Multiple Trauma

How much blood can a pt. loose during a femur fracture?

2 L

What is the primary survey composed of?

A-B-C-D-E Airway Breathing Circulation Disability Exposure Priority patient history 1. Comorbidities? 2. Pregnant? 3. Substance abuse?

Secondary survey

AMPLE Allergies Medications PMH, Past surgical history Last meal Events (surrounding accident)

Higher velocity bullet

Cavitation ("blast effect") Energy dispersion outward from bullet path

Volume changes due to hypovolemia

Decreased circulating volume Decreased preload

Types of great vessel injury?

Dissection Rupture

Charting with gunshot wounds

Don't chart entrance/exit Just label it wound A and B

Flail chest patho

During inspiration: atmospheric pressure exceeds intrathoracic pressure Flail segment moves *IN* During expiration: intrathoracic pressure exceeds atmospheric pressure Flail segment moves *OUT* *Paradoxical breathing* See-saw motion

Stages of shock

Early compensatory/initial Progressive Refractory

Causes of hypovolemia

Hemorrhage Burns Sepsis Dehydration

Trauma Resuscitation Causes

Hemorrhage Hypovolemia shock resulting from acute blood loss Early recognition and treatment is key in survival Blood loss Chest : 2.5L per hemothorax Abdomen : 6L from damaged organs and vessels Pelvis/retroperitoneum : May exsanguinate from vessel injury due to bone fragments Femur : Up to 1.5 L per External wounds

2nd in Trimodal Distribution of Fatal Injuries

In the ED or operating room Minutes to hours Caused by: subdural or epidural hematoma, hemo- or pneumothorax, liver or spleen lacerations/rupture, pelvic fractures and other conditions associated with massive hemorrhage

Cardiac Tamponade

Life threatening - blood fills pericardial sac r/t injury As blood builds up, heart motion becomes more restricted It doesn't take much. Beck's triad - elevated RAP w/ JVD, hypotension, muffled heart sounds Pulsus paradoxus (10 mmHg decrease in BP on inspiration) Tachycardia (heart pumps faster as motion is restricted to try to maintain CO)

Nursing management for pelvic injuries

Monitor for S&S of hemorrhage Fluid resuscitation DO NOT MOVE PATIENT Monitor lower extremities (color, motion, signs of neuro or vascular compromise)

Moderate pulmonary contusion

More significant increase in RR, HR Inability to cough effectively, lung crackles c/o chest pain ABG, decreased PaO2, increased PCO2 r/t poor ventilation

Fat Emboli Syndrome

Most frequently associated with long bone and pelvic fractures Fat globules enter bloodstream after being displaced by trauma to bone

Types of blunt trauma

Motor vehicle crash Pedestrians hit by car Falls Contact sports Crush injuries Physical assault

Vehicular Ejection

Multiple injuries, especially head and SCI Injury risk increases by 300% when ejection occurs

What causes rhabdomyolysis?

Muscle damage from untreated compartment syndrome Crush injuries Muscle breakdown from long periods of laying in the same position (pinned or lying unconscious on a hard surface) Extreme exercise Muscle death, muscles break down and clog the kidneys

Rhabdomyolysis

Muscle fibers break down, get into the circulation and damage the kidneys

Management priority with flail chest?

Must stabilize chest!

Is a chest x-ray the first option for tension pneumo?

NO! It takes too long and they will die

*Trauma triad*

Need to break the cascade Warm pt. Correct coagulopathy/FFP & cryoprecipitate Keep BP elevated to perfuse tissues

Do you remove an impaled object?

No! Never remove an impaled object - support with bandage & keep covered If there is an evisceration cover with normal saline 4x4's

What to look for in pelvic injuries

Perianal ecchymosis Pain on palpation "rocking" of illiac crests Hematuria Lower extremity rotation or paresis **Bleed a lot** Watch for volume loss, vital sign changes Not going to move these patients very much

Complications of ACS

Reperfusion systole: byproducts of ischemia circulate to the heart causing acidosis related impairment of electrical activity. Patient must be resuscitated with sodium bicarbonate Pulmonary embolism: associated with reperfusion. Monitor for dyspnea, pleuritic CP, signs of shock, oxygen and thrombolytics must be available Nursing implications: maintain and monitor oxygenation, wound care, mechanical ventilation, volume resuscitation, vasopressors

Flail Chest

Ribs are broken in two or more places causing free floating ribs in chest cavity

Flail chest clinical presentation

Severe chest pain Paradoxical breathing Adventitious (or no) breath sounds Inability to clear own secretions Abnormal ABG (low O2, high CO2) Recent history of severe chest trauma Associated injuries Can get pneumo from bone puncturing lung

Primary survey & resuscitation

Short Identify & treat life-threatening conditions Don't miss anything Stabilize patient

Treatment of FES

Symptomatic treatment and supportive care Ventilator management with peep and high flow oxygen Intubate/vent - airway pressure/O2 Selected pulmonary vasodilator inhaled nitric oxide or Flolan Chest tube for pneumo Sedation/neuromuscular blocking agents Rotoprone bed or prone position

Rule of the primary survey

When you discover a life-threatening problem, stop, fix that problem then continue with the survey

Low energy penetrating traumatic injury

Knives, arrows

Treating tension pneumo

Release the pressure! Anticipate insertion of a large bore needle (14 gauge or larger, 2nd intercostal space midclavicular line) attached to a 3 way stopcock and a large syringe Anticipate chest tube placement

Treatment of ACS

Decompressive laparotomy -> open abdominal management bringing its own morbidity and potential mortality Prevention is key if at all possible - treat hemorrhage timely, control in order to avoid high crystalloid volumes

Common blunt trauma injuries

Head injuries (acceleration/deceleration & shearing) Spinal cord injuries (shearing, acceleration/deceleration) Fractures (shearing & compression) Abdominal/thorax (shearing & compression

Unrestrained driver

Head/facial, liver, spleen, bowel injuries Fractured ribs, sternum, femur, hip Contusions: Pulmonary, cardiac Spinal cord injury

Abdominal Compartment Syndrome (ACS) Causes

*Life threatening* 1. Post injury primary ACS in shocked, coagulopathic patient with severe abdominal injuries 2. Post injury secondary ACS in patients with trauma and severe extra abdominal bleeding needing large volume of transfusions 3. Uncontrolled bleeding coupled with large volumes of crystalloid resuscitation leads to increased intra-abdominal pressure *Fatal if not treated* Can happen r/t pelvic fractures You get to a point where there just isn't room for any more blood Causes increase in pressure, heart can't pump & lungs can't expand

Stages of hypovolemia

1. 750 ml loss 2. 750-1500 ml loss 3. 1500-2000 ml loss 4. >2000 ml loss

Complications of long bone fracture

Acute compartment syndrome Fat emboli syndrome Hypovolemic shock

Renal Hypoperfusion

Acute renal failure Metabolic acidosis Don't have adequate volume for heart to pump and perfuse organs which can lead to acute renal failure, metabolic acidosis Body trying to protect brain, heart, lungs

What damage can rhabdomyolysis cause?

Acute renal failure Permanent renal failure

How do you treat rhabdomyolysis?

Aggressive hydration (LR) May use diuretics (Lasix) May alkalinize the urine (w/ sodium bicarb drip - nephroprotective) Electrolyte replacement Monitor urine myoglobin levels - serial urine myoglobins until you have 2 negatives Dialysis if renal failure occurs (supporting kidneys until they heal)

Severe pulmonary contusion

All of symptoms of moderate plus ARDS - like manifestations Intubate and on vent

Blunt Chest Trauma

Associated with accelerating/decelerating forces Seen with MVC, assault (punched, kicked, hit with a bat), contact sports

1st in Trimodal Distribution of Fatal Injuries

At the scene or enroute Minutes to hours Caused by: laceration to brain, great vessels, and organs (aorta, heart). Upper (cervical) spinal cord injury

Indicators of shock

BP may or may not be low Hemodynamics more useful (CI/CO, SVR, SvO2) Good assessment and history of injury is important

Diagnosis of FES

Based on symptoms; hypoxemia, respiratory insufficiency, neurologic impairment CXR fairly normal in the majority of patients CT of chest may show focal area of ground glass opacification

Pleural compromise in chest trauma

Can be life threatening Secondary to blunt or open chest trauma Results in pneumo, hemothorax, hemopneumothorax, tension pneumothorax

Prone positioning

Can only be left prone for a period of time Positioning increases respiratory status b/c it changes air placement in lungs

Blunt Cardiac Injury

Cardiac contusion Bruising of myocardium CP, hypotension & sinus tachycardia are indicative when coupled with a chest injury pattern ST changes, dysrhythmia, or heart blocks may be apparent May do an echo to evaluate cardiac injury Symptomatic management, should resolve over time

Abdominal compartment syndrome systemic effects

Cardiovascular - elevated SVR, CVP, PAWP, tachycardia, decreased CO, hypotension (late) (heart is pumping against a large pressure) Pulmonary - decreased lung compliance, hypercapnia, hypoxemia, increased PIP, increased CO2 because they aren't ventilating well Renal - oliguria, azotemia, prerenal failure Neurologic - increased ICP, altered LOC GI - small bowel ischemia, sepsis, translocation of bacteria from gut, increased intraabdominal pressure, multiple organ dysfunction

Factors affecting response to injury?

Comorbidities Substance abuse Pregnancy Advanced age

Subcutaneous emphysema

Edematous appearance Palpation - feels and sounds like rice crispies Anticipate STAT chest x-ray *concerning when it starts interfering with airway* alters pt. voice and can be very disconcerting

How is ACS treated?

Fasciotomy Cut into muscle and release blood

Cardiac Tamponade Management

Fluid resuscitation Pericardiocentesis Thoracotomy with chest tube placement Complications - pneumothorax, liver laceration, cardiac dysrhythmias, artery laceration, myocardial puncture with additional tamponade

How do you measure abdominal pressure?

Foley - 25 cc in - clamp foley - hook up - measure mmHg

Hit by a motor vehicle

Fractures - femur, tibia, fibula, knee Traumatic brain injury Chest injury to children r/t where the bumper hits you

Medium energy penetrating traumatic injury

Hand guns, some rifles

Higher velocity bullet with bone impact

Hard fragments increase/widen tissue damage (bigger blast effect) Tumble & ya

Substance abuse

High incidence of consciousness altering substances as a contributing factor to injury Alcohol Barbituates Opiates Sedative-hypnotics Cocaine Marijuana History is extremely important!

Pulmonary contusion patho

High pressure waves from rapid compression/decompression result in vascular and tissue damage (ARDS like consequences - lungs become stiff & difficult to ventilate) Often delayed onset, 24-72 hours post injury

High energy penetrating traumatic injury

Hunting rifles, shotguns

Fat Emboli Syndrome Sx

Hypoxemia Neurologic abnormalities Sometimes a petechial rash

Fat Emboli syndrome

Hypoxemia, dyspnea, and tachypnea are the most frequent early findings Increased airway pressure Neurologic abnormalities develop in the majority of patients with FES The characteristic petechial rash may be the last component of the triad to develop May see coagulation abnormalities that mimic DIC (disseminated intravascular coagulation)

3rd in Trimodal Distribution of Fatal Injuries

ICU Days to weeks Caused by: sepsis, SIRS/MODS

Mild pulmonary contusion

Increased respiratory rate and HR Blood tinged sputum

Clinical manifestations of tension pneumothorax

Increasing anxiety, restlessness, pallor Cyanosis, increased SOB (restricted ventilation) Sub-q emphysema, neck vein distension Displaced trachea (mediastinal shift) Absent breath sounds on affected side Hyperexpansion of affected side Hypotension Shock (cardiovascular collapse - cold, clammy skin, circulatory distress) Panic No breath sounds on affected side

What vasculature is protected by the pelvis?

Inferior VC, illiacs Femoral & saphenous veins Abdominal aorta, illiacs & sacral arteries Gluteal & pudendal arteries

Damage Control Surgery

Initial OR Resuscitation Definitive restoration OR-pack-stabilize some- then go back to OR to fix more

What is abdominal traumatic injury?

Injuries occurring from the nipple line to the mid-thigh

Blunt trauma

Injuries resulting from external forces without disrupting skin integrity

Penetrating traumatic injury: mechanisms of injury

Injury resulting from missile Can be low, medium, or high energy Gunshot wounds - often associated w/ multiple internal injuries in chest/abdomen Stab wounds and impalement tend to be more localized

Traumatic Injury

Interaction of energy and force have a recipient Injury results from acute exposure to energy that the body is unable to tolerate Injury results in tissue and organ deformity and displacement Damage can be local, regional, or widespread Mechanisms of injury can help anticipate an injury pattern and complications Traumatic injury is a term specific to kinetic injury

Shock

Life threatening response to alterations in circulation

Low velocity bullet

Local trauma, no cavitation Small entrance and exit wounds

What structures can be affected with chest trauma?

Lungs Thorax Trachea Bronchus Diaphragm Esophagus Great vessels - aorta Bony skeleton

Possible complications for abdominal traumatic injury

Massive hemorrhage -> shock Intra-abdominal hypertension (IAH)

Do you turn patients with pelvic injuries?

Not at all Immobilize pelvis like a taco until OR

Tension pneumothorax

One way valve problem -air leak, tear does not seal -air sucked in during inhalation -not released during expiration Pressure continues to increase on affected side -displaces trachea and unaffected lung -impairs venous return to the heart (vena cava compression) Results in: decreased CO, cardiovascular collapse

Management alternatives for flail chest

Optimizing pulmonary function -pain control w/ excellent pulmonary toilet (NSAIDs, narcotics, intercostal nerve blocks) -Mechanical ventilation - internal splinting via control of pressure/ventilation -Surgical fixation (less common) **Pain control!

What type of urine can you expect with rhabdomyolysis?

Orange/pink thick urine

Long Bone Fractures

Orthopedic emergency Should go to the OR immediately for repair If too unstable for OR, traction or external fixation at the bedside

Causes of acute renal failure in trauma patients

Prerenal Intrarenal : intrinsic (in kidney) Postrenal

Mild ACS

Pressure 12-15mmHg. Raise head to allow maximum lung expansion & monitor

Moderate ACS

Pressure 16-25 mmHg. Sedation and NMB. Adequately fluid resuscitate

Severe ACS

Pressure >25mmHg. Requires urgent surgical decompression of the abdominal cavity. Often at the bedside. Volume resuscitate the patient as necessary

Pelvic Injury Management

Prevent/treat hemorrhage - embolization of bleeding vessels, packing pelvis Stabilization - temporary, interventional (unstable fx), external fixation device, definitive - internal fixation surgery

Mechanism of blunt injury: compression

Process of being pressed or squeezed together w/ resulting decrease in volume or size -Contusion (compression of heart and lung tissue between posterior and anterior chest wall) Hitting a steering wheel causes contusion

Abdominal trauma clinical presentation

Ranges from subtle to severe Increased abdominal girth, distention Guarding, rigidity with palpation Cullens sign - periumbilical ecchymosis Grey Turner's Sign - Flank ecchymosis Wounds - entrance & exit Presence of abdominal abrasions, hematomas, brusies, burns, tire treads or seat belt marks

Trauma resuscitation process

Recognition of source is crucial 2 large bore 14-16 gauge IV Crystalloid LR or NS PRBC type specific if possible Platelets for decreased platelets (below 50) Fresh frozen plasma for INR greater than 2 or PTT higher than 1-1.5x the control level Cryoprecipitate for Fibrinogen <0.8g/L Use rapid infuser with warmer

Chest trauma facts

There is some degree of chest trauma present in 6 out of 10 motor vehicle crashes About 25% of trauma deaths have cardiothoracic injury

Management of pulmonary contusion

Think of ARDS management: High levels of oxygen Intubation with mechanical vent for acute respiratory failure PEEP Sedation Pain control - breathe deeper, clear own secretions better when pain is controlled Use lowest pressure tolerable

Mechanisms of injury of blunt trauma

Tissues/organs become torn or compressed via acceleration/deceleration, shearing (tearing injuries) often with rotation, compression (squeezing)

Acute compartment syndrome

Too much pressure builds up in limb r/t bleeding, compresses vasculature & you do not have flow

Keys for resuscitation

Treat shock and prevent MODS

Hypoxemia, hypotension, acidosis activate

compensatory mechanisms

The higher the force applied the ________ _____ _______.

greater the damage As velocity increases so does tissue damage

Inadequate perfusion leads to

organ malfunction Not enough circulating volume to perfuse adequately

For cardiac tamponade, immediate intervention with _______________ is necessary

pericardiocentesis

Good parameters

vital signs/hemodynamic status: SBP >90; MAP >70 HR<100 OUP>30 ml/hr Oxygenation: Skin: warm, dry SVO2: 65-80% Acid Base Serum lactate <2.0 Base deficit + - 3.0