
way stopcock. dressing to allow for continued
E. Assess the patient for any mediastinal decompression en route to surgery or
shift that may have caused the heart to transfer to another care facility.
shift significantly.
F. Puncture the skin 1 to 2 cm inferior to Complication of Pericardiocentesis
the left of the xiphochondral junction, at a Aspiration of ventricle blood instead of
45-degree angle to the skin. pericardial blood.
G. Carefully advance the needle cephalad Cellulitis.
and aim toward the tip of the left scapula. Laceration of coronary artery or vein.
H. If the needle is advanced too far (into Laceration of ventricular
the ventricular muscle) an injury pattern epicardium/myocardium.
(eg, extreme ST-T wave changes or New hemopericardium, secondary to
widened and enlarged QRS complex) lacerations of the coronary artery or vein,
appears on the ECG monitor. This pattern and/or ventricular
indicates that the pericardiocentesis needle epicardium/myocardium.
should be withdrawn until the previous Local hematoma.
baseline ECG tracing reappears. Premature Pericarditis.
ventricular contractions also may occur, Ventricular fibrillation.
secondary to irritation of the ventricular Pneumothorax, secondary to lung
myocardium. puncture.
I. When the needle tip enters the blood- Puncture of aorta.
filled pericardial sac, withdraw as much Puncture of inferior vena cava.
nonclotted blood as possible. Puncture of esophagus.
J. During the aspiration, the epicardium Mediastinitis secondary to puncture of
reapproaches the inner pericardial surface, esophagus.
as does the needle tip. Subsequently, an Puncture of peritoneum.
ECG injury pattern may reappear. This
indicates that the pericardiocentesis needle Peritonitis, secondary to puncture
should be withdrawn slightly. Should this of peritoneum.

567
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-oOo-

Chapter Essence
In a Nutshell
57. .
Nursing Alerts
106. .
Nursing Management
139. .
Trainer’s Pearls
95. .

568
 - 569 -

Chapter
3 way occlusive dressing in Open Pnemothorax.
Chapter Outline
1. .

-oOo-
3 way occlusive dressing in Open can continue. Definitive surgical closure of
Pnemothorax the defect is usually required.

Manage an open pneumothorax by

promptly closing the defect with a sterile
occlusive dressing, large enough to overlap
the wound's edges, and taped securely on
three sides. Taping the occlusive dressing
on three sides provides a flutter-type valve
effect. As the patient breathes in, the
dressing is occlusively sucked over the
wound, preventing air from entering. When
the patient exhales, the open end of the
dressing allows air to escape. A chest tube
should be placed remote from the wound
as soon as possible. Securely taping all
edges of the dressing can cause air to
accumulate in the thoracic cavity resulting
in a tension pneumothorax unless a chest
tube is in place. Any occlusive dressing
(plastic wrap, petrolatum gauze, etc) may
be used as a stopgap so rapid assessment

-oOo-

Chapter Essence
In a Nutshell
58. .
Nursing Alerts
107. .
Nursing Management
140. .
Trainer’s Pearls
96. .

569
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Direct Compression Technique.
Chapter Outline
1. .
-oOo-
There are a number of methods that can be
used to stop bleeding and they all have one
thing in common—compressing a bleeding
blood vessel in order to stop the bleeding.
If you don’t have a trauma first aid kit:
Apply direct pressure on the wound (Cover
the wound with a clean cloth and apply
pressure by pushing directly on it with
both hands)
1. Take any clean cloth (for example, a
shirt) and cover the wound.
2. If the wound is large and deep, try
to “stuff” the cloth down into the wound.
3. Apply continuous pressure with
both hands directly on top of the bleeding
wound.
4. Push down as hard as you can.
5. Hold pressure to stop bleeding.
Continue pressure until relieved by
medical responders.
If you do have a trauma first aid kit:
For life-threatening bleeding from an arm
or leg and a tourniquet is NOT available OR
for bleeding from the neck, shoulder or
groin:
• Pack (stuff) the wound with a
bleeding control (also called a hemostatic)
gauze, plain gauze, or a clean cloth and
then apply pressure with both hands
1. Open the clothing over the bleeding
wound. (A)
2. Wipe away any pooled blood.
Chapter
3. Pack (stuff) the wound with
bleeding control gauze (preferred), plain
gauze, or clean cloth. (B)
4. Apply steady pressure with both
hands directly on top of the bleeding
wound. (C)
5. Push down as hard as you can.
6. Hold pressure to stop bleeding.
Continue pressure until relieved by
medical responders.
For life-threatening bleeding from an arm
or leg and a tourniquet is available:
• Apply the tourniquet
1. Wrap the tourniquet around the
bleeding arm or leg about 2 to 3 inches
above the bleeding site (be sure NOT to
place the tourniquet onto a joint—go above
the joint if necessary).
2. Pull the free end of the tourniquet to
make it as tight as possible and secure the
free end. (A)
3. Twist or wind the windlass until
bleeding stops. (B)
4. Secure the windlass to keep the
tourniquet tight. (C)
5. Note the time the tourniquet was
applied. (D)
Note: A tourniquet will cause pain but it is
necessary to stop life-threatening bleeding.
571
- 572 -

-oOo-

572
 - 573 -

Chapter Essence
In a Nutshell
59. .
Nursing Alerts
108. .
Nursing Management
141. .
Trainer’s Pearls
97. .

573
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Chapter
Management of Agitated Patients
Chapter Outline
1. .

-oOo-

Patients under Influence • Signs and symptoms of intra-

• Intoxication is associated with abdominal and retroperitoneal injury are
aggressive behavior, impaired reflexes and less reliable so extensive investigations are
coordination, and inappropriate avoidance required
responses which complicates the initial • Alcohol intoxication predisposes to
assessment of injury. It’s important to abdominal wall laxity and thus less
differentiate substance vs.emergency protection from blunt trauma
medical condition. • Full stomachs increase the risk of
• Patient may initially refuse gastric injury
treatment. Interaction and cooperation is • Hepatomegaly, splenomegaly
difficult. There may be increased need for common and these organs are vulnerable
invasive diagnostic and therapeutic to trauma
procedures Neurological Assessment
Airway and C-spine Mental status ( Due to head injury , Shock,
• Full stomach predispose to vomiting Hypoglycemia until proven otherwise)
and aspiration, especially during airway • Euphoria
management • Confusion
• Endotracheal intubation for airway • Psychosis
protection is required frequently • Disorientation
• Higher degree of trauma to the • Paranoia
spinal cord and much worse neurologic Speech:
and functional recovery • Slurred (Alcohol or sedatives)
Breathing • Ramble (Hallucinogens)
• May have lower blood Pupils
pressures and carbondioxide o Constricte (Opiates and Early
levels due to hyperventilation Barbiturate use)
• High-flow oxygen and capnography o Fixed and dilated (High-dose
is require barbiturates)
Circulation o Dilated ( Amphetamines , Cocaine ,
• Alcohol diminish the patient’s Hallucinogens)
capacity to respond to hemorrhagic shock Marijuana
• Volume depletion is common as a Patients with signs of head trauma and
result of the diuretic effect of alcohol or focal or generalized seizures need an
vomiting urgent CT scan. CT scans of the head should
• Peripheral vasodilation contribute be performed for any patient with
to hypotension and hypothermia deteriorating mental status, focal
• Cardiac depressant effect increases neurologic findings, new-onset seizures
the depth of shock and volume even without obvious signs of history of
requirements trauma, failure to improve over time, or
• Need early and adequate fluid mental status changes out of proportion to
resuscitation the degree of intoxication.
Abdominal injury Improving cooperation

575
 - 576 -
• Identify yourself and orient patient
to surroundings
• Treat with respect and avoid being
judgmental
• Acknowledge concerns and feelings
• Let patients know what will be
required of them
• Ask closed-ended questions for
history
Interacting with uncooperative patients:
• Be firm
• Set limits to behavior
• Consider physical restraint
• Only if unable to provide adequate
care
Summary
• Know signs and symptoms of abuse
• Recognize patient who may be
impaired
• Attention to specific areas for
critical changes
• Provide life-saving interventions for
substances
• Interaction strategies for improving
patient cooperation are very important.
• Safety is primary concern
D-Disability: Neurological status,
Consciousness, Focal Neurological
Deficit
• Prevention of secondary brain
injury by maintaining adequate
oxygenation and perfusion are the main
goals of initial management.
• In Case of Quadriplegia or
Paraplegia, Urgent MRI Spine is Indicated
• Patient to be shifted in Spine Board
• CT Scan Brain is indicated in History
of
o Loss of Consciousness
o ENT Bleed
o Vomiting
o Headache
• Immediate CT Brain is Indicated in
o Unconscious Patients
o Lucid Interval
MANAGEMENT OF AGITATED PATIENT
The Violent and Aggressive Patient:
Behavioural disturbances and aggression
in the emergency department is an
increasing problem confronting emergency
clinicians every day. 50% of attacks on
health care workers occur in the
emergency department. These patients
may self refer or be referred to the ED by
concerned family members, other health
professionals i.e., GPs, community mental
health teams, or transported by police or
paramedics in an aroused and agitated
state for assessment, management and to
rule of organic cause for their behaviour. It
is the responsibility of emergency
clinicians/ nurses to assess and manage
these patients properly, with-out biases,
and with the same thoroughness that you
assess every patient with. These patients
can challenge yourself as a clinician, your
colleagues that you work with, and some
can even be a challenge to whole
emergency department. These patients
have a high morbidity and mortality, and
present you with an even higher medico-
legal risk from their behaviour, injuries
they may have obtained, or from the
underlying organic illness that is causing
their adverse behaviour.
Duty of care and zero tolerance policies:
Some emergency departments and
hospitals have adopted zero tolerance
policies in order to prevent verbal and
physical abusive behavior towards staff.
The concept of zero tolerance originated in
the USA, and refers to specific actions or
behaviors that will not be tolerated, and
were originally used to stop crime, gangs
and drugs in schools.
The concept of introducing a zero tolerance
policy into the emergency department
setting is fundamentally flawed.
Patient’s presenting to the ED who are
abusive towards staff could be displaying
behaviour that is related to head injury,
overdose, psychiatric condition or other
organic problem.
You as a clinician have a duty of care to
these patients to provide assessment and
treatment. Don’t be fooled into a policy that
576
 - 577 -
takes away patients fundamental right to Impulsivity
access care and proper treatment. Restlessness, pacing
Agitation
Medical causes of violence and aggression Suspiciousness
in patients: Property damage
o Head injury Rage (especially children)
o Substance abuse and intoxication Intimidating physical behaviour (clenched
o Underlying mental illness fist, shaping up)
o Hypoxia C= Conversation
o Metabolic disturbances/ Patient self-report
Hypoglycaemia Admits to weapon
o Infection: meningitis, encephalitis, Admits to history of violence
sepsis Thoughts about harm to others
o Hyperthermia or hypothermia Threats to harm
o Seizures: post ictal or status Admits to substance use/abuse
epilepticus Command hallucinations to harm other
o Vascular: stroke or subarachnoid Admits extreme anger
haemorrhage Investigating the violent and aggressive
patient:
Risk factors for sudden related violence: Investigations should be guided by history
o Younger age and physical examination.
o Male gender
o History of violence Consider:
o Past juvenile detention o Blood sugar level
o History of physical abuse by parent o Full blood count
or guardian o Urea, Electrolytes, Creatinine
o Substance dependence only o Paracetamol, Ethanol level
o Comorbid mental health and o Urinalysis
substance disorder o Urine drug screen if available
o Victimization in past year o +/- Head CT/MRI
ABC of assessing the potentially violent o +/- Lumbar Puncture
patient: ED management for violence and
A= Assessment: aggression:
Primary Survey o Early recognition and use of de-
Appearance escalation strategies aimed at diffusing a
Current medical status volatile situation is the preferred approach.
Psychiatric History (history of violence) o Consider personal safety at all times
Current medication o Consider the safety of other patients
Oriented (time, place, person) and their visitors at all time
Physiological indications for impending o Place the person in a quiet and
aggression secure area and let staff know what is
Flushing of skin happening and why Never turn your back
Dilated pupils on the individual
Shallow rapid respirations o Don’t walk ahead of the individual
Excessive perspiration and ensure adequate personal space
B= Behavioural indications: o Provide continuous observation and
Observation of behavior record behaviour changes in patient notes
General behaviour (intoxicated, anxious, o Wear personal duress alarm if
hyperactive) available
Irritability o Let the person talk (everyone has a
Hostility, anger story to tell, let them tell it)

577
 - 578 -
o Never block off exits and ensure you sedation can be given while attempting IV
have a safe escape route canulation,
Indications for Restraining and sedating a o Once you choose to start chemical
violent and aggressive patient: sedation, you have full responsibility to
• Preventing harm to the patient maintain the patient’s airway, breathing,
• Preventing harm to other patients circulation, provide bladder care,
• Preventing harm to caregivers and hydration, and general nursing care to that
other staff patient.
• Preventing serious disruption or o Benzodiazepines are preferred in
damage to the environment the ED, as have prompt onset of action, and
• To assist in assessing and a good safety profile.
management off the patient o Antipsychotic”s has a role when
• Restraints should never be use for patient is not responding to
ease of convenience benzodiazepines, and as an adjunct to the
Managing the violent and aggressive benzo’s to achieve sedation.
patient:
Physical/Mechanical Restraints Benzodiazepines:
Clinicians should beware of local policies, Midazolam:
laws and acts before restraining patients Start with 2.5-5mg IV or IM increments and
Applying physical restraints is a team work upwards .Short acting medication
sport, 1 for each limb and 1 to lead the that provides rapid sedation, in titrated
restraint and manage the airway. doses.Maximum effect in 10mins, and last
Physical restraint should always be up to 2 hours.
followed up with chemical and mechanical Diazepam:
restraints. Physical restraints need to be Start with 5-10 PO or IV increments and
secure enough to restrain the patient, but work upward.
able to be easily removed if the patient Longer acting than Midazolam, works well
begins to vomit, seizure, or loose’s control for managing withdrawal symptoms
of their airway. IV administration causes short lived
Restraints must be applied in the least stinging sensation, do not dilute dose to
restrictive maner and for the shortest prevent this
period of time. Padding should be applied Lorazepam:
between restraints and the patients to 1-2mg PO
prevent neurovascular injury and regular Patient needs to be willy to take oral
neurovascular observations should be medication
perform every 15-30mins whilst patient is Provides sedation up to 4-6 hours
physically restrained. Antipsychotics:
The clinician ordering the restraints should Haloperidol:
document the reason for restraints, what .5-10mg IV or IM
limbs are restrained, how frequent Older conventional antipsychotic
neurovascular observations are needed, Avoid in patients with QT prolongation as
and when the restraints need reviewed, increases risk of torsades de points Risk of
generally every 2 hours restraints should dystonic drug reaction
be reviewed by treating clinician.
Chemical Restraints/Sedation: Droperidol:
o Remember you are generally 2.5-10MG IV or IM
treating the undifferentiated patient, with Older conventional antipsychotic
limited access to past medical history. Avoid in patients with QT prolongation as
o These patients are generally increase risk of torsades de points Risk of
reluctant to take oral medications, IV dystonic drug reaction
access needs to be obtained, or IM or SL Chlorpromazine:

578
 - 579 -
100-200mg IV infusion over 24 hours Lowered seizure threshold
Used in patients resistant to newer Special problems in the elderly
antipsychotics and benzodiazapines Pitfalls in managing the violent and
Avoid S/C or IM as risk of skin necrosis, agitated patient:
maximum daily dose 1000mg. o Always remember that your goal of
Barbiturates: sedating and restraining these patients is
Thiopentone for their benefit
25mg IV increments until sedation has not yours, you’re doing to it so that you can
been achieved manage and investigate these patient
Very controversial, however recent reports o Assuming a patient’s confusion and
have shown effectiveness in managing agitation is related to alcohol intoxication,
patients with benzodiazepine tolerance, its estimated up
using low dose barbiturates with good to 50% of head injuries are alcohol related.
effect. o Psychiatric conditions rarely
Complications of sedation and restraining present suddenly or with visual, tactile, or
patients: olfactory hallucinations. These patients
Respiratory depression and pulmonary require thorough medical assessment to
aspiration rule out organic cause.
Sudden cardiac death/Excited delirium o Alcohol intoxication increases
Hypotension suicide risk. 40-60% of of people who
Deep venous thrombosis & pulmonary commit suicide have alcohol in their
embolus system at time of death. Proper evaluation
Rhabdomyolysis of the suicidal patient cannot be
Dystonic reactions undertaken until their sober, and you have
Neuroleptic malignant syndrome a duty of care to ensure this happens.
Anticholinergic effects These patients should not be allowed to
Delirium sign out against medical advice.
Lactic acidosis

-oOo-

Chapter Essence
In a Nutshell
60. .
Nursing Alerts
109. .
Nursing Management
142. .
Trainer’s Pearls
98. .

579
 - 581 -

Chapter
Adult Seizures
.
Chapter Outline
1. .

-oOo-

581
 - 582 -

-oOo-

Chapter Essence
In a Nutshell
582
 - 583 -

61. .
Nursing Alerts
110. .
Nursing Management
143. .
Trainer’s Pearls
99. .

583
 - 585 -

Chapter
Paediatric Seizures
.
Chapter Outline
1. .

-oOo-

585
- 586 -

-oOo-

586
 - 587 -

Chapter Essence
In a Nutshell
62. .
Nursing Alerts
111. .
Nursing Management
144. .
Trainer’s Pearls
100. .

587
 - 589 -

Chapter
Stroke Protocol
.
Chapter Outline
1. .

-oOo-

589
- 590 -

590
 - 591 -

-oOo-

Chapter Essence
In a Nutshell
63. .
Nursing Alerts
112. .
Nursing Management
145. .
Trainer’s Pearls
101. .

591
 - 593 -

Chapter
Head Injury Protocol (Mild Moderate Severe)
.
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
64. .
Nursing Alerts
113. .
Nursing Management
146. .
Trainer’s Pearls
102. .

593
- 594 -

594
 - 595 -

Chapter
Spinal Injury.
Chapter Outline
1. .

-oOo-
Step 1:
A.Patients with suspected spine injury
must be protected from further injury.
Such protection includes applying a
semirigid cervical collar and long back
board, per-forming a modified logroll to
ensure neutral alignment of the entire
spine, and remov-ing the patient from the
long spine board as soon as possible.
B. Paralyzed patients who are immobilized
on a long spine board are at particular risk
for pressure points and decubitus ulcers.
Therefore, paralyzed patients should be
removed from the long spine board as soon
as possible after a spine injury is
diagnosed, i.e., within 2 hours.
Step 2
Fluid Resuscitation and Monitoring
A. CVP monitoring: Intravenous fluids
usually are limited to maintenance levels
unless specifically needed for the
management of shock. A central venous
catheter should be inserted to carefully
monitor fluid administration.
B. Urinary catheter: A urinary catheter
should be inserted during the primary
survey and resuscitation phases to moni-
tor urinary output and prevent bladder
distention.
C.Gastric catheter: A gastric catheter
should be inserted in all patients with
paraplegia and quadriplegia to prevent
gastric distention and aspiration.

-oOo-

Chapter Essence
In a Nutshell
65. .
Nursing Alerts
114. .
Nursing Management
147. Nursing care can prevent or mitigate further injury and promote the best possible
patient outcome. Focus your care on:
148. • maintaining stable blood pressure (BP)
149. • monitoring cardiovascular function
150. • ensuring adequate ventilation and lung function
151. • preventing and promptly addressing infection and other complications.
152. Use serial SCI assessments with a consistent grading tool to monitor and
communicate motor and sensory improvement or deterioration, including reflexes, deep
tendon function, and rectal tone. Be sure to establish baseline findings and perform serial
assessments—usually hourly or more often during the initial injury phase and less often as
the injury stabilizes. Conduct additional assessments and document findings each time the
patient has been moved out of bed (for instance, for diagnostic tests) or if you suspect
deterioration.
153. Establishing a baseline helps caregivers promptly detect improvement or

595
 - 596 -

deterioration. Assessment should be interprofessional, involving the provider, nurse, and

physical therapist.
154. Always logroll the patient to check for rectal tone as well as when repositioning,
toileting, and performing skin care or chest physiotherapy (CPT). .
Trainer’s Pearls
103. .

596
 - 597 -

Chapter
Facio Maxillary Injury
Chapter Outline
1. .

-oOo-

(Beginning of Chapter)
ER 3 : Resuscitation : Disability : Facio Maxillary Injury

a. Definition : Injury to Facial or Maxilla or adjoining Muscuolo Skeletal Structure either

alone or in association with Head and or Spine Injuries
b. Life Threatening Complications
i. Bleeding and Aspiration of Blood into Respiratory Tree EVEN WHEN THE PATIENT IS
FULLY CONSCIOUS
c. Please do tracheostomy (or of surgeon is not available intubate the patient and connect
to Ventilator) EVEN if the Patient is Fully Conscious and EVEN if the Lungs are Clear and EVEN
if the Respiration is Normal

(End of Chapter)

-oOo-

Chapter Essence
In a Nutshell
66. .
Nursing Alerts
115. .
Nursing Management
155. .
Trainer’s Pearls
104. .

597
 - 599 -

Chapter
Protocol for Hanging and Mechanical Asphyxia
Chapter Outline
1. .

-oOo-

Protocol for Hanging and Mechanical Asphyxia

INITIAL EMERGENCY DEPARTMENT • Respiratory complications = major
CARE – ABCs cause of delayed mortality in near-
• Endotracheal intubation (ETI) may hanging victims
become necessary with little warning • Pulmonary edema
• If ETI unsuccessful, consider • Neurogenic: centrally mediated, massive
cricothyroidotomy; if unsuccessful, sympathetic discharge; often in
percutaneous trans-laryngeal association with serious brain injury,
ventilation may be used temporarily poor prognostic implication
• Fluid resuscitation must be performed • Post-obstructive: due to marked
judiciously – risk of ARDS and cerebral negative intrapleural pressure,
edema generated by forceful inspiratory effort
• Monitor for cardiac arrhythmias against extrathoracic obstruction; when
• Altered / comatose patient => treat as obstruction removed, may have rapid
cerebral edema with elevated ICP onset pulmonary edema leading to
• Radiological study: ARDS
o Chest radiograph • Carotid intimal dissection or thrombus
o CT brain formation
o CT C-spine • Tracheal stenosis
o Consider CTA head/neck or • Neurologic sequelae
MRA head/ Neck • Transient hemiplegia
FURTHER CARE AND POTENTIAL • Central cord syndrome
COMPLICATIONS • Seizures
Even if the initial presentation is clinically • Spinal cord injury
benign, all near-hanging victims and those o Long-term
with vascular compromise should be paraplegia/quadriplegia
admitted for 24 hours observation => risk o Short-term autonomic
of delayed airway and pulmonary dysfunction
complications
BEWARE COMPLICATIONS!

-oOo-

Chapter Essence
In a Nutshell
67. .

599
 - 600 -

Nursing Alerts
116. .
Nursing Management
156. .
Trainer’s Pearls
105. .

600
 - 601 -
Chapter Outline
1. .
-oOo-
Drowning is a process resulting in primary
respiratory impairment from
submersion/immersion in a liquid
medium. The most important and
detrimental consequence of submersion is
hypoxia. Victims of drowning may develop
primary or secondary hypothermia. The
term “neardrowning” is no longer in use
Modifications to Basic Life Support for
Drowning
Recovery from the Water
When attempting to rescue a drowning
victim, the rescuer should get to the victim
as quickly as possible, preferably by some
conveyance (boat, raft, surfboard, or
flotation device). The rescuer must always
be aware of personal safety routine
stabilization of the cervical spine is not
necessary unless the circumstances leading
to the submersion episode indicate that
trauma is likely.
Rescue Breathing
The first and most important treatment of
the drowning victim is the immediate
provision of ventilation. Prompt initiation
of rescue breathing increases the victim’s
chance of survival. Rescue breathing is
usually performed when the unresponsive
victim is in shallow water or out of the
water. If it is difficult for the rescuer to
pinch the victim’s nose, support the head,
and open the airway in the water, mouthto-
nose ventilation may be used as an
alternative to mouthto- mouth ventilation.
There is no need to clear the airway of
aspirated water, because only a modest
amount of water is aspirated by the
majority of drowning victims and it is
-oOo-
Chapter
Drowning.
rapidly absorbed into the central
circulation, so it does not act as an
obstruction in the trachea. The routine use
of abdominal thrusts or the Heimlich
maneuver for drowning victims is not
recommended.
Chest Compressions
As soon as the unresponsive victim is
removed from the water, the rescuer
should open the airway, check for
breathing, and if there is no breathing, give
2 rescue breaths that make the chest rise
(if this was not done in the water). After
delivery of 2 effective breaths, the health
care provider should check for central
pulse and if it is absent he should
immediately begin chest compressions and
provide cycles of compressions and
ventilations.
Once the victim is out of the water, if the
victim is unresponsive and not breathing
(and the healthcare provider does not feel
a pulse) after delivery of 2 rescue breaths,
rescuers should attach an AED and attempt
defibrillation if a shockable rhythm is
identified.
601
 - 602 -

Chapter Essence
In a Nutshell
68. .
Nursing Alerts
117. . Desired Outcomes
118. • Client will maintain optimal gas exchange, as evidenced by arterial blood
gases (ABGs) within client’s usual range, oxygen saturation of 90% or higher, alert,
responsive mentation or no further decline in the level of consciousness, relaxed breathing,
and baseline heart rate for the client.
119. Nursing Interventions Rationale
120. Assess the client’s level of consciousness. Within three minutes of submersion,
near-drowning clients are unconscious and are at risk for cerebral edema.
121. Assess the client’s respiratory rate, depth, and rhythm. Changes in the
respiratory rate and rhythm are early warning signs of impending respiratory difficulties.
Impairment of gas exchange can result in both rapid, shallow breathing patterns and
hypoventilation. Hypoxia is associated with increased breathing effort.
122. Auscultate lung for breath sounds such as crackles and wheezing. Crackles are
caused by fluid accumulation in the airways and by pulmonary edema. Wheezing is related
with bronchospasm.
123. Monitor for signs of respiratory difficulties such as nasal flaring, stridor, retractions,
and the use of accessory muscles. The breathing pattern alters to increase chest
excursion to facilitate effective breathing.
124. Assess for any signs of worsening pulmonary edema. Pink, frothy sputum is a
classic sign of pulmonary edema; this necessitates the need for mechanical ventilation.

125. Monitor oxygen saturation and ABGs as ordered. Pulse oximetry is a useful tool
to detect changes in oxygenation. Oxygen saturation should be at 90% or greater.
Decreasing PaO2 and pulse oximetry readings and increasing PaCo2 are signs of respiratory
failure.
126. Monitor chest-x-ray readings. Chest X-ray reports on all submersion victims
are done to assess for degree of aspiration and lung injury. Radiographic studies of lung
water lag behind the clinical presentation by 24 hours.
127. Provide suctioning as per client’s need only. Hypoxia and the Valsalva maneuver
with suctioning may increase intracranial pressure (ICP).
128. Maintain the client’s airway and assist with ventilations as needed while protecting
the cervical spine. Maintaining patent airway is always the first priority. Cervical spine
injuries should always be considered in victims of near-drowning especially after a dive.
129. Provide oxygenation as ordered. If the client has spontaneous breathing, a
supplemental oxygenation is administered by mask.
130. Anticipate the need for intubation and mechanical ventilation. The outcomes of
pulmonary injury are a clinical picture of acute respiratory distress syndrome: pulmonary
edema, atelectasis, hyaline membrane formation, and pulmonary capillary injury. Early
intubation and mechanical ventilation are suggested to prevent full decompensation of the
client. Mechanical ventilation provides supportive care to maintain adequate oxygenation
and ventilation.
Nursing Management
157. .
Trainer’s Pearls

602
 - 603 -

106. .

603
 - 605 -

Chapter
Thoracic Injuries
Chapter Outline
1. .

-oOo-

Tension pneumothorax: • Neck veins may be flat secondary to

• Clinical diagnosis hypovolemia
• Chest pain, air hunger, respiratory • Absence of breath sounds and/or
distress, tachycardia, hypotension, dullness to percussion on one side of the
tracheal deviation, unilateral absence of chest
breath sounds, neck vein distention, • Management: Restoration of blood
cyanosis. (V.S. cardiac tamponade) volume and decompression of the chest
• Hyperresonant percussion. cavity.
• Immediate decompression: Needle • Indication of thoracotomy:
decompression/ chest tube. o a. Immediately 1500 mLof
blood evacuated.
Open pneumothorax: o b. 200mL/hr for 2-4 hrs.
• 2/3 of the diameter of the trachea – o c. Patient’s physiology status.
impaired effective ventilation o d. Persistent blood
• Sterile occlusive dressing, taped transfusion requirements.
securely on 3 sides.
• Chest tube Cardiac tamponade:
• Beck’s triad: venous pressure elevation,
Flail chest: decline in arterial pressure, muffled
• 2 ribs fractured in two or more places. heart tones.
• Severe disruption of normal chest wall • Pulsus paradoxicus.
movement. • Kussmaul’s sign.
• Paradoxical movement of the chest wall. • PEA
• Crepitus of ribs. • Echocardiogram.
• The major difficulty is underlying lung • Management: Pericardiocentesis.
injury ( pulmonary contusion)
• Pain. Simple Pneumothorax
• Adequate ventilation, humidified • Breath sounds are decreased on the
oxygen, fluid resuscitation. affected side. Percussion demonstrates
• The injured lung is sensitive to both hyperresonance.
underresuscitation of shock and fluid • CXR
overload. • Chest tube insertion  F/U CXR..
• Never use general anesthesia or positive
Massive hemothorax: pressure ventilation to patient who
• Compromise respiratory efforts by sustains traumatic pneumothorax until a
compression, prevent adequate chest tube is inserted.
ventilation.
• Rapid accumulation of > 1500 mL o Hemothorax
blood in the chest cavity. • Lung laceration/ intercostal vessel
• Hypoxia laceration/ Int.mammary a. Laceration.
• Chest tube

605
 - 606 -

• Guide line of surgical exploration. o Presence of a pleural or

apical cap
Pulmonary Contusion o Left hemothorax
• Respiratory failure. o Fractures of the first or
• Patients with significant hypoxia should second rib or scapula.
be intubated. • Angiography is the gold standard.
• Monitoring. • On critical.

Tracheobronchial Tree Injury Traumatic Diaphragmatic Injury

• Hemoptysis, subcutaneous emphysema, • More commonly diagnosed on the left
tension pneumothorax with a side
mediastinal shift. • NG tube
• Pneumothorax associated with a • UGI series.
persistent large air leak after tube • Direct repair.
thoracostomy.
• Bronchoscopy Mediastinal Traversing Wounds
• Opposite main stem bronchial • Surgical consultation is mandatory.
intubation. • Hemodynamic abnormal : thoracic
• Intubation may be difficult  operative hemorrhage, tension pneumothorax,
intervention pericardial tamponade.
• Mediastinal emphysema: esophageal or
Blunt Cardiac Injury tracheobronchial injury.
• Result in: Myocardial muscle contusion, • Mediastinal hematoma: great vessel
cardiac chamber rupture, valvular injury.
disruption. • Spinal cord.
• Hypotension, ECG abnormalities, wall- • For stable patient.
motion abnormality o Angiography
• ECG: VPC, sinus tachycardia, Af, RBBB, o Water-soluble contrast
ST seg. changes. esophagography
• Elevated CVP. o Bronchoscopy
• Monitor. o CT
o Ultrasonography.
Traumatic Aortic Disruption
• High index of suspicion Others
• Adjunctive radiological signs: • Subcutaneous emphysema
o Widened mediastinum • Traumatic Asphyxia
o Obliteration of the aortic o Compression of the SVC.
knob o Upper torso, facial and arm
o Deviation of the trachea to plethora.
the right • Rib, Sternum, and Scapular fractures.
o Obliteration of the space • Blunt esophageal Rupture
between the pulmonary
artery and the aorta
o Depression of the left main a. Tension Pneumothorax
bronchus b. Cardiac Tamponade
o Deviation of the esophagus c. Hemothorax
to the right d. Flail Chest
o Widened paratracheal stripe e. Open Pneumothorax
o Widened paraspinal f. Tracheobronchial Tree
interfaces g. Blunt Cardiac Injuries
i. Myocarditis
606
 - 607 -
h. Traumatic Diaphramatic Rupture
i. Blunt Esophageal Injury
j. Subcutaneous Emphysema
k. Pulmonary Contusion
l. Rib Fracture
Thoracic Injuries
(a) Tension Pneumothorax
• A tension pneumothorax develops when
a "one-way-valve" air leak occurs either
from the lung or through the chest wall.
Air is forced into the thoracic cavity
without any means of escape,
completely collapsing the affected lung.
The mediastinum and trachea are
displaced to the opposite side,
decreasing venous return and
compressing the opposite lung.
• The most common causes of tension
pneumothorax are mechanical
ventilation with positive end-expiratory
pressure, spontaneous pneumothorax in
which ruptured emphysematous bullae
have failed to seal, and blunt chest
trauma in which a parenchymal lung
injury has failed to seal. Occasionally
traumatic defects in the chest wall may
cause a tension pneumothorax. A
significant incidence of pneumothorax is
associated with subclavian or internal
jugular venous catheter insertion.
• Tension pneumothorax is a clinical
diagnosis and should not be made
radiologically. A tension pneumothorax
is characterized by respiratory distress,
tachycardia, hypotension, tracheal
deviation, unilateral absence of breath
sounds, neck vein distention, and
cyanosis as a late manifestation. Because
of the similarity in their
symptomatology, a tension
pneumothorax initially may be confused
with cardiac tamponade. However, a
tension pneumothorax is more common.
Differentiation may be made by a
hyperresonant percussion note over the
ipsilateral chest.
• Tension pneumothorax requires
immediate decompression and is
managed initially by rapidly inserting a
needle into the second intercostal space
in the midclavicular line of the affected
hemithorax. This maneuver converts the
injury to a simple pneumothorax. (Note:
The possibility of subsequent
pneumothorax as a result of the needle
stick now exists.) Repeated
reassessment is necessary. Definitive
treatment usually requires only the
insertion of a chest tube into the fifth
intercostal space (nipple level), anterior
to the midaxillary line.
• Nursing alert
• Traumatic open pneumothorax calls for
emergency interventions.
Stopping the flow of air through the
opening in the chest wall is a life-saving
measure.
• Relief of tension pneumothorax is
considered an emergency
measure.
(b) Cardiac Tamponade
• Cardiac tamponade most commonly
results from penetrating injuries. Blunt
injury also may cause the pericardium to
fill with blood from the heart, great
vessels, or pericardial vessels. The
human pericardial sac is a fixed fibrous
structure, and only a relatively small
amount of blood is required to restrict
cardiac activity and interfere with
cardiac filling. Removal of small
amounts of blood or fluid, often as little
as 15 mL to 20 mL, by
pericardiocentesis may result in
immediate hemodynamic improvement.
• The classic Beck's triad consists of
venous pressure elevation, decline in
arterial pressure, and muffled heart
sounds. However, muffled heart tones
are difficult to assess in the noisy
emergency department. Distended neck
veins, caused by the elevate central
venous pressure, may be absent due to
hypovolemia. Pulsus paradoxus, a
decrease in systolic pressure during
inspiration in excess of 10 mm Hg, also
may be absent in some patients or
difficult to detect in some emergency
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settings. In addition, tension patients to the appropriate facility is
pneumothorax - particularly on the left necessary. Open pericardiotomy may be
side - may mimic cardiac tamponade. life-saving but is indicated only when a
Kussmaul's sign (a rise in venous qualified surgeon is available.
pressure with inspiration when • Once these injuries and other
breathing spontaneously) is a true immediate, life-threatening injuries
paradoxical venous pressure have been treated, attention may be
abnormality associated with tamponade. directed to the secondary survey and
Electromechanical dissociation in the definitive care phase of potential, life-
absence of hypovolemia and tension threatening thoracic injuries
pneumothorax suggests cardiac
tamponade. (c)Hemothorax
• Pericardiocentesis is indicated for • Massive hemothorax results from a
patients who do not respond to the rapid accumulation of more than 1500
usual measures of resuscitation for mL of blood in the chest cavity. It is most
hemorrhagic shock and who have the commonly caused by a penetrating
potential for cardiac tamponade. wound that disrupts the systemic or
Insertion of a central venous line may hilar vessels. It may also be the result of
aid diagnosis. Life-saving blunt trauma. The blood loss is
pericardiocentesis should not be complicated by hypoxia. The neck veins
delayed for this diagnostic adjunct. A may be flat secondary to severe
high index of suspicion coupled with a hypovolemia or may be distended
patient who is unresponsive to because of the mechanical effect of
resuscitative efforts are all that is intrathoracic blood. This condition is
necessary to initiate pericardiocentesis discovered when shock is associated
by the subxyphoid method. with the absence of breath sounds
• Even though cardiac tamponade is and/or dullness to percussion on one
strongly suspected, the initial side of the chest.
administration of intravenous fluid will • Massive hemothorax is initially
raise the venous pressure and improve managed by the simultaneous
cardiac output transiently while restoration of blood volume and
preparations are made for decompression of the chest cavity.
pericardiocentesis via the subxyphoid Large-caliber intravenous lines and
route. The use of a plastic-sheathed rapid crystalloid infusion are begun and
needle is preferable, but the urgent type-specific blood is administered as
priority is to aspirate blood from the soon as possible. If an auto-transfusion
pericardial sac. Electrocardiographic device is available, it may be used. A
monitoring may identify current of single chest tube (#38 French) is
injury and needle-induced inserted at the nipple level, anterior to
dysrhythmias. Because of the self- the midaxillary line, and rapid
sealing qualities of the myocardium, restoration of volume continues as
aspiration of pericardial blood alone decompression of the chest cavity is
may relieve symptoms temporarily. completed. When massive hemothorax
However, all patients with positive is suspected, prepare for
pericardiocentesis due to trauma will autotransfusion. If 1500 mL is
require open thoracotomy and immediately evacuated, it is highly likely
inspection of the heart. that the patient will require an early
Pericardiocentesis may not be thoracotomy.
diagnostic or therapeutic because the • Some patients who have an initial
blood in the pericardial sac is clotted. volume output of less than 1500 mL, but
Preparations for transfer of these continue to bleed, may require a

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thoracotomy. This decision is based on
the rate of continuing blood loss (200
mL/hour). During patient resuscitation,
the volume of blood initially drained
from the chest tube and the rate of
continuing blood loss must be factored
into the amount of intravenous fluid
replacement. The color of the blood
(arterial or venous) is a poor indicator
of the necessity for thoracotomy.
• Penetrating anterior chest wounds
medial to the nipple line and posterior
wounds medial to the scapula should
alert the physician to the possible need
for thoracotomy, because of possible
damage to the great vessels, hilar
structures, and the heart, with the
associated potential for cardiac
tamponade. Thoracotomy is not
indicated unless a surgeon is present
and the procedure is performed by a
physician qualified by training and
experience.
(d)Flail Chest
A flail chest occurs when a segment of the
chest wall does not have bony continuity
with the rest of the thoracic cage. This
condition usually results from trauma
associated with multiple rib fractures. The
presence of a flail chest segment results in
severe disruption of normal chest wall
movement. If the injury to the underlying
lung is significant, serious hypoxia may
result. The major difficulty in flail chest
stems from the injury to the underlying
lung. Although chest wall instability leads
to paradoxical motion of the chest wall
with inspiration and expiration, this defect
alone does not cause hypoxia. Associated
pain with restricted chest wall movement
and underlying lung injury contribute to
the patient's hypoxia.
Flail chest may not be apparent initially
because of splinting of the chest wall. The
patient moves air poorly, and movement of
the thorax is asymmetrical and
uncoordinated. Palpation of abnormal
respiratory motion and crepitus of rib or
cartilage fractures aids diagnosis. A
satisfactory chest roentgenogram may
suggest multiple rib fractures, but may not
show costochondral separation. Arterial
blood gases, suggesting respiratory failure
with hypoxia, also may aid in diagnosing a
flail chest.
Initial therapy includes adequate
ventilation, administration of humidified
oxygen, and fluid resuscitation. In absence
of systemic hypotension, the
administration of crystalloid intravenous
solutions should be carefully controlled to
prevent overhydration. The injured lung in
a flail chest is sensitive to both
underresuscitation of shock and fluid
overload. Specific measures to optimize
fluid measurement must be taken for the
patient with flail chest.
The definitive treatment is to re-expand
the lung, ensure oxygenation as completely
as possible, administer fluids judiciously,
and provide analgesia to improve
ventilation. Some patients can be managed
without the use of a ventilator. However,
prevention of hypoxia is of paramount
importance for the trauma patient, and a
short period of intubation and ventilation
may be necessary until the diagnosis of the
entire injury pattern is complete. A careful
assessment of the respiratory rate, arterial
oxygen tension, and an estimate of the
work of breathing will indicate appropriate
timing for intubation and ventilation. Not
all patients with a flail chest require
immediate endotracheal intubation.
(e).Open Pneumothorax ("Sucking Chest
Wound")
Large defects of the chest wall, which
remain open, result in an open
pneumothorax or sucking chest wound.
Equilibration between intrathoracic
pressure and atmospheric pressure is
immediate. If the opening in the chest wall
is approximately two thirds the diameter of
the trachea, air passes preferentially
through the chest defect with each
respiratory effort, because air tends to
follow the path of least resistance through
the large chest-wall defect. Effective
ventilation is thereby impaired, leading to
hypoxia.
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Manage an open pneumothorax by
promptly closing the defect with a sterile
occlusive dressing, large enough to overlap
the wound's edges, and taped securely on
three sides. Taping the occlusive dressing
on three sides provides a flutter-type valve
effect. As the patient breathes in, the
dressing is occlusively sucked over the
wound, preventing air from entering. When
the patient exhales, the open end of the
dressing allows air to escape. A chest tube
should be placed remote from the wound
as soon as possible. Securely taping all
edges of the dressing can cause air to
accumulate in the thoracic cavity resulting
in a tension pneumothorax unless a chest
tube is in place. Any occlusive dressing
(plastic wrap, petrolatum gauze, etc) may
be used as a stopgap so rapid assessment
can continue. Definitive surgical closure of
the defect is usually required.
(f). Tracheobronchial Tree
1. larynx
Fracture of the larynx is a rare injury, and
is indicated by the following triad:
Hoarseness
Subcutaneous emphysema
Palpable fracture crepitus.
If the patient's airway is totally obstructed
or the patient is in severe respiratory
distress, an attempt at intubation is
warranted. If intubation is unsuccessful, a
tracheostomy (not surgical
cricothyroidotomy) is indicated, followed
by operative repair. If the patient has
sustained blunt trauma to the larynx,
exhibits subtle symptoms, and a fracture is
suspected, computed tomography may be
helpful in identifying a fracture of the
larynx.
2. Trachea
Direct trauma to the trachea, including the
larynx, can be either penetrating or blunt.
Blunt injuries may be subtle, and history is
all-important.
Penetrating trauma is overt and requires
immediate surgical repair. Penetrating
injuries are often associated with
esophageal, carotid artery, and jugular vein
trauma. Because of the blast effect,
penetrating injuries caused by missiles are
often associated with extensive tissue
destruction surrounding the area of
penetration.
Noisy breathing indicates partial airway
obstruction that suddenly may become
complete. Absence of breathing suggests
that complete obstruction already exists.
When the level of consciousness is
depressed, detection of significant airway
obstruction is more subtle. Observations of
labored respiratory effort may be the only
clue to airway obstruction and
tracheobronchial injury. Endoscopic
procedures and CT scanning aid the
diagnosis.
3. Bronchus
Injury to a major bronchus is an unusual
and fatal injury that is frequently
overlooked. The majority of such injuries
result from blunt trauma and occur within
one inch of the carina. Although most
patients with this injury die at the scene,
those who reach the hospital alive have a
30% mortality, often due to associated
injuries.
If suspicion of a bronchial injury exists,
immediate surgical consultation is
warranted. A patient with a bronchial
injury frequently presents with
hemoptysis, subcutaneous emphysema, or
tension pneumothorax with a mediastinal
shift. A pneumothorax associated with a
persistent large air leak after tube
thoracotomy suggests a bronchial injury.
More than one chest tube may be necessary
to overcome a very large leak.
Bronchoscopy confirms the diagnosis of
the injury.
Treatment of tracheobronchial injuries
may require only airway maintenance until
the acute inflammatory and edema
processes resolve. Major deviation or
compression of the trachea by extrinsic
masses, ie, hematomas, must be treated.
Intubation frequently may be unsuccessful
because of the anatomic distortion from
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paratracheal hematoma, major
laryngotracheal injury, and associated
injuries. For such patients, operative
intervention is indicated. Patients
surviving with bronchial injuries may
require direct surgical intervention by
thoracotomy.
(g)Blunt Cardiac Injuries
Myocardial contusion, although difficult to
diagnose, is another potentially lethal
injury from blunt chest trauma. The
patient's reported complaints of
discomfort are often bypassed as being
associated with chest wall contusion or
fractures of the sternum and/or ribs. The
diagnosis of myocardial contusion is
established by abnormalities on the
electrocardiogram, two-dimensional
echocardiography, and associated history
of injury. The electrocardiographic changes
are variable and may even indicate frank
myocardial infarction. Multiple premature
ventricular contractions, unexplained sinus
tachycardia, atrial fibrillation, bundle
branch block (usually right), and ST
segment changes are the most common
electrocardiographic findings.
Elevated central venous pressure in the
absence of obvious cause may indicate
right ventricular dysfunction secondary to
contusion.
Patients with myocardial contusion are at
risk for sudden dysrhythmias. They should
be admitted to the critical care unit for
close observation and cardiac monitoring.
(h). Traumatic Diaphramatic Rupture
A traumatic diaphragmatic rupture is more
commonly diagnosed on the left side
because the liver obliterates the defect on
the right side, while the appearance of
bowel, stomach, or nasogastric tube is
more easily detected in the left chest. Blunt
trauma produces large radial tears that
lead to herniation. Penetrating trauma
produces small perforations that often take
some time, even years, to develop into
diaphragmatic hernias.
These injuries are missed initially if the
chest film is misinterpreted as showing an
elevated left diaphragm, acute gastric
dilatation, a loculated pneumohemothorax,
or subpulmonary hematoma. If a laceration
of the left diaphragm is suspected, a gastric
tube should be inserted. When the gastric
tube appears in the thoracic cavity on the
chest film, the need for special contrast
studies is eliminated. Occasionally, the
diagnosis is not identified on the initial
roentgenogram or after chest tube
evacuation of the left thorax. An upper
gastrointestinal contrast study should be
performed if the diagnosis is not clear. The
appearance of peritoneal lavage fluid in the
chest tube drainage also confirms the
diagnosis.
Right diaphragmatic ruptures are rarely
diagnosed in the early postinjury period.
The liver often prevents herniation of other
abdominal organs into the chest. The
appearance of an elevated right diaphragm
on chest roentgenogram may be the only
finding. Operation for other abdominal
injuries often reveals diaphragmatic tears.
The treatment is direct repair.
(i).Blunt Esophageal Injury
Esophageal trauma is most commonly
penetrating. Blunt esophageal trauma,
although very rare, may be lethal if
unrecognized. Blunt injury of the
esophagus is caused by a forceful expulsion
of gastric contents into the esophagus from
a severe blow to the upper abdomen. This
forceful ejection produces a linear tear in
the lower esophagus, allowing leakage into
the mediastinum. The resulting
mediastinitis and immediate or delayed
rupture into the pleural space cause
empyema. Esophageal trauma may be
caused by mishaps of instrumentation
(nasogastric tubes, endoscopes, dilators,
etc).
The clinical picture is identical to that of
postemetic esophageal rupture. Esophageal
injury should be considered for any patient
who (1) has a left pneumothorax or
hemothorax without a rib fracture, (2) has
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received a severe blow to the lower
sternum or epigastrium and is in pain or
shock out of proportion to the apparent
injury, or (3) has particulate matter in their
chest tube after the blood begins to clear.
Presence of mediastinal air also suggests
the diagnosis, which often can be
confirmed by contrast studies and/or
esophagoscopy.
Wide drainage of the pleural space and
mediastinum with direct repair of the
injury via thoracotomy is the treatment if
feasible. If the repair is tenuous or not
feasible, esophageal diversion in the neck
and gastrostomy of the lower and upper
gastric segments usually is carried out,
thereby avoiding continued soiling of the
mediastinum and pleura by gastric and
esophageal contents.
(j).Subcutaneous Emphysema
Subcutaneous emphysema may result from
airway injury, lung injury, or rarely, blast
injury. Although it does not require
treatment, the underlying injury must be
addressed.
(k)Pulmonary Contusion
Pulmonary contusion is the most common
potentially lethal chest injury seen in North
America. The respiratory failure may be
subtle and develops over time rather than
occurring instantaneously. The plan for
definitive management may change with
time warranting careful monitoring and re-
evaluation of the patient.
Some patients with stable conditions may
be managed selectively without
endotracheal intubation or mechanical
ventilation. Patients with significant
hypoxia should be intubated and ventilated
within the first hour after injury.
Associated medical conditions, eg, chronic
pulmonary disease and renal failure,
predispose to the need for early intubation
and mechanical ventilation.
If the patient cannot maintain satisfactory
oxygenation or has any of the above
complicating features, intubation and
mechanical ventilation should be
considered. Pulse oximetry, ABG
determination, ECG monitoring, and
appropriate ventilatory equipment are
necessary for optimal management. Any
patient with the aforementioned pre-
existing conditions and who is to be
transferred should be intubated and
ventilated.
(l).Rib Fracture
The ribs are the most commonly injured
component of the thoracic cage. Injuries to
the ribs are often significant. Pain on
motion results in splinting of the thorax,
which impairs ventilation.
Tracheobronchial secretions cannot be
eliminated easily. The incidence of
atelectasis and pneumonia rises strongly
with pre-existing lung disease.
The upper ribs (1 to 3) are protected by the
bony framework of the upper limb. The
scapula, humerus, and clavicle, along with
their muscular attachments, provide a
barrier to rib and scapular injury.
Fractures of the scapula, and first or
second ribs often indicate major injury to
the head, neck, spinal cord, lungs, and the
great vessels. Because of the severity of the
associated injuries, mortality can be as high
as 50%. Surgical consultation is warranted.
The middle ribs (4 to 9) sustain the
majority of blunt trauma. Anteroposterior
compression of the thoracic cage will bow
the ribs outward with a fracture in the
midshaft. Direct force applied to the ribs
tends to fracture them and drive the ends
of the bones into the thorax with more
potential for intrathoracic injury, such as
pneumothorax. As a general rule, a young
patient with a more flexible chest wall is
less likely to sustain rib fractures.
Therefore, the presence of multiple rib
fractures in young patients implies a
greater transfer of force than in older
patients. Fractures of the lower ribs (10 to
12) should increase suspicion for
hepatosplenic injury.
Localized pain, tenderness on palpation,
and crepitus are present in rib injury
patients. A palpable or visible deformity
suggests rib fractures. A chest
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roentgenogram should be obtained
primarily to exclude other intrathoracic
injuries and not just to identify rib
fractures. Fractures of anterior cartilages
or separation of costochondral junctions
have the same implications as rib fractures,
but will not be seen on the
roentgenographic examinations.
Special rib technique roentgenograms are
expensive, may not detect all rib injuries,
add nothing to treatment, require painful
positioning of the patient, and are not
useful. Taping, rib belts, and external
splints are contraindicated. Relief of pain is
important to enable adequate ventilation.
Intercostal block, epidural anesthesia, and
systemic analgesics may be necessary.

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Chapter Essence
In a Nutshell
69. .
Nursing Alerts
131. . Nursing Approach to the Client with Chest Injuries, Pneumothorax, or Hemothorax
132. Nursing Assessment
133.
134. 1. Assess for history of the injury.
135. 2. Assess presence of signs and symptoms of impaired respiratory function
(dyspnea, chest pain, asymmetric chest movements, signs of paradoxical breathing,
cyanosis, anxiety, bloody sputum)
136. 3. Assess chest wall for presence of wounds and fractures.
137. 4. Assess signs of increased intrathoracic pressure (mediastinal shift, trachea shift,
progressive signs of respiratory and cardiovascular insufficiency).
138. 5. Lung auscultation shows diminution or absence of breathing sounds on the
affected side.
139. 6. Assess vital signs, CVP, ECG, fluid balance.
140. 7. Assess diagnostic tests and procedures for abnormal values (chest x-ray, CT,
pleural puncture).
141.
142. Nursing Diagnosis
143.
144. 1. Increased risk of hypoxia and respiratory failure related to injury.
145. 2. Increased risk of hypovolemia and shock related to hemorrhage and impaired
cardiac function.
146. 3. Pain related to injury.
147. 4. Anxiety related to the symptoms of disease and fear of death.
148.
149. Nursing Plan and Interventions
150.
151. Goals
152.
153. 1. Maintain respiratory and cardiovascular function.
154. 2. Prevent avoidable injury and complications.

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155. 3. Then surgical intervention prescribed, prevent postoperative complications.

156. 4. Relief or diminish symptoms.
157. 5. Decreased anxiety with increased knowledge.
158.
159. Interventions
160.
161. 1. Assess, report , and record signs and symptoms and reactions to treatment.
162. 2. Observe respiratory status closely, report immediately if changed.
163. 3. Monitor vital signs, fluid balance, level of consciousness closely.
164. 4. Administer oxygen and other medications as prescribed, monitor for side effects.
165. 5. Maintain patency of chest tubes, observe appropriate connections and presence
of negative pressure in system.
166. 6. Administer blood transfusions and IV therapy as prescribed, monitor for side
effects.
167. 7. Place client in the high-Fowler position then has chest injury, on a side of the
chest tube insertion then hemothorax presents to provide drainage.
168. 8. Monitor laboratory tests results for abnormal values.
169. 9. Prepare client and his family for surgical intervention.
170. 10. For client after surgical intervention provide postoperative care and observe
possible postoperative complications.
171. 11. Encourage the client to turn and cough and breath deeply.
172. 12. Observe signs of possible secondary pulmonary infection, report immediately.
173. 13. Provide appropriate skin care to prevent pressure sores.
174. 14. Provide emotional support to client, explain all procedures to decrease anxiety
and to obtain cooperation.
175. 15. Instruct client regarding disease, diagnostic procedures, treatment and its
complications, home care, daily activities, restrictions and follow-up.
176.
177. Evaluation
178.
179. 1. Maintain adequate respiratory function and gas exchange.
180. 2. Tolerates progressive activity, verbalize reduction in anxiety and pain.
181. 3. No evidence of complications.
182. 4. Maintains stable vital signs, fluid balance, and nutritional state.
183. 5. Laboratory tests results shows no abnormalities.
184. 6. Demonstration of understanding of situation, diagnostic and treatment
procedures, and need for follow-up.
Nursing Management
158. .
Trainer’s Pearls
107. .

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Chapter
Abdominal Injuries
.
Chapter Outline
1. .

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Abdominal InjuriesAbdominal Injuries B. Penetrating Trauma

A surgeon must evaluate all penetrating
Two major types of abdominal trauma injuries of the abdomen. Penetrating
occur: blunt and penetrating. In either case, trauma to the flanks, buttocks, and lower
early patient evaluation by a surgeon is chest may produce intra-abdominal
essential. injuries as well and should be regarded
A. Blunt Trauma with a high degree of suspicion.
Intra-abdominal visceral damage must be C. Management
strongly suspected following blunt trauma
to the abdomen, especially because Management of blunt and penetrating
evidence is frequently subtle and trauma to the abdomen includes:
misleading. Diagnosis of such injuries is Re-establishing vital functions and
often difficult, and an aggressive approach optimizing oxygenation and tissue
is mandatory. Multiple injuries are perfusion.
common, and common signs and Delineating the injury mechanism.
symptoms guide the diagnostic process. Maintaining a high index of suspicion
Assessment of the mechanisms of injury related to occult vascular and
may provide some insight. If clinical retroperitoneal injuries.
findings are absent of obscured by other Repeating a meticulous physical
injuries, special techniques must be examination, assessing for changes.
applied. Peritoneal lavage, properly Selecting special diagnostic maneuvers as
performed, is a valuable diagnostic tool for needed, performed with a minimal loss of
these patients. A specific organ injury time.
diagnosis is not necessary - only the finding Early recognition for surgical intervention
of an acute abdominal injury. and prompt celiotomy.

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Chapter Essence
In a Nutshell
70. .
Nursing Alerts
185. .
Nursing Management
159. . The following interventions are routine for a patient with abdominal trauma:
160.
161. * Insert two large-bore intravenous (I.V.) lines to infuse 0.9% sodium chloride or
lactated Ringer's solution, according to facility protocol.
162.
163. * Control the patient's pain without sedating him, so you can continue to assess his
injuries and ask him questions. Generally, I.V. analgesics such as morphine can adequately
manage pain without sedation.
164.
165. * Insert an indwelling urinary catheter, unless you suspect a urinary tract injury. For
example, bloody urine or a prostate gland found to be in a high position during a rectal
exam could indicate damage to the urinary tract. If the patient is to have a rectal
examination, delay catheter insertion until afterward.
166.
167. * Draw blood specimens stat for baseline lab values. (Appropriate tests are listed
later in this article.)
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168.
169. * Insert a gastric tube to decompress the patient's stomach, prevent aspiration, and
minimize leakage of gastric contents and contamination of the abdominal cavity. This also
gives you access to gastric contents to test for blood.
170.
171. * Administer tetanus prophylaxis and antibiotics as ordered.
172.
173.
174. Assessing abdominal injuries
175. Blunt injuries suffered during an MVC can be especially difficult to detect. A
penetrating abdominal injury, such as a stab wound, causes more obvious damage that
commonly involves hollow organs such as the small bowel. (To review the various types of
trauma, see Forces behind abdominal injury.)
176.
177. If your patient is stable, perform a complete assessment using inspection,
auscultation, percussion, and palpation. If he's unstable, you may have to rely on
inspection and auscultation alone.
178.
179. Inspection
180. Look for and document obvious abnormalities, including distension, contusions,
abrasions, lacerations, penetrating wounds, and asymmetry. If the patient was in an MVC,
look for a contusion or abrasion across his lower abdomen, known as the "seat belt sign."
Areas of purple discoloration should make you suspicious. Ecchymosis around the
umbilicus (Cullen's sign) or flanks (Grey-Turner's sign) may indicate retroperitoneal
hemorrhage, but these signs may not appear for hours or days.
181.
182. Auscultation
183. If resuscitation efforts aren't under way, auscultate your patient's baseline bowel
sounds and listen for abdominal bruits. Always auscultate before percussion and palpation
because those procedures can change the frequency of bowel sounds. Listen to all four
quadrants of his abdomen and his thorax.
184.
185. The absence of bowel sounds could be an early sign of intraperitoneal damage.
Bowel perforation and the spread of blood, bacteria, and chemical irritants can cause
diminished or absent bowel sounds. Bowel sounds in the chest may signal a ruptured
diaphragm with herniation of the small bowel into the thoracic cavity. Abdominal bruits
(vascular sounds due to turbulent blood flow that resemble systolic heart murmurs) might
signal an arterial injury or aneurysm.
186.
187. Before you percuss and palpate your patient's abdomen, ask him to point to painful
areas and be sure to examine them last. If his pain is severe, skip percussion and palpation;
diagnostic studies such as ultrasound and computed tomography (CT) studies are
necessary to evaluate his abdomen.
188.
189. Percussion
190. In a normal abdomen, percussion elicits dull sounds over solid organs and fluid-
filled structures (such as a full bladder) and tympany over air-filled areas (such as the
stomach). The following findings are abnormal:
191.

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192. * Pain with light percussion suggests peritoneal inflammation.

193.
194. * Fixed dullness in the left flank and shifting dullness in the right flank while the
patient is lying on his left side (Ballance's sign) signal blood around the spleen or spleen
injury.
195.
196. * Dullness over regions that normally contain gas may indicate accumulated blood
or fluid.
197.
198. * Loss of dullness over solid organs indicates the presence of "free air," which
signals bowel perforation.
199.
200.
201. Palpation
202. Begin gently palpating your patient's abdomen in an area where he hasn't
complained of pain. Palpate one quadrant at a time for involuntary guarding, tenderness,
rigidity, spasm, and localized pain. Keep in mind that these signs and symptoms might not
be present if he has competing pain from another injury, a retroperitoneal hematoma,
spinal cord injury, or decreased level of consciousness or if he's under the influence of
drugs or alcohol. Generalized discomfort during palpation may signal peritonitis. An
abdominal mass might be a collection of blood or fluid. (See "Assessing the Abdomen" in
the May issue of Nursing2003 for more on assessment techniques.)
203.
204. Your patient also may need an internal examination. A rectal examination can help
pinpoint injury to the urinary tract or pelvis. A vaginal examination can reveal a vaginal
injury or the presence of a foreign body, such as bone from a pelvic fracture.
205.
206. Signs of internal injuries
207. Certain telltale signs can help you sort out the many internal injuries that can occur
with abdominal trauma. For example, a victim of an MVC can sustain a lap belt injury that
deserves special attention. When a quick stop whips the upper torso forward, the seat belt
above the bony pelvic girdle can momentarily trap the viscera against the spine and impose
shearing and compression injuries to the gut and mesentery. Most common in this
situation are mesenteric hematoma, devascularization of the bowel, severe damage
leading to rupture of the bowel wall, bruising, and hemorrhage of the abdominal wall that
follows the belt pattern.
208.
209. Signs and symptoms of lap belt injury usually develop slowly and may be
overshadowed by other injuries. Any MVC victim who has ecchymosis in the imprint of a
seat belt on his abdomen or develops late abdominal pain, distension, paralytic ileus, or
slow return of gastrointestinal function should be evaluated for abdominal injuries.
210.
211. Spleen injury is usually associated with blunt trauma. Fractures of ribs 10 to 12 on
the left should raise your suspicion of spleen damage, which ranges from laceration of the
capsule or a nonexpanding hematoma to ruptured subcapsular hematomas or
parenchymal laceration. The most serious types of injury are a severely fractured spleen or
vascular tear that causes splenic ischemia and massive blood loss. (See Pinpointing key
injuries for more details.)
212.

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 - 619 -

213. Liver injury is common because of the liver's size and location. Severity ranges from
a controlled subcapsular hematoma and lacerations of the parenchyma to hepatic avulsion
or a severe injury of the hepatic veins. Because liver tissue is very friable and the liver's
blood supply and storage capacity are extensive, a patient with liver injuries can
hemorrhage profusely and may need surgery to control the bleeding.
214.
215. The most common kidney injury is a contusion from blunt trauma; suspect this type
of injury if your patient has fractures of the posterior ribs or lumbar vertebrae. Other renal
injuries include lacerations or contusion of the renal parenchyma caused by shearing and
compression forces; the deeper a laceration, the more serious the bleeding. Deceleration
forces may damage the renal artery; collateral circulation in that area is limited, so any
ischemia is serious and may trigger acute tubular necrosis.
216.
217. Hollow organ injuries, which can occur with blunt or penetrating trauma, most
commonly involve the small bowel. Deceleration with shearing may tear the small bowel,
generally in relatively fixed or looped areas.
218.
219. Blunt forces cause most bladder injuries. The bladder rises into the abdominal
cavity when full, so it's more susceptible to injury. If a distended bladder ruptures or is
perforated, urine is likely to escape into the abdomen. If the bladder isn't full when
ruptured, urine may leak into the surrounding pelvic tissues, vulva, or scrotum.
Trainer’s Pearls
108. .

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Chapter
Pelvic Injuries.
Chapter Outline
1. .

-oOo-

Pelvic Injuries
Pelvic Fractures:
• Assessment:
o The flank, scrotum and perianl area should be inspected
o Blood at the urethral meatus, swelling/bruishing/laceration in the peritoneum,
vagina, rectum, or buttock open pelvic facture
o Palpation of a high-riding prostate gland.
o Manual manipulation of the pelvis should be performed only once.
• Management:
• Exsanguination with/without open pelvic fracture (BP<70mmHg)
o Initiate ABCDEs → If transfer neccessary, apply PASG
o If open go to OR for possible perineal exploration and celiotomy ; if closed,
supraumbilical DPL or Ultrasound to exclude intraperitoneal hemorrhage.
▪ Positive : After operation Reduce & apply fixation device as appropriate
▪ Negative : Reduce & apply fixation device as appropriate
o Hemodynamically Abnomal → Angiography
• Blood pressure stabilizees with difficulty and closed/unstable fracture (BP 90-
110mmHg)
o Initiate ABCDEs → If transfer neccessary, apply PASG
o supraumbilical DPL or Ultrasound to exclude intraperitoneal hemorrhage.
▪ Positive : After celiotomy , Reduce & apply fixation device as appropriate
▪ Negative : reduce & apply fixation device as appropriate
▪
o Hemodynamically Abnomal → Angiography
• Blood Pressure normal and closed/unstable or stable fracture (BP 120 mmHg)
o Initiate ABCDEs → If transfer neccessary, apply PASG
o Evaluate for other injuries
o Apply fixation device if needed for patient mobility
-oOo-

Chapter Essence
In a Nutshell
71. .
Nursing Alerts
186. .
Nursing Management
220. Nursing Management
221. ________________________________________
222. Nursing management for close and open fractures should be differentiated.
223. Nursing Assessment
224. Assessment of the fractured area includes the following:

621
 - 622 -

225. • Close fracture. The patient with close fracture is assessed for absence of
opening in the skin at the fracture site.
226. • Open fracture. The patient with open fracture is assessed for risk for
osteomyelitis, tetanus, and gas gangrene.
227. • The fractured site is assessed for signs and symptoms of infection.
228. Diagnosis
229. Based on the assessment data gathered, the nursing diagnoses developed include:
230. • Acute pain related to fracture, soft tissue injury, and muscle spasm.
231. • Impaired physical mobility related to fracture.
232. • Risk for infection related to opening in the skin in an open fracture.
233. Planning & Goals
234. Main Article: 8 Fracture Nursing Care Plans
235. Planning and goals developed for a patient with fracture are:
236. • Relief of pain.
237. • Achieve a pain-free, functional, and stable body part.
238. • Maintain asepsis.
239. • Maintain vital signs within normal range.
240. • Exhibit no evidence of complications.
241. Nursing Interventions
242. Nursing care of a patient with fracture include:
243. • The nurse should instruct the patient regarding proper methods to control
edema and pain.
244. • It is important to teach exercises to maintain the health of the unaffected
muscles and to increase the strength of muscles needed for transferring and for using
assistive devices.
245. • Plans are made to help the patients modify the home environment to
promote safety such as removing any obstruction in the walking paths around the house.
246. • Wound management. Wound irrigation and debridement are initiated as
soon as possible.
247. • Elevate extremity. The affected extremity is elevated to minimize edema.
248. • Signs of infection. The patient must be assessed for presence of signs and
symptoms of infection.
249. Evaluation
250. The following should be evaluated for a successful implementation of the care plan.
251. • Pain was relieved.
252. • Achieved a pain-free, functional, and stable body part.
253. • Maintained asepsis.
254. • Maintained vital signs within normal range.
255. • Exhibited no evidence of complications.
256. Discharge and Home Care Guidelines
257. After completion of the home care instructions, the patient or caregiver will be able
to:
258. • Control swelling and pain. Describe approaches to reduce swelling and pain
such as elevating the extremity and taking analgesics as prescribed.
259. • Care of the affected area. Describe management of immobilization devices
or care of the incision.
260. • Consume diet to promote bone healing.
261. • Mobility aids. Demonstrate use of mobility aids and assistive devices safely.
262. • Avoid excessive use of injured extremity and observe weight-bearing limits.

622
 - 623 -

263. Documentation Guidelines

264. The focus of documentation should include:
265. • Client’s description of response to pain and acceptable level of pain.
266. • Prior medication use.
267. • Level of function.
268. • Ability to participate in specific or desired activities.
269. • Signs and symptoms of infectious process.
270. • Wound/ incision site.
271. • Plan of care.
272. • Teaching plan.
273. • Response to interventions, teaching, and actions performed.
274. • Attainment or progress toward desired outcomes.
275. • Modifications to plan of care.
276. • Long term needs..
Trainer’s Pearls
109. .

623
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Chapter Outline
1. .
-oOo-
Management of Extremity Injuries
Proper management of fractures and
dislocations will decrease the incidence of
pain, disability, and serious complications.
Treatment in the prehospital setting is
directed at proper immobilization of the
injured part by the use of an appropri-ate
splint and padding. Even with proper
immobilization, patients may require
analgesic medication to control their pain.
Purpose of Splinting
The objective of splinting is to prevent
motion in the broken bone ends. The
nerves that cause the most pain in a
fractured extremity lie next to the bone.
The broken bone can injure the nerves,
causing a very deep, severe pain. Splinting
not only decreases pain, but also limits
further damage to muscles, nerves, and
blood vessels by preventing further motion
of the broken bone ends
When to Splint
There is no simple rule for splinting that
determines the precise sequence to follow
in every patient. In general, the seriously
injured patient will be better off if you
splint only the spine (long backboard)
before transport. Extremity fractures can
be temporarily stabilized by careful
packaging on the long back-board for
patients who require a load-and-go
approach. This does not mean that you
should not identify and protect extremity
fractures, but that it is better to do
additional splinting en route to the hospital
after you have taken care of other
priorities, including shock management. It
is never appropriate to spend time
splinting a limb to prevent disability when
that time may be needed to save the
patient’s life. Conversely, if the patient
Chapter
Injuries to Extremities.
appears to be stable, extremity fractures
should be splinted before moving the
patient for all the reasons noted earlier.
Applying a Thomas Traction Splint
(Half-Ring Splint)
The Thomas splint was used exclusively
prior to the advent of modern traction
devices. During World War I, its use
decreased the mortality rate for battlefield
femur fractures from 80% to 40%. At that
time it was considered one of the greatest
advancements in medical care. It is still
used in some countries and in the absence
of other options. To apply a Thomas
traction splint, follow these steps:
Have your partner support the leg
and maintain gentle traction while you cut
away the clothing and remove the shoe and
sock to check the pulse and sensation at
the foot.
Position the splint under the injured
leg. The ring goes down, and the short side
goes to the inside of the leg. Slide the ring
snugly up under the hip, where it will be
pressed against the ischial tuberosity.
Attach the top ring strap.
Apply padding to the foot and ankle.
Apply the traction hitch around the
foot and ankle .
Maintain gentle traction by hand.
Attach the traction hitch to the end
of the splint.
625
 - 626 -
Increase traction by Spanish
windlass action, using a stick or tongue
depressors.
Position two support straps above
the knee and two below the knee. Do not
place over fracture site.
Release manual traction and
reassess circulation and sensation.
Support the end of the splint so that
there is no pressure on the heel.
Any hard object may be used to restrict the
movement of the joints above and below
the fracture site to achieve
immobilization
Splinting of extremity injuries must be
deferred until life-threatening problems
are identified and managed. However, all
such injuries must be splinted before
patient transport. Specific types of splints
can be applied for specific fracture needs.
The pneumatic antishock garment (PASG)
has not proved to be an effective or safe
splint for extremity injuries, although it
may be helpful temporarily for patients
with life-threatening hemorrhage from
pelvic injuries. A long spine board provides
a "total body splint" for multiple injured
patients with possible or definite unstable
spine injuries. However, its hard, unpadded
surface may cause pressure sores on the
patient's occiput, scapulae, sacrum, and
heels. Therefore, as soon as possible, the
patient should be moved carefully to an
equally supportive padded surface, using a
scoop-style stretcher to facilitate the
transfer. The patient should be fully
immobilized and an adequate number of
personnel should be available during this
transfer.
A. Femoral Fractures
Femoral fractures are best provisionally
immobilized with traction splints. The
traction splint's force is applied distally at
the ankle. Proximally, the splint is secured
to the thigh and hip area. Traction splints
may be used for ipsilateral femoral and
tibial fractures. Excess traction may cause
skin damage to the foot or ankle, perineal
injury, and neurovascular compromise
from pressure stretching of anatomic
structures. Hip fractures can be similarly
immobilized with a traction splint,
especially if the leg is shortened and
malrotated. Alternatively, the injured leg is
merely secured to the other leg and/or the
stretcher. Hip dislocations may produce a
fixed deformity. If gentle realignment of the
limb with manual traction is not possible,
pillows or other bulky padding and tape
may be used to support the limb in the
most comfortable position.
B. Knee Injuries
A long-leg splint, a traction-type splint
applied with minimal traction, or a
commercial knee-immobilizator may be
used to support the injured knee.
Additional stability is provided by splinting
the opposite leg. Padding may be needed to
maintain some knee flexion.
C. Tibia Fractures
Tibia fractures are best immobilized with a
well-padded board or metal gutter, long-
leg splint. A gently inflated pneumatic
splint also is good. For proximal fractures,
a traction-type splint can be used, but
beware of excessive traction. When
aligning a tibial fracture in a splint, make
sure that rotation is correct.
D. Ankle Fractures
Ankle fractures may be immobilized with a
pillow splint or padded-board splint,
avoiding pressure over bony prominences.
Assess the neurovascular status before and
after the splint is applied.
E. Upper Extremity and Hand Injuries
The hand can be temporarily splinted in an
anatomic, functional position, with the
wrist slightly dorsiflexed and the fingers
gently flexed. This position usually can be
achieved by gently immobilizing the hand
over a large role of gauze, and using a short
arm splint as well.
The forearm and wrist are immobilized flat
on padded or pillow splints.
The elbow is splinted in a flexed position,
either by using padded splints or by direct
626
 - 627 -
immobilization to the body with a sling and
swath device.
The arm is immobilized by splinting to the
body or simple application of a sling or
swath, which can be augmented with
splints for unstable fractures.
Shoulder injuries are managed similarly,
using bulky padding as necessary.
Circumferential bandages, used to apply
molded and padded, splints, can have a
tourniquet effect. The extremity must be
monitored frequently for vascular
compromise. All splints must be padded
over bony prominences.
All jewelry, including rings, bracelets, etc,
must be removed before splinting any
extremity injury to prevent pressure on the
area and circulatory embarrassment.
627
- 628 -

628
 - 629 -
-oOo-

Chapter Essence
In a Nutshell
72. .
Nursing Alerts
187. Nursing Diagnosis
188. • Risk for Trauma
189. Risk factors may include
190. • Loss of skeletal integrity (fractures)/movement of bone fragments
191. • Weakness
192. • Getting up without assistance
193. Desired Outcomes
194. • Maintain stabilization and alignment of fracture(s).
195. • Display callus formation/beginning union at fracture site as appropriate.
196. • Demonstrate body mechanics that promote stability at the fracture site.
197. Nursing Interventions Rationale
198. Maintain bed rest or limb rest as indicated. Provide support of joints above and
below fracture site, especially when moving and turning. Provides stability, reducing
possibility of disturbing alignment and muscle spasms, which enhances healing.
199. Secure a bedboard under the mattress or place patient on orthopedic bed.
Soft or sagging mattress may deform a wet (green) plaster cast, crack a dry cast, or
interfere with pull of traction.
200. Support fracture site with pillows or folded blankets. Maintain neutral position of
affected part with sandbags, splints, trochanter roll, footboard. Prevents unnecessary
movement and disruption of alignment. Proper placement of pillows also can prevent
pressure deformities in the drying cast.
201. Use sufficient personnel for turning. Avoid using abduction bar for turning patient
with spica cast. Hip, body or multiple casts can be extremely heavy and
cumbersome. Failure to properly support limbs in casts may cause the cast to break.
202. Observe and evaluate splinted extremity for resolution of edema. Coaptation splint
(Jones-Sugar tong) may be used to provide immobilization of fracture while excessive
tissue swelling is present. As edema subsides, readjustment of splint or application of
plaster or fiberglass cast may be required for continued alignment of fracture.
203. Maintain position or integrity of traction. Traction permits pull on the long axis of
the fractured bone and overcomes muscle tension or shortening to facilitate alignment and
union. Skeletal traction (pins, wires, tongs) permits use of greater weight for traction pull
than can be applied to skin tissues.
204. Ascertain that all clamps are functional. Lubricate pulleys and check ropes for
fraying. Secure and wrap knots with adhesive tape. Ensures that traction setup is
functioning properly to avoid interruption of fracture approximation.
205. Keep ropes unobstructed with weights hanging free; avoid lifting or releasing
weights. Optimal amount of traction weight is maintained. Note: Ensuring free
movement of weights during repositioning of patient avoids sudden excess pull on fracture
with associated pain and muscle spasm.
206. Assist with placement of lifts under bed wheels if indicated. Helps maintain
proper patient position and function of traction by providing a counterbalance.
207. Position patient so that appropriate pull is maintained on the long axis of the bone.

629
 - 630 -

Promotes bone alignment and reduces risk of complications (delayed healing and
nonunion).
208. Review restrictions imposed by therapy such as not bending at waist and sitting up
with Buck traction or not turning below the waist with Russell traction. Maintains
integrity of pull of traction.
209. Assess integrity of external fixation device. Hoffman traction provides stabilization
and rigid support for fractured bone without use of ropes, pulleys, or weights, thus
allowing for greater patient mobility, comfort and facilitating wound care. Loose or
excessively tightened clamps or nuts can alter the compression of the frame, causing
misalignment.
210. Review follow-up and serial X-rays. Provides visual evidence of proper alignment
or beginning callus formation and healing process to determine level of activity and need
for changes in or additional therapy.
211. Administer alendronate (Fosamax) as indicated. Acts as a specific inhibitor of
osteoclast-mediated bone resorption, allowing bone formation to progress at a higher
ratio, promoting healing of fractures and decreasing rate of bone turnover in presence of
osteoporosis.

212. Initiate or maintain electrical stimulation if used. May be indicated to promote

bone growth in presence of delayed healing or nonunion.
213. .
Nursing Management
277. .
Trainer’s Pearls
110. .

630
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Chapter
Trauma in Children – Paediatric Trauma..
Chapter Outline
• Introduction
• Special considerations
• Skeleton
• Airway
• Spinal cord/ C spine Breathing
• Circulation and shock Disability
• Exposure
• FAST and Family
• Head Injury
• Chest Trauma
• Abdominal Trauma
• Child Abuse/ Battered baby

-oOo-

Introduction • Less fat/elastic tissue and close

Most common cause of death and disability
in children. Blunt trauma is more than
Penetrating trauma Falls > MVA > Abuse>
Drowning > Burns.Falls and vehicular
crash accounts for 90% of paediatric
trauma.
Multiple injuries are common Evaluation of
all organ systems if mechanism of injury is
concerning
Special considerations
• They are not just small adults
• Unique anatomic and physiologic
differences
• Management principles are the
same
• Most common single organ system
injury associated with death is head
trauma <4 years of age animal bites and
burns. 5 to 9 years old bicycle and
pedestrian injuries. >9 years fatal and
nonfatal motor vehicle–related trauma.
Anatomic considerations
Size and shape:
• Head-to-body ratio is greater , brain
less myelinated, and cranial bones thinner,
resulting in more serious head injury.
• Smaller body mass so impact
imparts greater force per unit body area
proximity of vital organs
• Chances are more of high frequency
of multiple injuries
• A fast heart rate and slow capillary
refill may be the first signs of shock.
Skeleton
Incomplete and more pliable- SALTER
HARRIS type fractures Identification of
fractures implies massive energy.
Airway
Indications for endotracheal intubation
• Any inability to ventilate by bag-
valve mask
• Glasgow Coma Scale (GCS) score of
less than 9 (to secure the airway and
provide controlled hyperventilation)
• Respiratory failure from hypoxemia
(flail chest and pulmonary contusions)
• Hypoventilation (e.g., injury to
airway structures or spinal cord injury

631
 - 632 -
• The presence of decompensated • Persistent grunting requires
shock resistant to initial fluid ventilation
administration. • Respiratory rate: Fast, then periods
Endotracheal Intubation of apnea or very slow
• No blind nasotracheal intubation for • Chest wall movements
<8 years • Percussion and breath sounds
• Uncuffed tube • Tracheal deviation
• Sizing the tube • Hypoventilation is the most
• (Age + 1) / 4 common cause of cardiac arrest in children.
• Diameter of nares of nose OR little
finger. Infants:
• Frequently reassess placement • Immature response to hypoxia
RSI in children: • Nasal breathers.
• Preparation • Diaphragm 1° muscle of respiration
• Preoxygenation • Easily fatigued
• Premedication (Atropine 0.1-0.5mg) • Aerophagia displaces diaphragm
• Sedation (Midazolam 0.1mg/kg OR Circulation and shock
Thiopentone 4-5mg/kg) • Increased heart rate, Slow capillary
• Post intubation care refill,
Spinal cord • Decreased peripheral pulses
• Spinal cord is fortunately rare (only • Altered sensorium.
5%) in children • Check vital signs every 5 min.
• It is associated with 60% mortality Continuous oximeter and cardiac monitor.
rate. Treatment and Interventions
• Differences in patterns of C spine • Two large-bore intravenous sites
injuries in children as compared to adults • Consider central line or
• Spinal Cord Injury Without intraosseous line
Radiographic Abnormality (SCIWORA) • Bolus with 20 mL/kg of warmed
• Dislocation/Relocation Injuries. normal saline and repeat if necessary.
C-Spine Consider intubation and ventilation.
Anatomic differences • Transfuse 10-20 mL/kg for
• Facets joints horizontal, anterior decompensated shock secondary to blood
wedging vert bodies loss
• Interspinous ligaments and joint
capsules are more flexible injury w/o #
(SCIWORA) Large head, less muscles Systemic Response to Blood Loss In
fulcrum C2-3 Children
• A more tenuous spinal cord blood SYSTEM MILD MODE SEVERE
supply and a greater elasticity of the BLOODV RATE BLOODV
vertebral column, predisposes SCIWORA OLUME BLOOD OLUME
Radiologic considerations LOSS(<39 VOLU LOSS(>45
• Increased distance between dens %) ME %)
and C1 (4-5 mm) LOSS(3
• Pseudosubluxation 0%-
• C2-3, C3-4: 3-4 mm or 50% 45%)
vertebral body width Swischuk’s Cardiova Increased Marke Tachycar
(spinolaminar) line scular heart dly dia
Breathing rate; increas followed
• Look for signs of distress: increased weak, ed by
work of breathing thready heart bradycar
• Retractions, flaring, grunting periphera rate; dia; very

632
 - 633 -
l pulses; weak, weak or
normal thread absent
systolic y central
blood central pulses;
pressure pulses; absent
(80-90 + absent periphera
2 x age inperiph l pulses;
years); eral hpotensio
normal pulses; n (70 + 2
pulse low x age in
pressure normal years);
systoli narrowed
c blood pulse
pressu pressure
•
re (70- (or
• Disability: Neurologic Assessment
80 + 2 undetecta
• Assessment
x age ble
•
in diastolic
• Level of consciousness— AVPU
years); blood
scale and age-appropriate Glasgow Coma
narrow pressure)
Scale (GCS)
ed
• Pupil size and reactivity
pulse
• Extremity movement and tone
pressu
• Posturing and reflexes
re (1)
Treatment and Interventions
Central Anxious; Lethar Comatose
• Stabilize spinal column.
Nervous irritable; gic;
• If GCS score < 9: rapid sequence
System confused dulled
intubation (RSI)
respon
• If altered mental status, obtain a
se to
head computed tomography scan and
pain
neurosurgical consultation.
(2)
• With signs of herniation : mannitol
Skin Co Cyanot Pale and
0.25 to 0.5 g/kg IV, and hyperventilation to
ol, ic; cold
a PCO2 of 30 to 35 mm Hg.
mottled; marke
• Cerebral perfusion pressure of at
prolonge dly
least 50 mm Hg in children.
d prolon
• Assess for signs of spinal injury
cappillary ged
Exposure
refill capilla
• Assess for hidden trauma
ry refill
• Maintain normothermia because
Urine Low to Minim Nil
hypothermia may increase metabolic
Output(3 very low al
demand
)
• Warmed humidified oxygen,
warmed fluids, warmed blood, head wraps,
and convective warmers or radiant heat
• Child’s blood volume: 80ml/kg
sources
•
• Preventing and treating
• Fluid resuscitation guidelines
hypothermia is a matter of survival.
• 20ml/kg bolus of crystalloids.--> 3
• Also good time to concurrently
such boluses may be given if no response
begin imaging and further diagnostic
10ml/ kg of PRBCs Operation
testing
FAST and Family

633
 - 634 -
• FAST evaluates for traumatic free
fluid in the peritoneum (hepatorenal,
perisplenic, and retrovesicular ) and
pericardial space.In hemodynamically
unstable children: may point to concealed
hemorrhage and the need for intervention.
• In hemodynamically stable children:
may indicate the need for CT, closer
observation, repeat abdominal
examinations or repeat ultrasound
examinations.
• In the management of children, the
family (caregivers) could be added to the
primary survey.
• Rapidly informing the family of
about evaluation and progress helps to
lessen their stress.
• Allowing family members to be
present during resuscitations is acceptable
Head Injury
Anatomic differences
• Protective fontanelles and open
sutures
• Plasticity
• Big head torque
• Soft cranium injury w/o fracture
• Less myelin more shearing forces
• Big head ( brain doubles in size in 1
to 6 months and 80% adult brain size by 2
yrs.
• Neuronal plasticity due to
incomplete myelinisation. Very prone to
get seizures and hypoxia.
• Prognosis poorer thn adults.
•
• Aggressive and early interventions.
• Early appropriate neurosurgical
referral.
Chest Trauma
• 2nd leading cause pediatric trauma
death. 10% of all injuries.
• Soft and pliable chest wall leads to
organ injury without overlying fractures.
• Difficult diagnosis and poorly
tolerated
• Mobility of mediastinum causes
tension pneumothorax and flail segments.
• Pulmonary contusion most
common.
Abdominal trauma
• Softer, thinner wall.
• Low abdominal muscle tone.
• Lower-riding liver and spleen
• Leads to organ injury easily
Child Abuse/ Battered baby
• Requires high index of suspicion
• Causes: poverty, single parent,
substance abuse, <2 yr, disability, low birth
wt.
• Most common cause of death are
head & abdominal trauma
• Interview child & parent separately
Child Abuse: Management
• Documentation
• Full Physical exam (rectal, genital)
Skeletal survey
• CT head, abdomen if required
• Child Protection
634
 - 635 -

-oOo-

Chapter Essence
In a Nutshell
73. .
Nursing Alerts
214. .
Nursing Management
278. .
Trainer’s Pearls
111. .

635

Chapter Outline
1. .
Introduction
Trauma complicates 6-7% of all
pregnancies. It is the leading cause of death
in pregnant women. Fetal mortality after
maternal blunt trauma is 3.4-38%.
Common mechanisms of injury are RTA,
burns, falls, domestic violence, physical
abuse.
Key points
• Initial assessment and management
priorities for resuscitation are same as
those for other trauma patients
• Specific anatomic and physiologic
changes of pregnancy may alter the
response to injury
• Modified approach to the
resuscitation process
• Main principle guiding therapy must
be that resuscitating the mother will
resuscitate the fetus
• Detect early pregnancy in female
trauma patients of child bearing age
• The first priority is identification of
life threatening injuries to the woman
• A multidisciplinary team approach,
Involve obstetrician, neonatal team if birth
is imminent
• Do not withhold medications, tests,
treatments and procedures required for
the woman’s stabilisation Test for Rh D
status and administer Rh
immunoglobulin in Rh D negative women
Initiate perimortem CS within 4–6 minutes
of no response to effective CPR
Primary Survey
• Airway/cervical spine control,
breathing and circulation /hemorrhage
control, with the mother receiving
treatment priority
• Supplemental oxygen is essential to
prevent maternal and fetal hypoxia
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Chapter
Trauma in Pregnancy.
-oOo-
• Severe trauma stimulates maternal
catecholamine release, which causes
uteroplacental vasoconstriction and
compromised fetal circulation
• Prevention of aortocaval
compression is also essential to optimize
maternal and fetal hemodynamics
Pregnant patients beyond 20 weeks'
gestation should not be left supine during
the initial assessment Left uterine
displacement by 15-20 degree tilting of the
backboard to the left by placing wedge
under the spinal board.
• As final measure, the uterus can be
manually displaced.
• Hypovolemia should be suspected
before it becomes apparent because of the
relative pregnancy induced hypervolemia
and hemodilution that may mask
significant blood loss
• Aggressive volume resuscitation is
encouraged even for normotensive
patients
• The pneumatic antishock garment
(PASG) may be used to stabilize lower
extremity fractures and perhaps control
hemorrhage but inflation of the abdominal
compartment of the PASG should be
avoided because if compromises
D uteroplacental blood flow.
Secondary Survey
• Complete history, including
obstetrical history
• Head to toe physical examination
• Evaluation and monitoring the fetus
• Pelvic and rectal examinations
should be performed.
• Aside from the usual secondary
survey, assessment of the injured pregnant
patient should rule out vaginal bleeding,
ruptured membranes, a bulging perineum,
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the presence of contractions, and an
abnormal fetal heart rate and rhythm.
Fetal Assessment
• Fetal heart rate :normal range for
the fetal heart rate is 120 to 160
beats/minute Continuous electronic fetal
heart-rate monitoring (EFM) Any viable
fetus of 24 or more weeks' gestation
requires monitoring after any trauma
event ultrasound may help identify other
problems such as cord prolapse and
placenta previa
• Evaluation of the fetus for
gestational age, cardiac activity and
movement. If time permits, a complete
biophysical profile may be performed.
Radiology
• Fetal irradiation should be
minimized by shielding the abdomen when
feasible with a lead apron. When many
radiographs are required over a long
period, a thermoluminescent dosimeter
may be attached to the patient to serve as a
guide to the dosage of radiation delivered
Medication considerations
• Eclamptic Seizures (Acute or
Impending): magnesium sulfate
• Tetanus Booster: If indicated,
tetanus or tetanus-diphtheria booster is
safe
• Antibiotics: Usual antibiotics for
open wounds are generally safe for
pregnant women; e.g., amoxycillin,
ceftriaxone or, if allergic, clindamycin
• Anesthesia: No problem with local
anesthesia
• Analgesia: Acute trauma pain
control with narcotics can be given in any
trimester as required
• Rh immune globulin (RhIG): 40% of
trauma victims will have fetal-maternal
bleed. All Rh-negative trauma victims
should be considered for 1 vial of RhIG
(300 ug IM)
• Even with negative Kleihauer-Betke
(KB) test, (may not have adequate
sensitivity to detect very small quantities
of fetal blood)
• It should be given as soon as
possible, and within 72 hours of the
accident.
Penetrating Trauma
• Consider a laparotomy on all
gunshot wounds or stab wounds to the
upper abdomen
• Stabs to lower abdomen can receive
non-surgical management if the mother
and fetus are free of significant injury
Indications to Consider Cesarean Delivery
• Control of maternal hemorrhage
• Viable fetus in distress
• Gunshot to abdomen with viable
fetus
• Peri-mortem cesarean may be
indicated for fetus considered viable
Perimortem Cesarean Delivery
• During maternal resuscitation,
adequate oxygenation, fluid loading, and
left lateral decubitus should be tried to see
if maternal circulation can be improve
• No response to advanced life
support within 2-3minutes:maternal
cardiopulmonary resuscitation must be
continued, anterior thoracotomy with
open-chest cardiac massage (OCM) but
without aortic cross-clamping and
emergency cesarean section for a viable
fetus
Gestational age greater than 24-25 weeks:
• Emergency cesarean birth probably
will favorably affect maternal or fetal
outcome.
Gestational age of 26 to 32 weeks:
• When external cardiac massage is
not effective, OCM should be seriously
considered before an emergency cesarean
section
After 32 weeks gestation:
o If ECM is not effective, an
emergency cesarean section must be
performed immediately.
o If ECM is effective, ECM may be
continued for 5 minutes. If spontaneous
circulation is not restored emergency
cesarean delivery must be performed.
o If this fails to revive the mother,
OCM may be considered
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o Personnel trained in neonatal
resuscitation should be available to attend
the infant.
Diagnosis and Management
A. Initial Assessment
1. Patient position
Uterine compression of the vena cava
reduces venous return to the heart, thereby
decreasing cardiac output and aggravating
the shock state. Elevated caval pressures
below the point of compression can lead to
extension of placental separation.
Therefore, unless a spinal injury is
suspected, the pregnant patient should be
transported and evaluated on her left side.
If the patient is in a supine position, the
right hip should be elevated and the uterus
should be displaced manually to the left
side to relieve pressure on the inferior
vena cava.
2. Primary survey
Follow the ABCs and administer
supplemental oxygen. If ventilatory
support is required, consideration should
be given to hyperventilating the patient.
Because of the increased intravascular
volume and the rapid contraction of the
uteroplacental circulation shunting blood
away from the fetus, the pregnant patient
can lose up to 35% of her blood volume
before tachycardia, hypotension, and other
signs of hypovolemia occur. Thus, the fetus
may be "in shock" and deprived of vital
perfusion, while the mother's condition
and vital signs appear stable. Crystalloid
fluid resuscitation and early type-specific
blood administration are indicated to
support the physiologic hypervolemia of
pregnancy. Avoid administering
vasopressors to restore maternal blood
pressure, because these agents further
reduce uterine blood flow, resulting in fetal
hypoxia.
B. Secondary Assessment
The secondary survey should follow the
same pattern as in the nonpregnant
patient. Indications for diagnostic
peritoneal lavage are the same and this
may be conducted safely if the incision is
made in the midline well above the fundus
of the uterus. The examination of the
patient should include an assessment of
uterine irritability, fundal height and
tenderness, fetal heart tones, and fetal
movement. Use a Doppler ultrasound
stethoscope or fetoscope to auscultate fetal
heart tones. Pay careful attention to the
presence of uterine contractions
suggesting early labor; or tetanic
contractions accompanied by vaginal
bleeding, suggesting premature separation
of the normally implanted placenta. The
evaluation of the perineum should include
a formal pelvic examination. The presence
of amniotic fluid in the vagina, evidenced
by a pH of 7 to 7.5, suggests ruptured
chorio-amniotic membranes. Cervical
effacement and dilatation, fetal
presentation, and the relationship of the
fetal presenting part to the ischial spines
should be noted. Because vaginal bleeding
in the third
trimester may indicate disruption of the
placenta and impending death of the fetus,
an obstetrician ideally should carry out the
vaginal examination or be called
immediately if blood is coming from the
cervical os. The decision regarding an
emergency cesarean section should be
made in conjunction with an obstetrician.
Admission to the hospital is mandatory in
the presence of vaginal bleeding, uterine
irritability, abdominal tenderness, pain or
cramps, evidence of hypovolemia, changes
in or absence of fetal heart tones, or
leakage of amniotic fluid. Care should be
provided at a facility with appropriate fetal
and maternal monitoring and treatment
capabilities. The fetus may be placed in
jeopardy even with apparent, minor
maternal injury.
C. Monitoring
1. Patient
If possible, the patient should be monitored
on her left side after physical examination.
Monitoring of the CVP response to fluid
challenge is extremely valuable in
maintaining the relative hypervolemia
required in pregnancy.
A correlation between maternal serum
bicarbonate level and fetal outcome has
been suggested. Therefore, it may be useful
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to monitor the maternal serum bicarbonate
level in addition to other hemodynamic
parameters. It should be noted that serum
bicarbonate level may be depressed in
these patients when large volumes of
normal saline are infused. The requirement
for saline infusion itself may be a reflection
of severity of injury and blood loss opposed
to the bicarbonate itself.
2. Fetus
Fetal distress can occur at any time and
without warning. Although fetal heart rate
can be determined with any stethoscope,
the fetal heart rate and rhythm is best
monitored continuously using the
ultrasonic Doppler cardioscope. The fetus
should be monitored continually to ensure
early recognition of fetal distress.
Inadequate accelerations of fetal heart rate
in response to fetal movement, and/or late
or persistent decelerations of fetal heart
rate in response to uterine contractions
indicate fetal hypoxia.
Indicated radiographic studies should be
performed, because the benefits certainly
outweigh potential risk to the fetus.
However, unnecessary duplication of films
should be avoided.
D. Definitive Care
In addition to the spectrum of injury found
in a nonpregnant patient, trauma during
pregnancy may cause uterine rupture. The
uterus is protected by the bony pelvis in
the first trimester, but it becomes
increasingly susceptible to injury as
gestation progresses. Traumatic rupture
may present a varied clinical picture.
Massive hemorrhage and shock may be
present or only minimal signs and
symptoms may be present.
Roentgenographic evidence of rupture
includes extended fetal extremities,
abnormal fetal position, or free
intraperitoneal air. Suspicion of uterine
rupture mandates surgical exploration.
Placental separation from the uterine wall
(abruptio placentae) is the leading cause of
fetal death after blunt trauma. Abruptio can
occur following relatively minor injuries
especially late in pregnancy. With
separation involving 25% of the placental
surface, external vaginal bleeding and
premature labor may begin. Larger areas of
placental detachment are associated with
increasing fetal distress and demise. Other
than external bleeding, signs and
symptoms may include abdominal pain,
uterine tenderness, uterine rigidity,
expanding fundal height, and maternal
shock. Uterine ultrasonography will
frequently demonstrate the lesion.
With extensive placental separation or
with amniotic fluid embolization,
widespread intravascular clotting may
develop causing depletion of fibrinogen,
other clotting factors, and platelets. This
consumptive coagulopathy may emerge
rapidly. In the presence of lifethreatening
amniotic fluid embolism and/or
disseminated intravascular coagulation,
uterine evacuation should be accomplished
on an urgent basis.
Consequences of fetomaternal hemorrhage
include not only fetal anemia and death,
but also isoimmunization if the mother is
Rh-negative. Since as little as 0.01 mL of
Rhpositive blood will sensitize 70% of Rh-
negative patients, the presence of
fetomaternal hemorrhage in an Rh-
negative mother should warrant Rh
immunoglobulin therapy. This should be
undertaken early in consultation with and
under the direction of an obstetrician.
Although a positive Kleihauer-Betke test (a
maternal blood smear allowing detection
of fetal RBCs in the maternal circulation)
indicates fetomaternal hemorrhage, a
negative test does not exclude minor
degrees of fetomaternal hemorrhage that
are capable of sensitizing the Rhnegative
mother. Where this test is readily available,
increasing ratios of fetal to maternal RBCs
demonstrated in sequential maternal blood
smears may be used as an index of
increasing fetomaternal hemorrhage. All
pregnant Rh-negative trauma patients
should be considered for Rh
immunoglobulin therapy unless the injury
is so minor or remote from the uterus as to
make fetomaternal hemorrhage unlikely. In
situations where there is doubt as to the
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severity of the injury or the presence of
fetomaternal hemorrhage, then the
traumatized pregnant Rh-negative patient
should receive Rh immunoglobulin
therapy. Three hundred micrograms of Rh
immunoglobulin therapy is required for
every 30 mL of fetomaternal hemorrhage.
In 90% of cases the volume of fetomaternal
hemorrhage is less than 30 mL.
Immunoglobulin therapy should be
instituted within 72 hours of injury.
The large, engorged pelvic vessels that
surround the gravid uterus can contribute
-oOo-
Chapter Essence
In a Nutshell
74. .
Nursing Alerts
215. .
Nursing Management
279. .
to massive retroperitoneal bleeding after
blunt trauma with associated pelvic
fractures.
Initial management is directed at
resuscitation of the pregnant patient and
stabilization of her condition because the
fetus' life at this point is totally dependent
on the integrity of the mother's. Fetal
monitoring should be maintained after
satisfactory resuscitation and stabilization
of the mother's condition.
Obstetric consultation is necessary for the
care of the fetus.
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Trainer’s Pearls
112. .

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Chapter Outline
1. .
-oOo-
Geriatric Trauma
Defining the term "elderly" is a difficult
task as it involves both chronologic and
physiologic components. Elderly
population is divided into two groups: the
"young old" (65 to 80 years of age) and the
"old old" (80 years of age and older).
Although they sustain
traumatic injury less commonly than
children and young adults, the mortality
rate for trauma in the elderly is higher than
in younger people
Physiologic differences in the elderly
Virtually all organ systems
experience a progressive decline in
function
By 65yr 50% population
develops coronary artery stenosis.
Thickening of the cardiac muscle develops
which can lead to congestive heart failure
or pulmonary edema. Cardiac index
declines progressively after 40 and
maximum heart rate declines thus masks
tachycardia in trauma often added by beta
blocker therapy. Normal BP may imply
shock in preexisting hypertension.
Atrophy of the brain after 70
leads to a significant reduction in brain
mass and there is significant space
between the two puts the elderly at a
higher risk of a subdural hematoma after
sustaining a closed head injury. The
reduction of brain size can lead to issues
with eyesight, cognition and hearing. A
progressive decline in central nervous
system function leads to a loss of
proprioception, balance and overall motor
coordination, as well as a reduction in eye–
hand coordination, reaction time and an
unsteady gait. These degenerative changes
are often accompanied by osteoarthritis.
Kidney looses nephrons with age after 50
declining GRF, Creatinine clearance .
Chapter
Trauma in Old Age.
Thus kidney becomes more
susceptible to hypovolemia. Decreased
thermoregulatory capacity make makes
them more prone to hypothermia.
Frequently take multiple medications for
control of various diseases and conditions.
Pathophysiology of Geriatric Trauma
In geriatric population pre-existing
diseases lead to more severe injuries. Co-
morbid diseases complicate recovery in
this age group. Medications alter “normal”
function and vital signs. Less dramatic
physiologic response is seen with
increasing age. Limit of physiologic
tolerance is narrow.
Mechanisms of injury
• Falls
• Motor Vehicle Crashes (MVC)
Pedestrian vs. Motor Vehicle Burns
• Assaults
FALLS
• There are age-related make the
elderly more prone to tripping and falling
• Difficulty in recognizing and
avoiding environmental hazards.
• Syncope has been implicated
secondary to dysrhythmias, venous
pooling, autonomic derangement, hypoxia,
anemia, or hypoglycemia in many
• Other include alcohol and
medications, most notably sedative,
antihypertensive, antidepressant, diuretic,
and hypoglycemic agents.
MOTOR VEHICLE CRASHES
o Decreased cerebral and motor skills
and memory and judgment losses that can
compound the difficulty in operating a
motor vehicle.
o Decreased auditory or visual acuity,
slower reaction time which may make it
more difficult to recognize dangerous
traffic situations while driving
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PEDESTRIAN-VEHICLE COLLISONS
• Reduced peripheral vision and
decreased hearing
• Cognitive, memory, and judgment
skills are often diminished
• Postural changes due to
musculoskeletal decline
• All these may limit access to
information needed to make rational
decisions about crossing the street.
BURNS
• Higher fatality rate than do younger
adults with the same extent of burn, and
even nonmajor burns
• Less than 20 percent body surface
area may be significant.
• Increasing age, male gender, burn
size, presence of full-thickness burn, and
presence of inhalation injury contribute to
mortality
• The Baux Index, a simple addition of
age and percentage body surface area
burned, has continuing prognostic value
• A Baux Index of 75 represents a
severe burn and an index of 100 is usually
fatal.
VIOLENCE
• Elderly persons are seen as ideal
targets for robberies because they may
possess various age-related physical
deficiencies.
• Ethanol consumption by the
assailant or victim has been found to be
involved in the majority of fatal assaults.
• Emergency physicians also should
have a heightened suspicion for elder or
parental abuse in the geriatric trauma
patient
Important Considerations
History
AMPLE History
• Medications must be carefully listed,
as many elderly patients are on cardiac
agents, diuretics, psychotropic agents, and
anticoagulants.
Resuscitation
AIRWAY
• Upper airway obstruction is more
likely Dentures
• Air tight seal for mask ventilation is
more difficult
• Brittle trachea
• Cervical spine disease results in
more difficulty with airway management
BREATHING
• Decreased airway reflexes
• Decreased clearance of secretions
• Decreased response to hypoxia and
hypercarbia
• Increased dead space
• Reduced functional residual
capacity (FRC)
• Reduced oxygen reserve
• Decreased thoracic expansion
• Early closure of small airways
• Reduced lung elasticity
• Reduced alveolar surface area
• Increased work of breathing
• Increase V/Q mismatch.
CIRCULATION
• Difficult access because of poor skin
and vessels
• The clinician should not be led into
a false sense of security by "normal"
• vital signs.
• There is progressive stiffening of
the myocardium with age that results in a
decreased effectiveness of the pumping
mechanism.
• Conduction defects may be
exacerbated by the stress of illness or
trauma.
• 1-adrenergic sympathetic activity
(chronotropy and inotropy) is reduced
(decreased efficacy of inotropes).
• Coronary artery disease may be
present
• The presence of drugs with the
potential to modify the response to trauma
is common (polypharmacy). Anti-
hypertensive agents (e.g. Diuretics, -
blockers and calcium channel blockers)
interfere with the interpretation and
achievement of goals for resuscitation.
• Emergency physicians should be
wary of a "normal" heart rate and blood
pressure in the geriatric trauma victim.
DISABILITY
• Brain shrinkage is common which in
combination with brittle intracranial
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vessels that may be under tension and
increased numbers of falls accounts for the
increased frequency of subdural
haematomas
• Pharmacological effects of aging
reflect changes in the absorption,
distribution, metabolism and excretion of
many drugs.
• There is a decreased requirement
for sedation/anaesthesia
• Pain threshold remains the same;
pain tolerance is increased.
• The effects on many drugs result in
increased sensitivity; high levels and
prolonged half-life requiring decreased
doses and increased intervals.
EXPOSURE & ENVIRONMENT
• Hypothermia is common in elderly
trauma patients even in warm
environments. There is a lower BMR, more
heat loss and less insulation.
• Careful attention to
thermoregulation must be ensured.
• Pressure sores, adrenal
insufficiency and hypothyroidism.
Markers for poor outcome
• Age greater than 75 years
• Glasgow Coma Scale score less than
7 the cervical spine is properly assessed,is
• Presence of shock upon admission
• Severe head injury
• Development of sepsis
• Injury Severity Score (ISS)
correlates with mortality rates,but does not
fully capture the potential for mortality in
this age group.
Specific injuries
HEAD INJURY
• Subtle changes in cognition,
memory, and data acquisition may
confound evaluation of the elderly patient's
mental status.
• When evaluating the patient's
mental status during the neurologic
examination, it should not be assumed that
alterations in mental status are due solely
to any underlying dementia or senility.
• Elderly persons experience a much
lower incidence of epidural hematomas
than the general population as there is
relatively denser fibrous bond between the
dura mater and the inner table of the skull
in older individuals.
• There is, however, a higher
incidence of subdural hematomas in
elderly so more liberal indications for
computed tomography (CT) scanning of the
head are justified in geriatric age group.
CERVICAL SPINE INJURY
• Spine injuries may be difficult to
evaluate in geriatric patients. Cognitive
problems or brain injury may make the
clinical evaluation of the spine more
difficult.
• According to Canadian C-Spine Rule,
trauma in patients aged 65 years or more
has a high risk factor for C-spine injury,
even with stable vital signs and Glasgow
Coma Scale score of 15.
• Thus, C-spine imaging in all such
elderly patients is warranted.
• Odontoid fractures were
particularly common in geriatric patients,
accounting for 20 percent of geriatric
cervical spine fractures, as compared with
5 percent of nongeriatric fractures. In
elderly trauma patients with neck pain,
maintaining cervical immobilization until
important.
• Because underlying cervical
arthritis may obscure fracture lines, the
elderly patient with persistent neck pain
and negative plain radiographs should
undergo CT scanning of the cervical spine.
• Preexisting cervical spine
pathology, such as osteoarthritis, may
predispose elderly patients to spinal cord
injuries. With hyperextension injuries,
elderly patients may develop a central cord
syndrome.
CHEST INJURY
• In blunt trauma, rib fractures are
the most common injury found.
• Hemopneumothorax, pulmonary
contusion, flail chest, and cardiac
contusion, can quickly lead to
decompensation in elderly individuals
whose baseline oxygenation status may
already be diminished.
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• Geriatric patients are more
susceptible to the development of hypoxia
and respiratory infections following
trauma.
• The main therapeutic goal is
aggressively maintaining adequate oxygen
delivery.
• Frequent arterial blood gas analysis
may provide early insight into elderly
patients' respiratory function and reserve.
• Prompt tracheal intubation and use
of mechanical ventilation should be
considered in patients with more severe
injuries, respiratory rates greater than 40
breaths per minute, or when the partial
pressure of arterial oxygen (Pao2) is <60
mm Hg or the partial pressure of carbon
dioxide in arterial gas (Pao2) is >50 mm
Hg.
ABDOMINAL TRAUMA
• The abdominal examination in
elderly patients is notoriously unreliable as
compared to younger patients.
• Even with an initially benign
physical examination, emergency
physicians must have a high index of
suspicion for intraabdominal injuries in
patients who have associated pelvic and
lower rib cage fractures.
• For unstable patients, and especially
those with multiple scars on the abdominal
wall from previous procedures, the focused
assessment with sonography for trauma
(FAST) examination is the ideal diagnostic
study to detect free intraperitoneal fluid.
ORTHOPEDIC INJURY
• Elderly patients are predisposed to
orthopedic injuries as a consequence of
skeletal osteopenic and osteoporotic
changes.Hip fracture is the single most
common diagnosis that leads to
hospitalization.
• Hip fractures occur primarily in four
areas: intertrochanteric, transcervical,
subcapital, and subtrochanteric.
• Intertrochanteric fractures are the
most common, followed by transcervical
fractures.
• Bleeding from closed pelvic and
long-bone fractures can cause hypovolemia
in elderly patients.
• Long-bone fractures of the femur,
tibia, and humerus may produce a loss of
mobility with a resulting decrease in the
independent lifestyle
• Falls on the outstretched hand
increase the risk for Colles fractures. These
fractures can usually be treated with closed
reduction and immobilization.
• The incidence of humeral head and
surgical neck fractures in elderly patients
also are increased by falls on the
outstretched hand or elbow.
Trauma in old age group
Triage of Elderly Patients
Early aggressive trauma care has been
shown to improve outcome for geriatric
patients with survivable injuries, yet
elderly patients are more likely to remain
in their community and receive care at a
non-designated trauma service.
Recognition of the increased risk of poor
outcome in this population should prompt
consideration of early transfer to a higher
level of trauma care unless the family or
patient has decided not to pursue
aggressive resuscitation efforts. Advanced
age alone should not be used as the sole
criterion for denying or limiting care in this
patient population. With the exception of
patients who are moribund on arrival, an
initial aggressive approach should be
pursued as the majority will return home
and up to 85 percent will return to
independent function.
Changes in physiologic response
The following factors should be considered
when evaluating a geriatric patient after
injury:
By age 65, 50 percent of the
population has coronary artery stenosis.
Cardiac index declines linearly with
age and the maximal heart rate begins to
decline after age 40. Significant blood
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volume loss may be masked by the absence
of early tachycardia. This can be further
compromised by pre-injury beta blocker
therapy.
Systolic blood pressure generally
increases with age such that a systolic
blood pressure of 120 mm Hg may
represent hypotension in an elderly patient
whose pre-injury blood pressure was 170
to 180 mmHg.
The kidney begins to lose nephron
units after age 50 resulting in a decline in
glomerular filtration rate and creatinine
clearance. The aged kidney is thus more
susceptible to hypovolemia.
Elderly patients are at increased
risk for hypothermia because of decline in
thermoregulatory ability.
As a result of this loss of physiologic
reserve and the fact that early shock can be
underappreciated in the elderly, several
authors have advocated early monitoring
of the cardiovascular system to optimize
resuscitation after injury. Measurements of
the base deficit are also thought to be
useful in determining the status of the
resuscitation.
Assessment
Primary survey (the following specific
issues are common in the elderly trauma
patient)
• Airway
• Look for airway anomalies likely to
complicate management including
dentures and limited mouth opening
(temporomandibular arthritis).
• Bag mask ventilation is facilitated
with dentures in place.
• Patient with chronic C-spine
abnormalities such as diffuse idiopathic
skeletal hyperostonsis (DISH) should be
anticipated to have a difficult airway.
• Breathing
• Apply supplemental high flow
oxygen early given limited respiratory
reserve.
• Maintain a low threshold for
obtaining an arterial blood gas (ABG).
• Circulation
• Vital signs may be an unreliable
guide in the elderly.
• Baseline hypertension is common,
and medications further obscure vital sign
measurement.
• Low end-tidal CO2 or elevated base
deficit on ABG may be better predictors of
compensated shock in this population.
Check ABG.
• Goal-directed therapy
• Geriatric trauma patients are very
sensitive to both hypovolemia and fluid
overload. Monitor the geriatric patient fluid
status hourly in the ER. Patients requiring
significant fluid resuscitation may need
invasive monitoring and so should be
moved to the intensive care unit (ICU) as
soon as possible.
• Avoid high-volume continuous
intravenous (IV) fluid therapy in patients
who have been appropriately resuscitated.
• Chronic medications
• Geriatric patients may be on several
chronic medications that may affect the
trauma work-up, including:
• Beta-blockers may keep heart rate
low, even in patients with major
hypovolemic shock.
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• Screen all geriatric patients for
antiplatelet and anticoagulant medications.
• Oral anticoagulants may increase
risk of bleeding. Early STAT head computer
tomography (CT) may be required in
patients at risk for head injury, and rapid
reversal may be necessary. (See: Head
Injury in Anticoagulated Patient protocol).
• Geriatric patients at risk for fluid
overload who are on chronic oral
anticoagulants and require reversal may
benefit from Prothrombin Complex
Concentrate (PCC) to minimize fluid
administration.
• Exposure
a. Avoid hypothermia: All IV fluids
given are warmed, blood products (except
platelets) given on via rapid infuser with
active warming. Warm blankets placed on
patient and mechanical warming device
(Bair Hugger) if time permits.
1. Analgesia and sedative medications
Sedative medication such as
benzodiazepine in patients who are not
intubated should be used with caution. The
combination of these medications with
analgesic drugs can cause significant
respiratory decompensation or worsen
delirium. In general, mind-altering
medications, such as benzodiazepines,
should be minimized or not used in this
population.
Agitated patients should be
evaluated for hypoxia, hypoventilation, and
shock, before administration of any
sedatives.
Older people are more sensitive to
analgesic medication. Recommend initial
lower doses to avoid hypotension or
respiratory decompensation.
Secondary survey (the following specific
issues are common in the elderly trauma)
• Neurology
Repeat neurological examination
may be necessary.
Obtaining an accurate assessment of
neurologic function is complicated by
reduced sensation of normal aging, and
underlying dementia.
• Cervical spine clearance
When clinically possible,
prioritizing the spine clearance in geriatric
trauma patients, as early mobilization and
head of the bed-up is associated with
decreased rate of aspiration and
respiratory decompensation. (See: Cervical
Spine Guideline)
• Imaging
Chest and pelvis X-rays should be
considered for mild trauma (e.g. falls).
CT Head for all elderly with closed
head injury.
CT C-Spine (See Cervical Spine
Guideline Adult Age 65-plus Algorithm).
CT Chest/Abd/Pelvis (See: Blunt
Abdominal Trauma Guideline) with spine
reconstruction.
• Laboratory
Complete Blood Count (CBC),
Chemistry (Chem 10), Blood Alcohol
Content (BAC), Lactate, Base Deficit,
Prothrombin Time (PT), Partial
Prothrombin Time (PTT), International
Normalized Ratio (INR), Type and Screen,
and the following additions:
Electrocardiogram (ECG)
Troponin for abnormal ECG or
concern for chest injury or cardiac event.
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Creatine Kinase (CK) for suspected
rhabdomyolysis.
Specific Injury Patterns
Rib Fractures
Chest wall injuries are a particular problem
in the elderly patient population and are
not well tolerated. Several studies have
demonstrated increased morbidity and
mortality for elderly
patients when compared to younger
patients with similar injuries. Elderly
patients with greater than six rib fractures
have increased mortality and risk of
nosocomial pneumonia. The presence of
three or more rib fractures has been
associated with increased mortality and
duration of ICU and hospital care.
Underlying pulmonary contusions may also
cause significant pulmonary morbidity and
may not become evident until 24 to 48
hours after injury.
The pain associated with rib fractures
impairs ventilatory function and increases
pulmonary morbidity. Management of
these patients is therefore focused on
achieving adequate analgesia and clearance
of pulmonary secretions. Recent studies
have suggested improved outcome with
the use of epidural analgesia following rib
fractures to obtain adequate pain relief.
It is important to recognize the potential
severity of even minimal rib fractures in
the elderly population and to have a low
threshold for hospitalization, ICU
admission, and adoption of an aggressive
pain management strategy.
Traumatic brain injury (TBI)
Elderly patients are at increased risk for
TBI even following what appears to be a
minor mechanism such as a fall from
standing. Elderly patients are at higher risk
of intracranial hemorrhage with a three-
fold higher risk of subdural hematomas
when compared to younger patients. A
subdural hematoma can result in a gradual
neurologic decline that may not be
appreciated by the clinician. In addition,
the high rate of anticoagulant (coumadin)
and anti-platelet agent use in the elderly
population can lead to rapid progression of
an intracranial hemorrhage once initiated.
Although it is clear that elderly patients
with TBI have a higher mortality than the
younger population, triage decisions
cannot be made based solely on the
Glasgow coma score at admission. The
Eastern Association for the Surgery of
Trauma (EAST) guidelines recommend, “to
adopt an initial course of aggressive
treatment (with the possible exception of
the patient who is moribund upon arrival),
followed by a re-evaluation of the patient’s
neurologic status at 72 hours post
admission. The intensity of the subsequent
care provided can then be based on the
initial response to therapy.”
Early “aggressive” care should include
rapid reversal of anticoagulants including
the use of Prothrombin Complex
Concentrate (PCC) and transfusions of
fresh frozen plasma (FFP) for patients on
Coumadin (see Head Injury in
Anticoagulated Patients Guideline).
Patients presenting with a GCS less than
eight will usually require endotracheal
intubation for airway protection. As with
all TBI patients, resuscitation should seek
to avoid episodes of hypoxia and/or
hypotension.
Elder abuse
Elder abuse is a term referring to any
knowing, intentional, or negligent act by a
caregiver or any other person that causes
harm or a serious risk of harm to a
vulnerable adult. This includes physical,
emotional or sexual abuse, exploitation,
neglect, or abandonment. The National
Center on Elder Abuse (NCEA) suggests
one in ten patients over the age of 65 are
victims of abuse many of which go
unreported. The circumstances
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surrounding the injury should be examined
to detect this often unrecognized situation.
Reporting of elder abuse is required for all
healthcare professionals.
Disposition
Three or more rib fractures require
hospital admission for geriatric patients
(fewer if clinically significant pain is
present).
Additional reasons for admission:
Decreased functional status
Poorly controlled pain
Concern for elder abuse
Determining the cause for injury
(syncope, MI, infection, etc.).
Patients with metabolic acidosis or ongoing
instability should receive only essential
imaging and be admitted rapidly to the ICU.
Consider ICU admission for pelvic fracture
in the elderly.
ICU admission required for geriatric
patients with three or more rib fractures
and:
-oOo-
Chapter Essence
In a Nutshell
75. .
Nursing Alerts
216.
Nursing Management
280.
Trainer’s Pearls
113.
Chronic obstructive pulmonary
disease (COPD) or congestive heart failure
(CHF) history
Significant pain: Consider early
epidural analgesia or paravertebral
catheter
Mental status changes due to acute
trauma or chronic disease
Pulmonary contusion/laceration or
hemothorax/pneumothorax
Flail chest.
Abnormal oxygenation (Pulmonary
Function P/F ratio greater than 300 or
clinical judgment) or abnormal ventilation
(respiratory acidosis or increased
respiratory effort).
Consults
Improved outcomes for the geriatric
trauma patients occur with proactive
efforts to obtain a geriatric consult with a
geriatrician or multidisciplinary team with
geriatric experience. Geriatric consultation
with a comprehensive geriatric assessment
(CGA) are associated with fewer episodes
of delirium, fewer falls, decreased
likelihood of discharge to a long-term care
facility, and a decrease in hospital days.
.
.
.
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Chapter Outline
1. .
-oOo-
1.Thermal Burns
Immediate life-saving measures for the
burn patient include the recognition of
inhalation injury and subsequent
endotracheal intubation, and the rapid
institution of intravenous fluid therapy. All
clothing should be removed rapidly.
Early stabilization and management of the
burn patient include:
Identifying the extent and depth of
the burn.
Depth of Burn
The depth of burn is important in
evaluating the severity of the burn,
planning for wound care, and predicting
functional and cosmetic results. First-
degree burns (eg, sunburn) are
characterized by erythema, pain, and the
absence of blisters. They are not life
threatening, and generally do not require
intravenous fluid replacement. This type of
burn will not be discussed further in this
chapter.
Second-degree burns or partial-thickness
burns are characterized by a red or mottled
appearance with associated swelling and
blister formation. The surface may have a
weeping, wet appearance and is painfully
hypersensitive, even to air current.
Full-thickness or third-degree burns
appear dark and leathery. The skin also
may appear translucent, mottled, or waxy
white. The surface is painless and generally
dry.
Establishing fluid guidelines
according to the patient's weight.
Chapter
Burns.
The "Rule of Nines" is a useful and practical
guide to determine the extent of the burn.
The adult body configuration is divided
into anatomic regions that represent 9%,
or multiple of 9%, of the total body surface.
Body surface area differs considerably for
children. The infant's or young child's head
represents a larger proportion of the
surface are, and the lower extremities a
lesser proportion, that an adult's. The
percentage of total body surface of the
infant's head is twice that of the normal
adult.
Remember, the palm (not including the
fingers) of the patient's hand represents
approximately 1% of the patient's body
surface. This guideline helps estimate the
extent of burns of irregular outline or
distribution.
Evaluation of the circulating blood volume
is often difficult in the severely burned
patient. Blood pressure may be difficult to
obtain and may be unreliable. Monitoring
hourly urinary outputs reliably assesses
circulating blood volume in the absence of
osmotic diuresis (eg, glycosuria).
Therefore, an indwelling urethral catheter
should be inserted. A good rule of thumb is
to infuse fluids at a rate sufficient to
produce 1.0 mL of urine per kilogram body
weight per hour for children who weigh 30
kilograms or less, and 30 to 50 mL of urine
per hour in the adult.
The burn patient requires 2 to 4 mL of
Ringer's lactate solution per kilogram body
weight per percent body surface burn in
the first 24 hours to maintain an adequate
circulating blood volume and provide
adequate renal output. The estimated fluid
volume is then proportioned in the
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 - 652 -
following manner: one half of the total
estimated fluid is provided in the first eight
hours postburn, and the remaining one half
is administered in the next 16 hours. To
maintain an average urinary output of 1
mL per kilogram per hour in small children
who weigh 30 kilograms or less, it may be
necessary to calculate and add glucose-
containing maintenance fluids to the burn
formula.
Any resuscitation formula provides only an
estimate of fluid need. Fluid requirement
calculations for infusion rates are based on
the time from injury, not from the time
fluid resuscitation is initiated. The amount
of fluid given should be adjusted according
to the individual patient's response, ie,
urinary output, vital signs, and general
condition.
Initiating a patient-care flow sheet.
A flow sheet, outlining the patient's
management, should be initiated when the
patient is admitted to the emergency
department. This flow sheet should
accompany the patient when he is
transferred to the burn unit.
Obtaining baseline laboratory and
roentgenographic studies.
1. Blood
Obtain samples for CBC, type and
crossmatch, carboxyhemoglobin, serum
glucose, electrolytes, and pregnancy test in
all females of child-bearing age. Arterial
blood samples also should be obtained for
blood gas determinations.
2. Roentgenograms
A chest film should be obtained. An
additional film may be required if
endotracheal intubation and/or subclavian
or internal jugular vein catheterization are
accomplished. Other roentgenograms may
be indicated for appraisal of associated
injuries.
Maintaining peripheral circulation
in circumferential burns by performing an
escharotomy if necessary.
• Remove all jewelry.
• Assess the status of distal
circulation, checking for cyanosis, impaired
capillary refilling, or progressive
neurologic signs (ie, paresthesia and deep
tissue pain). Assessment of peripheral
pulses in burn patients is best performed
with a Doppler Ultrasonic Flow Meter.
• Circulatory embarrassment in a
circumferentially burned limb is best
relieved by escharotomy, preferably with
surgical consultation. Incision of the eschar
to relieve edema pressure can be
performed as an emergency procedure
without anesthesia, because the incision is
limited to insensate full-thickness burn.
The incision must extend across the entire
length of the eschar in the lateral and/or
medial line of the limb including the joints.
The incision is limited to nonviable tissue,
and to limit blood loss, viable subeschar
tissue should not be incised. Escharotomy
of the fingers is rarely indicated and should
be done only in consultation with an
experienced burn surgeon.
• Circumferential burns of the thorax
may impair respiratory excursion.
Bilateral, escharotomy incisions in the
anterior axillary lines should be considered
if respiratory excursions are limited.
• Fasciotomy is seldom required.
However, it may be necessary to restore
circulation for patients with associated
skeletal trauma, crush injury, high-voltage
electrical injury, or burns involving tissue
beneath the investing fascia.
Identifying which burn patients
require transfer to a burn unit or center.
A. Types of Burn Injuries
The American Burn Association has
identified the following types of burn
injuries that usually require referral to a
burn center:
Partial-thickness and full-thickness
burns greater than 10% of the total body
surface area (BSA) in patients under 10
years or over 50 years of age.
652
 - 653 -
Partial-thickness and full-thickness
burns greater than 20% BSA in other
age
groups.
Partial-thickness and full-thickness
burns involving the face, eyes, ears, hands,
feet, genitalia, or perineum or those that
involve skin overlying major joints.
Full-thickness burns greater than
5% BSA in any age group.
Electrical burns, including lightning
injury; (significant volumes of tissue
beneath the surface may be injured and
result in acute renal failure and other
complications).
Significant chemical burns.
Inhalation injury.
Burn injury in patients with pre-
existing illness that could complicate
management, prolong recovery, or affect
mortality.
Any burn patient in whom
concomitant trauma poses an increased
risk of morbidity or mortality may be
treated initially in a trauma center until
stable before transfer to a burn center.
Children with burns seen in
hospitals with qualified personnel or
equipment for their care should be
transferred to a burn center with these
capabilities.
Burn injury in patients who will
require special social and emotional or
long-term rehabilitative support, including
cases involving suspected child abuse and
neglect.
B. Transfer procedure
1. Transfer of any patient must be
coordinated with the burn-center
physician.
2. All pertinent information regarding
tests, temperature, pulse, fluids
administered, and urinary output should
be recorded on the burn/trauma flow sheet
and sent with the patient. Any other
information deemed important by the
referring or receiving physician also is sent
with the patient.
2.Chemical Burns
Chemical injury can result from exposure
to acids, alkalies, or petroleum products.
Alkali burns are generally more serious
than acid burns, because the alkalies
penetrate more deeply. Removal of the
chemical and immediate attention to
wound care are essential.
Chemical burns are influenced by the
duration of contact, concentration of the
chemical, and amount of the agent.
Immediately flush away the chemical with
large amounts of water, using a shower or
hose if available, for at least 20 to 30
minutes. Alkali burns require longer
irrigation. If dry powder is still present on
the skin, brush it away before irrigation
with water. Neutralizing agents have no
advantage over water lavage, because
reaction with the neutralizing agent may
itself produce heat and cause further tissue
damage. Alkali burns to the eye require
continuous irrigation during the first eight
hours after the burn. A small-caliber
cannula can be fixed in the palpebral sulcus
for such irrigation.
3. Electrical Burns
Electrical burns result from a source of
electrical power making contact with the
patient's body. Electrical burns frequently
are more serious than they appear on the
surface. The body may serve as a volume
conductor of electrical energy and the heat
generated results in thermal injury of
tissue. Different rates of heat loss from
superficial and deep tissues account for
relatively normal overlying skin coexisting
with deep muscle necrosis.
Rhabdomyolysis results in myoglobin
release, which can cause acute renal
failure.
The immediate management of a patient
with a significant electrical burn includes
attention to the airway and breathing,
establishment of an intravenous line,
electrocardiographic monitoring, and
placement of an indwelling urinary
catheter. If the urine is dark, assume that
hemochromogens are in the urine. Do not
653
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wait for laboratory confirmation before
instituting therapy for myoglobinuria.
Fluid administration should be increased
to ensure a urinary output of at least 100
mL per hour in the adult. If the pigment
does not clear with increased fluid
administration, 25 grams of mannitol
should be administered immediately and
-oOo-
12.5 grams of mannitol should be added to
subsequent liters of fluid in order to
maintain the diuresis.
Metabolic acidosis should be corrected by
maintaining adequate perfusion and
adding sodium bicarbonate to alkalinize
the urine and increase the solubility of
myoglobin in the urine.

Chapter Essence
In a Nutshell
76. .
Nursing Alerts
217. .
Nursing Management
281. Nursing Management: Emergent/Resuscitative Phase
282. Assessment
283. Focus on the major priorities of any trauma patient; the burn wound is a
secondary consideration, although aseptic management of the burn wounds and invasive
lines continues.
284. Assess circumstances surrounding the injury: time of injury, mechanism of
burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious
chemicals, and any related trauma.
285. Monitor vital signs frequently; monitor respiratory status closely; and
evaluate apical, carotid, and femoral pulses particularly in areas of circumferential burn
injury to an extremity.
286. Start cardiac monitoring if indicated (eg, history of cardiac or respiratory
problems, electrical injury).
287. Check peripheral pulses on burned extremities hourly; use Doppler as
needed.
288. Monitor fluid intake (IV fluids) and output (urinary catheter) and measure
hourly. Note amount of urine obtained when catheter is inserted (indicates preburn renal
function and fluid status).
289. Assess body temperature, body weight, history of preburn weight, allergies,
tetanus immunization, past medicalsurgical problems, current illnesses, and use of
medications.
290. Arrange for patients with facial burns to be assessed for corneal injury.
291. Continue to assess the extent of the burn; assess depth of wound, and
identify areas of full and partialthickness injury.
292. Assess neurologic status: consciousness, psychological status, pain and
anxiety levels, and behavior.
293. Assess patient’s and family’s understanding of injury and treatment. Assess
patient’s support system and coping skills.
294. Interventions
295. Promoting Gas Exchange and Airway Clearance
296. Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse
oximetry, and carboxyhemoglobin levels.
297. Assess breath sounds and respiratory rate, rhythm, depth, and symmetry;
654
 - 655 -

monitor for hypoxia.

298. Observe for signs of inhalation injury: blistering of lips or buccal mucosa;
singed nostrils; burns of face, neck, or chest; increasing hoarseness; or soot in sputum or
respiratory secretions.
299. Report labored respirations, decreased depth of respirations, or signs of
hypoxia to physician immediately; prepare to assist with intubation and escharotomies.
300. Monitor mechanically ventilated patient closely.
301. Institute aggressive pulmonary care measures: turning, coughing, deep
breathing, periodic forceful inspiration using spirometry, and tracheal suctioning.
302. Maintain proper positioning to promote removal of secretions and patent
airway and to promote optimal chest expansion; use artificial airway as needed.
303. Restoring Fluid and Electrolyte Balance
304. Monitor vital signs and urinary output (hourly), central venous pressure
(CVP), pulmonary artery pressure, and cardiac output.
305. Note and report signs of hypovolemia or fluid overload.
306. Maintain IV lines and regular fluids at appropriate rates, as prescribed.
Document intake, output, and daily weight.
307. Elevate the head of bed and burned extremities.
308. Monitor serum electrolyte levels (eg, sodium, potassium, calcium,
phosphorus, bicarbonate); recognize developing electrolyte imbalances.
309. Notify physician immediately of decreased urine output; blood pressure;
central venous, pulmonary artery, or pulmonary artery wedge pressures; or increased
pulse rate.
310. Maintaining Normal Body Temperature
311. Provide warm environment: use heat shield, space blanket, heat lights, or
blankets.
312. Assess core body temperature frequently.
313. Work quickly when wounds must be exposed to minimize heat loss from the
wound.
314. Minimizing Pain and Anxiety
315. Use a pain scale to assess pain level (ie, 1 to 10); differentiate between
restlessness due to pain and restlessness due to hypoxia.
316. Administer IV opioid analgesics as prescribed, and assess response to
medication; observe for respiratory depression in patient who is not mechanically
ventilated.
317. Provide emotional support, reassurance, and simple explanations about
procedures.
318. Assess patient and family understanding of burn injury, coping strategies,
family dynamics, and anxiety levels. Provide individualized responses to support patient
and family coping; explain all procedures in clear, simple terms.
319. Provide pain relief, and give antianxiety medications if patient remains
highly anxious and agitated after psychological interventions.
320. Monitoring and Managing Potential Complications
321. Acute respiratory failure: Assess for increasing dyspnea, stridor, changes in
respiratory patterns; monitor pulse oximetry and ABG values to detect problematic oxygen
saturation and increasing CO2; monitor chest xrays; assess for cerebral hypoxia (eg,
restlessness, confusion); report deteriorating
322. respiratory status immediately to physician; and assist as needed with
intubation or escharotomy.

655
 - 656 -

323. Distributive shock: Monitor for early signs of shock (decreased urine output,
cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, blood
pressure, or increasing pulse) or progressive edema. Administer fluid resuscitation as
ordered in response to physical findings; continue monitoring fluid status.
324. Acute renal failure: Monitor and report abnormal urine output and quality,
blood urea nitrogen (BUN) and creatinine levels; assess for urine hemoglobin or myoglobin;
administer increased fluids as prescribed.
325. Compartment syndrome: Assess peripheral pulses hourly with Doppler;
assess neurovascular status of extremities hourly (warmth, capillary refill, sensation, and
movement); remove blood pressure cuff after each reading; elevate burned extremities;
report any extremity pain, loss of peripheral pulses or sensation; prepare to assist with
escharotomies.
326. Paralytic ileus: Maintain nasogastric tube on low intermittent suction until
bowel sounds resume; auscultate abdomen regularly for distention and bowel sounds.
327. Curling’s ulcer: Assess gastric aspirate for blood and pH; assess stools for
occult blood; administer antacids and histamine blockers (eg, ranitidine [Zantac]) as
prescribed..
Trainer’s Pearls
114. .

656
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Chapter
Adult Hypoglycemia Protocol.
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
77. .
Nursing Alerts
218. . Guidelines for Nurses on How to Manage Hypoglycemia
219. Mild and Moderate Lows (<4.0 mmol/L)
220. • Individual is able to self-test and treat low blood glucose
221. • Test blood glucose level
222. • Treat with 15g of fast acting carbohydrate such as:
223. o 5 dextrose tables (3 g each)*, or
224. o 3 glucose tablets (5 g each)*, or
657
 - 658 -

225. o 3/4 cup (175 ml) regluar pop, or

226. o 3/4 cup juice, or
227. o 3 teaspoons sugar or honey, or
228. o 6 lifesavers
229. • Pre-planning for hypoglycemia should occur if individual is NPO or unable to
swallow; an order for IV Dextrose or IM Glucagon should be obtained (An order should be
obtained in advance for all clients treated with insulin)
230. • Repeat blood glucose test again in 15 minutes. Treat again with another 15
g fast-acting carbohydrate if blood glucose remains less than 4.0 mmol/L. Retest in 15
minutes. Continue to retreat and retest until blood glucose is above 4.0 mmol/L
231. • If the next meal is more than 60 minutes away, have a snack of 15 g of
starch and include protein source. For example: 1/2 cheese sandwich
232. • Explore possible causes of hypoglycemia
233. *Treatment required for hypoglycemia if on Glucobay
234. Severe Lows (<2.8 mmol/L or unable to swallow)
235. • Individual is not able to treat self and requires assistance with treatment of
hypoglycemia
236. • Test blood glucose level
237. • If conscious and able to swallow treat with 20 g fast-acting carbohydrate:
238. o 7 dextrose tablets (3 g each)*, or
239. o 4 glucose tablets (5 g each)*, or
240. o 1 cup (250 ml) of regular pop, or
241. o 1 cup juice, or
242. o 4 teaspoons of sugar or honey, or
243. o 8 lifesavers
244. • If unconscious, NPO or unable to swallow give 1 mg Glucagon injection IM (if
ordered) or IV dextrose 20 to 50 ml D50W (if ordered) and/or call 911 prn
245. • Inform your diabetes team of the event
246. • Repeat blood glucose test again in 15 minutes. If blood glucose is less than
4.0 mmol/L, continue to retreat with 15 g fast-acting carbohydrate and retest every 15
minutes until blood glucose is above 4.0 mmol/L
247. • If glucagon has been used, follow with carbohydrate as soon as the
individual is able to swallow
248. • If the next meal is more than 60 minutes away, provide a snack of 15 g of
starch and a protein source, For example: 1/2 cheese sandwich.
249. • Explore possible causes of hypoglycemia.
Nursing Management
328. .
Trainer’s Pearls
115. .

658
 - 659 -

Chapter
Gastric Lavage.
Chapter Outline
1. .

-oOo-
GASTRIC LAVAGE o Emesis basin
Gastric lavage is a method of o Suction source with suction catheter
gastrointestinal decontamination, o Funnel or large (50 to 100 mL)
performed in the setting of an ingested syringe
overdose or acute poisoning, to decrease o Tap water or saline
the absorption of substances in the o Bulb suction device or large syringe
stomach. If timed and performed o Water-soluble lubricant
appropriately, this technique can o Orogastric lavage tube (Boas tube)
significantly reduce the amount of o Resuscitative equipment readily
ingestant available for absorption and thus available.
effectively decrease the total dose o The method described below is a
absorbed. An absolute contraindication to passive open system method which uses
gastric lavage is a deteriorating level of gravity to instill and drain the lavage fluid.
consciousness with loss of protective Procedur
reflexes or an unprotected airway. In this
setting the airway must first be secured by 1. Informed consent should be
endotracheal intubation. Gastric lavage can obtained
then be performed once the airway is Arrange necessary equipments Supine
protected. position while on insertion the tube
Contraindications for gastric lavage Measure the length of oro-gastric tube
o Abnormal or absent from the tragus of the ear to the angle of
pharyngeal/upper gastrointestinal the mouth & down to the xiphisternum
anatomy Mark up the spot up to which to be
o Active or substantial antecedent inserted
vomiting Apply adequate jelly over the tube
o Caustic ingestion Insert the tube gently & ask the patient to
o Coagulopathy swallow.
o Decreased mental status , Inactive If patient is restless or the Airway is at risk,
or diminished airway reflexes intubate
o Large pills and Large or sharp Confirm the tube position by auscultation.
foreign body Press the Siphon & listen for the sound in
o Nontoxic or minimally toxic the epigastrium
ingestion Position the patient left laterally with head
o Significant aspiration risk (e.g., end down. Positioning the patient on right
hydrocarbon ingestion lateral may increase gastric emptying &
Equipment absorption of the poison.
o Pulse oximeter First siphon & hold the funnel down
o Cardiac monitor to evacuate any gastric content
o Noninvasive blood pressure
monitor Dilute activated charcoal in tap water to
o Protective clothing make it slurry. Dose 1gm/kg
o Bite blocker BWT. Administer charcoal slurry through
o Oral airway the funnel end.

659
 - 660 -
Pour 150ml of tap water holding the funnel Complications
higher up. o Cardiac dysrhythmias
o Electrolyte abnormalities
Keep the funnel end down & see for o Esophageal tear or perforation
effluent. Note the smell of the effluent.If no o Gastric perforation
effluent siphon. Repeat the steps till clear & o Hypothermia
odorless effluent comes out. o Laryngospasm
o Nasal, oral, or pharyngeal injury
Insert a Ryle’s tube & remove the Boer’s o Pneumothorax
tube to facilitate administration of Multi- o Pulmonary aspiration
Dose Activated Charcoal for the next 48 o Tracheal placement
hours. o Tube impaction

660
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-oOo-

Chapter Essence
In a Nutshell
78. .
Nursing Alerts
250. Nurses role in the care of patients with poisoning
251. • Assess airway, breathing, circulation, and neurological status
661
 - 662 -

252. • Assist in intubation and maintain a patent airway

253. • Provide privacy when assessing the patient
254. • Monitor vital signs
255. • Perform gastric lavage
256. • Collect information on the amount and type of substance(s) taken, and length of
time since
257. ingestion should be ascertained.
258. • Ensure the police is intimated about the medico legal case
259. • Provide emotional support and honest information about the patient’s condition
to the
260. relatives. Provide information on available support groups and community
organizations
261. • Provide clear and understandable information about the care process to the
patients.
262. • Confidentiality and its limits should be explained to patients and their
relatives/carers
263. • Ensure patient is sent for psychiatry consult before discharge.
Nursing Management
329. .
Trainer’s Pearls
116. .

662
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Chapter Outline
1. .
-oOo-
Any case of Injury or ailment where some
criminality is involved is called a
MedicoLegal Case (MLC)". eMLC is a simple
IT implementation with potential to bring
much needed transparency in medico legal
system in India.
Disadvantages with Conventional Accident
Registers
• Handwriting issues
• Non-Reproducibility
• Not tamper proof
• Storage issue
e- MLC Concept
• Hand writing not a problem
• Reproducible
• Tamper-proof
• Electronic signature
• Identity of issuing doctor is clear
• Space for Storage of Papers is not
needed
JPN Apex Trauma centre , AIIMS
implemented an electronic medical record
system with the objective of creating a
tamper-proof eMLC that could be printed
in a format mandated by law thereby
satisfying all legal requirements.
• Phase I : The manual format was
replicated electronically in the software.
• Phase II : Intervention based changes
were made in the existing template to
give a more accurate information about
the
• management of airway, breathing and
circulation
• Phase III : Integration of patient
photograph into the eMLC for authentic
patient identification.
Chapter
eMLC.
Phase IV : the images of patient wounds
can also be integrated into the MLC
• Phase IV : the images of patient wounds
can also be integrated into the MLC
Process
• After registration, photo of the patient is
captured with the registration slip by
doctor/ NIS . Patient photo is then
uploaded by the NIS (Nurse Informatics
Specialist ) in the software.
• The doctor makes the MLC and uploads
photo of patient.
• The printout of the MLC is obtained by
NIS.
• NIS gets the MLC duly signed by the
concerned doctor after verification.
• 2 copies of signed MLC is handed over to
the duty constable/registration counter
by NIS.
The implementation of this system has
simplified the work of doctors, police and
the judiciary. Doctors no longer have to
waste time entering demographics of the
patient because all medical details in eMLC
are easy to enter as they are template
driven.
It also prevents duplication of work. The
software enables the police and judiciary to
procure tamperproof (authentication can
be done online), legible and fully filled
documents.
There are occasions when there is a doubt
on the authenticity of the MLC and by
virtue of eMLC, one could easily check the
scanned record and verify the authenticity
immediately. PDF Link is also available in
CPRS to view MLC from any system.
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Similar System will be introduced in TAEI
Centres initially and all Hospitals in due
course

-oOo-

Chapter Essence
In a Nutshell
79. .
Nursing Alerts
264. .
Nursing Management
330. .
Trainer’s Pearls
117. .

664
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Chapter Outline
1. .
-oOo-
The secondary survey does not begin until
the primary survey (ABCs) is completed,
resuscitation is initiated, and the patient's
ABCs are reassessed.
The secondary survey is a head-to-toe
evaluation of the trauma patient, including
vital sign assessment - blood pressure,
pulse, respirations, and temperature. Each
region of the body is completely examined.
The potential for missing an injury or to
not appreciate the significance of an injury
is great, especially in the unresponsive or
unstable patient. Examples of these injuries
are cited as pitfalls after each anatomic
region examined is discussed in this
chapter.
In this survey a complete neurologic
examination is performed, including a GCS
score, if not done during the primary
survey. During this evaluation indicated
roentgenograms are obtained. Such
examinations can be interspersed into the
secondary survey at opportune times.
Special procedures, eg, peritoneal lavage,
radiologic evaluation, and laboratory
studies, also are obtained during this time.
Complete evaluation of the patient requires
repeated examination of the patient. The
secondary assessment might well be
summarized as "tubes and fingers in every
orifice."
A. History
Every complete medical assessment should
include a good history of the
injuryproducing mechanism. Many times
such a history cannot be obtained from the
patient. Prehospital personnel and family
must be consulted to obtain present and
past information that may shed light on the
patient's present physiologic state. The
"AMPLE" history is a useful mnemonic to
obtain the patient's pertinent history.
Chapter
Secondary Survey
A Allergies
M Medications currently taken
P Past illnesses
L Last meal
E Events/environment related to the
injury.
The patient's present state is greatly
influenced by the mechanism of injury.
Prehospital personnel can provide valuable
insight into such mechanisms and should
report pertinent data to the examining
physician. Types of injuries can be
predicted based on the direction and
amount of energy force. Injury usually is
classified into two broad categories blunt
and penetrating.
1. Blunt trauma
Blunt trauma results from automobile
collisions, falls, and other transportation-,
recreation-, and occupation-related
injuries.
Important information to obtain about
automobile collisions includes: seat belt
usage, steering wheel deformation,
direction of impact, damage to the
automobile in terms of major deformation
or intrusion into the passenger
compartment, and ejection of the
passenger from the vehicle. Ejection from
the vehicle greatly increases the chance of
major injury.
Injury patterns may often be predicted by
the mechanism of injury which
demonstrates the importance of an
accurate history. Such injury patterns also
are influenced by age groups and activities
2. Penetrating trauma
Penetrating trauma, injuries from firearms,
stabbings, and impaling objects, is
increasing rapidly. Factors determining the
type and extent of injury and subsequent
management include the region of the body
injured, the organs in the proximity to the
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path of the penetrating object, and the
velocity of the missile. Therefore, the
velocity and caliber of the bullet, the
trajectory, and the distance from weapon
to wounded may provide important clues
to the extent of injury
Mechanisms of Injury and Related
Suspected Injury Patterns
Mechanisms of Injury Suspected Injury
Patterns
Frontal impact - Cervical spine fracture ,
Bent steering wheel - Anterior flail chest,
Knee imprint in dashboard Myocardial
contusion , Bull's-eye fracture of
windshield Pneumothorax, Transection of
aorta (decelerating injury) Fractured,
spleen or liver Posterior
fracture/dislocation of hip and/or knee.
Side impact - to automobile Contralateral
neck sprain, Cervical spine fracture, Lateral
flail chest, Pneumothorax ,Traumatic aortic
rupture, Diaphragmatic rupture, Fractured
spleen or liver (depending on side of
impact) Fractured pelvis or acetabulum.
Rear impact - automobile collision Cervical
spine injury
Ejection from vehicle - Ejection from the
vehicle precludes meaningful prediction of
injury patterns, but places the patient at a
greater risk from virtually all injury
mechani-ms. Mortality is increased
significantly.
Motor vehicle-pedestrian - Head injury
Thoracic and abdominal injuries Fractured
lower extremities.
3. Injuries due to burns and cold
Burns are another significant type of
trauma that may occur alone or may be
coupled with blunt and penetrating trauma
resulting from a burning automobile,
explosion, falling debris, the patient's
attempt to escape the fire, or an assault
with a firearm or knife. Inhalation injury
and carbon monoxide intoxication often
complicate burn injury. Therefore, it is
important to know the circumstances
surrounding the burn injury.
Specifically, knowledge of the environment
in which the burn injury occurred (open or
closed space), as well as substances
consumed by the flames (plastics,
chemicals, etc), and possible associated
injuries sustained is critical in the
treatment of the patient.
Acute or chronic hypothermia without
adequate protection against heat loss
produces either local or generalized cold
injuries. Significant heat loss may occur at
moderate temperatures (15 to 20 degrees
centigrade) if wet clothes, decreased
activity, or vasodilatation caused by
alcohol or drugs compromise the patient's
ability to conserve heat. Such historical
information can be obtained from
prehospital personnel.
4. Hazardous environment
History of exposure to chemicals, toxins,
and radiation are important to obtain for
two reasons. First, these agents can
produce a variety of pulmonary, cardiac, or
internal organ derangement in the injured
patient. Secondly, these same agents also
present a hazard to health care providers.
Frequently, the physician's only means of
preparation is to have knowledge of the
general principles of management of such
agents and immediate access to the
Regional Poison Control Center.
B. Physical Examination
1. Head
The secondary survey begins with
evaluating the head and identifying all
related and significant injuries. The entire
scalp and head should be examined for
lacerations, contusions, and evidence of
fractures. Because edema around the eyes
may later preclude an in-depth
examination, the eyes should be re-
evaluated for
a. Visual acuity
b. Pupillary size
c. Hemorrhages of the conjunctiva and
fundi
d. Penetrating injury
e. Contact lenses (remove before edema
occurs)
f. Dislocation of the lens.
A visual confrontation of both eyes can be
performed by having the patient read a
Snellen Chart or words on an intravenous
container or 4x4 dressing package. This
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procedure frequently identifies optic
injuries not otherwise apparent.
Pitfalls:
1. Hyphema
2. Optic nerve injury
3. Lens dislocation or penetrating injury
4. Head injury
5. Posterior scalp laceration.
2. Maxillofacial
Maxillofacial trauma, not associated with
airway obstruction or major bleeding,
should be treated after the patient is
stabilized completely and life-threatening
injuries have been addressed. Definitive
management may be safely delayed
without compromising care at the
discretion of appropriate specialists.
Patients with fractures of the midface may
have a fracture of the cribriform plate. For
these patients, gastric intubation should be
performed via the oral route.
Pitfalls:
1. Pending airway obstruction
2. Changes in airway status
3. Cervical spine injuries
4. Exsanguinating midface fracture
5. Lacrimal duct lacerations
6. Facial nerve injuries.
3. Cervical spine and neck
Patients with maxillofacial or head trauma
should be presumed to have an unstable
cervical spine injury (fracture and/or
ligamentous injury), and the neck should
be immobilized until all aspects of the
cervical spine have been adequately
studied and an injury excluded. The
absence of neurologic deficit does not
exclude injury to the cervical spine, and
such injury should be presumed until a
complete cervical spine radiographic series
is obtained.
Examination of the neck includes both
inspection, palpation, and auscultation.
Cervical spine tenderness, subcutaneous
emphysema, tracheal deviation, and
laryngeal fracture may be discovered on a
detailed examination. The carotid arteries
should be palpated and auscultated for
bruits. Evidence of blunt injury over these
vessels should be noted and, if present,
should arouse a high index of suspicion for
carotid artery injury. Occlusion or
dissection of the carotid artery may occur
late in the injury process without
antecedent signs or symptoms.
Protection of a potentially unstable cervical
spine injury is imperative for patients
wearing any type of protective helmet.
Extreme care must be taken when
removing the helmet.
In penetrating trauma, wounds that extend
through the platysma should not be
explored manually in the emergency
department. This type of injury requires
surgical evaluation in the operating room.
Pitfalls:
1. Cervical spine injury
2. Esophageal injury
3. Tracheal or laryngeal injury
4. Carotid injury (penetrating or blunt).
4. Chest
Visual evaluation of the chest, both
anterior and posterior, identifies such
conditions as open pneumothorax and
large flail segments. A complete evaluation
of the chest wall requires palpation of the
entire chest cage - feeling each rib and the
clavicle. Sternal pressure may be painful if
the sternum is fractured or costochondral
separations exist. Contusions and
hematomas of the chest wall should alert
the physician to the possibility of occult
injury.
Significant chest injury is manifested by
pain and/or shortness of breath.
Evaluation of the internal structures is
done with the stethoscope, followed by a
chest roentgenogram. Breath sounds are
auscultated high on the anterior chest wall
for pneumothorax and at the posterior
bases for hemothorax. Auscultatory
findings may be difficult to evaluate in a
noisy environment, but may be extremely
helpful. Distant heart sounds and narrow
pulse pressure may indicate cardiac
tamponade. Cardiac tamponade or tension
pneumothorax may be suggested by the
presence of distended neck veins, although
associated hypovolemia may minimize this
finding or eliminate it altogether.
Decreased breath sounds and shock may
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be the only indication of tension
pneumothorax and the need for immediate
chest decompression.
The chest roentgenogram confirms the
presence of a hemothorax or
pneumothorax. Rib fractures may be
present, but they may not be visible on the
roentgenograph. A widened mediastinum
or deviation of the nasogastric tube to the
right may suggest an aortic rupture.
Pitfalls:
1. Tension pneumothorax
2. Open chest wound
3. Flail chest
4. Cardiac tamponade
5. Aortic rupture.
5. Abdomen
Abdominal injuries must be identified and
treated aggressively. The specific diagnosis
is not as important as the fact that an injury
exists and surgical intervention may be
necessary. A normal initial examination of
the abdomen does not exclude a significant
intra-abdominal injury. Close observation
and frequent re-evaluation of the abdomen,
preferably by the same observer, is
important in managing blunt abdominal
trauma. Over time, the patient's abdominal
findings may change. Early involvement by
a surgeon is essential.
Patients with unexplained hypotension,
neurologic injury, impaired sensorium
secondary to alcohol and/or other drugs,
and equivocal abdominal findings should
be considered as candidates for peritoneal
lavage. Fractures of the pelvis or the lower
rib cage also may hinder adequate
diagnostic examination of the abdomen,
because pain from these areas may be
elicited when palpating the abdomen.
Pitfalls:
1. Liver or splenic rupture
2. Hollow viscus and lumbar spine injury
(seat belts, deceleration)
3. Pancreatic injury
4. Major intra-abdominal vascular injury
5. Renal injury 6. Pelvic fracture(s).
6. Perineum / rectum / vagina
The perineum should be examined for
contusions, hematomas, lacerations, and
urethral bleeding.
A rectal examination is an essential part of
the secondary survey. Specifically, the
physician should assess for the presence of
blood within the bowel lumen, a high-
riding prostate, the presence of pelvic
fractures, the integrity of the rectal wall,
and the quality of the sphincter tone.
For the female patient, a vaginal
examination also is an essential part of the
secondary survey. The physician should
assess for the presence of blood in the
vaginal vault and vaginal lacerations.
Additionally, pregnancy tests should be
performed on all females of childbearing
age.
Pitfalls:
1. Urethral injury
2. Rectal injury
3. Bladder injury
4. Vaginal injury.
7. Musculoskeletal
The extremities should be inspected for
contusion or deformity. Palpation of the
bones, examining for tenderness,
crepitation, or abnormal movement, aids in
the identification of occult fractures.
Anterior to posterior pressure with the
heels of the hands on both anterior iliac
spines and the symphysis pubis can
identify pelvic fractures. Additionally,
assessment of peripheral pulses can
identify vascular injuries.
Significant extremity injuries may exist
without fractures being evident on
examination or roentgenograms. Ligament
ruptures produce joint instability. Muscle-
tendon unit injuries interfere with active
motion of the affected structures. Impaired
sensation and/or loss of voluntary muscle
contraction strength may be due to nerve
injury or to ischemia, including that due to
compartment syndrome.
Thoracic and lumbar spinal fractures
and/or neurologic injuries must be
considered based on physical findings and
mechanism of injury. Other injuries may
mask the physical findings of spinal
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injuries, which may go unsuspected unless
the physician obtains the appropriate
roentgenograms.
Pitfalls:
1. Spine fractures
2. Fractures with vascular compromise
3. Pelvic fractures
4. Digital fractures.
8. Neurologic
A comprehensive neurologic examination
includes not only motor and sensory
evaluation of the extremities, but also re-
evaluation of the patient's level of
consciousness and pupillary size and
response. The GCS Score facilitates
detection of early changes and trends in
the neurologic status.
Any evidence of paralysis or paresis
suggests major injury to the spinal column
or peripheral nervous system.
Immobilization of the entire patient, using
short or long spine boards, a semirigid
cervical collar, and/or other cervical
immobilization devices, must be
maintained until spinal injury can be
excluded. The common mistake of
immobilizing the head and freeing the
torso allows the cervical spine to flex with
the body as a fulcrum. Complete
immobilization of the entire patient is
required at all times until a spinal injury is
excluded, and especially when a patient is
transferred.
Early consultation with a neurosurgeon is
required for patients with neurologic
injury. Changes in the level of
consciousness should be monitored as
these may reflect progression of the
intracranial injury. If a patient with a head
injury deteriorates neurologically,
oxygenation and perfusion of the brain and
the adequacy of ventilation (ABCs) must be
reassessed. Intracranial surgical
intervention may be necessary. The
neurosurgeon must make the decision
whether such conditions as epidural and
subdural hematomas or depressed skull
fractures require operative intervention.
Pitfalls:
1. Increased intracranial pressure
2. Subdural or epidural hematoma
3. Depressed skull fracture
4. Spine injury.
VIII. Re-evaluation
The trauma patient must be re-evaluated
constantly to assure that new findings are
not overlooked, and to discover
deterioration in previously noted
symptoms. As initial life threatening
injuries are managed, other equally life-
threatening problems and less severe
injuries may become apparent. Underlying
medical problems that may severely affect
the ultimate prognosis of the patient may
become evident. A high index of suspicion
and constant alertness facilitate early
diagnosis and management.
The relief of severe pain is an important
part of the management of the trauma
patient. Effective analgesia usually requires
the use of intravenous opiates that may
adversely affect the surgeon's ability to
initially and continuously evaluate the
patient accurately. The use of intravenous
opiates may cause respiratory depression
and mask neurologic signs. Therefore,
opiates and other strong analgesics should
be withheld until surgical consultation has
occurred.
Continuous monitoring of vital signs and
urinary output is essential. For the adult
patient, maintenance of urinary output of
50 mL/hour is desirable. In the pediatric
patient over one year of age, an output of 1
mL/kg/hour should be adequate. Arterial
blood gas and cardiac monitoring devices
should be employed. Pulse oximetry on
critically injured patients and end-tidal
carbon dioxide monitoring on intubated
patients should be considered.
IX. Definitive Care
The interhospital triage criteria, published
by the American College of Surgeons
Committee on Trauma, helps determine the
level, pace, and intensity of initial
management of the multiple-injured
patient. It takes into account the patient's
physiologic status, obvious and anatomic
injury, mechanisms of injury, concurrent
diseases, and factors that may alter the
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 - 670 -
patient's prognosis. Emergency alcohol concentrations and other drugs
department and surgical personnel should may be particularly pertinent.
use these criteria to determine if the
patient requires transfer to a trauma SECONDARY SURVEY
center or closest appropriate hospital The secondary survey does not
capable of providing more specialized care. begin until:
The closest appropriate hospital should be the primary survey is completed,
chosen based on its overall capabilities to resuscitation efforts are well
care for the injured patient established,
X. Disaster the patient is demonstrating
Disasters frequently overwhelm local and normalization of vital functions.
regional resources. Plans for management Head-to-toe evaluation
of such conditions must be evaluated and Complete history and PE
rehearsed frequently to enhance the Reassessment of all vital signs.
possibility of significant salvage of injured Complete NE.
patients. Indicated x-rays are obtained.
XI. Records and Legal Considerations Special procedures
A. Records Tubes and fingers in every orifice
Meticulous record-keeping with time
documented for all events is very History:
important. Often more than one physician AMPLE history
cares for the patient. Precise records are Allergies
essential to evaluate the patient's needs Medications currently used
and clinical status. Accurate records during Past illness/ Pregnancy
the resuscitation can be facilitated by a Last meal
member of the nursing staff whose sole job Events/ Environment related to the injury
is to record and collate all patient
information. Mechanism/blunt/penetrating/burns/cold
/hazardous environment

Medical-legal problems arise frequently, Physical Examination:

and precise records are helpful for all Table 1.
concerned. Chronologic reporting with
flow sheets helps both the attending Pitfalls:
physician and consulting physician to Facial edema in patients with
quickly assess changes in the patient's massive facial injury or patients in coma
condition. can preclude a complete eye examination.
B. Consent for Treatment Blunt injury to the neck may
Consent is sought before treatment if produce injuries in which clinical signs and
possible. In life-threatening emergencies it symptoms develop late.(e.g. Injury to the
is often not possible to obtain such intima of the carotid a.)
prospective consent. In such cases The identification of cervical n.
treatment should be given first and formal root/brachial plexus injury may not be
consent obtained later. possible in the comatose patient.
C. Forensic Evidence Decubitus ulcer from
If injury due to criminal activity is immobilization on a rigid spine
suspected, the personnel caring for the board/cervical collar.
patient must preserve the evidence. All Children often sustain significant
items, such as clothing and bullets, must be injury to the intrathoracic structures
saved for law enforcement personnel. without evidence of thoracic skeletal
Laboratory determinations of blood trauma.

670
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A normal initial examination of the Additional x-rays of the spine and
abdomen does not exclude a significant extremities
intraabdominal injury. CT of the head, chest, abdomen, and
Patients with impaired sensorium spine
secondary to alcohol/drugs are at risk. Contrast urography
Injury to the retroperitoneal organs Angiography
may be difficult to identify. Bronchoscopy
Female urethral injury are difficult Esophagoscopy
to detect. Others
Blood loss from pelvic fractures can REEVALUATION
be difficult to control and fatal hemorrhage The trauma patient must be
may result. reevaluated constantly to assure that new
Fractures involving the bones of findings are not overlooked.
extremities are often not diagnosed. A high index of suspicion
Most of the diagnostic and Continuous monitoring of vital signs
therapeutic maneuvers increase ICP. and urinary output is essential.
ABG/cardiac monitoring/ pulse
ADJUNCTS TO THE SECONDARY oximetry
SURVEY Pain relive- IV opiates/anxiolytics.
These specialized tests should not be
performed until the patient’s DEFINITIVE CARE
hemodynamic status has been normalized Transfer to a trauma center or
and the patient has been carefully closest appropriate hospital.
examined.
-oOo-
Hidden Injury

Chapter Essence
In a Nutshell
80. .
Nursing Alerts
265. .
266. Focused History and Physical Exam (Secondary Survey)
267. A focused history and physical exam should be performed after the initial
assessment. It is assumed that the life-threatening problems have been found and
corrected. If you have a patient with a life-threatening problem that requires intervention
(i.e. CPR) you may not get to this component. The main purpose of the focused history and
physical is to discover and care for a patient's specific injuries or medical problems.
268. Focused History and Physical Exam
269. The focused history and physical exam includes a physical examination that focuses
on a specific injury or medical complaint, or it may be a rapid examination of the entire
body.
270. It also includes obtaining a patient history and vital signs.
271.
272.
273. Patient History - A patient history includes any information relating to the current
complaint or condition, as well as past medical problems that could be related. Utilize
bystanders/family... when needed
274. Acronym to obtain a patient's history
275. S - Signs/symptoms

671
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276. A - Allergies
277. M - Medications
278. P - Pertinent past medical history
279. L - Last oral intake
280. E - Events leading to the illness or injury
281. Rapid assessment - this a quick, less detailed head - to toe assessment of the most
critical patients
282. Focused assessment - This is an exam conducted on stable patients. It focuses on a
specific injury or medical complaint.
283. Vital signs - This include pulse, respirations, skin signs, pupils and blood pressure.
This may include documenting the oxygen saturation level (this is highly useful when
dealing with chemical agent exposure).
284. Pulse - Assess for rate, rhythm, and strength
285. Respiration - Assess for rate, depth, sound, and ease of breathing
286. Skin signs - Assess for color, temperature, and moisture
287. Pupils - Check pupils for size, equality, and reaction to light. Constricted pupils in a
mass casualty event are highly suggestive of nerve agent/organophosphate toxicity.
288.
289.
290.
291. Age-associated Vital Signs
292. Age Blood pressure Pulse Respiratory rate
293. Term Newborn (3 kg)
294. Age 12 hours 50-70 / 25-45 80-200 40-60
295. Age 96 hours 60-90 / 20-60
296. Age 7 days 74 +/- 22 mmHg (Systolic BP)
297. Age 42 days 96 +/- 20 mmHg (Systolic BP)
298. Infant (6 months old) 87-105 / 53-66 80-180
299. Toddler (2 years old) 95-105/53-66 80-180 24
300. Schoolage (7 years old) 97-112/57-71 60-160
301. Adolescent (15 years old) 112-128/66-80 60-160 12
302.
303.
304.
305. Head to Toe Examination of a Trauma Patient with Significant MOI - The physical
examination of the patient should take no more than two to three minutes
306. Neck - Examine the patient for point tenderness or deformity of the cervical spine.
Any tenderness or deformity should be an indication of a possible spine injury. If the
patient's C-spine has not been immobilized immobilize now prior to moving on with the
rest of the exam. Check to see if the patient is a neck breather, check for tracheal deviation
307. Head - Check the scalp for cuts, bruises, swellings, and other signs of injury.
Examine the skull for deformities, depressions, and other signs of injury. Inspect the
eyelids/eyes for impaled objects or other injury. Determine pupil size, equality, and
reactions to light. Note the color of the inner of the inner surface of the eyelids. Look for
blood, clear fluids, or bloody fluids in the nose and ears. Examine the mouth for airway
obstructions, blood, and any odd odors.
308. Chest - Examine the chest for cuts, bruises, penetrations, and impaled objects.
Check for fractures. Note chest movements a look for equal expansion.
309. Abdomen - Examine the abdomen for cuts bruises, penetrations, and impaled

672
 - 673 -

objects. Feel the abdomen for tenderness. Gently press on the abdomen with the palm
side of the fingers, noting any areas that are rigid, swollen, or painful. Note if the pain is in
one spot or generalized. Check by quadrants and document any problems in a specific
quadrant.
310. Lower Back - Feel for point tenderness, deformity, and other signs of injury
311. Pelvis - Feel the pelvis for injuries and possible fractures. After checking the lower
back, slide your hands from the small of the back to the lateral wings of the pelvis. Press in
and down at the same time noting the presence of pain and/ or deformity
312. Genital Region - Look for wetness caused by incontinence or bleeding or impaled
objects. In male patients check for priapism (persistent erection of the penis). This is an
important indication of spinal injury
313. Lower Extremities - Examine for deformities, swellings, bleedings, discolorations,
bone protrusions and obvious fractures. Check for a distal pulse. The most useful is the
posterior tibial pulse which is felt behind the medial ankle. If a patient is wearing boots and
has indications of a crush injury do not remove them. Check the feet for motor function
and sensation.
314. Upper Extremities - Examine for deformities, swellings, bleedings, discolorations,
bone protrusions and obvious fractures. Check for the radial pulse (wrist). In children check
for capillary refill. Check for motor function and strength.
315.
316.
317.
318. Rapid Physical Exam - Unresponsive Medical Patient
319. The rapid physical examination of the unresponsive medical patient is almost the
same as the rapid trauma assessment of a trauma patient with a significant mechanism of
injury. You will rapidly assess the patient's head, neck, chest, abdomen, pelvis, extremities
and exterior.
320.
321.
322.
323. Focused Physical Exam - Responsive Medical Patient
324. The focused physical exam of the responsive medical patient is usually brief. The
most important information is obtained through the patient history and the taking of vital
signs. Focus the exam on the body part that the patient has the complaint about.
325.
326.
327.
328. In a mass casualty situation pay particular attention to following signs and
symptoms;
329. Head
330. • Is headache present
331. • Are the pupils are the pinpoint, dilated, asymmetrical in size
332. • Are the conjunctiva injected, draining,
333. • Does the patient complain of eye pain, photophobia or blurring of vision
334. • Is salivation, drooling, and/or rhinorrhea present
335. • Is nasal flaring present
336. • Note skin color - i.e. is the patient cyanotic
337. • Note the smell of the patients breath
338. • Is the patients throat sore, red

673
 - 674 -

339. Neck
340. • Is stridor present
341. • Are the muscles in the neck "pulling"
342. Chest/Lungs
343. • Note the presence of increased work of breathing i.e. retractions, increased
rate
344. • Note the presence of stridor
345. • Note the presence of wheezing, rhonchi, rales, decreased breath sounds
346. • Note the presence of central cyanosis
347. • Does the patient complain of burning in the chest or chest pain
348. Heart/Circulation
349. • Note the presence of irregular, fast or slow heart rhythms
350. • Note the presence of diminished or absent peripheral pulse
351. • Note the presence of prolonged capillary refill in children
352. • Note the color and temperature of the distal extremities
353. Abdomen
354. • Is the abdomen painful, tense, distended or rigid?
355. • Does the patient have cramping, vomiting or diarrhea
356. Pelvis
357. • Check for incontinence of urine or feces
358. Neurological
359. • What is the patient's mental status? Is he (she) seizing?
360. • Is the patient dizzy?
361. • Did syncope occur?
362. • Was there sudden collapse
363. • Does he (she) have muscle twitching?
364. Skin
365. • Is the skin painful, burning numb or tingly
366. • Is the skin erythematous
367. • Are there vesicles, bullae
368. • Is there necrosis
Nursing Management
331. .
Trainer’s Pearls
118. .

674
 - 675 -

Chapter
AIS
Chapter Outline
1. .

-oOo-
The Abbreviated Injury Scale (AIS) is an • 1 body region
anatomically-based, consensus-derived, • 2 type of anatomical structure
global severity scoring system that • 3,4- specific anatomical structure
classifies each injury by body region • 5,6- level
according to its relative importance on a 6 • 7- Severity of score
point ordinal scale. AIS is the basis for the
Injury Severity Score (ISS) calculation of
the multiply injured patient. AIS CLASSIFICATIONS

The Abbreviated Injury Scale produced by There are nine AIS chapters corresponding
the Association for the Advancement of to nine body regions:
Automotive • 1 Head
Medicine (AAAM) Based in Ilinois U.S.A. It • 2 Face
was Developed in 1971 to aid vehicle crash • 3 Neck
investigators and it was Extended in 1990 • 4 Thorax
to be more relevant to medical audit and
• 5 Abdomen
research
• 6 Spine
• 7 Upper Extremity
Evolution of AIS
• 8 Lower Extremity
• „ 1976 - Clarified injury terminology
• 9 External, Unspecified and other.
• „ 1980 - Revised ‘brain’ section
• „ 1985 - Extended in 1990 to be more
Type of Anatomic Structure
relevant to medical audit and research
AIS Code Region
• „ 1990 – Introduced age (<15) to some
• 1 Whole Area
injury descriptors
• 2 Vessels
• „ 1990 - Update-98
• 3 Nerves
o Expanded coding rules
o Clarified coding of External • 4 Organs (inc. muscles/ligaments)
injuries • 5 Skeletal (inc. joints)
o Included the Organ Injury • 6 Loss of Consciousness (head only)
Scale grades
• „ 2004 – Update due with expansion of 3/4 Specific Anatomic Structure
Orthopaedic codes Whole Area
AIS Code Region
The score describes three aspects of the 02 Skin Abrasion
injury using seven numbers written as 04 Contusion
12(34)(56).7 06 Laceration
• Type 08 Avulsion
10 Amputation
• Location
20 Burn
• Severity
30 Crush
40 Degloving
Each number signifies
50 Injury - NFS

675
 - 676 -
60 Penetrating
Head - Loss of Consciousness (LOC) 5/6 Level
02 Length of loss of consciousness Specific Injuries are assigned consecutive
04-08 Level of consciousness two-digit numbers beginning with 02
10 Concussion Fractures, rupture, laceration, etc.
Spine
02 Cervical The AIS classifies individual injuries by
04 Thoracic body region as follows:
06 Lumbar • AIS 1 – Minor
Vessels, Nerves, Organs, Bones, Joints • AIS 2 – Moderate
02 Vessels • AIS 3 – Serious
04 Nerves • AIS 4 – Severe
06 Organs • AIS 5 – Critical
08 Bones • AIS 6 – Maximal (currently untreatable)
10 Joints

Abbreviated injury Score

AIS- Injury Example AIS % prob. of
Code death
1 Minor superficial laceration 0
2 Moderate fractured sternum 1–2
3 Serious open fracture of humerus 8 – 10
4 Severe perforated trachea 5 – 50
5 Critical ruptured liver with tissue 5 – 50
loss
6 Maximum total severance of aorta 100
9 Not further specified
(NFS)

-oOo-

Chapter Essence
In a Nutshell
81. .
Nursing Alerts
369. .
Nursing Management
332. .
Trainer’s Pearls
119. .

676
 - 677 -

Chapter
ISS
Chapter Outline
1. .

-oOo-
The Injury Severity Score (ISS) assesses the include those to the diaphragm, rib cage,
combined effects of the multiply-injured and thoracic spine.
patients and is based on an anatomical • Abdominal or pelvic contents injuries
injury severity classification, the include all lesions to internal organs.
Abbreviated Injury Scale (AIS). The ISS is Lumbar spine lesions are included in the
an internationally recognised scoring abdominal or pelvic region.
system which correlates with mortality, • Extremities or pelvic girdle injuries
morbidity and other measures of severity. include sprains, fractures, dislocations
and amputations.
The ISS is calculated as the sum of the • External and other trauma injuries
squares of the highest AIS code in each of include lacerations, contusions,
the three most severely injured ISS body abrasions, and burns, independent of
regions. These body regions are: their location on the body surface,
• Head or neck except amputation burns that are
• Face assigned to the appropriate body region.
• Chest Other traumatic events assigned to this
• Abdominal or pelvic contents ISS body region are: electrical injury,
• Extremities or pelvic girdle frostbite, hypothermia and whole body
• External (explosion-type) injury.
Injury Severity Scores range from 1 to 75. If
an injury is assigned an AIS of 6 ISS SCORING RULES
(identifying a currently untreatable injury), The ISS is the sum of the squares of the
the ISS score is automatically assigned 75. highest AIS code in each of the three most
severely injured ISS Body Regions.
ISS BODY REGIONS
There are only 6 Injury Severity Score (ISS) The following example demonstrates an
Body Regions to which injuries can be ISS calculation:
assigned, although the AIS 2005 - Update • ISS Body Region* Injury AIS
2008 dictionary is divided into 9 Code Highest AIS AIS²
anatomical chapters. • HEAD/NECK Cerebral contusion
NFS 140602.3
The following may assist with assigning the • Internal carotid artery transection
body regions. (neck) 320212.4 4 16
• Head or neck injuries include injury to • FACE Closed fractured nose
the brain or cervical spine, skull or 251000.1 1
cervical spine fractures and • CHEST Rib fractures left side, ribs 3
asphyxia/suffocation. –4 450202.2 2
• Facial injuries include those involving • ABDOMEN Retroperitoneal
mouth, ears, nose and facial bones. Haematoma 543800.2 2 4
• Chest injuries include all lesions to • EXTREMITIES Fractured femur
internal organs, drowning and (NFS) 853000.3 3 9
inhalation injury. Chest injuries also

677
 - 678 -

• EXTERNAL Abrasions (NFS) o ISS =

910200.1 1 29

-oOo-

Chapter Essence
In a Nutshell
82. .
Nursing Alerts
370. .
Nursing Management
333. .
Trainer’s Pearls
120. .

678
 - 679 -

Chapter
MHIPS.
Chapter Outline
1. .

-oOo-
There are six major prognostic factors o Absent 1
incorporated in the MHIPS: age, best motor o Impaired 2
response (as measured using the Glasgow o Normal 3
Coma Scale, GCS17), pupillary response to • Oculocephalic response
light, oculocephalic response, CT scan o Absent 1
findings and other associated systemic o Impaired 2
injuries. Each prognostic factor has been o Normal 3
divided into three subgroups, according to • CT scan findings
prognosis. The subgroup factor with the o Absent basal cisterns/
best prognosis has been assigned a score of Midline shift >5 mm/ Lesion
3, the subgroup with the worst prognosis, density >3 cm diameter 1
1, and the intermediate subgroup, 2. The o Partly effaced basal cisterns/
maximum total score is 18 and the Midline shift <5 mm/ Lesion
minimum total score is 6 density <3 cm diameter 2
o Normal basal cisterns/ No
Prognostic factor Subgroup Score midline shift/ No lesions 3
• Age • Systemic injuries
o >45 years 1 o Thoracic/Abdominal visceral
o 15–45 years 2 injuries/ >2 long bone
o <15 years 3 fractures 1
• Best motor response (Glasgow Coma o One or two long bone
Scale) fractures 2
o 1–2 1 o No other systemic or long
o 3–4 2 bone injuries 3
o 5–6 3
• Pupillary light response

-oOo-

Chapter Essence
In a Nutshell
83. .
Nursing Alerts
371. .
Nursing Management
334. .
Trainer’s Pearls
121. .

679
 - 681 -

Chapter
Blood Investigations
Chapter Outline
1. .

-oOo-
The Following Investigations are required ABG is indicated for
for all patients • patients on ventilator
• Blood Sugar at Admission • Clinical Suspicion of Acid Base Balance
• Blood Urea • Unconscious Patients
• Serum Creatinine
• Serum Electrolytes If Patient is likely to be operated, following
• Blood Grouping and Rh Typing are required
• CBC, Hematocrit • HIV
• HBsAg
HbA1c is indicated if • HCV
• Patient has History of Diabetes • CT / BT
• Random Blood Sugar is High • PT / aPTT / INR

-oOo-

Chapter Essence
In a Nutshell
84. .
Nursing Alerts
372. .
Nursing Management
335. .
Trainer’s Pearls
122. .

681
 - 683 -

Chapter
ECG
Chapter Outline
1. .

-oOo-

ECG is mandated for All patients admitted in ER

-oOo-

Chapter Essence
In a Nutshell
85. .
Nursing Alerts
373. .
Nursing Management
336. .
Trainer’s Pearls
123. .

683
 - 685 -

Chapter
X Rays.
Chapter Outline
1. .

-oOo-

Chest X Ray is Mandated for All patients admitted in ER

Other Xrays are mandated as per the site of injury
Extremities are always X Rayed bilaterally for comparison
-oOo-

Chapter Essence
In a Nutshell
86. .
Nursing Alerts
374. .
Nursing Management
337. .
Trainer’s Pearls
124. .

685
 - 687 -

Chapter
ECHO.
Chapter Outline
1. .

-oOo-
ECHO is mandated for
1. All Over 40 years of age
2. Evaluation Suggestion of Cardiac Problems

-oOo-

Chapter Essence
In a Nutshell
87. .
Nursing Alerts
375. .
Nursing Management
338. .
Trainer’s Pearls
125. .

687
 - 689 -

Chapter
Ultrasonogram.
Chapter Outline
1. .

-oOo-
Ultrasonogram is mandated for
1. Findings in eFAST
2. Pregnant Women
3. Acute Abdomen

-oOo-

Chapter Essence
In a Nutshell
88. .
Nursing Alerts
376. .
Nursing Management
339. .
Trainer’s Pearls
126. .

689
 - 691 -

Chapter
CT
Chapter Outline
1. .

-oOo-
CT Brain is Mandated in • Neck Stiffness
• Head Injuries • Neck instability
• Scalp Injuries • Injury to Neck
• History of Headache • Paraplegia / Paraparesis / Quadriplegia
• History of LOC / Quadriparesis
• History of Vomiting
• History of ENT Bleed CT Chest is mandated in
• GCS Less than 15 • Chest Injuries
• Peri orbital Ecchymosis
• Sub Conjuctival Hemorhage
CT Abdomen is mandated in
CT Facial Bones is mandated in • 1 Abdominal Injuries (Blunt or
• Facial Injuries Penetrating)

CT Pelvis is mandated in
CT Cervical Spine is mandated in • Pelvic Injuries
• Neck pain • Bleeding from Urethra

-oOo-

Chapter Essence
In a Nutshell
89. .
Nursing Alerts
377. .
Nursing Management
340. .
Trainer’s Pearls
127. .

691
 - 693 -

Chapter
MRI.
Chapter Outline
1. .

-oOo-
MRI Spine is indicated in • Paraplegia / Paraparesis / Quadriplegia
• Clinical Suspicion of Spine Injury / Quadriparesis
• Neck pain
• Neck Stiffness MRI Brain is indicated for
• Neck instability • Suspected Bilateral Isodence Chronic
• Injury to Neck SDH
-oOo-

Chapter Essence
In a Nutshell
90. .
Nursing Alerts
378. .
Nursing Management
341. .
Trainer’s Pearls
128. .

693
 - 695 -

Chapter
Anaesthesiologist Opinion
Chapter Outline
1. .

-oOo-
1. All patients requiring Airway maintenance and Ventilatory Support
2. All patients being planned for Surgery
-oOo-

Chapter Essence
In a Nutshell
91. .
Nursing Alerts
379. .
Nursing Management
342. .
Trainer’s Pearls
129. .

695
 - 697 -

Chapter
Neurosurgeon Opinion
.
Chapter Outline
1. .

-oOo-
• Head Injuries
• Scalp Injuries
• Spine Injuries
• History of Headache
• History of LOC
• History of Vomiting
• History of ENT Bleed
• GCS Less than 15
• Focal Neurological Deficit
• Peri orbital Ecchymosis
• Sub Conjuctival Hemorhage
• Unequal Pupils
-oOo-

Chapter Essence
In a Nutshell
92. .
Nursing Alerts
380. .
Nursing Management
343. .
Trainer’s Pearls
130. .

697
 - 699 -

Chapter
Neurologist Opinion
.
Chapter Outline
1. .

-oOo-
• History of Headache
• History of LOC
• History of Vomiting
• GCS Less than 15
• Focal Neurological Deficit

-oOo-

Chapter Essence
In a Nutshell
93. .
Nursing Alerts
381. .
Nursing Management
344. .
Trainer’s Pearls
131. .

699
 - 701 -

Chapter
Cardiologist Opinion
.
Chapter Outline
1. .

-oOo-
Patients More than 40 years
Clinical suggestion of Heart Disease

-oOo-

Chapter Essence
In a Nutshell
94. .
Nursing Alerts
382. .
Nursing Management
345. .
Trainer’s Pearls
132. .

701
 - 703 -

Chapter
General Physician Opinion
.
Chapter Outline
1. .

-oOo-
For Medical Emergencies
-oOo-

Chapter Essence
In a Nutshell
95. .
Nursing Alerts
383. .
Nursing Management
346. .
Trainer’s Pearls
133. .

703
 - 705 -

Chapter
General Surgeon Opinion
.
Chapter Outline
1. .

-oOo-
For Surgical Emergencies
-oOo-

Chapter Essence
In a Nutshell
96. .
Nursing Alerts
384. .
Nursing Management
347. .
Trainer’s Pearls
134. .

705
 - 707 -

Chapter
Obstetrician Opinion
.
Chapter Outline
1. .

-oOo-
Suspected or Confirmed Pregnancy
Acute Abdomen in Woman
Pelvic Injuries in Women
Sexual Assault in Women
-oOo-

Chapter Essence
In a Nutshell
97. .
Nursing Alerts
385. .
Nursing Management
348. .
Trainer’s Pearls
135. .

707
 - 709 -

Chapter
Paediatrician Opinion
.
Chapter Outline
1. .

-oOo-
All Children Less than 12 years
-oOo-

Chapter Essence
In a Nutshell
98. .
Nursing Alerts
386. .
Nursing Management
349. .
Trainer’s Pearls
136. .

709
 - 711 -

Chapter
Ophthalmologist Opinion
.
Chapter Outline
1. .

-oOo-
Loss of Vision,
Disturbance in Vision
Diplopia
Sub conjunctival Hemorrhage, Periorbital Ecchymosis
Unequal Pupils

-oOo-

Chapter Essence
In a Nutshell
99. .
Nursing Alerts
387. .
Nursing Management
350. .
Trainer’s Pearls
137. .

711
 - 713 -

Chapter
ENT Surgeon
.
Chapter Outline
1. .

-oOo-
ENT Bleed
Tracheostomy, if other competent specialists are not available
-oOo-

Chapter Essence
In a Nutshell
100. .
Nursing Alerts
388. .
Nursing Management
351. .
Trainer’s Pearls
138. .

713
 - 715 -

Chapter
Plastic Surgeon Opinion.
.
Chapter Outline
1. .

-oOo-
Degloving Injuries
Hand Injuries
Burns

-oOo-

Chapter Essence
In a Nutshell
101. .
Nursing Alerts
389. .
Nursing Management
352. .
Trainer’s Pearls
139. .

715
 - 717 -

Chapter
Vascular Surgeon Opinion..
.
Chapter Outline
1. .

-oOo-
Absent Peripheral Pulse
Cold Extremities
Open Vessel Injuries
Compartmental Syndrome
-oOo-

Chapter Essence
In a Nutshell
102. .
Nursing Alerts
390. .
Nursing Management
353. .
Trainer’s Pearls
140. .

717
 - 719 -

Chapter
Criteria for Monitoring and Evaluation.
Chapter Outline
1. .

-oOo-

For All Patients in Red and Yellow Zone Sometimes anatomic abnormalities
• ECG (e.g., urethral stricture
• Oxygen Saturation or prostatic hypertrophy)
• GCS Chart preclude placement of
• BP Chart an indwelling bladder
• TPR Chart catheter, despite
• I/O Chart meticulous technique.
Nonspecialists should avoid
When Indicated excessive manipulation of
• ICD Care the urethra or use
• ET Care of specialized
• Catheter Care instrumentation. Consult a
urologist early
• ICP Monitoring Care
• EVD Care

Urinary-Catheters
• Urinary output is a sensitive indicator of
Gastric-Catheters
the patient’s volume status and reflects
• A gastric tube is indicated
renal perfusion.
o to reduce stomach
• It is Indicated for All Patients in RED
distention,
Category
o to decrease the risk of
• Monitoring of urinary output is best aspiration, and
accomplished by the insertion of an o to assess for upper
indwelling bladder catheter. gastrointestinal hemorrhage
• Transurethral bladder catheterization is from trauma.
contraindicated in patients in whom • In All patients in Red
urethral injury is suspected.
• Decompression of the stomach reduces
• Urethral injury should be suspected in the risk of aspiration, but does not
the presence of one of the following: prevent it entirely.
o Blood at the urethral meatus • Thick or semisolid gastric contents will
o Perineal ecchymosis not return through the tube, and actual
o High-riding or nonpalpable
passage of the tube can induce vomiting.
prostate
• For the tube to be effective, it must be
• Accordingly, a urinary catheter should
positioned properly, be attached to
not be inserted before the rectum and appropriate suction, and be functional.
genitalia have been examined, if urethral Blood in the gastric aspirate can be
injury is suspected.
indicative of oropharyngeal (swallowed)
• Urethral integrity should be confirmed blood, traumatic insertion, or actual
by a retrograde urethrogram before the injury to the upper digestive tract.
catheter is inserted

719
 - 720 -

• If the cribriform plate is known to be Head Shave

fractured or a fracture is suspected, the • Is Indicated for All patients in Red
gastric tube should be inserted orally to Category with Suspected Head Injury
prevent intracranial passage. • Is Indicated when there is a scalp Injury
• In this situation, any nasopharyngeal • Is Indicated in patients who are under
instrumentation is potentially observation for conditions which pay
dangerous. potentially require surgery

-oOo-

Chapter Essence
In a Nutshell
103. .
Nursing Alerts
391. .
Nursing Management
354. .
Trainer’s Pearls
141. .

720
 - 721 -

Chapter
Protocols for Transferring patients from ER to other
departments.
Chapter Outline
1. .

-oOo-
The relevant protocols for Inter and Intra Hospital Transfer has to be followed

-oOo-

Chapter Essence
In a Nutshell
104. .
Nursing Alerts
392. .
Nursing Management
355. .
Trainer’s Pearls
142. .

721
 - 723 -

Chapter
Glasgow Outcome Scale
Chapter Outline
1. .

-oOo-

The Glasgow Outcome Score (GOS) is a 1. Death : Severe injury or death

scale so that patients with brain injuries, without recovery of consciousness
such as cerebral traumas can be divided 2. Persistent vegetative state : Severe
into groups that allow standardised damage with prolonged state of
descriptions of the objective degree of unresponsiveness and a lack of higher
recovery. The first description was in 1975 mental functions
by Jennett and Bond. 3. Severe disability : Severe injury
with permanent need for help with daily
Application living
The Glasgow Outcome Score applies to 4. Moderate disability : No need for
patients with brain damage allowing the assistance in everyday life, employment is
objective assessment of their recovery in possible but may require special
five categories. This allows a prediction of equipment.
the long-term course of rehabilitation to 5. Low disability : Light damage with
return to work and everyday life. minor neurological and psychological
deficits.

-oOo-

Chapter Essence
In a Nutshell
105. .
Nursing Alerts
393. .
Nursing Management
356. .
Trainer’s Pearls
143. .

723
 - 725 -

Chapter
Japanese Orthopedic Association Score (JOA).
Chapter Outline
1. .

-oOo-

Criterion Points o Urinary retention 1

o Severe dysfunction 2
• Motor function of Upper extremity o Mild dysfunction 3
o Paralysis 1 o Normal function 4
o Fine motor function
massively decreased 2 • Scoring Method and Interpretetion
o Fine motor function o Total score 0–17. The lower
decelerated 3 the score the more severe
o Discreet weakness in hands the deficits.
or proximal arm 4 Normal function 16 + 17
o Normal function 5 Grade 1: 12–15
Grade 2: 8–11
• Motor function of Lower extremity Grade 3: 0–7
o Unable to walk 1 Weight of the criterion in percentage of 17
o Need walking aid on flat floor points: upper extremity 23.5%; lower
2 extremity 23.5%; sensory 3 × 11.8% (total:
o Need handrail on stairs 3 35.4%); bladder and bowel function 17.6%
o Able to walk without walking
aid, but inadequate 4 References
o Normal function 5 Eur Spine J. 2007 December; 16(12): 2096–
2103.
• Upper extremity/lower extremity/trunk Yue WM, Tan SB, Tan MH et al (2001) The
Sensory Function Torg-Pavlov-ratio in cervical spondylotic
o Apparent sensory loss 1 myelopathy: a comparative study between
o Minimal sensory loss 2 patients with cervical spondylotic
o Normal function 3 myelopathy and a nonspondylotic,
nonmyelopathic population. Spine
• Bladder function 26(16):1760–1764.

-oOo-
Chapter Essence
In a Nutshell
106. .
Nursing Alerts
394. .
Nursing Management
357. .
Trainer’s Pearls
144. .

725
 - 727 -

Chapter
Karnofsky Performance Scale
Chapter Outline
1. .

-oOo-
The Karnofsky Performance Scale Index allows patients to be classified as to their functional
impairment. This can be used to compare effectiveness of different therapies and to assess the
prognosis in individual patients. The lower the Karnofsky score, the worse the survival for
most serious illnesses.
KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA

Able to carry on normal activity 100 Normal no complaints;

and to work;
no special care needed.
Unable to work;
able to live at home and care for
most personal needs;
varying amount of assistance
needed.
Unable to care for self;
requires equivalent of institutional
or hospital care;
disease may be progressing
rapidly.
no evidence of disease.
90 Able to carry on normal activity;
minor signs
or symptoms of disease.
80 Normal activity with effort;
some signs or symptoms of disease.
70 Cares for self;
unable to carry on normal activity or to do active
work.
60 Requires occasional assistance, but is able to care
for most of his personal needs
50 Requires considerable assistance and frequent
medical care.
40 Disabled; requires special care and assistance.
30 Severely disabled; hospital admission is indicated
although death not imminent.
20 Very sick; hospital admission necessary; active
supportive treatment necessary.
10 Moribund; fatal processes progressing rapidly.
0 Dead
-oOo-

Chapter Essence
In a Nutshell
107. .
Nursing Alerts
395. .
Nursing Management
358. .
Trainer’s Pearls
145. .

727
 - 728 -

Hidden Injuries
Death
Disclosing Death
AMA . Discharge at Request, Abscond

728
 - 729 -

Chapter
.
Chapter Outline
1. .

-oOo-

-oOo-

Chapter Essence
In a Nutshell
108. .
Nursing Alerts
396. .
Nursing Management
359. .
Trainer’s Pearls
146. .

729
- 731 -

731
 - 733 -

1
Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health
Metrics and Evaluation. India: Health of the Nation's States - The India State-level Disease Burden
Initiative. New Delhi, India: ICMR, PHFI, and IHME; 2017.
ii
Pathophysiology of polytrauma - Keel, M. & Trentz O. - Injury, Volume 36, Issue 6, Pages 691-709
iii
Ross, Darrell Lee; Chan, Theodore C (2006). Sudden Deaths in Custody. ISBN 978-1-59745-015-7.
iv
Council., National Safety. Injury facts. National Safety Council. Research and Statistics Department.
(2015 ed.). Itasca, IL. ISBN 9780879123345. OCLC 910514461.
v
Sayadi, Roya (May 2010). Swallow Safely: How Swallowing Problems Threaten the Elderly and
Others (First ed.). Natick, MA: Inside/Outside Press. pp. 46–47. ISBN 9780981960128.
vi
Kelly, CA; Upex A; Bateman DN. (February 2005). "Comparison of consciousness level assessment
in the poisoned patient using the alert/verbal/painful/unresponsive scale and the Glasgow Coma Scale".
Annals of Emergency Medicine. 44 (2): 108–113. doi:10.1016/j.annemergmed.2004.03.028.
vii
McNarry, AF; Bateman, DN (January 2004). "Simple bedside assessment of level of consciousness:
comparison of two simple assessment scales with the Glasgow Coma scale". Anaesthesia. 59 (1): 34–7.
doi:10.1111/j.1365-2044.2004.03526.x. PMID 14687096.
viii
Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2:81-4.