403 Trauma

Concussion

- A brain injury w/brief loss of neurological function, especially LOC from seconds to hours - Neuro dysfunctions: confusion, disorientation, antegrade or retrograde amnesia - Symptoms: headache, nausea, irritability, impaired memory and concentration, fatigue - Diagnosis is based on LOC since brain is structurally intact

Brown-Sequard Syndrome

- Damage to only one side of the cord - Produces loss on voluntary motor movement on the same side of the injury with the loss of pain, temperature and sensation on the opposite side - Side with the best motor control has little or no sensation and vice versa

Subacute Subdural Hematoma

- Develops symptomatically 2 days to 2 weeks after trauma due to slow expansion. Clinical deterioration and appearance of symptoms is slower than acute, but is treated with same interventions

Severe Brain Injury

- GCS 8 or < after resuscitation or deteriorates to this level within 48 hours of admission - Ventilatory support with ICP and hemodynamic monitor - CT scan to rule out mass lessons that can be surgically ameliorated - In CCU for continual assessment, management and monitoring

Moderate Brain Injury

- GCS 9-12 - LOC up to 6 hours - At risk for deterioration from cerebral edema and increased ICP. - Hospitalized w/serial assessments. Hemodynamic and ICP monitoring and ventilatory support may not be required unless other system injuries need it. - CT is performed and repeated if patient's neuro status deteriorates.

Traumatic Brain Injury Pathophysiology: Secondary Injury - Hypotension

- Leads to inadequate perfusion to neural tissue - Rare w/TBI's, unless terminal medullary failure occurs - If hypotensive and unconscious, need to perform chest, abdomen and pelvic assessment to assess for internal injuries

Trimodal Distribution of Trauma Deaths: First Peak

- Victims who die before medical attention can be provided. - Occurs minutes after injury - Can occur at the scene of injury on enroute to the medical facility - Causes of death: laceration of brain or brainstem, high spinal cord injury, injury to hear or aorta or other large vessels

List the Phases of Trauma Care

1. Prehospital resuscitation 2. Hospital resuscitation (in the ER) 3. Definitive Care and Operative Phase 4. Critical Care 5. Intermediate Care 6. Rehabilitation

Bladder Trauma

A large percentage of bladder injuries result from pelvic fractures.42 Physical findings may include lower abdominal bruising, distention, and pain. More definitive findings include difficulty in voiding or incomplete recovery of irrigation fluids from catheterized patients.43 Bladder injuries are classified as contusions, extraperitoneal ruptures, intraperitoneal ruptures, or combined injuries. The type of injury depends on the location and strength of the blunt force and volume of urine in the bladder at the time of injury. Extraperitoneal rupture of the bladder may be managed conservatively with catheterization and antibiotics for 7 to 10 days.44 Unresolved extravasation may require surgical intervention.

Spinal Cord Injuries

Diagnosis should include detailed history of events, precise evaluation of sensory and motor function, and radiographic studies.

Thoracic Injuries Mechanism of Injury

Involves trauma to the chest wall, lungs, heart, great vessel and esophagus 1. Blunt - Combination of acceleration-deceleration injury and direct transfer mechanics - Often from falls or MVCs 2. Penetrating - Damage depends on penetrating object

Complications of Trauma: Pain

Pain may come from many sources, including surgery, procedures, and trauma. Trauma may contribute to cellular death and inflammation that leads to pain. Relief of pain is a major component in the care of trauma patients. An issue that often complicates pain management is the high incidence of substance abuse among patients who sustain traumatic injury. Trauma patients, regardless of substance use history require multimodal acute pain management (see Chapters 9 and 10).

Complications of Trauma: Sepsis

The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained (see Chapter 35).

Special Consideration: Older Patient

Trauma affects people of all ages. Older patients are predisposed to traumatic injuries because of the inevitable consequences of aging. The ability to react to or avoid environmental hazards is impaired because of age-related deterioration of the senses and changes in motor strength, postural stability, balance, and coordination (see Chapter 9). Older persons experience most of the falls that result in injuries, and these falls are likely to occur from level surfaces or steps.59 Factors that predispose older persons to falls are summarized in Box 34-16. Because many of the falls may be caused by an underlying medical condition (e.g., syncope, myocardial infarction, dysrhythmias), management of the older patient who has fallen must include an evaluation of events and conditions immediately preceding the fall. The exposure of older adults to MVC trauma is a consequence of the increasing growth of the older population and the growing number of older drivers and occupants of motor vehicles. Factors that predispose older adults to MVCs are summarized in Box 34-17. Many deaths of older individuals occur in crosswalks. Physiologic deterioration of cerebral and motor skills and alterations in visual and auditory acuity cause older pedestrians to walk directly into the path of oncoming vehicles. Trauma in older adults can be associated with higher mortality rates, even when the injuries are less severe. Older adults have a higher complication rate and a higher mortality rate, starting at age 65 years, because of pre-existing medical conditions, decreased physiologic reserves, and decreased ability to compensate for severe injury.60 Older patients who do survive traumatic injury are often faced with changes in their preinjury functional status. Relatively minor trauma can be the event that changes the lifestyle of an older person from one of relative independence to one that requires prolonged rehabilitation or skilled nursing care. Discharge planning early in the patient's hospitalization is necessary. The concept of limited physiologic reserve in the older trauma patient highlights the key difference between the average younger trauma patient with normal physiologic reserve and the older patient with underlying physiologic derangements. Age-related changes that occur in virtually every organ system may not produce evidence of organ dysfunction in the resting state. However, the ability of organs to augment function in response to traumatic stress may be greatly compromised. Fluid resuscitation is an integral part of trauma resuscitation. Patients on chronic diuretic therapy may require more volume and potassium supplementation as a result of chronic volume and potassium depletion. The assessment and management of hypovolemic shock is more complex in the older trauma patient. Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of hypovolemia—tachycardia.9 Loss of physiologic reserve and the presence of pre-existing medical conditions are likely to produce further conflicting hemodynamic data. The older patient's lack of physiologic reserve makes it imperative that early nutritional support is initiated. Many older adults take daily anticoagulants and/or antiplatelet medications to prevent thrombotic or embolic complications from preexisting medical conditions. Traumatic injury in conjunction with a prolonged International Normalized Ratio (INR) greatly increases the risk of major hemorrhage. It is essential that systemic anticoagulation be corrected as soon as possible after admission, and when head injury is suspected, a CT of the head is urgently obtained.60 Trauma protocols are well established for the management of young patients after injury. Clinicians increasingly are recognizing that these protocols must be individualized for the older trauma patient. The best outcomes for this patient population have been achieved through early, appropriate, aggressive trauma care, with admission to a trauma center with resources and protocols to provide excellent care to injured adults regardless of age.60

SCI Screening for Spinal Cord Injury

- Integral to assessments of trauma patients - Severity, alterations in mental state, intoxication and distracting injuries dictate the type and extent of examination required to clear C-spine - Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee created guidelines for clearance of C-spine. -- Uses CT scan for assessment -- On admission, spine is palpated for obvious deformities and pain to touch -- If patient has distracting injuries, intoxicated or received analgesics, examination may be deferred -- MRI may be used for definitive diagnosis for stabilized patients

Prehospital Resuscitation

- Immediate stabilization and transportation - Focuses: airway management, controlling bleeding and shock, immobilizing patient and transporting patient to medical facility - Personnel at this time should be able to communicate information to triage to plan out advance care

SCI Nursing Management: Musculoskeletal Complications

- Immobilized due to contracture risks. When muscle is denervated, the finer shortens and produces a contracture. Irreversible contractures lead to skin breakdown, inability to perform ADLs, poor posture, and inability to use adaptive devices - PT and OT should be considered early - ROM exercises should be performed as soon as spine had been stabilized - Footdrop splints should be applied on admission to prevent contractures and prevent skin breakdown of the heels. Handsplints should be applied for quadraplegics. Both should be removed q2h. - Halo Vest Management: inspecting pins and tractions for security, correct positioning and turning, placement of wrenches on front of vest in case of cardiac arrest and maintenance of skin integrity inside the halo vest

Neurologic Assessment of Traumatic Brain Injury

- Important tool to measure severity and dictate prognosis and the plan for treatment and evaluation - GCS is critical. Assess pupil and motor strength early and ongoing. - After injuries are identifies and assessed from GCS or LOC, it is classified to mild, moderate or severe .

SCI Nursing Management: Elimination Complications

- Initially after SCI, bladder and bowel tone are flaccid and function depends on the location and severity of injury - Foley catheter placed on admission, and should be removed 3-4 days after. Then intermittent catherization should be done q4-6 hours - Overdistended bladder w/T6 or above injuries may trigger autonomic dysreflexia - Major problems: abdominal distention, constipation and fecal impactions b/c innervation b/w brain and defecation centre in sacral cord had been disrupted -- Bowel program to prevent fecal impaction and encourage normal and regular bowel function instituted. Should not go more than 3-4 days w/o BM. If so, use laxatives or stool softeners, especially if patient is using opiates. - Successful bowel program: Consistent timing, proper positioning, physical activity, appropriate fluid intake, high-fibre diet and reflex stimulatoin

SCI Mechanism of Injury: Axial Loading

- Injuries occur from vertical force along the spinal cord. - Seen with falls where individual lands on their bottom or feet - Compression injuries cause burst fractures of the vertebral body and send fragments into spinal canal or into the cord

Tetraplegia

- Injury occurs from C1 to T1 - Residual muscle function depends on the specific cervical segments involved

Paraplegia

- Injury occurs in thoracolumbar region (T2 to L1) - May have full use of arms and need wheelchair, but some may have limited ability to ambulate with walking aids - Thoracic L1 and L2 injuries produce paraplegia with variable innervation to intercostal and abdominal muscles

Anterior Cord Syndrome

- Injury to the anterior gray horn cells (motor), the spinothalamic tracts (pain), anterior spinothalamic tract (light touch) and corticospinal tracts (temperature) - Loss of motor function and sensations of pain and temperature below the injury - Position and pressure senses remain intact - Often caused by flexion injuries or acute herniation of an intervertebral disc

Subdural Hematoma

- Accumulation of blood between the dura, and underlying arachnoid membrane - Related to rupture of bridging veins b/w cerebral corte and dura. - Major causes are acceleration/deceleration/rotational forces -- Often associated wing cerebral contusions and intracerebal hemorrhage - 1/3 of severe head injuries - Three types based on time frame and clinical symptoms: Acute, Subacute & Chronic

Abdominal Injuries

- From blunt or penetrating trauma. - Two major life-threatening conditions that occur after abdominal trauma are hemorrhage and hollow viscus perforation with associated peritonitis. - Death occurring after 48 hours following injury is the result of sepsis and its complications.

Acute Subdural Hematoma

- Occurs after severe blow to head - Clinical presentation determined by severity of injury and blood accumulation - Requires close monitoring for deterioration of LOC (sometimes has lucid period before) and lateralizing signs (e.g. unequal pupil or motor movements) - TX: Rapid surgical invention (e.g. craniotomy, burr hole evacuation, craniectomy and aggressive medical management)

Traumatic Brain Injury Pathophysiology: Secondary Injury - Brain Edema

- Occurs as a result of changes in the cellular environment caused by contusion, loss of auto regulation and increased permeability of BBB. - Can be focal as it localizes around the area of contusion or issue as a results of hypotension or hypoxia - Proper oxygen management can minimize brain edema

AI Physical Assessment

- Assess and document location of entry and exit sites - Inspect patient's abdomen for discoloration: -- Purplish around the flanks or umbilicus (Cullen sign) indicates blood in the abdominal wall. -- Ecchymosis in the flank area (Turner-Grey sign) may indicate retroperitoneal bleeding or a pancreatic injury. -- Hematoma in the flank area suggests kidney injury. - Distended abdomen may indicate the accumulation of blood, fluid, or gas resulting from a perforated organ or ruptured blood vessel. - Auscultation of the abdomen may reveal friction rubs over the liver or spleen and may indicate rupture. - The abdomen is assessed for rebound tenderness and rigidity. These assessment findings indicate peritoneal inflammation. - Referred pain to the left shoulder (Kehr sign) may indicate a ruptured spleen or irritation of the diaphragm from bile or other material in the peritoneum. - Subcutaneous emphysema palpated on the abdomen suggests free air as a result of a ruptured bowel.

Abdominal Compartment Syndrome

- Assessed for additional complications, including ongoing hemorrhage, intra-abdominal hypertension (IAH), and abdominal compartment syndrome. -Abdominal compartment syndrome: end-organ dysfunction caused by IAH. -- Increased pressure can be caused by bleeding, ileus, visceral edema, or a noncompliant abdominal wall. -- Increased abdominal cavity pressure can impinge on diaphragmatic excursion and can affect ventilation. - Clinical manifestations: Decreased CO, increased pulmonary vascular resistance, increased peak pulmonary pressures, decreased urine output, and hypoxia. - Intra-abdominal pressure can be measured through a urinary catheter after the injection of 25 mL of sterile saline. - Intra-abdominal hypertension (IAH) is defined as an intra-abdominal pressure greater than or equal to 12 mm Hg (normal 5 to 7 mm Hg). - IAH may be graded: -- Grade I (12 to 15 mm Hg) -- Grade II (16 to 20 mm Hg), -- Grade III (21 to 25 mm Hg) -- Grade IV (greater than 25 mm Hg) - The abdominal perfusion pressure may be calculated (MAP— IAP), with a normal value being greater than 60 mm Hg. - Surgical decompression of the abdomen may be required for abdominal pressures greater than 20 to 25 mm Hg that are associated with signs of organ dysfunction, such as decompensating heart, lung, and kidney status. - After surgical decompression is completed and the pressure relieved, the patient may receive a temporary abdominal closure ("open abdomen") wherein the skin and abdominal fascia are left open. Temporarily closing the abdomen with a sterile perforated plastic sheet, clips, vacuum-assisted techniques, and many other options. In some cases closed suction drains are brought out through a sterile plastic drape over the entire wound. The wound is closed permanently in the days, weeks, and months following the surgery or it is allowed to heal by secondary intention and eventual skin grafting.

Kidney Trauma

- Blunt trauma, resulting in contusions or lacerations without urinary extravasation. - S&S: Injury to the kidneys may be reflected by flank ecchymosis and fracture of inferior ribs or spinous processes. Gross or microscopic hematuria may be present; however, the extent of kidney damage is often incongruous with the degree of hematuria.43 Gross hematuria can exist with minor injuries and usually clears within a few hours. CT is the most accurate modality available for diagnosing kidney injury because it can assess the extent of parenchymal laceration,urine extravasation, surrounding hemorrhage, and the presence of vascular injury.43 Contusions and minor lacerations can usually be treated with observation. The success of nonoperative management may be enhanced by using angiographic embolization. Nonoperative treatment of patients with major lacerations and vascular injuries may be achieved in those who are hemodynamically stable.44 Operative interventions may be performed in patients with kidney injuries with a devascularized segment of the kidney. Postoperative and postinjury complications can include infection, hemorrhage, infarction, extravasation, calcification, acute kidney injury, and hypertension

Trimodal Distribution of Trauma Deaths: Third Peak

- Can occurs days to weeks after injury - Death occurs in the critical care unit - Causes of death: sepsis, MODS

Combined Abdominal Organ Injuries

- Damage control surgery: Surgical intervention w/non-traditional techniques for patients with multiple visceral injuries -- The three phases of this treatment strategy are the initial operation (damage control laparotomy), critical care unit resuscitation and definitive reoperation (Staged Abdominal Reconstruction) -- Initial Operation: control contamination and hemorrhage. Intra-abdominal packing. Temporary closure. --- Damage control laparotomy may be considered if some clinical parameters are met: acidosis (pH less than 7.2), hypothermia (temperature less than 35° C), and clinical coagulopathy and/or if the patient is receiving a massive transfusion. --- Hypothermia induced by an open visceral cavity in conjunction with massive blood transfusion can lead to coagulopathy and continued bleeding, which results in shock and metabolic acidosis. The triad of *hypothermia, coagulopathy, and acidosis* creates a self-propagating cycle that can eventually lead to an irreversible physiologic insult. The initial operation must be completed quickly to terminate this selfpropagating cycle. -- Critical Care Unit Resuscitation: correct coagulopathy. Rewarming. Maximize hemodynamics. Ventilatory support. Injury identification. -- Planned Reoperation: Pack removal. Definitive repair. - The duration of the initial operation is kept to a minimum. The decision to abbreviate the initial operation is made early during surgery.

AI: Liver Injuries

- Dx: Abdominal CT is to identify and assess the severity of the injury to the liver. - Severity of liver injuries is graded to provide a mechanism for determining the amount of trauma sustained by that organ, the care needed, and the possible outcomes - Nonoperative management: -- Monitor for signs of hemorrhage. --- Serial serum hematocrit and hemoglobin levels and vital signs are monitored over several days. --- Patients with penetrating or blunt liver trauma who are hemodynamically unstable may require surgical intervention to achieve hemostasis. Resection of the devitalized tissue is required for massive injuries. --- Hemorrhage is common with liver injuries, and ligation of the hepatic arteries or veins may be required to control hemorrhage. --- Drains may be placed intraoperatively to prevent hematoma development. --- Hemodynamic instability can result from hemorrhage and hypovolemic shock, leading to fluid volume deficit, decreased cardiac output, and decreased tissue perfusion. --- A massive transfusion protocol may be implemented to restore blood volume and correct coagulopathies. - Monitor the patient's response to medical therapies. Continued hemodynamic instability (e.g., hypotension, decreased cardiac output) despite aggressive medical intervention may indicate continued hemorrhage, in which case an exploratory laparotomy may be required to determine and correct the source of bleeding. - The patient's postoperative course may be complicated by coagulopathy, acidosis, and hypothermia. Jaundice may occur as a sign of liver dysfunction, but it may also be caused by reabsorption of hematomas or breakdown of transfused red blood cells.

AI Diagnostic Procedures: Diagnostic Peritoneal Lavage

- Help to exclude or confirm the presence of intra-abdominal injury. - Patient's bladder emptied then a small incision is made in the abdomen through the skin and into the peritoneum. A small catheter is inserted. -- If frank blood is encountered, intra-abdominal injury is evident, and the patient is taken immediately to the OR. -- If gross blood is not initially encountered, a liter of fluid (lactated Ringer or 0.9% normal saline) is infused through the catheter into the abdomen. The intravenous bag is then placed in a dependent position, and abdominal fluid is allowed to drain into the intravenous bag. The drainage fluid is sent to the laboratory for analysis. Positive DPL results signal intraabdominal trauma and usually necessitate surgical intervention - DPL is invasive, has been associated with complications, and cannot exclude retroperitoneal injuries.

AI: Hollow Viscus Injuries

- Hollow viscus: Hollow organs in the abdomen, such as the stomach, small intestine, and large intestine. - From blunt or penetrating trauma. - Dx: Challenging b/c injuries may not show up on CT or ultrasound. - Serial measurements of WBC count can help determine the presence or absence of HVI. - Intestinal contents (e.g., bile, stool, enzymes, bacteria) can leak into the peritoneum and cause peritonitis. - Tx: Surgical resection and repair is almost always required. - Post-op course dictated by the amount of spillage of intestinal contents. Will be observed for signs of sepsis and for abscess or fistula formation.

AI Mechanism of Injury: Blunt

- In MVCs, most likely to occur when a vehicle is struck from side. -- Front seat passenger, liver injury is likely when the point of impact is on the same side as the passenger. -- A driver is likely to sustain injury to the spleen when the impact is on the driver's side. - Blunt trauma to the thorax can produce injuries to the liver, spleen, and diaphragm. - Deceleration and direct forces can produce retroperitoneal hematomas. - Blunt abdominal injuries often are hidden, requiring careful assessment and reassessment.

AI Diagnostic Procedures

- Insertion of a nasogastric tube and urinary catheter serves as a useful diagnostic and therapeutic aid. -- NG tube can decompress the stomach, and contents can be checked for blood. -- Urine obtained from the urinary catheter can also be tested for the presence of blood. - Serial laboratory test results may be nonspecific for the patient with abdominal trauma. Because of hemoconcentration, hemoglobin and hematocrit results may not reflect actual values. Serial values are more valuable in diagnosing abdominal injuries. - Physical examination alone in patient is unreliable, therefore suspected abdominal trauma case should have diagnostic testing simultaneously during the primary and secondary surveys. - Noninvasive tests include bedside ultrasound, CT, and chest and abdominal radiographs.

CDV Injuries: Aortic Injury

- Most lethal blunt thoracic injuries. - Sudden deceleration from speeds of 20 mph are most commonly associated with BAI. - Injuries associated with aortic injury include a first or second rib fracture, high sternal fracture, left clavicular fracture at the level of the sternal margin, and massive hemothorax. - BAI should be suspected in all victims of trauma with a rapid deceleration or acceleration mechanism of injury. - Sites of aortic disruption (in order of frequency): 1. Aortic isthmus, just distal to the subclavian artery (where the vessel is fixed to the chest bythe ligamentum arteriosum); 2. Ascending aorta (where the aorta leaves the pericardial sac) 3. Descending aorta (where the aorta enters the diaphragm); and avulsion of the innominate artery from the aortic arch. - Nurse Interventions: Assesses BP in both arms (tear in the aortic arch may create a pressure gradient between arms). If aortic disruption suspected, BP compared between upper and lower extremities (baroreceptors stimulation -> upper extremity hypertension with relative lower extremity hypotension) -- Assess for a pulse deficit at any site, unexplained hypotension, sternal pain, precordial systolic murmur, hoarseness, dyspnea, and lower extremity sensory deficits. - Initial chest radiograph is obtained in the upright position. Findings suggesting aortic injury include a widened mediastinum, obscured aortic knob, deviation of the left main stem bronchus or nasogastric tube, and opacification of the aortopulmonary window. - Spiral or helical CT if the initial chest radiograph is inconclusive, but the definitive diagnosis is made by aortography in indeterminate cases. - During the resuscitation phase for a patient with aortic disruption, BP management is the primary goal to minimize injury. - Patients with tears at the aortic isthmus are typically hypertensive, and minimizing stress on the vessel is achieved by maintaining the SBP<90 mmHg by using antihypertensive agents such as sodium nitroprusside. - Definitive surgical intervention early in the resuscitation. Surgical repair may be achieved by a graft, primary anastomosis, and bypass - Post-op care is directed toward BP stabilization, with the goal of minimizing vessel stress while maintaining TP, which typically is accomplished with the use of sodium nitroprusside. - Careful assessment of post-op paraplegia needed b/c lack of blood flow to the spinal column might have occurred perioperatively. Paraplegia is closely related to the duration of clamp time intraoperatively. Monitors for signs of bowel ischemia (e.g., tube feeding intolerance, lactic acidosis) and acute kidney injury (e.g., poor urinary output, rising serum creatinine) b/c blood flow to the mesentery and kidney may have been compromised as a result of the injury or aortic clamp time.

AI Mechanism of Injury: Penetrating

- Outside appearance does not reflect the extent of internal injury. - Commonly injured organs from knife wounds are the colon, liver, spleen, and diaphragm. - Gunshot wounds to the abdomen usually are more serious than are stab wounds. A bullet destroys tissue along its path. Inside the abdomen, a bullet can travel in erratic paths and ricochet off bone. - Death from penetrating injuries depends on the injury to major vascular structures and resultant intra-abdominal hemorrhage. - Tx: Majority GSW patients receive a laparotomy, selected patients may be managed nonoperatively.

AI Diagnostic Procedures: Bedside Ultrasound (Focused Assessment Sonography for Trauma (FAST examination))

- Performed at most trauma centers to evaluate the patient for the presence of intra-abdominal blood. - Used for the detection of abdominal free fluid and hemoperitoneum. - Typically, the right and left upper abdominal quadrant areas are examined: the right upper quadrant (Morrison's pouch); the left upper quadrant splenorenal area; the pericardial sac; and the pelvis (Douglas' pouch)3 - The primary disadvantage of FAST is the need for free intraperitoneal fluid to produce a positive study result. - Negative FAST result may be followed by serial ultrasound examinations, abdominal CT, or by DPL - Hemodynamically unstable patients with a positive FAST, specifically free fluid noted in the abdomen, generally undergo emergency surgery to achieve hemostasis. - Although the FAST test has had good sensitivity and specificity, it is not intended to replace DPL or CT. - Obese abdomens and patients with ascites may have erroneous results, and further workup for these patients is warranted. - Ultrasound is limited in its ability to diagnose diaphragmatic, intestinal, or pancreas injuries. - Abdominal CT provides information about specific organ injury, pelvic injury, and retroperitoneal hemorrhage.

Genitourinary Injuries Mechanism of Injury

- Rarely occurs alone. - From blunt or penetrating trauma. - Should be suspected in patients with: Trauma to lower chest or flank, contusions or hematoma or tenderness over flank, lower abdomen or perineum genital swelling or discolouration, blood at urethral meatus, hematuria after Foley catheter placement, difficult with micturition

Genitourinary Injuries Assessment

- Should occur after patient has been stabilized. - S&S: -- Flank pain or colic pain. -- Rebound tenderness can be elicited if intraperitoneal extravasation of urine has occurred. -- Inspection may reveal blood at the urethral meatus. -- Bluish discoloration of the flanks may indicate retroperitoneal bleeding, whereas perineal discoloration may indicate a pelvic fracture and possible bladder or urethral injury. - Hematuria is the most common assessment finding with genitourinary trauma; however, the absence of gross or microscopic hematuria does not exclude a urinary tract injury.

AI: Spleen Injuries

- The spleen is the organ most commonly injured by blunt abdominal trauma and is second to the liver as a source of life-threatening hemorrhage - Graded for the purpose of determining the amount of trauma sustained, the care needed, and the possible outcomes - Monitor hemodynamically stable patients with serial hematocrit values and vital signs. - Progressive deterioration may indicate the need for operative management. Patients who exhibit hemodynamic instability require operative intervention with urgent laparotomy.40 Patients who have had a splenectomy are at risk for the development of overwhelming postsplenectomy sepsis with streptococcal pneumonia. These patients require the polyvalent pneumococcal vaccine (Pneumovax) to help promote immunity against most pneumococcal bacteria. - Patients with isolated spleen injuries that require surgical intervention rarely are admitted to the critical care unit. Complications after splenic trauma include wound infection, sepsis, subdiaphragmatic abscess, and fistulas of the colon, pancreas, and stomach.

Complications of Trauma: Acute Kidney Injury

Assessment and ongoing monitoring of kidney function is critical to the survival of the trauma patient. The cause of posttraumatic acute kidney injury is complex and may involve a variety of factors, as listed in Box 34-14. Prevention of kidney failure is the best treatment, and it begins with ensuring adequate volume to provide adequate renal artery perfusion. Serial assessments of blood urea nitrogen (BUN) and creatinine levels commonly are used to evaluate kidney function. Progressive kidney failure requires prompt diagnosis and treatment (see "Acute Kidney Injury" in Chapter 27).

Pelvic Mechanism of Injury

Blunt trauma to the pelvis can be caused by MVCs, falls, or a crushing injury. Motorcycle and car crashes have the highest incidence of pelvic fractures. One study found that the biomechanical factors associated with pelvic fractures included no airbag deployment, a smaller vehicle, and lateral deformation location (front vs. rear).45 Pelvic injuries may be associated with damage to underlying vessels, both arterial and venous.

Complications of Trauma: Compartment Syndrome

Compartment syndrome is a condition in which increased pressure within a limited space compromises circulation, resulting in ischemia and necrosis of tissues within that space. Among those at high risk for the development of compartment syndrome are patients with lower extremity trauma, including fractures, penetrating trauma, vascular ruptures, massive tissue injuries, or venous obstruction. Clinical manifestations of compartment syndrome include obvious swelling and tightness of an extremity, paresis, and pain of the affected extremity. Diminished pulses and decreased capillary refill do not reliably identify compartment syndrome because they may be intact until after irreversible changes have occurred. Elevated intracompartmental pressures confirm the diagnosis. The treatment can consist of simple interventions, such as removing an occlusive dressing, to more complex interventions, including a fasciotomy.

Complication of Trauma: Venous Thromboembolism

Despite improvements in the care of the trauma patient, venous thromboembolism (VTE), which includes both DVT and pulmonary emboli, remains an important cause of morbidity and mortality in the multiply injured trauma patient. Major trauma patients are at very high risk for VTE.56 The factors that form the basis of VTE pathophysiology are blood stasis, injury to the intimal surface of the vessel, and hypercoagulopathy. Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and immobility. Trauma patients are at the greatest risk for developing thromboembolism early in their hospitalization. Prevention is key. Routine thromboprophylaxis for the high-risk trauma patient includes use of low-molecular-weight heparin starting as soon as it is considered safe to do so and use of a mechanical method of prophylaxis, such as sequential compression devices.56 For patients in whom the lower leg is inaccessible, foot pumps may act as an effective alternative to lower the rate of VTE.

Complications of Trauma: Fat Embolism

Fat embolism syndrome can occur as a complication of orthopedic trauma. The clinical onset of fat embolism syndrome ranges from 12 to 72 hours after injury.54 Fat embolism syndrome appears to develop as a result of fat droplets that leak from fractured bone and embolize to the lungs. The droplets are broken down into free fatty acids that are toxic to the pulmonary microvascular membranes. Pulmonary fat emboli alter pulmonary hemodynamics and pulmonary vascular permeability. The lung becomes highly edematous and hemorrhagic. The clinical presentation is almost indistinguishable from that of ARDS. Early stabilization of unstable extremity fractures may limit the seeding of fat droplets into the pulmonary system.54

Complications of Trauma: Infection

Infection remains a major source of mortality and morbidity in critical care units. The trauma patient is at risk for infection because of contaminated wounds, invasive therapeutic and diagnostic catheters, intubation and mechanical ventilation, host susceptibility, and the critical care environment. Nursing management must include interventions to decrease and eliminate the trauma patient's risk of infection. The patient with multiple trauma is at risk for infection because of host susceptibility (including pre-existing medical conditions) and the adverse effect of trauma on the immune system. Wound contamination poses an infection risk for the trauma patient, especially with injuries resulting from deep or penetrating trauma. Exogenous bacteria (from the external environment) can enter through open wounds. Exogenous bacteria can be introduced by dirt, grass, and debris inoculated into the wound at the time of injury, or they can be introduced by personnel during wound care. Endogenous bacteria (from the internal environment) can be released as a result of gastrointestinal or genitourinary perforation, which spills bacteria into the internal environment. Meticulous wound care is essential. The goals of wound care include minimizing infection risks, removing dead and devitalized tissue, allowing for wound drainage, and promoting wound epithelialization and contraction. Wound healing also is accomplished through interventions that promote tissue perfusion of well-oxygenated blood and that ensure adequate nutritional support for wound healing. Standard interventions for the prevention of ventilatorassociated pneumonia, catheter-associated urinary tract infections, and central-line-associated bloodstream infection apply to the trauma patient. Proper hand hygiene, invasive catheter care, prompt removal of unnecessary tubes and lines, patient positioning, and medical asepsis or sterile technique for all invasive procedures are paramount to optimal to patient outcome.

Complication of Trauma: Missed Injury

Nursing assessment of the multiply injured patient in the critical care unit may reveal missed diseases or missed injuries. Missed injuries have a reported incidence of 1.3% to 39% and are a cause of morbidity and mortality.57 Missed disorders may include pre-existing undiagnosed medical illnesses such as endocrine disorders (diabetes, hypothyroidism), myocardial infarction, hypertension, decreased respiratory reserve, undiagnosed kidney failure, or malnutrition. Patients who have head injuries with a GCS of 8 or less and greater injury severity scores are more likely to have missed injuries or delayed diagnoses.57 Occasionally, injuries may not be diagnosed in the precritical care phases. Missed injuries are commonly discovered in the first 24 to 48 hours of the hospital stay during the routine

Genitourinary Nursing Management

Nursing diagnoses that can be applicable in caring for a patient with genitourinary trauma include Risk for Gastrointestinal Perfusion, Risk for Infection, and Deficient Fluid Volume. After the patient is admitted to the critical care unit, the nurse makes an assessment according to the ATLS guidelines. After the patient's condition has stabilized, nursing management of postoperative kidney trauma is similar to that for genitourinary surgery. The primary nursing interventions include assessment for hemorrhage, maintenance of fluid and electrolyte balance, and maintenance of patency of drains and tubes. Measurement of urinary output includes drainage from the urinary catheter and the nephrostomy or suprapubic tubes. Drainage from these areas is recorded separately. Urine output is measured frequently until bloody drainage and clots have cleared. Gentle irrigation of drainage tubes may be required to clear clots and maintain the patency of the tubes.

Complications of Trauma: Hypermetabolism

Nutritional support is an essential component in the care of critically ill trauma patients. Within 24 to 48 hours after traumatic injury, a predictable hypermetabolic response occurs. The metabolic response to injury mobilizes amino acids and accelerates protein synthesis to support wound healing and the immunologic response to invading organisms. Stress hypermetabolism occurs after any major injury and is characterized by increases in metabolic rate and oxygen consumption. Energy requirements accelerate to promote immune function and tissue repair. The goal of early aggressive nutrition is to maintain host defenses by supporting this hypermetabolism and to preserve lean body mass.51 Most nutrition experts advocate beginning enteral nutrition as early as possible. Current guidelines recommend enteral feedings be initiated within 72 hours for patients with blunt and penetrating abdominal injuries and those with severe head injuries. 51 Enteral feeding sites can include the gastric route or any site beyond the pylorus of the stomach, including the duodenum and jejunum. Prompt feeding tube placement by the critical care nurse must be a priority, unless contraindicated. Diminished or absent bowel sounds do not mean the small bowel is not working. Small bowel function and the ability to absorb nutrients remain intact, despite the presence of gastroparesis and absent bowel sounds. Because access to the stomach can be obtained more quickly and easily than the duodenum, early gastric feeding is possible.51 Patients at risk for pulmonary aspiration due to gastric retention or gastroesophageal reflux should receive enteral feedings into the jejunum.51 If enteral feeding is not successful, parenteral nutrition should be initiated by day 7.51

Complications of Trauma: Rhabdomyolysis and Myoglobinuria

Patients with a crush injury are susceptible to the development of rhabdomyolysis, with subsequent secondary kidney failure. Crush injuries can compromise blood flow. Loss of arterial blood flow, particularly to the extremities, results in the loss of oxygen transport to distal tissues and ischemia. This initiates a cascade of events that leads to the necrosis of skeletal muscle cells. As cells die, intracellular contents—particularly potassium and myoglobin—are released. Myoglobin, a muscular pigment, is a large molecule that gets lodged in the glomerulus, resulting in presence of myoglobinuria. Circulating myoglobin can lead to the development of kidney failure by three mechanisms: decreased renal perfusion, cast formation with tubular obstruction, and direct toxic effects of myoglobin in the kidney tubules.55 Dark tea-colored urine suggests myoglobinuria. Testing for myoglobin in the urine can be done, but may take several days, depending on laboratory resources available for this test. The most rapid screening test is a serum creatine kinase level. Urine output and serial creatine kinase levels should be monitored. Rhabdomyolysis should be suspected in all patients who experience crush injuries wherein blood flow to the muscle is interrupted for a prolonged amount of time. Prevention of kidney dysfunction is paramount through the administration of IV fluids.55 If rhabdomyolysis is diagnosed, treatment is aimed at prevention of subsequent kidney failure. Aggressive administration of intravenous fluids increases renal blood flow and decreases the concentration of nephrotoxic pigments.55 Alkalinization of the urine and administration of diuretics have been studied, but their roles in the prevention or management of rhabdomyolysis are not firmly established.55 Nursing management is directed toward achievement of fluid and electrolyte balance. The patient should be assessed for hypernatremia, hyperosmolarity, acute kidney injury, and volume status.

Complications of Trauma: Acute Respiratory Distress Syndrome

Post-traumatic respiratory failure is often due to the development of ARDS.52 ARDS can be caused by direct injury to the lungs or indirect injury (see "Acute Respiratory Distress Syndrome" in Chapter 20).52 Primary direct injuries in the trauma patient can include aspiration, inhalation, and pulmonary contusion. 50 The indirect injuries include sepsis, massive transfusion, fat emboli, and missed injury. ARDS in the trauma patient can develop 24 to 72 hours after initial injury. The patient receiving multiple blood products, particularly fresh-frozen plasma, must also be monitored for transfusion-related acute lung injury (TRALI). Signs of TRALI are similar to those of ARDS, although there is a temporal relationship between the new onset of respiratory distress and the transfusion of blood products.53

Pelvic Injury Assessment

Signs of pelvic fracture include perianal ecchymosis (scrotum or vulva), indicating extravasation of urine or blood, pain on palpation or "rocking" of the iliac crests, lower limb paresis or hypesthesia, hematuria. Lower extremity rotation or leg shortening is also cause for suspicion of a pelvic injury. Patients with a suspected pelvic injury should have a rectal examination to assess for SCI or presence of occult or obvious rectal bleeding. The diagnosis of pelvic fracture is made by an anteroposterior pelvic radiograph with the patient in the supine position and/or CT scan of the pelvis.47 Additional radiographs may be required for definitive treatment, but the timing depends on the patient's hemodynamic stability.

Special Consideration: Meeting Needs of Family Members and Significant Other

The impact of traumatic injury can be devastating for patients and for family members and significant others. They are faced with a crisis situation for which they have had little time to prepare. Trauma can precipitate a crisis within the family. Families may exhibit physical and sociocultural reactions and a combination of emotional reactions, including anger, fear, powerlessness, confusion, and mistrust. Recovery from traumatic injury can be long and frustrating for families. There may be many peaks and valleys of good days and bad days. During this time, the family may exhaust its social and financial support systems. Nurses should recognize this and facilitate supportive relationships for families. A trend has evolved to move away from a paternalistic model of care to one that incorporates the family into all aspects of care, including resuscitation. Family members wish to remain close to their loved ones during these times, and there has been demonstrated benefit to the patient and the family in this model of care delivery.58 One study demonstrated that family members present during trauma resuscitation suffered no ill psychologic effects and scored equivalent to those family members who were not present on anxiety, satisfaction, and well-being measures.58 Regardless of the specific system of care delivery, the nurse ensures the family is supported during all aspects of care. A valuable intervention is to bring families of trauma patients together in support groups. Trauma family support groups can offer sharing of experiences, expression of emotions, mutual support, sharing of coping strategies, and education about hospital and community services.

Pelvic Fractures

The pelvis is a ring-shaped structure composed of the hip bones, sacrum, and coccyx. Because the pelvis protects the lower urinary tract and major blood vessels and nerves of the lower extremities, pelvic trauma can result in life-threatening hemorrhage and in urologic and neurologic dysfunction. The mortality rate from pelvic trauma ranges from 8% to 40%,45,46 mostly due to hemorrhagic shock. The volume of blood contained within the pelvis can be compared to volume of a cylinder (similarly shaped to the pelvis) wherein: Volume = × (radius)2 × height Note that the radius plays a large role in determining volume requirements. When the pelvic ring is disrupted, the radius increases, thereby increasing blood volume capacity. There is also loss of the tamponade effect of the retroperitoneal tissues and intrapelvic organs, contributing to further bleeding.47 Because the pelvic area is a highly vascular compartment already, it can sequester a large volume of blood; death within 24 hours of injury is most often due to hemorrhagic shock.45

Complication of Trauma: Multiple Organ Dysfunction Syndrome

assessments of the trauma tertiary survey. Injuries are missed for a variety of reasons as summarized in Box 34-15. In the critical care unit, a missed injury may be suspected if the patient fails to show appropriate response to medical or surgical intervention. Change in the character of drainage from wounds or catheters may represent biliary or duodenal injuries. Hypotension and a falling hematocrit level despite aggressive fluid administration may indicate an expanding hematoma. As the patient begins to mobilize, small bone fractures and sprains may manifest. The critical care nurse must be alert to the possibility of a missed injury, especially when the patient does not appear to be responding appropriately to interventions. The physician must be notified immediately because potential complications of infection and hemorrhage may be life-threatening. Nurses play a key role in identifying missed injuries, particularly when patients regain consciousness and begin to increase their activity.

Emergency Department Resuscitation: Resuscitation Phase - Massive Transfusion Resuscitation

- Emphasis on blood products rather than crystalloids or correction traumatic coagulopathy - Protocols outlines the types of blood products used will help with planning and release of them during chaotic situations, but no defined mixture has been set.

Emergency Department Resuscitation: Rapid Primary Survey - Exposure

- Exposure and environmental control. - Removal clothing for thorough assessments - Protect from hypothermia with warm blankets, ambient room temperature and warmed IV fluids

Cerebral Hematomas

- Extravasation of blood creates a space-occupying lesion within the cranial vault that can lead to increased ICP - Subdural and Epidural: extraparenchymal (outside of brain tissue) hematomas which produce unjust through pressure and displacement of tissues - Intracerebral: directly damages neural tissue and may produce further damage with pressure and tissue displacement

SCI Mechanism of Injury: Penetrating Injuries

- From any object that penetrates the cord - Causes permanent damage from anatomically transecting the spinal cord

Maxillofacial Mechanism of Injury

- From blunt or penetrating trauma - Associated injuries include concussion, skull fracture, rhinorrhea, SCI, and fractures of other bones - Facial skeleton absorb the energy to protect brain, spinal cord, eyes and pharynx - Nasal, zygoma and manidibular condyle bones most at risk to fracture - Bullet wounds may lead to hemorrhage and airway obstruction - Ranges from soft tissue injury from abrasions to destruction of most of the facts and skeletal fracture

SCI Pathophysiology

- From mechanical force that disrupts neurological tissue, vascular supply or both - Primary injury: neuro damage that occurs at the moment of impact - Secondary injury: biochemical processes affecting cel function. Can occur within minutes of injury and then last for days to weeks. Worsens the injury with its effects -- Spinal cord ischemia and neuro dysfunction from events including: systemic and local vascular changes, electrolyte and biochemical changes, neurotransmitter accumulation and local edema

SCI Mechanism of Injury: Hyperextension

- From the backward and downward motion of the head (e.g. rear-ended MVC), where the spinal cord is stretched and distorted - Neuro deficits with this injury from contusion and schema of cord w/o significant bony involvement - Mild form is whiplash

Mild Brain Injury

- GCS 13-15 - LOC up to 15min - Often seen in ER, then discharged with family who will routinely evaluate patient and will bring back patient if neuro symptoms appear

SCI Nursing Management

- Goal in CCU is to prevent life-threatening complications while maximizing function of all organ systems - Interventions aimed at preventing secondary injury and complications of neuro deficits - Interventions aimed at optimizing nutrition, elimination, skin integrity, psychosocial and mobility

SCI Nursing Management: Integumentary Complications

- High risk for pressure ulcers b/c lack of motor control and sensation - Prevention important through diligent assessments, skin care, and frequent position changes. - Special beds (e.g. low air loss beds) may be required

TI Pulmonary Injuries: Open Pneumothorax

- "sucking chest wound" through penetrating trauma leading to open communication between atmosphere and intrathoracic pressure resulting in immediate lung deflation. Air makes sucking sound during inflation through the hole. - S&S: Same symptoms as tension pneumothorax. Also may palpate subcutaneous emphysema around wound. - Tx: Place sterile occlusive dressing over wound at end of expiration and secure it on three sides. Occludes the wound, but prevents air from re-entering. Chest tube will be place ASAP and surgery may be needed to close wound.

Incomplete Injury

- A mixed loss of voluntary motor activity and sensation remains below the level of injury

Traumatic Brain Injury Pathophysiology: Secondary Injury - Hypercapnia

- A powerful vasodilator of cerebral vessels, which increases cerebral blood volume and intracranial pressure - Caused by hypoventilation of unconscious patient

Emergency Department Resuscitation: Resuscitation Phase

- Aimed at ensuring adequate TP - Hypovolemic shock is most common shock - Should identify hemorrhages and treat stat -- Treatment: Initiate IV (preferably 2 large bore IVs, but can also do peripheral, intraosseous or central line). Will also draw blood work at this time. -- ABGs and lactate are good O2 indicators - Initiate urinary and gastric catheters (to decrease gastric distention and lower aspiration risk)

Emergency Department Resuscitation: Rapid Primary Survey - Circulation

- Assess for decreased CO, impaired TP or deficient fluid volume - Direct pressure for external exsanguination. - Rapid Assessment: -- LOC: data for cerebral perfusion -- Skin color: ashen, gray, white or pale skin can be signs of hypovolemia -- Pulse: Assess femoral and carotid pulses bilaterally for rate, regularity and quality --- No pulse, initatie ACLS -- ECG: assess for rhythm and presence of dysrhythmias

Emergency Department Resuscitation: Rapid Primary Survey - Airway w/ C-Spine Protection

- Assess for ineffective airway clearance -- At risk w/altered LOC, drugs and alcohol, maxillofacial or thoracic injuries - Assess for airway obstructions that can be caused by foreign bodies, blood clots or broken teeth - Assess for airway patency -- Inspect oropharynx for obstructions, listen for air movement at nose and mouth and auscultate lung fields -- If patient can speak, likely that airway is patent - C-Spine Immobilization -- Do not rotate, hyperflex or hyperextend C-spine to maintain airway -- Immobilize until injuries are ruled out -- GCS of 8 or less or displays non-purposeful motor movements should have definitive airway placed

Emergency Department Resuscitation: Rapid Primary Survey - Breathing

- Assess for ineffective breathing patterns and impaired gas exchange - ABGs - Apply supplemental oxygen. Will wean patient when stable - Assess chest wall integrity, RR, depth and symmetry - Auscultate to assess gas flow in lungs - Percussion to identify air or blood in chest - If decreased breath sounds or altered chest wall integrity requires chest tube - Endotracheal intubation may be required for those who have compromised airways caused by mechanical factors, unconscious or have ventilatory issues

Posterior Cord Syndrome

- Associated with cervical hyperextension injury to posterior column - Loss of position, pressure and vibration sense below the injury - Motor and pain & temperature sensation remain intact - May not be able to ambulate because position loss impairs spontaneous movement

Central Cord Syndrome

- Associated with cervical hyperextension-hyperflexion injury and hematoma formation in the centre of the cervical cord - Injury produces motor and sensory deficits more pronounced in upper than lower extremities - Varies with bowel and bladder dysfunction

Emergency Department Resuscitation: Secondary Survey

- Begins when primary survey is complete, resuscitation is well established and patient's VS are normalizing - Head-to-toe assessment - History taking (AMPLE) -- Allergies -- Medications -- Past medical history/pregnancy -- Last meal -- Events/environment related to injury - Tox screen on every trauma - Should also perform diagnostic tests such as x-ray, CT scans, ECG etc. - Continuous monitoring - Support patient and their family

Traumatic Brain Injury Pathophysiology: Secondary Injury

- Biochemical and cellular response to initial trauma that can exacerbate primary injury and cause loss of brain tissue not originally damaged - Often due to hypoxia or hypotension from extra cranial trauma - Causes: -- Tissue Ischemia -- Hypotension -- Hypercapnia -- Brain Edema

Intracerebral Hematoma

- Bleeding occurs within cerebral tissue - Traumatic Causes (e.g. depressed skull fractures, penetrating injures or sudden accel-decel motion - May be expanding lesion, but also may be late ICH into neurotic center of a contused area is possible - May cause sudden clinical deterioration of patient 6-10 days after trauma - Tx: surgical removal or non-surgical management. Often only surgical if significant ICP effects. -- Outcome depends on location, size, mass effect and displacement of intracranial structures

TI Pulmonary Injuries: Hemothorax

- Blunt or penetrating trauma causing bleeding into pleural space from intercostal or internal mammary, arteries, lungs, heart or great vessels. -- Lacerations to lung parenchyma are low pressure and stop bleeding spontaneously -- Arterial bleeds from hillier vessels require immediate surgical intervention - Massive = >1500ml of blood - Leads to decreased vital capacity as well as decreased venous return and CO. - Assessments: hypovolemic shock, diminished or absent breath sounds, collapsed neck veins, midline trachea, dullness to percussion on one side of chest. - Dx: Clinical assessment due to need for immediate treatment. - Tx: IV fluid resuscitation. Chest tube on affected side w/connected auto transfusion device. Thoracotomy for patients needing persistent blood transfusions or have significant bleeding (1500ml initial tube insertion or >200ml for 2-4 hours), or when there are injuries to CDV structures.

TI Pulmonary Injuries: Pulmonary Contusion

- Bruised lung from blunt trauma or other chest injuries. The most common potentially lethal. May be uni- or bilateral. - Manifests as a hemorrhage, followed by alveolar and institial edema, which may be local or widespread -- Alveolar edema -> decreased compliance, increased pulmonary vascular resistance, and decreased pulmonary blood flow. Result = ventilation-perfusion imbalance - Clinical Manifestations (may take 24-48hr to develop): Ecchymosis at site of impact. Moist crackles in contused lung. Cough w/blood tinged sputum. Systemic arterial hypoxemia. - Dx: radiography with infiltrates to area of external chest area in 24-48hrs following injury. Contusions will usually resolve slowly after this period, unless complications occur - Tx: Aggressive respiratory care. Ambulation. Deep-breathing exercises. Turning. Incentive spirometry. Removal of airway secretions to avoid infections and improve ventilation. If unilateral contusion, position patient with good lung down. Pain control w/NSAID, intercostal nerve block, opiate, thoracic epidural - Severe contusions may continue to deteriorate. Respiratory acidosis, increase in peak airway and plateau pressures, increased WOB. May require endotracheal intubation or mechanical ventilation with positive end-expiratory pressure - Complications: pneumonia, ARDS, lung abscesses, emphysema, and pulmonary embolism. - Risk factors for increased mortality: shock, head injury, flail chest, falls from >20ft, old age, other diseases

Contusion

- Brusing of the brain related to acceleration and deceleration forces that led to the hemorrhage of the superficial parenchyma - Most common in frontal and temporal lobe - Coup Injury: brain tissue affected under the point of impact - Contrecoup Injury: brain tissue affected in a line opposite to point of impact - Clinical manifestations are related to the location and severity of the contusion, or the presence of associated lesions - Large contusions can develop over 2-3 days due to edema and hemorrhaging. Also can increase ICP. - Contusions often associated with subdural hematoma - Contusions at the tip of the temporal are common and dangerous as edema in the tentorium area can lead to rapid LOC and herniation even at low ICP. - Diagnosis by CT. Nurse should ensure thorough neuro assessment are done. Must look for change in pupils and vital signs. - Tx: Medical or surgical therapies. -- Large contusions require because it can develop for 2-3 days. May require surgical intervention to prevent increased ICP or edema -- Smaller, focal contusions need serial neurological assessment and ICP monitoring.

TI Pulmonary Injuries: Tension Pneumothorax

- Caused by an injury that perforates chest wall or pleural space, allowing air flow to the pleural space during inspiration, but gets trapped. - Pressure in pleural space increases, injured sides collapses and mediastinum shifts to opposite side. -- Compromised gas exchange due to collapsed lung - Pressure exerted on heart leads to decreased venous return and CO. - S&S: SOB, tachycardia, hypotension, and sudden chest pain to shoulders, tracheal deviation, breath sounds absent or decreased. Percussion-> hyperresonant sound over affect side - Dx: Clinical Assessment, not time for chest radiograph due to need for immediate treatment. - Tx: 14g large needle or chest tube inserted into affected lung, allowing immediate release of air from the pleural space.

TI Chest Wall Injuries: Flail Chest

- Caused by blunt trauma - 2+ ribs are fracture in 2 or more areas, causing them to free float - Dx: The floating segment will move paradoxically compared to rest of chest wall -- Inspiration: chest wall expands, floating segment sucked in. -- Expiration: chest wall moves in, floating segment moves out - Palpation: crepitus and tenderness - Chest radiograph - ABGs: hypoxia - Increases WOB, but hypoxemia would be due to underlying pulmonary contusion - Physiologic effects: impaired chest wall motion of flail chest, decreased tidal volume and vital capacity and impaired cough (-> hypoventilation and atelactasis) - Tx: O2 management, fluid management, analgesia pain management . Intubation and mechanical vent may be required for further hypoxia

Missile Injuries

- Caused by objects that penetrate the skull to produce a significant focal damage but little accel-decel or rotational injury. - Can be depressed (caused by skull fracture and penetration of bone into brain tissue), penetrating (missile enters cranial cavity, but does not exit) or perforation (missile that enters and exits) - Risk of infection and cerebral abscess - If fragments are embedded, location and risks of increased neuro deficits is weighed against the infection and abscess risk - Outcome based on location, degree and velocity of missile

SCI Medical Management: Non-Surgical

- Chosen when SCI is stable. Cervical Injury Tx - Immobilization of fracture site and realignment of dislocation by skeletal traction with two-point tongs, which are inserted through shallow burr holes and connected to weights. Can be applied at bedside w/local anesthetic. -- Patient should then be C-spine immobilized on kinetic or regular bed. --- Kinetic bed maintains spinal column alignment, but also provides constant turning motion to reduce pulmonary and skin breakdown --- Regular beds are difficult to use here to manage pulmonary system because of immobility - After spinal column has been realigned by skeletal traction, halo traction brace is applied. Involved metal ring secured to skull with temporal and occipital screws. The steel bars anchor the screws to the vest for C-Spine immobilization. Allows patient to ambulate and participate in self care. Thoracolumbar Injury Tx - Immobilization, often with bed rest, in flat bed and the use of a plastic or fiberglass jacket, body cast or brace. - Skeletal traction used in high thoracic injuries

Epidural Hematoma

- Collection of blood between the inner skull and outermost layer of the dura - Associated with skull fractures, middle meningeal artery lacerations or skull fractures with venous bleeding - Linear skulls fractures from a blow to the head may tear the middle meningeal artery, leading to bleeding and the creation of a pouch that expands into intracranial space - Indice is low. Can occur from either high or low impact injuries. - Occur from trauma to the skill and the meninges rather than acceleration or deceleration forces - Clinical manifestations: brief LOC followed by period of lucidity, rapid deterioration of LOC, dilated and fixed pupil on same side as impact (hallmark of EDH), severe/localized headache, sleepy - Diagnosis: based on clinical symptoms or imagining (CT scan) - Treatment: surgical intervention to remove blood and cauterize bleeding vessels

Skull Fracture

- Common; alone does not cause neuro deficits - Can be open (torn dura) or closed (non-torn dura) - Can be vault (parietal or temporal regions) or basilar (not detected on skull films, requires CT) - Assessment: CSF loss from ear or nose, battle signs (ecchymosis over mastoid process behind ears), raccoon eyes (subconjuntival and periorbital ecchymosis) or palsy of 7th cranial nerves - Higher risk or probability of intracranial hematoma - Open fractures require surgical intervention to remove skull fragments and to close dura - Basilar fracture complications include cranial nerve injury and CSF leakage (leading to fistula; increased bacterial infection and meningitis). Fistula formation is delayed, therefore these patients are kept for observation

Spinal Shock

- Condition after traumatic injury to spinal cord in which there is a complete loss of all muscle tone and reflexes below the injury - May appear completely w/o function, but all of the area may not be destroyed

Functional Injury of the SC

- Degree of disruption of normal spinal cord function - Depends on the motor or sensory structures damaged within the cord - Will be classified as complete or injury, but cannot be decided until spinal shock has been resolved

Chronic Subdural Hematoma

- Diagnosed days or months after injury - Usually middle age or older (also leads to long recovery) - At risk: those with balance or coordination issues or anticoag therapy - Symptoms: lethargy, absent-mindedness, headache, vomiting, stiff neck, photophobia, TIA signs, seizures, pupil changes or hemiparesis - Diagnosed with CT - Tx: Craniotomy, burr hole evacuation or catheter drainage -- Drilling holes, draining fluid with catheter in place for at least 24 hours. - Neuro status after tx'd depends on degree of dysfunction before treatment

SCI Assessments: Diagnostic Procedures

- Diagnostic radiographic evaluation: identify severity of damage to spinal cord. May include anteroposterior and lateral views. - CT scan of all cervical vertebrae and T1 to rule out cervicothoracic junction injury. - Flexion and extension views to identify subtle ligament injuries - Tomography, myelography and MRI may also be used

TI Chest Wall Injuries: Rib Fracture

- Life threatening w/3+ rib fractures, preexisting cardiopulmonary disease or patient is 65 y.o+ - 1st + 2nd rib fractures -> intrathoracic vascular injuries (e.g. brachial plexus, great vessels). Lots of force needed for these injuries do to the scapula, clavicle, humerus and muscles protecting them. - Middle rib fractures -> lung injury (e.g. pulmonary contusion, pneumothorax) - 7-12th rib fractures -> abdominal injuries (e.g. spleen and liver) - Pain w/respirations or rib compression may indicate rib fracture - Definitive Dx: Chest radiograph. - Tx: aggressive pulmonary PT, pain control to improve chest expansion and gas change. - Pain may be aggravated by respirator excursion. Often splits, takes shallow breaths and refuses to cough, leading to atelectasis and pneumonia. - Pain management goals to prevent pulmonary complications and patient comfort -- NSAIDs -- Intercostal nerve blocks -- Thoracic Epidural Analgesia -- Opiates -- Epidural analgesia - increase functional reserve capacity, dynamic lung compliance, and vital capacity, decrease airway resistance, increase PaO2 - No external splints because it would limit chest expansion - Patient's previous Hx and age dictates recovery - Should use and monitor incentive spirometry values

Autonomic Dysreflexia

- Lifethreatening condition with SC - Caused by massive sympathetic response to noxious stimuli (e.g. line insertions, full bladder) leading to bradycardia, HTN, facial flushing and headache - Immediate intervention needed to prevent cerebral hemorrhage, seizures and acute pulmonary edema - Tx: alleviating noxious stimuli. If symptoms persist, anti-HTN agents may be given. - Prevention of autonomic dysreflexia is imperative through good bowel and bladder program

Neurogenic Shock

- Loss of vasomotor tone and sympathetic innervation to the heart leading to injury to descending sympathetic pathways in the spinal cord - Relative hypovolemia and hypovolemic shock occurs, leading to hypotension and decrease systematic vascular resistance - SCI at T6 or above may have profound neurogenic shock from the interruption of the SNS and loss of vasoconstriction below the injury level - Blood vessel cannot constrict + slow HR = hypotension, venous pooling and decrease CO, which threatens cellular oxygenation - Can persist up to one month after injury - BP support may be required with sympathomimetic medications. Nurse should be careful with repositioning patient due to orthostatic BP

Traumatic Brain Injury Pathophysiology: Secondary Injury - Hypertension

- May initially appear with TBI patients - Caused by a loss of auto regulation - Leads to increase blood volume and intracranial pressure - Proper management leads to minimizing increased ICP effects -- As ICP increases, cerebral perfusion decreases

SCI Medical Management: Pharmacologic

- Methylprednisolone: used to improve neurologic outcome after SCI (but has associated infection risk) -- Currently used in guidelines for acute c-spine injuries -- Receives bolus w/continuous infusion for at least 24 hours (preferably 48 hours) if their treatment began 3 - 8 hours after injury -- Directly affects the changes within the spinal cord after injury by preventing post-traumatic spinal cord ischemia, improving energy metabolisms, restoring extracellular calcium and improving nerve impulse conduction

SCI Nursing Management: Pulmonary Complications

- Most common cause of SCI patient mortality - Initial and ongoing respiratory assessment are important for identifying actual or potential impairments in ventilation. -- Observation of RR and rhythm, symmetry of chest expansion, accessory muscle use, inspection of quantity and character of secretions, auscultations of breath sounds. Judicious ABG use. - Breathing pattern may be ineffective and may required intubation and mechanical ventilation. Patients with C3-C5 lesions may be weaned from mechanical ventilation. C3 may only require it at night. -- Weaning is complex b/c physical requirement of the diaphragm and fear of not being able to breathe - MUST be aware that Succinycholine must never be administered to patient 72 hours post injury because it may lead to hyperkalemia arrest - Pneumobelt: corset-like device that produces ventilation by assisting with expiration. - Abdominal binder: supports diaphragm in patients with high SCI and loss of abdominal innervation - Ineffective airway clearance may be caused of hypoventilation from the paralysis of respiratory muscles, increased bronchial secretions and atelectasis secondary to decreased cough. -- Frequent suctioning, but should not be vigorous due to vagus nerve stimulation leading to bradycardia. Hyperventilate prior to succtioning -- Bradycardia may be exacerbated by hypoxia likely to developing patients with cervical SCI -- Chest percussion and drainage facilitate removal of secretions -- Kinetic therapy beds, which can rotate 60 degrees on each side can help with continual postural drainage and mobilization of secretions -- Cough assistance may be used, similar to Heimlich maneuver - Impaired gas exchange can occur from hypoventilation, increased bronchial secretions that interfere with adequate gas diffusion, shunting from atelectasis and associated pulmonary injuries and complications (e.g. embolism)

SCI Mechanism of Injury: Hyperflexion

- Most often seen in cervical area (C5-C6) - Often caused by sudden deceleration motion (e.g. head on collisions) - Injury from compression of the cord due to fracture fragments or dislocation of vertebral bodies - Instability of spinal column occurs because of rupturing or tearing of the posterior muscles and ligaments

Critical Care Phase

- Nurse should communicate information to nurse in CCU with SBAR communication (Situation, Background, Assessment and Recommendations) to help determine the resources and personnel needed as well as the plan ofr the patient - Priority Nursing Care: ongoing physical assessments and monitoring, observing and preventing complications (e.g. ARDS, sepsis, prolonged shock states, MODS) - Optimizing oxygen management. Prevent hypoxemia, but don't over oxygenate. - Continued fluid resuscitation to maintain perfusion of vital organs.

Traumatic Brain Injury Pathophysiology: Primary Injury

- Occurs at moment of impact as a result of mechanical forces to the head - Severity depends on if it was localized or diffused (widespread) throughout brain - Direct injury to parenchyma or to vessels (leading to hemorrhage) - Mild to severe - Immediately after the injury, a cascade of neural and vascular processes are activated

CDV Injuries: Penetrating Cardiac Injury

- Occurs from mechanical or impalements. - Most common site of injury is the right ventricle because of its anterior position. - The mortality rate is high. Especially prehospital and most deaths occur within minutes after injury as a result of exsanguination or tamponade

Traumatic Brain Injury Pathophysiology: Secondary Injury - Tissue Ischemia

- Occurs in area of poor cerebral perfusion from hypoxia or hypotension - Tissues become edematous - Extreme vasodilation occurs to supply oxygen, leading to increased blood volume, intracranial volume and intracranial pressure

SCI Nursing Management: Cardiovascular Complications

- Occurs in most injuries above T6, but profound in C3 to C5 - TP Alterations b/c hypotension may require IV fluids - Requires close hemodynamic monitoring -- Guidelines recommend that hypotension <90mmHg should be avoided and correct ASAP after acute SCI -- MAP should be maintained at 85 to 90 mmHg for first 7 days after acute SCI - Assessment of fluid volume is required b/c pulmonary oedema risk to SCI patients. Pulmonary artery catheterization may be required to asses this. After fluid status optimized, inotropic or vasosupport can be implemented - Loss of thermoregulation due to SNS dysfunction -- Judicious use of heat/cold therapies or comfort measures required to avoid changes in body temperature -- Hypothermia: produces bradydysrhythmias and sinus arrest, and is concernable when patient is symptomatic. May be treated with inotropic medications such as isoproterenol or anticholinergic medication atropine -- both increased HR and myocardial O2 consumption. -- Also may try temporary transvenous or transcutaneous pacemaker. - Orthostatic hypotension concern w/prolonged bed rest -- When mobilizing patient, should gradually elevate head of bed and dangle their legs over the side of the bed. -- DVT risk high. Hard to detect in SCI patients due to pain and tenderness being N/A. Prevention important with low-dose heparin, low-molecular-weight heparin, sequential compression devices and embolic hose

Traumatic Brain Injury Mechanism

- Occurs when the mechanical forces are transmitted to the brain tissue - Can be blunt (from deceleration, acceleration or rotation forces) or penetrating trauma (causes direct damage to tissue) - Deceleration injury (contrecoup): brain crashes against the skull opposite to the point of impact after it has hit a hard surface - Acceleration Injury (coup) - when the brain has forcefully been hit causing the brain to move forward to the point of impact

CDV Injuries: Blunt Cardiac Injuries

- Occurs with blows to the chest. -- Sudden acceleration can cause the heart to be thrown against sternum. -- Sudden deceleration can cause the heart to be thrown against the thoracic vertebrae - Includes myocardial contusion, concussion, and rupture. - Right atrium and ventricle most injured because of their anterior position in the chest. - S&S: evidence of external chest trauma, sternal fractures (not always), chest pain that is similar to anginal pain but not typically relieved with nitroglycerin. . - The patient should be monitored for new onset of dysrhythmias and if present, should raise suspicion for BCI. - 12-lead ECG may reveal dysrhythmias, ST changes, heart block, or unexplained sinus tachycardia. Medical management: - Preventing and treating complications. - Administration of antidysrhythmic medications - TX for heart failure - Insertion of a temporary pacemaker to control conduction abnormalities. - Assessment of fluid and electrolyte balance to ensure adequate CO and myocardial conduction.

Penetrating Trauma

- Occurs with injuries that penetrate the skin and result in damage to internal structures and creates damage along its path (e.g. stabbings, firearms or impalements) - Hard to assess the extent of the internal injury immediately - Factors affecting severity: weapon type and the angle of penetration etc,

SCI Mechanism of Injury: Rotation

- Often occurs in conjunction with flexion or extension injury - Severe rotation of next or body results in tearing of posterior ligaments and displacement of spinal column

Blunt Trauma

- Often seen with motor vehicle crashes (MVCs), contact sports, blunt force injuries and falls. - Injuries occur because of forces sustained during rapid change in velocity (deceleration). Body stops suddenly, tissues and organs continue to move forward causing lacerations or crash injuries of internal body structures. - Force sustained = pt weight x speed of car (mph)

Emergency Department Resuscitation: Rapid Primary Survey - Disability

- Perform rapid neuro assessment and LOC. (AVPU/GCS) -- Alert -- Verbal stimuli response -- Painful stimuli response -- Unresponsive

CDV Injuries: Cardiac Tamponade

- Progressive accumulation of blood (120-150ml) in the pericardial sac - Results in increased intracardiac pressure and compression of the atria and ventricle -> decreased venous return and filling pressure -> decreased CO, myocardial hypoxia, HF, and cardiogenic shock. - Assessment: Beck's triad ( elevated central venous pressure with neck vein distention + muffled heart sounds + hypotension). Pulsus paradoxus (drop in SBP and pulse wave w/inspiration). PEA w/o hypovolemia and tension pneumothorax suggests cardiac tamponade. Ultrasonography to identify a hemopericardium. - Tx: Immediate treatment is required. Pericardiocentesis (aspiration of fluid from the pericardium by use of a large-bore needle, risk of lacerating coronary artery). Other: thoracotomy or median sternotomy. The goal of these procedures is to locate and control the source of bleeding.

Diffuse Axonal Injury

- Prolonged-traumatic coma that is not caused by a mass lesion - Caused by accel, decel, & rotational forces leading to damaged axons or interrupted axonal transmission (leads to LOC) - Pathology: Stretched or torn axons from movement of brain during impact. Leads to microscopic lesions throughout brain. - May be invisible on CT or MRI unless small hemorrhage occurred - Classifications -- Mild: maybe coma for 24 hours, decorticate/decerebrate posturing -- Moderate: maybe coma for >24 hours, decorticate/decerebrate posturing -- Severe: prolonged deep coma with periods of HTN, hyperthermia, excessive sweating - Treatment: supporting vital functions, maintenance of ICP. - Outcome of severe DAI is poor, because of extensive dysfunction of cerebral pathways

SCI Medical Management: Surgical

- Provides spinal stability in presence of unstable injury (e.g. disrupted ligaments & tendons, vertebral column that is unable to maintain normal alignment) - Identification and mobilization of unstable injuries important for patient with incomplete neuro deficits as a lack of stabilization may lead to complete neurologic deficits - When surgery should be performed is controversial Laminectomy: removal of the lamina of the vetebral ring to allow decompression and removal of bony fragments or disk material from the spinal canal Spinal Fusion: Surgical fusion of 2 - 6 vertebral elements to provide stability and prevent motion. Accomplished by use of bone parts or chips from iliac crest, wire or acrylic glue. Rodding: stabilized and realigns large spinal column segments. Rods (e.g. Harrington rods) are attached by screws and glue to posterior elements of spinal column. Most often down for thoracolumbar area

SCI Nursing Management: Maximizing Psychosocial Adaptation

- Provision of dedicated emotional support - Patient and family experience anxiety, grief, denial, anger, hopelessness and frustration b/c unknown long-term neuro deficits - Interventions: -- Promoting coping mechanisms, support systems, and adaptive skills. -- Providing simple, accurate and consistent information (decr anxiety) -- Include patients and family in decision making -- May involve others such as pastor, social workers, OT, psychiatric clinical nurse specialists

Emergency Department Resuscitation Steps

- Rapid Primary Survey > Resuscitation of Vital Functions >Secondary Survey > Initiation of Definitive Care

SCI Assessment: Neurologic Assessment

- Rapid neuro assessment not accurate for eventual deficits as it focuses on the functioning of the systems that coordinate vital functions - Detailed motor and sensory examination includes assessment of all 32 spinal nerves for dysfunction. Will look at the dermatomes (mapped pathways for sensory portion of spinal nerves) to assist in localizing functional sensory level of injury - Initial assessment should be carefully assessed as this will become the baseline to compare to. Ongoing spinal cord assessments will be documented during critical care phase.

Definitive Care and Operative Phase

- Specific injuries had been diagnosed and - Trauma is a "surgical disease" - Injuries that require it will have surgery during this phase then transfer to CCU

TBI Nursing Management

- Stabilizing VS - Prevention of further injury - Reducing ICP - Ongoing nursing assessments: important to recognize or respond to secondary injuries for prevention -- Hypotensive events: Maximize CPP through reducing ICP and restore MAP - Hemodynamic and fluid management is vital. Monitor arterial VP because hypotension in TBI patient is rare and may indicate other injuries -- If no cerebral ischemia, do not aggressively attempt to keep CPP above 70mHg with IV and vasopressutes b/c of ARDS -- Close monitoring is needed b/c changes in CDV function and catecholamine circulation leads to hemodynamic instability - Pulmonary care may be needed, but there is endotracheal suctioning may increase ICP -- Suctioning: Passes >10 seconds, 2 max passes for suctioning episodes, hyper oxygenate patient before and after each pass, minimize airway stimulation -- Capnography (monitoring of exhaled CO2 levels - Body temperature maintenance: high temperatures increase cerebral oxygen consumption, therefore achieve euthermia (36-37C) with careful infection monitoring, cooling measures and antipyretics - Catecholine surge after TBI increases infection and mortality risk. Beta blockers should be used to counter affect. - Controlling the environment: Minimize stimuli that create pain, agitation or discomfort b/c it can increase ICP. -- Give analgesics and sedatives -- Rest periods -- Stabilized ICP, can provide stimulation to their senses. Follow a schedule. Accurately document stimulus and response. Should be individualized and include family members. - Phamacological agents: -- Amantadine: Acts as N-methyl-D-aspartate antagonist and indirect dopamine agonist to facilitate awakening

Emergency Department Resuscitation: Resuscitation Phase - Damage Control Resuscitation

- Strategy to provide only interventions to control hemorrhage and contamination - Inclues permissive hypotension, using blood products rather than isotonic fluids and rapid/early corrections for coagulopathy with component therapy. Starts in field, but will continue to CCU.

TI Chest Wall Injuries: Ruptured Diaphragm

- Subtle and non-specfic symptoms: rapid rise in intra-abdominal pressure from compression of lower part of chest/upper abdomen - Diaphragm: little resistance to force, can rupture or tear. Abdominal viscera will then gradually move from positive pressure of the abdomen to the negative pressure in the thorax. Massive herniation of the abdominal contents into the thoracic cavity can compress the lungs and mediastinum, which decreases CO and venous return. Herniated bowel will then become strangulated and perforate. Can be life threatening. - Diaphragmatic herniation may affect respiration. -- Auscultate for bowel sounds in chest or unilateral breath sounds in ruptured diaphragm. -- Complains of shoulder pain, SOB and abdominal tenderness. - Thoracoscopy may be helpful in evaluation and diagnosing - Chest radiograph: reveal tip of NG tube above diaphragm, unilaterally elevated hemidiaphragm, hollow or solid mass above diaphragm and a shift of mediastinum away from affected side. - Tx: immediate repair

Complete Injury SCI

- Total loss of sensory and motor function below the level of injury - Complete dissection of the spinal cord and neurochemical pathways resulting in tetraplegia or paraplegia

Maxillofacial Injuries

- Trauma to faces results in complex physiological and psychological sequelae. - Vital functions affected: mastication, deglutination, perception of environment though sense, and respiration. - Psychological effects: may affect personal identity, appearance and communication.

Trimodal Distribution of Trauma Deaths: Second Peak

- Victims who die with a few hours after injury. - Can occur in the ER or OR - Causes of death: subdural or epidural hematoma, hemopneumothorax, ruptured spleen, liver laceration, pelvic fracture, injuries associated with extensive blood loss

Maxillofacial Medical Management

- Visualization and reduction of fragments. - Stabilization of plates and screws.

TBI Nursing Assessment

1. Evaluate ABC's - Pt w/moderate primary injury may deteriorate b/c of diffuse swelling and bleeding - Pt w/severe TBI w/spontaneous breathing may need prophylactic ventilatory support to reduce hypercapnia and hypoxia risk 2. Neurologic Assessment - LOC: to assess wakefulness - Orientationx3 - to assess mental alertness - Consciousness - assessing patient response to verbal and painful stimuli Motor movements - Pupillary response: Size, shape, equality (asymmetry should be reported immediately) and reactivity to light (constriction = parasympathetic innervation) or dilation (sympathetic innervation) -- Slow reaction = brainstem injury -- Blown pupil = compression of 3rd cranial nerve or transtentorial herniation -- Bilateral fixed pupils = midbrain involvement Respiratory function and vital signs 3. Serial Assessments - Hemodynamic Status - ICP monitoring: sedatives and muscle relaxants for ICP may mask neuro signs of patients w/severe TBI (pupil response and VS now extremely important). May need to turn off sedatives w/short lives like propofol for neuro exam.

Golden Hour

60 minute time frame that includes EMS activation, transportation to a medical facility, rapid resuscitation on arrival to ER and provision of definite care.

Maxillofacial Injuries Assessments and Diagnostic Procedures

ABCs - Prone to ineffective airway clearance and obstruction -- Tongue, edema, hemorrhage, foreign objects, vomit, broken teeth or bone fragment may obstruct airway -- "Look, listen and feel" to assess obstruction -- May require artificial airway. Endotracheal tube unless laryngeal fracture. Nasotracheal or NG intubation contraindicated with unstable facial fractures. Tracheostomy required for patients with hypo pharynx swelling or hemorrhage - Deficient fluid volume related to hemorrhage -- From bleeding of the ethmoid and maxillary sinuses. May require nasal packing. -- IV fluids given - C-Spine precautions until proven otherwise - Risk for Injury Head to Toe Assessment - Inspection and palpation of soft tissues - Inspect mouth for traumatic tooth displacement - Assess for contusion or abrasions. May seem unobtrusive, but damage may be underlying. - Inspect ear canal for occult lacerations - Careful inspection of orbit - Often associated with cervical SCI -- Altered LOC w/maxillofacial injuries suggest neurotrauma -- Fractures create infection risk esp. meningitis -- Inspect nasal and auditory canals for discharge for CSF discharge (will be tested for glucose, because CSF is high in in) - Axonal and coronal CT Scan: Location and displacement of fractures.

SCI Assessment: ABCs

Airway - Ensure oxygenation and perfusion to vitals organs including spinal cord - CDV and Resp assessments - Assess effective airway clearance - Must stabilize patient's neck to insert oral airway, which is needed to be placed before severe hypoxia can occur Breathing - Assess breathing patterns and gas exchange - Patients w/complete injuries above C3 -> paralysis of diaphragm and require ventilatory assistance Circulation - Assess CO and TP; at risk for impaired because of CDV alterations (also at risk for dyrhythmias, cardiac arrest, orthostatic hypotension, emboli and thrombophlebitis - Adequate TP assessed w/invasive and non-invasive hemodynamic monitoring - Cardiac monitoring for dysrhythmias from PNS, hypothermia or hypoxia

TBI Diagnostic Procedures

CT Scan - Identifies mass lesions and cerebral edema - May be used over a period of several days to assess areas of contusion and ischemia to detect delayed hematoma - Nurse should be here during CT scan to monitor and observe patient - Transporting patient can be be stressful on patient because of it causing increased ICP. ICP should be monitored at these times

Maxillofacial Mechanism of Injury: Maxillofacial Skeletal Injuries

Le Fort I - Horizontal fracture (around top of gum line) separating the maxillary arch from the upper facial skeleton Le Fort II - Fracture that goes from the gum line to around the bridge of the nose. -CSF leaks b/c communication between cranial base and cribriform plate Le Fort III - Fracture along the bottom of the eye sockets. - Associated with cranial disruption. -CSF leaks b/c communication between cranial base and cribriform plate

Trauma

Occurs when an external force of energy (e.g. mechanical, chemical, radiation) impacts the body and causes structural of physiological alterations or injuries

Maxillofacial Nursing Management

Protecting Airway - Reducing emesis and aspiration risk - Orogastric tube functioning assessed - Antiemetics administered - HOB at 30 degrees - Place patient on side or forward position if vomiting and use oral/nasal suctioning - Wire cutters should be at bedside in case vomit cannot be removed (would cut vertical attachments, not horizontal) - Pain Management - Nutritional needs assessment - Fluid balance assessment

SBAR

Situation: age, gender, mechanism of injury, admission diagnosis, LOC and GCS status, tests completes and results received, medications given, current issues Background: Significant medical or surgical history. At home medications. Assessments: Current assessment findings (VS, LOC, airway, mechanical ventilation setting), family members present and their response and knowledge of patient status Recommendations: Description of plan including fluid volume and blood products

TBI Medical Management

Surgical - If lesion is identified and displaces cerebral tissue or increases ICP, surgical intervention is need. - Craniotomy: removes EDH, SDH, or large ICH - Decompressive Craniectomy: For increased ICP. Removes overlying bone flat allow brain tissue to expand and swell Non-Surgical - Management of ICP - Maintenance of adequate cerebral perfusion pressure, oxygen and complication treatments - ICP monitoring is required for those with GCS <8 or abnormal CT findings. - Brain tissue oxygen monitoring