TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition

What are S/S of a ruptured diaphragm?

(Anything below the nipple line and should be evaluated for potential diaphragmatic injury). - Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Decreased breath sounds on injured side

What is diffuse axonal injury and its signs and symptoms?

(DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - severe DAI, coma = weeks/months or persistent vegetative state - Elevated ICP - Abnormal posturing - HTN - Hyperthermia - Excessive sweating because of autonomic dysfunction - Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits

How would you assess a patient with ocular, maxillofacial and neck trauma?

(Initial assessment) HISTORY - MOI? - Acceleration/Deceleration? - What was it caused by? - Pt restrained? Airbags deployed? Etc. - What are the pt's complaints? - Pt normally wear glasses or contacts? - Pt have hx of eye problems? - Pt ever have eye surgery? - Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION: - Inspect eye, orbits, face and neck - Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas - Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents - Determine whether lid lac's - Assess pupil's (PERRL) - Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome - Bilateral fixed and pinpoint pupils = pontine lesion or drugs - Mildly dilated pupil w/sluggish response may early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Assess for consensual response - Assess redness, eye watering, blepharospasm - Assess extraocular movement, except when an open globe injury is known or suspected. - Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle - Perform visual acuity exam - Use Snellen or handheld chart. Check uninjured eye first - Assess for blurred or double vision with injured eye and then with both eyes open - Inspect for rhinorrhea or otorrhea - If drng present, may indicate CSF leak - Observe for impaled objects - Assess occlusion of mandible and maxilla - Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx - Observe for uncontrolled bleeding PALPATION - Palpate periorbital area, face and neck for: - Tenderness - Edema - Step-off defects or depressions - Subcutaneous emphysema (esophageal or tracheal tear) - Palpate trachea above suprasternal notch - Trach deviation = late indication of tension pneumothorax or massive hemothorax - Assess sensory fx of perioribital areas, face and neck - Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side. - Check position of trachea DIAGNOSTIC STUDIES: - Xrays, CT scans, MRI's - Fluorescein staining - Slit-lamp exam - tonometry (measures intraocular pressure) - Bronchoscopy or esophagoscopy

How would you assess a pt with a cranial injury?

(Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness - Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration. - Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction. - Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma. - Position pt, elevate head to decrease ICP (but may also reduce CPP). - Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain - Prepare for ICP monitoring device - Administer mannitol as prescribed. - Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys. - Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Depressed skull fx - Sz at time of injury - Sz on arrival to ED - Hx of sz's - Penetrating brain injury - Acute subdural/epidural hematoma - Administer antipyretic med/Cooling blanket - Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP - Do not pack ears/nose if CSF leak suspected - Admin tetanus prophylaxis - Wound repair for facial/scalp Lac's - Admin other meds - Analgesics, sedatives, narcan, romazicon, etc. - Admin antibiotics - Pt's w/basilar skull fx need prophylaxis against meningitis - Prepare pt for OR, hospital admin or transfer.

How would you assess a pt with a thoracic injury?

(Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe chest wall - Assess breathing effort and RR - Symmetry - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) Palpation: - Palpate chest wall, clavicles and neck for: - Tenderness - Swelling or hematoma - Subcutaneous emphysema - Note presence of bony crepitus - Palpate central and peripheral pulses and compare quality between: - Right and left extremities - Upper and lower extremities - Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax) - Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury). Auscultation: - Auscultate compare BP in both UE's and LE's - Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain). - Auscultate chest for presence of BS (diaphragmatic rupture) - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP

What are aortic injuries S/S?

- Hypotension - Decreased LOC - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia

What could a flail chest be associated with?

- Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma

What intervention should be done if a pt presents with effective circulation?

- Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate

What are the mandibular fracture S/S?

- Malocclusion - Inability to open the mouth (trismus) - Pain, especially on movement - Facial asymmetry and a palpable step-off deformity - Edema or hematoma formation at the fracture site - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip

What are S/S of penetrating trauma/open or ruptured globe?

- Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements

What are the signs and symptoms of postconcussive syndrome?

- Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression

With any eye injury, what should the evaluation and ongoing assessments be?

- Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's

What are the S/S of a tension pneumothorax?

- Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign)

What are signs of a serious eye injury?

- Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure

What is a cerebral contusion and its S/S?

A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18-36 post injury. S/S: - Alteration in LOC - Behavior, motor or speech deficits - Abnormal motor posturing - Signs of increased ICP

Define central or transtentorial herniation.

A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium.

What is a Combitube?

A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult.

What is a subdural hematoma and its S/S?

A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's

What is a flail chest?

A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases.

dressing removal

A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three sides. he is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis and decreasing blood pressure. Which of the following is the MOST appropriate immediate intervention?

Initiate transfer to a trauma center

A pt is brought to the ED of a rural hospital following a high-speed MVC. When significant abd and pelvic injuries are noted in the primary survey, which of the following is the priority interventions?

bardycardia and absent motor function below the level of injury

A pt with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs?

elevating the extremity to the level of the heart

A pt with a lower extremity fracture complains of severe pain and tightness in his calf, minimally by pain medications. Which of the following is the priority nursing intervention?

What is the minimum permissive hypertension and a trauma patient?

A systolic of greater than or equal to 90 MMHG

What is a concussion and its signs and symptoms?

A temporary change in neurologic function that may occur as a result of minor head trauma. S/S: - Transient LOC - H/A - Confusion and disorientation - Dizziness - N/V - Loss of memory - Difficulty with concentration - Irritability - Fatigue

Upon initial assessment, what type of oxygen should be used for a pt breathing effectively?

A tight-fitting nonrebreather mask at 12-15 lpm.

compensated

A trauma pt is restless and repeatedly asking "where am i?" VS upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP 104/84, HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock?

What causes quarternary effects of blast traumas?

All explosion related injuries, illnesses, or diseases not due to the first three mechanisms. Injuries include external and internal burns, crush injuries, closed and open brain injuries, asthmatic or breathing problems from dust smoke or toxic fumes, angina, or hyper glycemia and hypertension.

defusings

All of these are considered a critical communication point in trauma care EXCEPT which of the following?

subdural hematoma

An elderly patient with a history of anticoagulant use presents after a fall at home today. She denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms?

ventilate with a bag mask device

An unresponsive trauma pt has an oropharygeal airway in place, shallow and labored respirations, and dusky skin. The trauma team has administered medications for drug-assisted intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step?

What are the signs of compensated shock?

Anxiety, confusion, restlessness, increased respiratory rate, narrowing pulse pressure were diastolic increases yet systolic remains unchanged, tachycardia with bounding pulses, and decreased urinary output

What is combined loading?

Any combination of tension compression torsion bending and/or shear.

1. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line

Auscultate the chest for:

Where do you listen to auscultate breath sounds?

Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line.

Breathing: To assess breathing expose the chest: 1. Inspect for a. spontaneous breathing b. symmetrical rise and fall c. depth, pattern, and rate of respiration d. signs of difficulty breathing such as accessory muscle use e. skin color (normal, pale, flushed, cyanotic) f. contusions, abrasions, deformities (flail chest) g. open pneumothoraces (sucking chest wounds) h. JVD i. signs of inhalation injury (singed nasal hairs, carbonaceous sputum)

B

Circulation and Control of Hemorrhage Inspect first for any uncontrolled bleeding Skin color palpate for central pulses - carotid and femoral - rate, rhythm, and strength Skin temp: cool, diaphoretic, or warm and dry

C

apply direct pressure to bleeding elevate extremity apply pressure over arterial sites Consider a pelvic binder for pelvic fractures consider a tourniquet cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation d. use rapid infusion device

C Interventions:

Describe the characteristics of cardiogenic shock

Cardiogenic shock results from pump failure in the presence of adequate intravascular volume. Lack of cardiac output and an organ perfusion occurs secondary to a decrease in myocardial contractility and or valvular insufficiency. This can happen with blunt cardiac trauma or an MI. Symptoms can include low blood pressure increase heart rate and respiratory rate chest pain shortness of breath dysrhythmias increase troponin and pale cool moist skin

padding the upper back while stabilizing the cervical spine

Caregivers carry in a 2 y/o into the ED who fell out of a second-story window. The pt is awake and crying with increased work of breathing and pale skin. Which of the following interventions has the highest priority?

Results from pump failure in the presence of adequate intravascular volume. There is a lack of cardiac output and end organ perfusion secondary to a decrease in myocardial contractility and/or valvular insufficiency. Ex: MI's or dysrhythmia are common causes

Cariogenic Shock

Describe the four types of spinal cord injury

Central cord injury results in greater weakness distally, anterior injury includes motor loss or weakness below the cord level of injury yet sensory is intact, Brown-Sequard (hemicord) is weak on one side with sensory deficit on opposite side, posterior cord syndrome although rare is when the patient is unable to use sense vibration in proprioception

What are s/s of chemical burns to the eye?

Chemical injuries require immediate intervention if it is to be preserved. S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids

activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP

Chemoreceptors:

What are the three stages of shock

Compensated, decompensated or progressive, and irreversible.

What is LeFort III fracture and its S/S?

Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion - CSF rhinorrhea

Describe the 3 types of Internal forces of energy transfer in the context of trauma.

Compression: The ability of the tissue to resist crush injury or force Tension: The ability to resist being pulled apart when stretched Shear: The ability to resist a force applied parallel to the tissue

What is compression?

Crushing by squeezing together

What is Cullen's sign and its significance?

Cullens sign is periumbilical bruising and is indicative of intraperitoneal bleeding

Disability - Neurologic Status 1. Assess pupils for equality, shape, and reactivity (PERRL) 2. Assess GCS (eye opening, verbal response, and motor response)

D

What is the DOPE mnemonic?

D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing

1. Get a CT 2. Consider ABG 's if decreased LOC 3. Consider glucose check

D Interventions

How do you assess Mnemonic "D"?

DISABILITY A = Alert V = Verbal P = Pain U = Unresponsive - GCS - PERRL? - Determine presence of lateralizing signs including: - Unilateral deterioration in motor movements or unequal pupils - Symptoms that help to locate area of injury in brain

D displaced tube O obstructed or kinked P pneumothorax E equipment failure , such as becoming detached from the equipment or loss of capnopgrahy

DOPE

What is shearing?

Damage by tearing or bending by exerting faucet different parts in opposite directions at the same time.

Describe the 3 types of external forces of energy transfer in the context of trauma.

Deceleration: Force from a sudden stop in the body's motion Acceleration: Force from a sudden onset in the body's motion Compression: Force from being crushed between objects

What are the symptoms of a subdural hematoma?

Decreased LOC, nausea vomiting headache and ipsilateral pupillary changes

What are the signs and symptoms of decompensated shock?

Decreased level of consciousness, hypertension, narrow pulse pressure, tachycardia with weak pulses, tachypnea, skin that is cool clammy and cyanotic, base access outside the normal range, and serum lactate levels greater than two to 4MMOL/L.

When capnography measurement reads less than 35MMHG, the nurse should consider increasing or decreasing the ventilation rate?

Decreasing the ventilation rate. By doing so, the nurse allows the patient to retain CO2.

Disruptions of the bony structures of the skull can result in what?

Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess

occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone. Goal: Volume replacement and vasoconstriction

Distributive Shock

Describe the characteristics of distributive shock.

Distributive shock occurs as a result of Mel distribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. This can occur with spinal cord injuries, sepsis, or anaphylaxis. Symptoms include low blood pressure heart rate respiratory rate preload and afterload, spinal tenderness, difficulty breathing, warm pink and dry skin with a cool core temperature.

Define the characteristics of neurogenic shock

Distributive shock with a T6 or higher injury results and vasodilation, bradycardia, flushed warm dry skin. Risk for temperature instability. Nursing interventions include maintaining warmth and spinal stabilization.

What are you looking for when percussing the chest?

Dullness: - hemothorax Hyperresonance - Pneumothorax

insert an oropharyngeal airway if there is no gag reflex

During the primary survey of an unconscious pt with multi-system trauma, the nurse notes snoring respirations. What priority nursing interventions should be preformed next?

Exposure and Environmental Control Remove all clothes and assess for any obvious injuries and uncontrolled bleeding

E

IF clothing is needed for evidence preserve in paper bag. Maintain body temp - cover the pt, turn up heat in room, administer warm fluids

E Interventions:

What is the Law of Conservation of Energy?

Energy can neither be created nor destroyed. It is only changed from one form to another.

Full set of vitals and family presence

F

What is the Mnemonic for the Secondary Assessment?

F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces

What is the first thing assessed under the Secondary Assessment?

FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence

True or false: NPAs and OPAs are definitive airways.

False. When placing one of these? One should consider the potential need for a definitive airway.

Reevaluation and Consider the need to Transfer

Final step in primary survey

1. Apnea 2. GCS 8 or less 3. Maxillary fractures 4. Evidence of inhalation injury (facial burns) 5. Laryngeal or tracheal injury or neck hematoma 6. High risk of aspiration and patients inability to protect the airway 7. Compromised or ineffective ventilation

Following conditions might require a definitive airway

Newton's Third Law of Motion

For every action there is an equal and opposite reaction

What is Newton's Second Law?

Force equals mass multiplied by acceleration of deceleration.

Get Resuscitation Adjuncts L - Labs (maybe a lactic acid), a b g 's, blood type M - monitors N - naso or oro gastric tubes O Oxygen and ETC02 monitors P - pain assessment and management

G

Define Minor Head Trauma.

GCS 13-15

What is the minimum permissive oxygenation level of a trauma patient?

Greater than or equal to 94%

History and Head to toe MIST - prehospital report MOI Injuries sustained S s/s in the field T treatment in the field if patients family present get a better hx on them

H

don't forget flanks!!! inspect of lacs, puncture wounds, contusions, auscultate then palpate: bowel sounds? any rigidity, guarding? begin with light palpation start to palpate with side that does not hurt maybe do a fast scan?

Head to toe assessment: Abdomen

inspect, auscultate, palpate any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles lacs, contusions, auscilate lung sounds and heart sounds

Head to toe assessment: Chest

any deformities? bleeding? contusions, lacs? skin temp?? place splints on deformities, pulses

Head to toe assessment: Extremities

inspect for lacs, abrasions, asymmetry of facial expressions palate for depressions and tenderness look at ears for drainage

Head to toe assessment: Head and face

immobilize cervical spine, tenderness, tracheal deviation

Head to toe assessment: Neck and cervical spine

any lacs? deformities? blood at the urtheral meatus palpate pelvis with high pressure over the iliac wings downward and medially

Head to toe assessment: pelvis and perineum

Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm. Ensure two large bore IVS are placed. Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred.

Hemothorax:

Describe the characteristics of hypovolemic shock

Hypovolemia is caused by a decrease in the amount of circulating volume usually caused by massive bleeding, but also can be from vomiting and diarrhea. Characteristics include low blood pressure and preload, increase heart rate respiratory rate and afterload, with contractility unchanged. Signs include obvious bleeding, weak peripheral pulses, pale cool and moist skin, distended abdomen, pelvic fracture, or bruise swollen and deformed extremities especially long bones.

from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume.

Hypovolemic Shock

What are the four types of shock?

Hypovolemic, Cardiogenic, Obstructive, & Distributive

inspect posterior surfaces blogroll with at least 3 people. maintain c spine take out backboard Rectal tone per MD

I

1. Suction the airway 2, Use care to avoid stimulating the gag reflex 3. If the airway is obstructed by blood or vomitus secretions, use a rigid suction device If foreign body is noted, remove it carefully with forceps or another appropriate method

If Airway is not patent

1. open the airway, use jaw thrust 2. insert an oral airway 3. assist ventilations with a bag mask 4. prepare for definitive airway

If breathing is absent..

1. Check the presence of adequate rise and fall of the chest with assisted ventilation 2. Absence of gurgling on auscultation over the epigastrium 3. Bilateral breath sounds present on auscultation 4. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor

If the pt has a definitive airway in what should you do?

reorganize care to C-ABC

If uncontrolled hemorrhage ..

Law of Conservation of Energy

Matter is neither created nor destroyed (but may change form)

Describe the measurement of an NPA

Measure from the tip of the patient's nose to the tip of the patients earlobe.

When would you use a nasopharyngeal airway versus an oral pharyngeal airway?

Nasopharyngeal airways is contraindicated in patients with facial trauma or a suspected basilar skull fracture. Oral pharyngeal airways is used in unresponsive patients unable to maintain their airway, without a gag reflex as a temporary measure to facilitate ventilation with a bag mask device or spontaneous ventilation until the patient can be intubated.

According to newtons law which of these two force is greater: size or force?

Neither. For each force there is an equal and opposite reaction.

What are the treatment goals for a TBI?

O2 saturation > or equal to 95%, systolic blood pressure > or equal to 100 MMHG, ICP < 15 MMHG, CPP > or equal to 60 MMHG, normal glycemia, hemoglobin > or equal to 7 g/DL, sodium 135-145, osmotic diuretics, anti-emetics, sedatives, anticonvulsants, head of bed at 30°, and neck at midline

results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion. Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma.

Obstructive Shock

Describe the characteristics of obstructive shock

Obstructive shock is it mechanical problem that results from hypoperfusion of the tissue due to an obstruction in either the vasculature or the heart resulting in decreased cardiac output. Some causes include a tension pneumothorax, cardiac tamponade, or venous air embolism on the right side of the heart during systole in the pulmonary artery.Signs include anxiety, muffled heart sounds, JVD, hypertension, chest pain, difficulty breathing, or pulses paradoxes.

What are the signs and symptoms of irreversible shock?

Obtunded stuporous or comatose state, marked hypertension and heart failure, bradycardia with possible dysrhythmias, decreased and shallow respiratory rate, pale cool and clammy skin, kidney liver and other organ failure, severe acidosis, elevated lactic acid levels, worsening base access on ABGs, coagulopathies with petechiae purpura or bleeding.

What are intracerebral hematoma's and its S/S?

Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia

can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking" Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair.

Open Pneumo:

trauma its need early supplemental oxygen, start with 15 mL O2 and titrate oxygen delivery.

Oxygen on trauma patients

Pediatric Assessment Triangle 1. General appearance - muscle tone, interactiveness, consoloability, poor or gaze, speech or cry 2. Work of breathing - inadequate or excessive, accessory muscle use, retractions, tripod position, abnormal upper airway sounds 3. Circulation of the skin - color, mottling or central or peripheral cyanosis, diaphoresis

PAT

What causes the primary effects of blast traumas?

The direct blast effects. Types of injuries include last long, tympanic membrane rupture and middle ear damage, abdominal hemorrhage and perforation, global rupture, mild Trumatic brain injury.

Differentiate between the three impacts of motor vehicle impact sequence.

The first impact occurs when the vehicle collided with another object. The second impact occurs after the initial impact when the occupant continues to move in the original direction of travel until they collide with the interior of the vehicle or meet resistance. The third impact occurs when internal structures collide within the body cavity.

What are contributing factors to injuries related to blunt traumas?

The point of impact on the patient's body, the type of surface that is hit, the tissues ability to resist (bone versus soft tissue, air-filled versus solid organs), and the trajectory of force.

What are the three factors that contribute to the damage caused by penetrating trauma's?

The point of impact, the velocity and speed of impact, and the proximity to the object.

endotracheal tube

The trauma nurse knows that placing a bariatric patient in a ramped position providers better visualization during the insertion of which device?

Define uncal herniation.

The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes.

What is a pulmonary contusion?

They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately.

What causes quinary effects of blasts traumas?

Those associated with exposure to hazardous materials from radioactive, biologic, or chemical components of a blast. Injuries include a variety of health effects depending on agent.

What is torsion?

Torsion forces twist ends in opposite directions.

Define the characteristics of spinal shock

Transient loss of function can include loss of reflexes and muscle tone below the level of industry with possible vascular response.

What is LeFort I fracture and its S/S?

Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion

What is Cushing's phenomenon or Cushing's Reflex?

Triad of progressive HTN, bradycardia and diminished respiratory effort.

brachial pulse

Under age of 1 where do you find a pulse

Aortic Dissection

Unequal extremity pulse strength possibility of..

What are the seven patterns of pathway injuries related to motor vehicle accidents?

Up and over, down and under, lateral, rotational, rear, roll over, and ejection.

What are the three processes that transfer oxygen from the air to the lungs and blood stream

Ventilation: the active mechanical movement of air into and out of the lungs; diffusion: the passive movement of gases from an area of higher concentration to an area of lower concentration; and perfusion: the movement of blood to and from the lungs as a delivery medium of oxygen to the entire body.

stabilized vital signs, improved mental status, improved urine output

What are indicators of increased perfusion?

pulse oximetry and capnography

What bedside monitoring parameters are used to assess for adequacy of O2 and effectiveness of ventilation?

velocity

What factor contributes most to the kinetic energy of a body in motion?

placental abruption

You are caring for a pt who was involved in a MVC and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal ht at the costal margin, and some dark bloody show. Varying accelerations and decelerations are noted on cariocgraphy. These findings are most consistent with which of the following?

500 mL/hr

You are treating a 27 y/o M in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred due to the need for emergent intubation. At what rate should you begin fluid resuscitation?

apply splint and elevate above the level of the heart

a 37 y/o F has a deformity of the L wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention?

serial FAST exams

a 49 y/o restrained driver involved in a MVC presents to the trauma center complaining of abd, pelvic, and bilateral lower extremity pain. VS are stable. The nurse can anticipate all of these after a negative FAST exam EXCEPT which of the following?

fat embolism

a pt has been in the ED for several hrs waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and complaining of leg pain. His wife reported that he suddenly became anxious and confused. Upon reassessment, the pt is restless with respiratory distress and petechiae to his neck. The pt is exhibiting s/sx most commonly associated with which of the following conditions?

Newton's First Law of Motion

an object in motion will remain in motion unless acted upon by another force

What is the planning and implementation for thoracic injury?

p. 142

What is tension?

stretching force by pulling at opposite ends

pelvic stability

the most reassuring finding for a male pt with hip pain after a fall is which of the following?

increased work of breathing?

which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax?

the aorta is torn at its attachment with the ligamentum arteriosum

which of the following occurs during the third impact of a motor vehicle crash?

How would you assess someone in hypovolemic shock?

(Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery?

What are signs of ineffective breathing?

- AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation.

What are factors that contribute to ineffective ventilation?

- AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age

What is the second thing assessed under the Secondary Assessment?

GIVE COMFORT MEASURES - Talking to pt - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain

What is assessed under the Mnemonic "H"?

HISTORY / HEAD-TO-TOE ASSESSMENT - MIVT - M = Mechanism of injury - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment

What is assessed under the Mnemonic "I"?

INSPECT POSTERIOR SURFACES - While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs. - Palpate vertebral column for deformity and areas of tenderness - Assess rectum for presence/absence of tone, presence of blood

Report your suspicion of maltreatment in accordance with local regulations

a 5 y/o child presents to the ED with bruises to the upper arm and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority survey. Which of the following is the priority nursing intervention?

What are S/S with blunt cardiac injury?

"Cardiac contusion" or "concussion." Common with MVC or falls from heights. - ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis

What are the S/S of a linear skull fx?

- H/A - Possible decreased LOC

What are the S/S of a depressed skull fx?

- H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site

What are the nursing interventions for a patient with a maxillofacial or neck injury?

- Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present. - Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds

What are the nursing interventions for a pt with an ocular injury?

- Assess visual acuity & reassess - Elevate HOB to minimize intraocular pressure - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects - Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe. - Provide psychosocial support - Obtain an ophthalmology consultation - Provide d/c instructions: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer

What are the S/S of orbital fracture (orbital blowout fracture)?

- Diplopia (double vision) - Loss of vision - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid - Infraorbital pain or loss of sensation - Orbital bony deformity

What are the S/S of flail chest?

- Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration.

What are neck injury S/S?

- Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing)

What are the S/S of pulmonary contusion?

- Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions

What are S/S of a rib fracture?

- Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity

What are the S/S of Hemothorax?

- Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side

What are the S/S of a pneumothorax?

- Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax)

What are the S/S of a basilar skull fx?

- H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea

ICP is a reflection of what three volumes? What happens when one increases?

1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP.

Describe the three impacts in the motor vehicle impact sequence

1. First Impact: Vehicle hits another object 2. Second Impact: Occupant hits the interior of the vehicle 3. Third Impact: Organcs hit other internal structures

What are the five forms in which energy exist?

1. Mechanical 2. Thermal 3. Chemical 4. Electrical 5. Radiant

Define the five mechanisms of injury in blast trauma.

1. Primary: Found in patients who were closest to the blast. Injuries are most commonly associated with air-filled organs 2. Secondary: Include fragment injuries, puncture wounds, lacerations, and impaled objects. Generally, these cause the most casualties 3. Tertiary: Result from the patient being blown into a large object. Injuries include pelvic or femur fractures an thoracic injuries. 4. Quaternary: Result from heat, flame, gas, and smoke and cause burn injuries. 5. Quinary: Injuries associated with radioactive, biological or chemical elements that may be present in the explosion.

What are the two types of herniation that occurs with ICP?

1. Uncal herniation 2. Central or transtentorial herniation

What is the recommended fluid bolus for a trauma?

500 ML's of warmed isotonic crystalloid. Ongoing fluid boluses of 500 ML's should be given judiciously with constant reassessments after administration.

straight cath for urine sample

A 20 y/o M presents to the ED complaining of severe lower abd pain after landing hard on the bicycle cross bars while preforming an aerial BMX maneuver. Secondary assessment reveals lower abd tenderness and scrotal ecchymosis. Which of the following orders would the RN question?

globe rupture

A 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected?

Expedite transfer to the closest trauma center

A 56 y/o M pt involved in a motor vehicle crash is brought to the ED of a rural critical access facility. He complains of neck pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority intervention for this patient?

What is the Mnemonic for the Initial Assessment?

A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm)

What is Newton's First Law?

A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force.

What are the S/S of pericardial tamponade?

A collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling. - Hyotension - Tachycardia or PEA - Dyspnea - Cyanosis - Beck's Triad (hypotension, distended neck veins + muffled heart sounds) - Progressive decreased voltage of conduction complexes on ECG

1. A- airway and Alertness with simultaneous cervical spinal stabilization 2. B- breathing and Ventilation 3. circulation and control of hemorrhage 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces

ABCDEFGHI

What are you looking for when auscultating lung sounds?

Absence of BS: - Pneumothorax - Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain

Define Hemothorax.

Accumulation of blood in the pleural space.

What is hyphema and its S/S?

Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure

Used at the beginning of the initial assessment 1. A Alert. If the pt is alert he or she will be able to maintain his or her airway once it is clear. 2. V responds to verbal stimuli responds to pain. If the patient needs verbal stimulation to respond, an airway adjunct may be needed to keep the tongue from obstructing the airway. 3. P responds to pain. If the pt. responds only to pain, he or she may not be able to maintain his or her airway adjunct may need to be placed while further assessment is made to determine the need for intubation. 4. U Unresponsive. If the pt. is unresponsive, announce it loudly to the team and direct someone to chk in the pt is pulseless while assessing if the cause of the problem is the airway.

Airway and AVPU:

A breath every 5 to 6 seconds: 10-12 ventilations per minute

Bag mask ventilation

.. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure

Baroreceptors:

Why does herniation occur? What are the symptoms?

Because of uncontrolled increases in ICP. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration

1. Hypotension 2. JVD 3. Muffled heart sounds

Becks Triad:

What are S/S with tracheobronchial injury?

Blunt trauma. "Clothesline-type" injuries. - Dyspnea, tachypnea - Hoarseness - Hemoptysis - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - S/S of airway obstruction

What are the four types of trauma related injuries?

Blunt, penetrating, thermal, or blast.

List the four main types of traumatic injury and give an example of each

Blunt: The result of a broad energy impact across a large surface area. Penetrating: The

Define Cushing's triad

Bradycardia, progressive hypertension (widening pulse pressure), and decreased respiratory effort

Uncontrolled Hemorrhage

Major cause of preventable death:

Stroke Volume X HR

Cardiac Output =

Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation. (Ultrasound guided)

Cardiac Tamponade Intervention:

When capnography measurement reads greater than 45MMHG, the nurse should consider increasing or decreasing the ventilation rate?

Increasing the ventilation rate. Doing so would allow the patient to blow off retained CO2.

1. Preparation and Triage 2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of transfer) 4. Secondary Survey (HI) with reevaluation adjuncts 5. Reevaluation and post resuscitation care 6. Definitive care of transfer to an appropriate trauma nurse

Initial Assessment

1. The tongue obstructing the airway 2. loose or missing teeth 3. foreign objects 4. blood, vomit, or secretions' 5. edema 6. burns or evidence of inhalation injury Auscultiate or listen for: 1. Obstructive airway sounds such as snoring or gurgling 2. Possible occlusive maxillofacial bony deformity 3. Subcutaneous emphysema

Inspect the mouth for:

Mechanism of Injury

Is how external forces are transferred to the body, resulting in injury

Biomechanics

Is the general study of forces and their effects.

Kinematics

Is the study of energy transfer as it applies to identifying actual or potential injuries.

What is kinetic energy (KE)?

KE equals 1/2 the mass (M) multiplied by the velocity squared.

What is the relationship between mass and velocity to kinetic energy?

Kinetic energy is equal to 1/2 the mass multiplied the square of its velocity therefore when mass is doubled so is the net energy, however, when velocity is doubled energy is quadrupled.

What medications are used during intubation?

LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents

tracheal deviation and jvd

Late signs of tension pneumo:

Define tension pneumothorax.

Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. Immediate decompression should be performed. Treatment should not be delayed.

Explain Hepatic Response.

Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas.

What is bending?

Loading about an axis. Bending causes compression on the side the person is bending toward intention to the opposite side

Describe the usefulness of the Haddon Matrix in prevention and reduction of injury

Looks at 3 phases of the event: Pre-event, event, and post-event. Looks at 4 factors involved in the event: The host (patient), the agent (cause), the physical evironment, and the socioeconomic environment. Countermeasures can be applied at each phase to help reduce injury.

What is a Laryngeal Mask Airway?

Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords.

What are the greatest risks for transport?

Loss of airway patency, displaced obstructive tubes lines or catheters, dislodge splinting devices, need to replace or reinforce dressings, deterioration in patient status change in vital signs or level of consciousness, injury to the patient and/or team members

What is a trademark symptom of an epidural hematoma

Loss of consciousness then awake and alert then loss of consciousness

50 to 150

MAP Range

What are the Rapid Sequence Intubation Steps?

PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry

1. bony fractures and possible rib fractures, which may impact ventilation 2. palpate for crepitus 3. subcutaneous emphysema which may be a sign for a pneumothorax 4. soft tissue injury

Palpate the chest for

Flail chest

Paradoxical chest wall movement

dysrhythmias

Patients with a crush injury should be monitored for which of the following conditions?

Measurement of an OPA

Place the proximal end or flange of the airway adjunct at the corner of the mouth to the tip of the mandibular angle.

Name the three ways to confirm ETT placement

Placement of a CO2 monitoring device, Assessing for equal chest rise and fall, and listening at the epigastrium and four lung fields for equal breath sounds.

Vital signs Interventions Primary survey Pain

Post resuscitation care parameters that are continuously evaluated:

Define Moderate Head Trauma

Postresuscitative state with GCS 9-13.

Define Severe Head Trauma.

Postresuscitative state with GCS score of 8 or less.

What happens to a ruptured diaphragm?

Potentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver. - Herniation of abdominal contents - Respiratory compromise b/c impaired lung capacity + displacement of normal tissue. - Mediastinal structures may shift to opposite side of injury

What causes the secondary effects of blast traumas?

Projectiles propelled by the explosion. Injuries include penetrating or blunt injuries or I penetration.

What is LeFort II fracture and its S/S?

Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea

Colorimetric CO2 detectors provide info about the presence or absence of CO2. A chemically treated indicator strip changes color revealing the presence or absence of exhaled CO2

Qualitative

Capnography monitors numeric value, as well as continuous waveform, indicating real-time measurement and trending over time.

Quantitative:

What she be done after the Secondary Assessment?

Reassess: - Primary survey, - VS - Pain - Any injuries

What causes the tertiary effects of blast traumas?

Results from individuals being thrown by the blast wind. Injuries include hole or partial body translocation from being thrown against a hard service: blunt or penetrating trauma's, fractures, traumatic amputations.

What is an epidural hematoma and its S/S?

Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly: - Compression of underlying brain - rapid increase in ICP - Decreased CBF - Secondary brain injury * Usually requires surgical intervention S/S: - Transient LOC - Lucid period lasting a few minutes to several hours - Rapid deterioration in neurologic status - Severe H/A - Sleepiness - Dizziness - N/V - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma

Define Pneumothorax.

Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea.

Sample is part of history S symptoms associated with injury A allergies and tetanus status M meds currently on including anticoagulant therapy P past medical hx L last oral intake E Events and environment factors related to the injury

SAMPLE

Pt is at hospital in the right amount of time, right care, right trauma facility, right resources

Safe Care:

labs, wound care, tetanus, administer meds, prepare for transfer

Secondary Reval Adjuncts

H,I

Secondary Survery

Explain Irreversible Shock.

Shock uncompensated or irreversible stages will cause compromises to most body systems. - Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage.

1. Dyspnea 2. Tachycardia 3. Decreased or absent breath sounds on the injured side 4. CP

Simple Pneumo assessment:

can be caused by blunt trauma. air escapes from injured lung to pleural space and negative intrapleural pressure is lost causing partial or collapsed lung

Simple Pneumothorax

Tx is based on size, presence of sx, and stability. For those are aysmpomatic and stable. Observation with or without oxygen. Larger pneumo who are unstable or likely to deteriorate a chest tube is placed.

Simple pneumo interventions:

1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign

Six P's of compartment syndrome:

1. Preparation 2. Preoxygenation 3. Pretreatment 4. Paralysis and Induction 5. Protecting and positioning - v 6. Placement of proof - secure the tube 7. Post intubation - secure ETT Tube, get X-ray for placement

Steps of Rapid Sequence Intubation

in massive transfusion protocol... responsible for dissolving clots

TXA

subdural hematoma

Tearing of the bridging veins is most frequently associated with which brain injury?

Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD.

Tension pneumo

A 14 gauge needle that is inserted into the 2nd intercostal space in the midclavicular line on the affected side over the top of the rib to avoid neuromuscular bundle that runs under the rib. Prepare for chest tube placement.

Tension pneumo intervention

Newton's Second Law of Motion

The acceleration of an object depends on the mass of the object and the amount of force applied.

the decrease coagulopathy .. you will you bleed more

The colder you are the more acidic you are..

Explain adrenal gland response.

When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water.

within 24 hrs of trauma

When is the tertiary survey completed fora trauma pt?

Before the arrival of the pt

When should PPE be placed:

a pertinent medical hx is crucial

Which of the following considerations is the most important when caring for a geriatric trauma pt?

bowel

Which of the following injuries is LEAST likely to be promptly identified?

identifying individuals who made mistakes during the traumatic event

Which of the following is NOT considered a benefit of debriefings?

pericardiocentesis

Which of the following is NOT considered goal-directed therapy for cardiogenic shock?

acidosis

Which of the following is a component of the trauma triad of death?

nausea and vomiting

Which of the following is a late sign of increased intracranial pressure?

flucuation in the water seal chamber

Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system?

advanced age

Which of the following is most likely to contribute to inadequate oxygenation and ventilation?

worsening pneumothorax

Which of the following is possible complication of positive-pressure ventilation?

it can worsen cord damage from an unstable spinal injury

Which of the following is true about the log-roll?

MARCH

Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage?

jaw thrust maneuver to open airway and assess for obstruction. If pt has a suspected csi, the jaw thrust procedure should be done by two providers. One provider can maintain c-spine and the other can perform the jaw thrust maneuver.

While assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should..

ask pt to pen his or her mouth

While assessing airway the patient is alert and responds to verbal stimuli you should..

Describe one fat embolism syndrome is most likely to occur in its characteristics

With longform fractures. Tachycardia, Thrombocytopenia, and petechiae rash.

What is the Munro-Kellie doctrine?

Within the skull 80% his brain, 10% is blood, and 10% is CSF. Any increase of any of the products results in increased intracranial pressure.

What are the most common type of injury associated with chest trauma?

blunt; MVC's. Penetrating; firarm injuries or stabbings

What are the late signs of Increased intracranial pressure

dilated, non-reactive pupil(s); abnormal motor posturing (flexion, extension, flaccidity); Cushing's triad, Unresponsive to per verbal and painful stimuli, bradycardia and decreased respiratory effort

What are the early signs of increased Intracranial pressure

headache, vomiting, behavioral changes that begin with restlessness and may progress to confusion, drowsiness, or impaired judgment

What is the trauma triad of death?

hypothermia, acidosis, coagulopathy

calcium

if a pt has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation?

What are the interventions for Effective/Ineffective Circulation?

- Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation)

What are the late observable signs of symptoms of increased ICP?

- Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia

What are the early signs and symptoms of increased ICP?

- Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement

What are the interventions for Disability?

- If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments - If pt is not alert or verbal, continue to monitor for any compromise to ABC's - If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation.

What is assessed and intervened for Expose/Environmental Controls?

- Remove clothing - Ensure appropriate decontamination if exposed to hazardous material - Keep pt warm - Keep clothing for evidence

What are signs of ineffective circulation?

- Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds

What are you looking for when palpating the chest wall, clavicles and neck?

- Tenderness - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax.

What are the late signs of breathing compromise?

- Tracheal deviation - JVD

How do you confirm ET Tube/Alternative Airway Placement?

- Visualization of the chords - Using bronchoscope to confirm placement - Listening to breath sounds over the epigastrum and chest walls while ventilating the pt - CO2 detector - Esophageal detection device - Chest x-ray

What is kinematics?

A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body.

pressure

An intubated and sedated pt in the ED has multiple extremity injuries with the potential for causing compartment syndrome. What is the most reliable indication of compartment syndrome in a patient who is unconscious?

What is vascular response?

As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP.

Mitigation

Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster . Which phase of the disaster life cycle does this describe?

after a physical examination if the pt has no radiologic abnormalities on CT

EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The pt is asking to have the cervical collar removed. When it is appropriate to remove the cervical collar?

Complete

EMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury?

Multiple requests for water

EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeobs screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance?

What is Surgical Cricothyrotomy?

Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include: - Aspiration - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis

Explain Hypovolemic Shock.

Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes: - Blood loss - Burns, etc.

How do you inspect the chest for adequate ventilation?

Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?) - JVD or tracheal deviation? (Tension pneumothorax)

What is Needle Cricothyrotomy

Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema

What is renal response?

Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes: - Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion.

Explain Distributive Shock.

Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities.

Explain Obstructive Shock.

Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock

Explain Cardiogenic Shock.

Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: - MI - Blunt cardiac injury - Mitral valve insufficiency - dysrhythmias - Cardiac Failure

Explain Pulmonary Response.

Tachypnea happens for 2 reasons: 1. Maintain acid-base balance 2. Maintain increased supply of oxygen * Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli.

hemoglobin does not readily release O2 for use by the tissues

What is the effect of hypothermia on the oxyhemoglobin dissociation curve?

a 52 y/o diabetic male with a partial thickness burn to the left lower leg

Which of the following patients warrants referral to a burn center?

narrowed

Which of the following pulse pressures indicate early hypovolemic shock?

to guage end-organ perfusion and tissue hypoxia

Why is a measure of serum lactate obtained in the initial assessment of a trauma patient?