Trauma

Airway Management

-Intubate (do this sooner rather than later) whenever airway compromise is present of imminent -Be prepared for difficult airway -Maintain spinal immobilization -Surgical airway may be required w/ severe face/neck injury (trach)

Open Pneumothorax

-It occurs when there is a large open wound in the chest wall. -When wound is > 2/3 the trachea diameter -Inspiration pulls air in through the wound into the pleural space -Air does not flow through the trachea into the lungs -Ventilation is ineffective -Lethal hypoxia and respiratory failure can occur.

Why would refusal of Blood products

-Jehovah's Witnesses -Concern about safety of the blood supply -Previous transfusion reaction -Desire to avoid getting blood unless critical

Spinal cord Injuries

-Loss of sensation and/or movement -Pain if nerve damage present -Loss of bowel and bladder control -Numbness and tingling

Risk Factors: Other

-Male Driver -Aggressive driving/speeding - Impaired driving --Distracted driving --Impaired driving --Drowsy driving

Penetrating Trauma: Gunshot Wounds

-Medium-velocity or high-velocity injuries -Damage done also to structures adjacent to the path of the bullet -Dense organs (liver and spleen) undergo more damage because they absorb more energy

Dashboard Knee- Treatment

-Pain relivers and anti-inflammatories -Joint aspiration, if needed -Surgery, if needed

Promote Mobility

-Provide active and passive exercises at least every 8 hours -Help the client turn, cough, and deep breath at least q 2 hours -Special bed if patient unable to reposition -Monitor for manifestations of DVT

Airway Tools

-Suction -Bag-valve mask attached to high flow oxygen -Oral and nasal airways -Rescue airways (Combi tube, Laryngeal mask airway) -Endotracheal tubes in a range of sizes -Cricothyrotomy kit -Laryngoscopes, including range of description size blades and handles - Adjunct intubating devices

Tranexamic Acid (TXA)

-TXA helps prevent the body from prematurely breaking down clots -Doesn't make new clots, only helps protect existing clots -Research has shown it safely reduces bleeding in children and adults for surgeries and procedures. -Military using for combat trauma injuries with positive results -Inexpensive

Airway Life Threats: Burns

-Thermal Injuries can cause airway edema - Inhalation injury can cause hypoxia

Penetrating Injuries: Other

-Usually caused by sharp, impaling object (Knives, broken bottle, ice pick) -Low velocity injury -Hemorrhage and Infection are most significant mechanisms responsible for mortality and morbidity

Common Injuries from MVA

-Whiplash -Head and Brain Trauma -Spinal Cord Injuries -Facial Injuries -Internal Organ Damage -Dashboard Knee

Flail Chest

-fracture of two or more adjacent ribs in two locations -Paradoxical movement of chest wall section -impairs ventilation directly -Associated w/ pulmonary contusion ◦Chest wall deformity noted on exam ◦Infiltrates noted on Chest x-ray ◦Supportive Treatment

Psychosocial supprt

-trauma is sudden and not predicted -Possible PTSD -Long-term consequences -Need empathy, understanding, or support

Diffuse Axonal Injury (DAI)

Brain injury with scattered lesions over the widespread area in white matter as well as gray matter. Most common type of TBI. Cause of unconsciousness and persistent vegetative state after severe head trauma.

Cullen sign

Characterized by edema, bruising, and discoloration of the fatty tissue surrounding the umbilicus.

Cardiac Tamponade

Compression of the heart caused by fluid collecting in the sac surrounding the heart Symptoms: ◦Dramatic drop in blood pressure ◦Shortness of breath ◦Lightheadedness ◦Chest Pain ◦Tachycardia and palpitations ◦Tachypnea

Direct Thrombin Inhibitors: Dabigatran

Dabigatran (Pradaxa) ◦Idarucizumab ◦Activated PCC ◦Antifibrinolytic agent (eg, tranexamic acid, epsilon-aminocaproic acid) ◦Anticoagulant discontinuation ◦Blood Transfusion if needed

Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints 3-8 major brain injury 9-12 moderate 13-15 mild brain injury

Hemorrhagic Shock

To decrease bleeding: -Apply pressure to external wounds -Apply splint to possible femur fracture -Apply pelvic binder to possible pelvic fracture If patients is pregnant, she should not be on her back, put her on her left side

Trauma Receiving Facility

Trauma Receiving Facility A Trauma Receiving Facility (TRF) is a designated facility that may include a hospital with no surgical coverage, to a small rural clinic. These facilities will provide initial resuscitation and stabilization and, as needed, will transfer critically injured patients to a higher level trauma facility.

Tension Pneumothorax S/S

small open wound allows air but does not allow air out -Unilaterally absent breath sounds on side of injury -Respiratory distress, may have external injury -Tachypnea -Hypoxemia -Tracheal deviation away from the pneumothorax -May have tachycardia and hypotension from obstructive shock -Usually diagnosed clinically, but will be visible on x-ray also

Risk Factors:Teen Drivers

teen drivers ages 16 to 19 are nearly three times more likely than drivers aged 20 and older to be in a fatal crash.

Risk Factors: Elderly

uInvolvement in fatal crashes, per mile traveled, begins increasing among drivers ages 70‒74 and are highest among drivers ages 85 and older. This trend has been attributed more to an increased susceptibility to injury and medical complications among older drivers rather than an increased risk of crash involvement.

Penetrating Abdominal Trauma

uSite of injury uGunshot: Most commonly small bowel, colon, and liver uStab wounds: Most commonly liver, small bowel, and diaphragm

Circulation Management

◦Control external hemorrhage with direct pressure ◦Ensure adequate IV access (2 large bore peripheral IV, IO, or "Trauma line") ◦Use isotonic crystalloid (vs. blood transfusion) ◦Emergent treatment is based on underlying injury

Circulatory Life Threat

◦Hemorrhagic Shock ◦Obstructive Shock ◦Tension Pneumothorax ◦Cardiac Tamponade

Tension Pneumothorax Diagnostics

◦Hypoxia: Mechanical compression of both lungs ◦Impaired Cardiac Filling: Direct compression of the heart ◦Impaired Venous Return: Increased Intrathoracic Pressure

Disability Management

◦If GCS < 8, intubate for airway protection ◦Supportive care is used to optimize oxygenation and perfusion ◦Emergent cranial imaging includes non-contrast CT ◦Emergent management is based on CT findings

Disability Assessment

◦Level of Consciousness (AVPU or GCS) ◦Pupillary Function ◦Four extremity movement ◦External Signs of Head/Neck Injury ◦Check Glucose

Breathing assessment

◦Look: Respiratory effort, note injuries ◦Listen: Equal breath sounds ◦Count: Respiratory rate ◦Monitor: Oxygen saturation

Neurological Life threats

◦Penetrating Cranial Injury ◦Intracranial Injury ◦Diffuse Axonal Injury ◦High Spinal Cord Injury ◦Intracranial Hemorrhage ◦Subdural Hematoma ◦Epidural Hematoma ◦Subarachnoid Hemorrhage ◦Intraparenchymal or Intraventricular Hemorrhage

Tension Pneumothorax

◦Pneumothorax occurs when air enters the pleural cavity, caused by lung injury ◦Tension Pneumothorax is caused by a one-way valve effect ◦During inspiration, air enters the pleural space. ◦During expiration, air is unable to exit pleural space. With each breath, more air is added

Diagnostic Studies

◦Portable X-rays -◦AP chest -◦Lateral cervical spine -◦Pelvis ◦Ultrasound (FAST exam) -◦Detect pericardial and intraperitoneal blood ◦Emergency Computed Tomography ◦Electrocardiogram ◦Laboratory Tests ◦Pregnancy Test ◦Blood Type and Match ◦Hemoglobin and Hematocrit ◦Arterial blood gas initially ◦Urine drug screen, blood alcohol level, and glucose

Second Survey

◦Primary survey complete and resuscitation efforts started ◦Identify all injuries with thorough head-to-toe assessment ◦Repeat VS, and assess for response to resuscitation efforts ◦Review patient hx, collect critical data about patient

Exposure/Environment and Secondary Survey

◦Remove all clothing/coverings ◦Avoid hypothermia ◦Complete head to toe exam ◦Examine axillae and perineum ◦Roll over to examine back (maintain C-spine immobilization) ◦Don't forget back of head/neck in collared patients

Special Considerations: Cold Injuries

◦Rewarm gradually

Special Considerations: Burn

◦Stop the burning process ◦Full thickness burns of extremities or thorax may require escharotomies to prevent compartment syndrome and impaired ventilation ◦With upper airway burns or inhalation injuries, early intubation and mechanical ventilation are indicated

Pulmonary Life Threats

◦Tension Pneumothorax ◦Open Pneumothorax ◦Flail Chest ◦Massive Hemothorax

Special Considerations: High-Voltage Electrical Injuries

◦Tissue Injury may not be apparent ◦Continuously monitor urine output ◦Continuous cardiac monitoring

Nursing Interventions

-ABCDE -Promote Fluid Balance -Prevent Infection -Promote Mobility -Offer Spiritual Comfort Measures

Hemorrhagic Shock

-Assess the Circulation Signs of hypoperfusion •Confusion, lethargy or agitation •Pallor or cold extremities •Weak or absent radial and femoral pulses •Tachycardia •Hypotension

Penetrating Trauma to Extremities

-Ballistic Injuries -Stab Injuries -Vascular Injuries -Nerve Injuries -Musculoskeletal Injuries

Infection

-Careful hand hygiene practices -Use strict standard precautions and aseptic technique when caring for wounds -Take and record vital signs every 2-4 hours -Provide adequate fluids and nutrition -Assess for manifestations of gas gangrene -Assess status of tetanus immunization -Use strict aseptic technique for inserting catheters, suctioning, etc.

Massive Hemothorax

-Collection of blood in the pleural space -caused by blunt or penetrating trauma -Treatment: Chest tube

Pre-Hospital Phase

-Coordination and communication with the receiving hospital so that the trauma team can be alerted and mobilized -Airway maintenance -Control of external bleeding and shock -Keeping the patient immobilized -Information gathering: Time of injury; related events; patient history. Key elements are the mechanism of injury to alert the trauma team to the degree and type of injury.

Management w/o Blood Products

-Correct coagulopathy and enhance hemostasis -Improve oxygen delivery -Optimize red blood cell production --Iron deficiency: IV iron --Folate deficiency: IV folic acid --Vitamin B12 deficiency or folic acid supplementation: IV or IM vitamin B12 --Renal failure: IV erythropoietin, if acceptable -Autologous Blood Transfusion

Healthcare Worker Violence

-ER and psychiatric unit nurses experience high levels of assault at the hands of clients -Healthcare workers are more likely to be attacked than prison guards or police officers. -Low job satisfaction, low retention rates, difficult recruitment, and detrimental effects

Treatment of Pneumothorax

-Emergent treatment is needle decompression. insert needle at second intercoastal space, midclavicular line -14-gauge Angiocatheter attached to a syringe. physician does this but the nurse assists. -Will need chest tube

Hemorrhagic Shock

-Examine the abdomen for tenderness or guarding Carefully assess pelvic stability. -Large volumes of blood may be hidden in thoracic, abdominal and pelvic cavities, or from femoral shaft fractures. -Ultrasound (FAST)

Head injury to Brain (Bruising, bleeding, and or swelling)

-Headache -Sensitivity to light, blurred vision -Nausea, dizziness, balance problems - Change in memory -Seizures and coma

Spinal cord injuries: Treatment

-Immobilization of the spine -Sedation -Methylprednisolone -Surgery, if possible -Physical therapy and rehabilitation -Pain medications

Whiplash treatment

- pain relievers - Muscle relaxants - lidocaine injections - Ice and Heat therapy - Physical therapy - Immobilization collar

Head Injury to Brain: diagnostic tests

- CT, MRI, and/or ECG - Application of Ice -Surgery, if needed for brain injury -Physical and/or speech therapy, if needed (may need to relearn everything)

Common Injuries from Seatbelt

- Fractured ribs - Fractured collar bone - Internal injuries - Organ Damage - Potential for punctured lung

Whiplash

- Neck stiffness and pain - Dizziness, blurred vision -headaches -Ringing in ears - Concentration and memory problems

Dashboard Knee

- Pain in the knee -Pain worse w/ bending or walking up stairs -Instability in the knee

Emergency Management w/o Blood Products

- Treat according to the accepted standard of care, if wishes unknown - Maintain hemodynamic stability: IV fluids, vasopressors, etc. - Reduce further blood loss: Consider blood loss when choosing procedures, and limit phelebotomy

Prevention of Motor Vehicle Deaths

- Use a seat belt in every seat, every trip -Children always properly buckled in the back seat in a car seat, or seat belt. whatever is appropiate - choose not to drive when impaired - Obey speed limits - drive w/o distractions

Hemorrhagic Shock

1. Send blood for type and crossmatch 2. Obtain two large bore IV catheters 3. If systolic BP,90 mmHg or pulse >110 bpm: -Give 500 mL bolus of Ringer's Lactate or NS -Keep patient warm -Reassess vitals -If still hypotensive after 2L of crystalloids, transfuse blood

Community Trauma Hospital

A Community Trauma Hospital (CTH) is a designated facility that typically does not have twenty-four (24) hours per day coverage of its emergency department. A CTH will typically have only one (1) surgeon on staff. With these exceptions, these facilities are similar to an Area Trauma Hospital and may serve as a referral center for Trauma Receiving Facilities.

4. The nurse is providing care to a client who was severely injured as the result of a motor vehicle crash (MVC). The client was the driver and the spouse died as the result of the accident. The client is exhibiting symptoms of grief. Which nursing action is most appropriate for this client A. Help the client understand that working through feelings about what occurred is an ongoing process. B. Ask the health care provider for an inpatient psychiatric referral. C. Tell the client that his family and friends will be his support system in this situation. D. Let the client know that anger directed toward the staff is not a positive way to deal with the MVC.

A. Help the client understand that working through feelings about what occurred is an ongoing process.

Mechanism of Injury**

Acceleration - sudden acceleration of the body MOA: whiplash Deceleration- Sudden slowing or stopping Crushing - ex.legs in dashboard being crushed Compression- Didn't crush but they were compressed Shearing- cutting or shearing of body part Penetrating Injuries- goes through. ex. bullet Inhaling Injuries Burn or Freezing Injuries Blast Injuries

Key Points to Keep in Mind During Primary Survey

Airway Obstruction is a major cause of death immediately following trauma Definitive guidelines for tracheal intubation in trauma do not exist Unintended extubation is the most common preventable cause of morbidity in trauma patients. ◦Unconscious patients with small pneumothoraces that are not visible or missed on the initial chest radiography may become tension pneumothoraces after tracheal intubation from positive pressure ventilation. ◦Hemorrhage is the most common preventable cause of mortality in trauma. Hypotension generally does not manifest until at least 30 percent of the patient's blood volume has been lost. ◦Brain injuries are common in patients who have sustained severe blunt trauma and even a single-episode of hypotension increase their risk of death.

Types of Traumas

Minor Trauma vs Multiple Trauma Intentional vs. Unintentional Blunt trauma vs Penetrating Trauma

Area Trauma Hospital

Area Trauma Hospital An Area Trauma Hospital (ATH) is a designated facility that has the facilities and surgical capabilities to provide care for the majority of injured patients. Are Trauma Hospitals may serve as a referral center for Community Trauma Hospitals and Trauma Receiving Facilities. An Area Trauma Hospital does not require a neurosurgeon on staff.

7. You are caring for a client with a frostbite on the feet. Place the following interventions in the correct order. 1. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C). 2. Remove the victim from the cold environment. 3. Monitor for signs of compartment syndrome. 4. Apply a loose, sterile, bulky dressing. 5. Administer a pain medication. A. 5,2,1,3,4 B. 2,5,1,4,3 C. 2,1,5,3,4 D. 3,2,1,4,5

B. 2,5,1,4,3

5. The nurse assesses a client who was involved in a motor vehicle crash (MVC). The nurse documents tachypnea and dyspnea. Which nursing diagnosis will the nurse use to plan appropriate interventions for this client? A. Altered neurological status B. Altered respiratory status C. Altered circulatory status D. Altered gastrointestinal status

B. Altered respiratory status

2. The nurse is providing care to a client who received sternal injuries as the result of an airbag deployment after a motor vehicle crash (MVC). The client is currently experiencing an abnormal heart rate. Which diagnostic test does the nurse anticipate for this client? A. A CT scan B. An ECG C. A MRI scan D. An EEG

B. An ECG

6. In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Brief neurologic assessment B. Complete set of vital signs C. Client's allergy history D. Initiation of pulse oximetry

B. Complete set of vital signs

10. A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following? A. "What was the initial first aid done?" B. "Where did the incident happen?" C. "What direction did the bullet enter into the body?" D. "How long ago did the incident occur?"

C. "What direction did the bullet enter into the body?"

3. The nurse is caring for a client experiencing seizure activity after a motor vehicle crash (MVC). Which diagnostic test does the nurse anticipate will be ordered for this client? A. An ECT B. A Urinalysis C. An EEG D. An ECG

C. An EEG

9. A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock? A. Cardiogenic B. Distributive C. Hypovolemic D. Obstructive

C. Hypovolemic

1. During the assessment of a client with a spinal cord injury that resulted from a motor vehicle crash (MVC), the nurse determines that the client has a poor cough with breathing. Based on this finding, which is the most appropriate action by the nurse? A. Place the patient in a prone position to promote the drainage of secretions. B. Assess lung sounds and respirations every 1-2 hours. C. Prepare the client for intubation and mechanical ventilation. D. Use tracheal suctioning to remove secretions.

C. Prepare the client for intubation and mechanical ventilation.

What suggests a direct laryngeal or tracheal injury?

Crepitus

Critical Information

Get AMPLE Information ◦A Allergies ◦M Medications ◦P Past Medical History ◦L Last Meal ◦E Events or Environment Related to the Injury

Emergent Treatment: Hemorrhagic Shock; Tension pneumothorax; Cardiac Tamponade

Hemorrhagic Shock: Localize/Control Bleeding Tension pneumothorax: Needle Compression Cardiac Tamponade: Pericardiocentesis

Airway Life Threats: C-spine Injuries

Immobilize C-Spine High C-Spine injury will impair respiratory drive (C3-C5)

Primary Survey

Initial Assessment Start w/ ABCDE A- Airway B- Breathing C- Circulation D- Disability E- Exposure and Environment

What is Trauma?***

Injury to human tissues and organs resulting from the transfer of energy from an external force

Circulation Assessment

Look ◦Color ◦Level of Consciousness ◦Capillary Refill ◦External bleeding Feel peripheral pulse strength oCarotid SBP > 60 oFemoral SBP > 70 oRadial SBP > 80 oDorsalis Pedis SBP > 90 Monitor oPulse oBlood Pressure

Penetrating Chest trauma: Injury

Organ Injury -Mediastinum, pericardium, trachea-brachial tree, diaphragmatic rupture Vascular Injury -Subclavian artery, internal thoracic artery, aorta, vena cava

Regional Trauma Center

Regional Trauma Center A Regional Trauma Center is a designated facility that has the medical staff and facilities to provide advanced care to trauma patients. A Regional Trauma Center also serves as a referral hospital for the Area Trauma Hospitals, Community Trauma Hospitals, and Trauma Receiving Facilities.

Direct Thromin Inhibitors: All the xabans

Rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Lixiana), betrixaban (Bevyxxa) ◦Andexanet alfa (AndexXa), if available ◦4-factor unactivated PCC* (eg, Kcentra) ◦Antifibrinolytic agent (eg, tranexamic acid, epsilon-aminocaproic acid) ◦Anticoagulant discontinuation ◦Blood Transfusion if needed

Penetrating Chest Trauma

Site of Injury -Gunshot Wound -Stabbing May result in: -Pneumothorax -Hemothorax -Rib Fracture

Emergency Management: Subdural/Epidural; Subarachanoid/Parenchymal or DAI

Subdural/Epidural: Surgical Evacuation Subarachnoid/Parenchymal or DAI: Manage Intracranial Pressure, supportive care

Airway Life Threats: Face/Neck injuries

Swelling: Hematoma or edema can compress airway Bleeding: nasopharyngeal bleeding cause aspiration risk Crepitus: suggests direct laryngeal or tracheal injury (popping sound, there is air in there)

Airway Assessment

Talking= Good! What if not talking? Ask why not? Unconscious? GCS<8=intubate Can't phonate? -Assume significant airway injury= emergency airway

Emergent treatment: Tension and Open Pneumothorax; Flail Chest; Massive Hemothorax

Tension: Needle Decompression Open: Occlusive dressing Flail Chest: Supportive (Intubate, ventilate) Massive: Tube Thoracotomy

Anticoagulant Reversal for Severe Bleeding

Warfarin ◦4-factor PCC ◦Vitamin K (intravenous) ◦Hold warfarin Heparin and LMW Heparin ◦Protamine sulfate

Trauma Prep

Who is on your team? What do you prepare for the trauma coming? -People -Supplies -Diagnostics

Grey Turner's Sign

bruising in flank area