Multiple Trauma

What are the 3 phases of shock

1. compensatory 2. progressive 3. refractory (MODS)

Triad of S&S in Fat Emboli Syndrome

1. neuro changes/abnormal 2. hypoxia 3. petechial rash

Conditions in which giving O+ blood is OK

1. pt. is above child bearing age 2. pt. is male

S&S Stage 3 hypovolemia

1500-2000 mL Major decreased CO, worsening vasoconstriction/shunting, decreased UOP, low BP and perfusion, increased lactate -height of compensatory mechanisms

S&S of Stage 1 hypovolemia

750 mL early compensation= increased HR, little increase BP

S&S Stage 2 hypovolemia

750-1500 mL Vasoconstriction in organs to shunt blood to heart, lungs, and brain, SNS response

S&S Stage 4 hypovolemia

> 2000 mL severe compromise!

What is the Primary Survey composed of?

ABCDE: Airway Breathing Circulation Disability Exposure OTHER: comorbidities, pregnancy, substance use

What is the Secondary Survey composed of?

AMPLE: Allergies Medication Past Medical History Last meal (bowel rupture/peritonitis) Events

Blunt Chest Trauma is often the result of what type of forces?

Accelerating/decelerating

What physiologic changes predispose an elderly person to injury?

Delayed response times, diminished senses (vision, hearing), unstable gait/balance, more chronic disease states, neuro compromise maybe, fragile vessels/skin, aged organs, osteoperosis? LIMITED PHYSIOLOGICAL RESERVE (inability to sustain self), lower BMR = HYPOTHERMIA! (blankets, room temp, warm fluid)

What anatomic changes happen during pregnancy that affects traumatic response?

Dilutionally anemic, the mother can have 2500 cc blood loss before hypovolemic S&S occur, BIG HEMORRHAGE RISK

How should the nurse prepare the patient in preparation for a massive blood transfusion?

Large Bore IV access (14, 16 gauge) NS or LR @ KVO Monitor for ARDS S&S with massive transfusion!

If the nurse finds a person with an impaled object in their abdomen, what should she do?

Leave the object in place!!!

What are S&S of a tension pneumothorax?

Mediastinal shift (displaces trachea), Decreased CO, anxiety, restless, palor, dusky lips, Sub-Q emphysema "crepitus", neck vein distension, cyanosis, SOA, absent breath sounds, hypotension, shock

What is Rhabdomyolysis?

Muscle fibers break down and get into circulation and damage the kidneys! --> can lead to acute or permanent RENAL FAILURE

What treatment will the nurse anticipate if a patient has a cardiac tamponade?

Pericardiocentesis (or a pericardial window)

An Rh- mother comes to the ER with a fall injury and suspecting mixing of maternal fetal blood. What should the nurse administer and why?

Rhogam. To prevent hemolytic reaction in Rh- mom (possiblity that baby is Rh+)

What is a complication of Sub-Q emphysema and what is it a sign of?

So much edema can cut off the airway, sign of a Tension Pneumothorax

Describe the "Trauma Triad"

a patient with a severe hemorrage/hypovolemia means decreased O2 delivery and decreased tissue perfusion which leads to 1. HYPOTHERMIA- halts the coagulation cascade causing 2. COAGULOPATHIES so your body tries to burn glucose for E and turns to anaerobic metabolism, leading to lactic acidosis and 3. METABOLIC ACIDOSIS *vicious cycle!

Acceleration vs. Deceleration

accel= going fast into something Decel= abrupt stop into something MOST COMMON mechanisms of injury - common head and SCI

What is Vena Cava Syndrome and how can a nurse prevent it?

When a pregnant woman lies on her back, her vena cava is compressed and causes major hypotension. The nurse must lay her LATERAL to prevent this and get blood to the vena cava.

What is included in the nursing management of a pelvic injury?

1. Volume resuscitation if hemorrhage 2. STABILIZE the pelvis (internal/external fixation, etc) ***DO NOT move the pt. until stabilized! Monitor neurovascular system (pain, pulses, paresthesia, paralysis, pallor)

Hemodynamics expected in hypovolemic shock

Decreased CO, SVR, and SvO2 - hypoxia, hypotension, acidosis!

What are the S&S of a pulmonary contusion and when is the time of onset often?

"bruised lung" from rapid compression/decompression ARDS like- stiff lungs, poor O2, chest discomfort (from mild HR and RR and blood tinged sputum, to moderate, to severe ARDS S&S) delayed onset 24-72 hours

S&S of pelvic injury?

"rocking" of illiac crests, hematuria, perianal ecchymosis, pain on palpation, LE paresis/rotation **Confirm with CT Scan

What is the management for Flail chest?

*Stabilize the chest! 1. Pain control (narcotics, NSAIDS, nerve blocks) 2. pulmonary toilet! (RISK atelectasis, pneumonia!)

List factors that may affect a person's physiological response to trauma/injury

-Comorbidities- heart disease, renal disease, DM, polypharmacy (*Beta Blockers wont increase HR with hypovolemia, Anticoagulant therapy) -Substance Abuse (problems w/ LOC assessments--> ***FOLLOW W/D PROTOCOL TO PREVENT W/D S&S, get a history!!!) - Advanced age - Pregnancy

Define Flail Chest and how can it be identified?

-Ribs broken in more than one place causing free floating ribs in chest cavity - PARADOXICAL BREATHING- flail segment moves IN on inspiration and moves OUT on expiration b/c P changes - pain w/ history severe chest trauma, diminished breath sounds, abnormal ABG

What is a tension pneumothorax?

Air is sucked into the lung during inspiration but not released on expiration (one way valve)

What are the signs of a Cardiac Tamponade?

Beck's Triad: 1. Increased RAP 2. Muffled heart sounds 3. hypotension Also, Pulsus Paradoxus= >10 mmHg decrease in SBP on inspiration

What is the biggest risk for a pelvic injury?

Bone fragments cut vasculature!!! SHOCK!!!

Why is hypothermia always BAD in trauma pts?

Cold Hgb cananot release O2 to the tissues as well as normothermic Hgb

Cullen's Sign vs. Grey Turner's Sign and what are they indicative of

Cullens= periumbilical ecchymosis Grey Turner= flank ecchymosis Indicative of LATE abdominal bleeding (also look for ABD girth, distention, guarding)

What is the biggest complication of a Long Bone fracture?

Fat Emboli (OR Emergency), Acute Compartment Syndrome, Hypovolemic Shock

Most likely injuries seen if a pedestrian is hit by a car

Fractures (femur, tibia, fibula, knee) TBI Chest injury (child)

Describe the CPR protocol for a pregnant trauma victim who is experiencing cardiac arrest.

If the woman is MORE than 24 (6 months) weeks pregnant, an emergency c-section is done in the ER and CPR will occur DURING and AFTER the c-section. (Not enough SV)

What is blunt trauma?

Injury from external forces without disrupting skin integrity (injuries can be hidden!!!) *MVA* - bruising is a clue!

What are the goal end points for resuscitation?

MAP >70 HR < 100 UOP >30ml/hr Skin warm/dry SvO2 65-80% Lactate < 2.0 BD/BE +- 3.0 *treat shock and prevent MODS*

What is the biggest concern for a patient who has had a traumatic abdominal injury? What is one way it can be identified?

MASSIVE HEMORRHAGE--> shock! - Leads to intrabdominal HTN (IAH) from increased volume in abdominal cavity, which decreases venous return

Universal Blood Donor

O-

What does the management include for a pulmonary contusion?

Oxygen, intubation, sedation, pain control, Rotaress bed (mobilize fluid in lungs)

What is the treatment of a tension pneumothorax?

RELEASE THE PRESSURE (large bore needle inserted), No CXR when detect

Define Blast Effect

Tissue and vascular damage that happens from projectile injury

What is the purpose of the Secondary Survey?

To find ALL injuries. *NOTE: if problem found, STOP and address it, then resume secondary survey

What is the average distribution of fatal injuries?

Trimodal: 1. Most- at scene/en route (brain, aorta, heart, C spine) 2. Less- in ED/OR 3. Least- ICU (days-weeks later)- Sepsis, MODS/SIRS, ARDS

What is the nursing management for Rhabdomyolysis?

aggressive fluid hydration (bolus with diuretics) to flush kidneys and increase UOP, electrolyte replacement (from loss in urine), monitor for MYOGLOBIN in urine (+ in Rhabdo)

Types of MEDIUM energy penetrating missiles

handgun, some rifles

Most likely injuries seen if pt. was an unrestrained driver

head/face, liver, spleen, bowel fracture- ribs, sternum, femur, hip Contusions- pulmonary/cardiac SCI

The _____ the speed and force applied, the _____ the damage/injury!!!

higher, greater

Types of HIGH energy penetrating missiles

hunting rifle, shot gun (high E can be displaced and cause more injury!)

Types of LOW energy penetrating missiles

knives, arrows, etc. (tend to be more localized than a GSW)

The primary trauma assessment of a pregnant woman should focus on the _____ and the secondary assessment can focus more on the ______

mother, fetus. *Note: resuscitation meds are dosed for the MOTHER

Define Yaw

object moves around horizontally

Define Tumbling

object tumbles forward in projectile injury

Body's response in Compensatory Shock include

release of epinephrine (increase HR and contractility) and norepinephrine (vasoconstriction) to compensate. body retains fluid. Increased RR to blow of CO2

What are potential causes of Rhabdomyolysis?

untreated compartment syndrome crush injuries muscle breakdown from laying in same position (unconscious somewhere???) extreme exercise

What lab values are most reflective of true volume deficit?

serum lactate (<2.o) and BD/BE (+-3.0) *Note: metabolic acidosis is best indicator of shock!

Compression

squeezing/pressed w/ resulting decrease in size - common abdomen, fractures

What are S&S of Acute Compartment Syndrome and how is it treated?

unusual amount of pain on palpation, decreased ROM, edema Treat with Fasciotomy

Shearing

tearing, often with rotation - common head, SCI, abdominal, fractures

Define Cavitation

temporary cavity formed from KE (lateral and forward)

What is the purpose of the Primary Survey and Resuscitation?

to find life-threatening conditions! stabilize the patient *NOTE: if a life-threatening condition is discovered, STOP and address the problem/stabilize, the resume assessment ***ALWAYS ASSUME SCI!!!