AN III Test 6 Trauma
Open Pneumothorax
-Aka "sucking chest wound" -Open communication between the atmosphere & intrathoracic pressure; results in immediate lung deflation -Air moves in & out of the hole in the chest producing a sucking sound on inspiration -Symptoms same as tension pneumo; may have subcut. emphysema around the wound
Thoracic Trauma - Aortic Injury signs and symptoms
-BP changes between upper extremities -Pulse deficit at any site -Unexplained hypotension -Sternal pain -Sensory deficits in lower extremities -Nurse must check BP in both arms and compare BP in upper extremities to BP in lower extremities (baroreceptors are stimulated causing hypertension in upper extremities & lower BP in lower extremities.
Trauma to the Liver nursing care
-Blood products, monitor drainage, maintain fluid balance -Monitor for coagulopathies -Bleeding from several sites will be seen -Blood product replacement to treat
Contusion
-Blow resulting in hemorrhage of brain microvasculature; secondary brain injury is common -Usually focal & superficial but may extend to deeper layers of the brain. Large contusions may result in decreased LOC & coma. Complications include cerebral edema which peaks 24-72 hours after the injury.
what are the signs and symptoms of a pulmonary contusion
-Hypoxemia -dyspnea -moist crackles -hemoptysis -tachypnea -Mimics ARDS in that lung tissue is poorly responsive to high fractions of inspired oxygen
Tension Pneumothorax treatment
-Immediate decompression with a 14-gauge needle inserted into the pleural space - an immediate rush of air should be heard -Chest tube inserted following decompression
Cardiac Tamponade treatment
-Immediate treatment is necessary! -Pericardiocentesis (aspiration of blood from the pericardial sac) -Surgical intervention to locate & control source of bleeding Diagnosed with: Echocardiogram
Hemothorax management
-Resuscitation with IV fluids -Chest tube to drain blood -Autotransfusion device may be used -May require thoracotomy if injuries to major structures or if bleeding continues -≥ 200 mL/hr for 2-4 hours or more than 1500 mL on initial tube insertion
Emergency Department Resuscitation: Damage control resuscitation
-Short ED treatment times -Stop the bleeding & correct physiologic abnormalities then perform surgery ASAP -Goal is to prevent lethal triad of acidosis, coagulopathy, & hypothermia
Trauma to the Hollow Organs
-Stomach, small & large intestines -Difficult to diagnose; hard to see on imaging studies -Intestinal contents leak into the peritoneum causing peritonitis which can lead to sepsis -Treatment: surgical resection & repair -Monitor closely for abscess, fistula, or sepsis development
Diffuse Axonal Injury
-Tearing & shearing of axons which worsens during the first 12-24 hours; prolonged or disabled signal conduction from white matter to gray matter; may be mild, moderate, or severe
*Late complications of splenectomy*
-Thrombocytosis (increased platelet count) -Increased risk of infection & streptococcal pneumonia with overwhelming postsplenectomy sepsis (OPSS) (OPSS occurs often and has a high mortality rate especially when it occurs within 1 year of surgery.)
what are signs and symptoms of ruptured diaphragm?
-bowel sounds heard in the chest -shoulder pain -shortness of breath -abdominal tenderness
signs and symptoms of Rhabdomyolysis
-tea colored urine - +myoglobin in the urine -elevated creatine kinase levels
Impact of Traumatic Injury on Family
-Crisis situation for which they have had little time to prepare -Emotional: anger, fear, powerlessness, confusion, mistrust -Very important to include and support family in all aspects of care -Trauma family support groups -Many peaks & troughs during recovery from trauma... can be a very long haul with lots of good days & bad days.
Trauma to the Bladder nursing considerations
-DON'T CATHETERIZE if blood seen at urethral meatus, scrotal hematoma or if prostate displaced. -DO CT first!!! -Suprapubic catheter may need to be placed instead of Foley. -Infection is main complication
Abdominal Compartment Syndrome signs and symptoms
-Decreased cardiac output -Increased pulmonary peak pressures -Decreased urine output -Hypoxia
Penetrating Trauma: Extent of Injury depends on...
-Density and compressibility of the tissue injured -Missile's velocity (low vs. high) -Fragmentation of the primary missile
Skull fracture: Depressed
-Depression of the skull over the area of impact; may be compound (open wound). -Bone fragments are driven into the underlying brain tissue.; may require surgical intervention
Emergency Department Resuscitation: SECONDARY SURVEY
-Done once pt is stabilized and the primary survey is complete -More detailed history & head-toe assessment -Diagnostic testing (x-rays, US, CT, angiography) -Other injuries may be uncovered esp. if pt is unable to speak (Pt may be unable to speak due to an ET tube, sedation, pain medication or decreased LOC.) -The secondary survey uncovers non-life threatening injuries. (It is important to constantly reassess the trauma patient bc injuries can go undetected.)
Trauma to the Spleen nursing interventions
-Due to vascularity, loses blood rapidly. -Observation period of 5 days is the standard. -Monitor carefully for hypotension and signs of bleeding. Complications include rebleeding, abscess, & pancreatitis. -Minor injuries treated w/ observation, serial CT's, serial H&H's, NG tube for gastric decompression
Clinical Manifestations of tension pneumothorax
-Dyspnea, tachycardia -Hypotension -Sudden chest pain -Tracheal deviation away from the injured side -Decreased or absent breath sounds on injured side -Hyperresonance to percussion of injured side -May be difficult to diagnose because of other injuries and shock that may muddle the symptoms.
EAST guidelines for Screening of BCI (Blunt Cardiac Injury)
-ECG on admission for suspected BCI -If ECG abnormal, admit for continuous cardiac monitoring -If ECG normal & troponin normal, BCI is ruled out -If patient hemodynamically unstable, echocardiogram may be performed
Abdominal Trauma signs and symptoms
-Entry and exit sites -Grey Turner sign (purplish discoloration of flanks indicative of retroperitoneal bleed) -Cullen sign (purplish discoloration of umbilicus indicative of blood in the abd wall) -Abdominal distension may indicate accumulation of blood, fluid, or gas d/t perforated organ or ruptured blood vessel -Rebound tenderness, rigidity
What does flail chest look like?
-Flail segment moves paradoxically compared to the rest of the chest wall -During inspiration, the intact portion of the chest wall expands while the injured portion is sucked in. During expiration, the chest wall moves in, while the flail segment moves out.
Genitourinary Injuries Assessment
-Flank pain -Rebound tenderness -Blood at the urinary meatus -Grey Turner sign -Perineal discoloration -Hematuria (most common sign)
Skull fracture: Basilar skull fracture
-Fracture at the base of the skull. Occurs at the base, or floor, of the skull; may be linear or displaced -symptoms include *otorrhea, rhinorrhea, Battle's Sign, & raccoon eyes*
3 problems that can occur with Trauma to the Kidneys
-Free hemorrhage -Contained hematoma -Intravascular clot development -All 3 of these problems that can occur decrease perfusion to the kidney by some form or another. With hemorrhage, it's by loss of intravascular blood. A hematoma or clot development can decrease circulation to and from the damaged kidney.
Flail Chest
-Fx of 2 or more consecutive ribs in 2 or more places and are no longer attached to the thoracic wall causing an unstable segment of the chest (free floating)
History Blunt trauma
-Height of fall -MVC: extraction time, ejection, steering wheel deformation, location in the automobile, restraint status, speed, direction of impact, occupants (number & morbidity status)
Trauma to the Kidneys signs and symptoms
-Hematuria -pain -ecchymosis over the flank (Grey Turner's sign)
Lethal Triad of Trauma
-Hypothermia -Acidosis -Coagulopathy -The combination of these 3 symptoms increases risk of death for a trauma victim.
Clinical manifestations of hemothorax
-Hypovolemic shock -Diminished or absent breath sounds on affected side -Collapsed neck veins -Hypotension -Dullness to percussion on affected side
Trauma to the Spleen signs and symptoms
-L upper quadrant pain radiates to L shoulder (Kehr's sign) -Hypovolemic shock -Elevated WBC count
Solid Organs
-Liver -Spleen -Pancreas -Kidneys
Low-velocity vs high velocity injuries
-Low-velocity injuries localize the injury to a small radius from the center of the tract. *They cause very little cavitation, really only pushing the tissue in the pathway aside.* (stab wounds, impalements) -With high velocity injuries, more serious injuries occur because the "missile" usually causes cavitation (forming of a cavity around the ammunition) and have more energy behind them. High velocity bullets are an example of a high energy missile. These bullets compress and push tissue away from the *bullet forming a cavity around the bullet and it's entire path through the body.*
ICP Management (recommended for GCS < 8)
-Maintain ICP < 20 mm Hg -Neuro checks every 1-2 hours -Maintain CPP > 60-70 mm Hg (CPP = MAP - ICP) -Maintain adequate oxygenation (intubate if GCS < 8)
Nursing Interventions to Decrease ICP
-Maintain proper body alignment (head in neutral position & avoid hip flexion) -Keep HOB elevated 30 degrees unless contraindicated -Quiet environment, cluster care, provide rest periods -Maintain normothermia -Prevent & treat seizures -Administer Mannitol as ordered -Administer pain meds, sedatives, &/or paralytics as ordered
Complications of Trauma: Infection
-Major source of morbidity & mortality -Risk factors for trauma patients: +Wound contamination (Wounds: dirt, grass, debris at the time of injury or bacteria from the healthcare environment/personnel; GI rupture & spillage) +Invasive procedures & catheters +Intubation & mechanical ventilation +Host susceptibility +Critical care environment
Infection Prevention
-Meticulous wound care -Handwashing -Standard interventions for prevention of VAP, CAUTI, CLABSI -Prompt removal of unnecessary invasive lines -Sterile technique for invasive procedures
Severity of Head Injury: GCS scoring for mild, moderate, and severe
-Mild: GCS score 13-15 -Moderate: GCS score 9-12 -Severe: GCS score 3-8
Complications of Multiple Trauma: Hypermetabolism
-Mobilizes amino acids & accelerates protein synthesis for wound healing & to support the immune response -Increases metabolic rate & oxygen consumption -Goal: early aggressive nutrition (initiate enteral feedings within 72 hours)
Trauma to the Spleen
-Most frequently injured organ by blunt trauma -High vascularity, plays role in body's response to infection
"Do Nots" of Trauma
-Never try to remove any impaled foreign object (knife, rebar, etc.) -Never insert anything nasally in head injury patients (NGT, nasopharyngeal airway, etc.)
Blunt trauma
-No break in the skin -More life-threatening b/c diagnosis is more difficult & extent of injury is less obvious -Injuries received due to rapid changes in velocity (either an increase or a decrease) -MVCs, falls, assaults, contact sports -As the body stops suddenly, the tissues & organs continue to move forward. Sudden change in velocity causes injuries that result in lacerations or crush injuries of internal structures.
Blunt Cardiac Injury -Treatment
-Oxygen administration -Continuous cardiac monitoring -Serial cardiac enzymes -Antidysrhythmic medications prn -Treatment of heart failure prn -Maintenance of fluid & electrolyte balance
Pelvic Fractures
-Pelvic fractures are life threatening & need stabilization quickly -Extensive blood loss associated with pelvic fractures -The most common cause of pelvic fractures are MVC's and MV vs pedestrian accidents.
Nursing interventions to prevent OPSS
-Post splenectomy administration of polyvalent pneumococcal vaccine is required to prevent OPSS -Pneumococcal vaccine is effective against many serotypes of streptococcal pneumoniae
Six Phases of Trauma Care
-Prehospital resuscitation -Hospital resuscitation -Definitive care and operative phase -Critical care -Intermediate care -Rehabilitation
Nursing Management to Prevent Complications
-Prevent infection -Recognize early signs of respiratory distress -Relieve pain -Provide adequate nutrition -Prevent renal failure -Evaluate risk for compartment syndrome -Discover missed injuries -Assess for s/sx of SIRS or MODS
Primary goal of treatment for bony thorax fractures
-Primary goal of treatment is prevention of pulmonary complications & patient comfort. -Pain management: NSAIDS, opiates, epidural analgesia, nerve blocks
Trauma to the Liver signs and symptoms
-R upper quad pain -rebound tenderness -hypoactive or absent bowel sounds -hypovolemic shock -Liver is very vascular!! Can cause life-threatening hemorrhage! -Rib fractures increase the risk of a liver injury. There can be a large amount of blood lost into the peritoneum.
Trauma to the Kidneys treatment
-Ranges from bedrest to surgery, monitor I & O, monitor for hematuria, monitor serial H/H, BUN, Cr -Contusions & minor lacs: monitor serial H/H Major lacs & vascular injuries: angiography (embolization) or surgical intervention -Nephrectomy may be necessary in some instances
Critical Care Phase
-Report given to ICU nurse prior to transfer using SBAR method -Constant monitoring: Primary & secondary surveys, Physical assessments, Response to medical therapies -Risk factors promptly identified & treated to prevent life-threatening complications
Pleural Space Injuries -Impaired Gas Exchange signs and symptoms
-Respiratory distress -Altered ventilation -Restlessness -Anxiety -Tachypnea -Decreased oxygenation -Poor color -Diaphoresis -Accessory muscle use, retractions
Complications of Trauma: Pulmonary Complications
-Respiratory failure; acute respiratory distress syndrome (ARDS) -Fat embolism syndrome (Fat embolism: In the lung, the fat droplets are broken down into free fatty acids which are toxic to the lung membranes; lung becomes edematous & hemorrhagic; symptoms resemble ARDS. Best prevention is early stabilization of unstable extremity fractures.) -Complication of ortho trauma; fat droplets leak from fractured bone & embolize to the lungs
Signs and symptoms hypovolemia & HV shock
-Resuscitation Phase: Assess for hypovolemia & HV shock -pale -cool -diaphoretic -prolonged capillary refill time -Remember, decreased perfusion is a top problem -LOC - irritability/confused to loss of consciousness -Resp - tachypnea. Remember, oxygenation is a top problem -Renal - decreased urine output -V/S - increased heart rate, decreased blood pressure
Trauma to the Liver treatment
-Stable: close observation, serial Hgb/Hct & CT -Unstable w/ persistent bleeding: surgical repair w/ drains for bile & blood -Small lacerations are repaired; larger injuries may require resection.
Hollow Organs
-Stomach -Intestines -Gallbladder -Urinary Bladder
Emergency Department Resuscitation: Interventions
-Stop the bleeding (compression or surgically) -Replace the volume (warmed IVF's) rapid infusion of isotonic fluids 1. 2 large bore IVs or a CVL 2. Crystalloids (NS or LR); colloids (albumin, dextran, hetastarch); blood products (PRBC, FFP, platelets, cryoprecipitate) Note: Colloids: encourage movement of fluid from the interstitial spaces into the circulatory system -Obtain blood samples 1. CBC, electrolytes, BUN, Cr, PT/PTT, Type & Screen, amylase, toxicology, LFTs, lactate, pregnancy screen
Thoracic Trauma - Ruptured Diaphragm
-Subtle, nonspecific symptoms (often missed) -Diaphragm ruptures or tears & abdominal organs gradually enter chest cavity - can compress lungs & heart causing decreased venous return & cardiac output -Requires immediate surgical repair -Rapid rise in intraabdominal pressure due to a compression force; i.e. a person thrown forward over the edge of the steering wheel in a high-speed MVC
Abdominal Compartment Syndrome treatment
-Surgical intervention if abd pressure > 20 mm Hg; after decompression, abd may be left "open" for a few days, weeks, or months. -Can measure abd pressure through a foley catheter after injection of 25 mL sterile saline.
Thoracic Trauma - Cardiac Tamponade
-Tamponade is when blood fills the pericardial sac around the heart. Which we are about to go through in more detail right after penetrating cardiac injury. -A symptom of blunt or penetrating trauma -Progressive accumulation of blood (120-150 mL) in the pericardial sac; compresses the atria & ventricles. (Normally, there is about 25 ml of fluid in the pericardial sac to cushion & protect the heart. ) -Leads to decreased venous return & filling pressure resulting in decreased cardiac output, myocardial hypoxia, heart failure, cardiogenic shock
Hemothorax
-The chest cavity will hold most of the patient's circulating blood volume -Source of bleeding = large blood vessel or mediastinal structure -Massive hemothorax = > 1500 mL blood in the chest
The first priority of care in thoracic injuries is always...
-The first priority of care in thoracic injuries is always AIRWAY. This includes immediate airway control and effective oxygenation and protection from aspiration -Airway obstruction may be the result of another injury or it could be the primary problem. The most common causes of airway obstruction are the tongue, avulsed teeth, dentures, secretions and blood. Also culprits in causing airway obstruction are injuries to the trachea, thyroid cartilage or cricoid.
Pelvic Fractures Treatment goals
-The main treatment goals in pelvic fractures is to stop the bleeding, prevent loss of function and prevent infection or sepsis. Pelvic binder or an external fixator temporarily stabilizes the pelvic fracture to control bleeding. Embolization may be indicated for hemorrhage control. -Stabilization: pelvic binder, external fixator w/ traction, surgical repair within 24-72 hrs -Permanent surgical repair usually performed within 24 to 72 hours when patient is hemodynamically stable.
How does flail chest affect the respiratory system
-This movement increases the work of breathing, but hypoxia is generally caused by underlying pulmonary contusions; flail chest may result in decreased tidal volume & impaired cough which result in atelectasis. -As the patient's pulmonary status gets worse, the paradoxical movement of the flail segment increases.
Penetrating Trauma: Severity of Gunshot wound depends on
-Type of gun -Type of ammunition -Distance & angle from which the gun was fired
History Penetrating trauma
-Type of weapon used -Caliber of weapon, number of shots fired, gender of assailant, position of victim & assailant
Subdural hematoma
-Usually a venous bleed that lies between the dura mater & the arachnoid layer -An arterial bleed has more pressure behind it than a venous bleed, so an epidural hematoma usually occurs more rapidly than a subdural hematoma -Treatment: craniotomy or burr holes to remove hematoma
Trauma to the Kidneys
-Usually caused by blunt trauma -A sudden deceleration injury causes the kidney to be thrown out of its normal position. When this happens, blood vessels around and within the kidney are torn or a rupture of the collecting system. Lacerations and contusions can also occur.
Penetrating Trauma
-Wounds caused by impalement or an object passing through tissue -Injury occurs along the path of penetration -Severity is r/t the structures damaged -External appearance is not indicative of internal injury -Injury is caused by the energy created and dispersed by the penetrating object into the surrounding tissues.
Abdominal Trauma Diagnostic tests
-X-ray -OG or NG tube placement (decompresses the stomach & can be checked for blood) -Foley catheter (urine is checked for blood) -Wound exploration -FAST: Focused Assessment Sonography for Trauma (portable & quick; ultrasound probe of various areas of the abdomen to determine presence of free fluid, blood, or free air in the abd. Patients with a positive FAST -free fluid in the abdomen- generally undergo emergency surgery.) -Abdominal CT (Free air or fluid, solid organ injuries)
Penetrating Trauma: Assessment
-find out the nature of the penetrating object, its velocity, length, & trajectory to help identify possible injuries. Injuries from penetrating trauma tend to localized. Obtain a description of the mechanism of gunshot injuries (weapon, ammunition, ballistics). -*So that injuries are not missed, it is imperative that the patient is undressed and assessed for entrance and exit wounds.* Must look at the front of the body, sides and the back of the body.
Epidural hematoma
-usually laceration of the middle meningeal artery between skull & the dura mater; occurs rapidly -May present in a coma or fully conscious. -*Usually brief loss of consciousness followed by period of lucidity then rapid deterioration; dilated & fixed pupil on side of injury* -Surgical intervention to evacuate hematoma
Subdural hematoma- 3 classifications
-Acute: symptoms within 24-48 hrs after injury -Subacute: symptoms 2 days to 2 weeks after injury -Chronic: symptoms appear more than 2 weeks after injury
Pleural Space Injuries - Tension Pneumothorax
-Air flows into the pleural space with inspiration & becomes trapped -As pressure increases, lung on the injured side collapses & causes mediastinal structures to shift to the opposite side -Pressure continues to build exerting pressure on the heart & aorta causing decreased cardiac output -Results in decreased tissue perfusion due to decreased cardiac output and impaired gas exchange (collapsed lung can not participate in oxygen exchange)
Solid organ injury response is
*Bleeding*
Hollow organ injury response is
*Rupture & release of contents causing peritonitis*
Secondary brain injuries: Coma
- alteration in consciousness caused by damage to both hemispheres of the brain or the brainstem
Secondary brain injuries: Ischemia
- decreased blood flow to the brain due to injury or compression r/t edema; occurs when bloodflow is inadequate to meet the brain's metabolic demands
Secondary brain injuries: Persistent vegetative state
- irreversible coma; inability to respond to the environment; patient's eyes open spontaneously with roving eye movements, involuntary lip smacking or chewing may be seen (lower brainstem functions; no upper cortical function)
Secondary brain injuries: Herniation syndrome
- pressure builds, brain tissue is displaced; classified according to the brain structures involved (i.e. uncal, central, tonsillar - P. 810) -Uncal herniation - herniation of the medial temporal lobe through the tentorium & into the brainstem -Central herniation - downward displacement of the cerebellar tonsils through the foramen magnum; compressing the brainstem
Cardiac Tamponade Symptoms
-*Beck's Triad* 1. Hypotension 2. Elevated central venous pressure w/ neck vein distension 3. Muffled heart sounds -Pulsus paradoxis: "an inspiratory systolic fall in arterial pressure of 10 mmHg or more during normal breathing." Caused by decreased cardiac output. Stroke volume decreases during inspiration -Pulseless electrical activity (PEA)
Rib fractures can be life-threatening if
-3 or more rib fractures -presence of preexisting disease (cardiopulmonary disease especially) -patient older than 65 years
Pulmonary Contusion: Complications
-ARDS -Pneumonia -Lung abscesses -Emphysema -Pulmonary embolism
Bony Thorax Fractures-Treatment
1. Airway management 2. Oxygen therapy 3. Pain management 4. Consider underlying structures & other potential injuries 5. Internal splinting thru ET tube w/ positive pressure ventilation
Thoracic Trauma: Immediate life threatening injuries requiring treatment in the primary survey
1. Airway obstruction 2. Tension pneumothorax 3. Cardiac tamponade 4. Open pneumothorax 5. Massive hemothorax 6. Flail chest
3 collisions in 1 crash
1. Car w/ another object 2. Occupant's body w/ car interior 3. Internal tissues w/ the rigid body surface structure (organs impact bone, vessels are stretched, contusions, lacerations, ruptures, etc.) -3 collisions occur in the crash. The first is when the car strikes the tree. The next collision is when the driver's body strikes the car interior, which could be the windows &/or airbag w/ his head and face, the steering wheel with his chest and abdomen, the dashboard w/ his knees. And that is if he is not thrown from the car and the passenger cab remains intact. The 3rd collision is when the body tissues impact rigid body surfaces such as bone, cartilage or muscle.
Chest tube steps
1. Connect to closed drainage system w/ suction 2. Monitor drainage (>200 ml/hour for 2 consecutive hours is above normal) 3. Monitor for air leak
Thoracic Trauma - Mild Pulmonary Contusion Interventions
1. Frequent respiratory assessment 2. Pulmonary care (suction, incentive spirometry, deep breathing, coughing, turning, etc.) 3. Pain control 4. Ambulation 5. Positioning - injured side up (good lung down) -The patient with a pulmonary contusion tends more toward respiratory acidosis. -If a person has chest pain r/t a pulmonary contusion, they are going to be afraid to expand their lungs completely and will avoid taking deep breaths. This is why pain control is so important in these patients -Chest physiotherapy may be used, but not well tolerated if there are coexisting rib fractures -Pain control: NSAIDS, opiates, intercostal nerve blocks, epidurals
Prehospital Resuscitation: Care emphasis ABC's
1. Maintain airway, ensuring adequate ventilation 2. Control external bleeding, prevent shock 3. Maintain spinal immobilization 4. Immediate transport (ground or air) -ABC's take precedence in the prehospital trauma setting. Goal of prehospital resuscitation is stabilization & transport.
Rib fractures are common....
1. Markers of serious intra-thoracic & abdominal injuries 2. Sources of significant pain 3. Predictors of pulmonary deterioration
Thoracic Trauma - Severe Pulmonary Contusion Interventions
1. Ventilator support w/ PEEP 2. Pain control 3. Sedation and/or paralytic agents - decreases the body's energy expenditure & respiratory requirements 4. Positioning - good lung down; prone positioning may be used in extreme cases -PEEP provides the needed pressure to keep the alveoli in the lungs open so that they can absorb oxygen better but PEEP also may decrease cardiac output & result in poor tissue perfusion. -Sedation and paralysis would be achieved through continuous IV infusions of medications. An example of sedative meds would be a propofol drip (aka diprivan). An example of a paralytic medication would be a vecuronium drip.
Thoracic Trauma -Pleural Space Injuries
Disruption of the chest wall that allows air or blood to build up in the pleural layers leading to a decrease in negative intrathoracic pressure (May be caused by blunt or penetrating trauma)
When there is no time to do for a type & cross what do you give?
Blood products: cross-matched is best but in an emergency O neg can be given (only when there is no time for a type & cross)
which type of trauma is usually more damaging - blunt force or penetrating trauma?
Blunt force due to the larger area over which the damaging force is spread over.
Trauma to the Bladder
Blunt trauma causes lacerations, contusions (most common), or rupture of the bladder Frequently linked w/ pelvic fractures Rupture: gross hematuria typically noted
Abdominal Compartment Syndrome
End-organ dysfunction caused by increased intraabdominal pressure. Increased abdominal pressure results in decreased blood flow & perfusion of organs.
Trauma to the Spleen diagnostic tests
FAST, DPL, or CT
When should you notify a HCP about chest tube drainage?
For chest tube drainage of more than 200 ml/hr for 2 consecutive hours, the nurse should notify the physician. A missed injury may be the culprit and further exploration should be done.
Abdominal Trauma can lead to what potential complications
Hemorrhage, shock, sepsis
The most common type of shock to occur in trauma patients
Hypovolemic shock
Why are elderly and alcoholics at an increased risk for Subdural hematomas
Increased risk in elderly & in alcoholism r/t increased incidence of falls in these populations
Thoracic Trauma: Potentially life-threatening injuries addressed in the secondary survey
Thoracic aortic disruption, tracheobronchial disruption, myocardial contusion, traumatic diaphragm tear, esophageal disruption and pulmonary contusion
Main goal for complications of trauma
Vigilant nursing assessment helps identify life-threatening complications so that EARLY & AGGRESSIVE treatment can be started!! Goal is to maintain organ function and prevent further complications!!!!!!!!!!!!!!
Prevention of Rhabdomyolysis
aggressive IV fluids
signs and symptoms for a subdural hematoma
headache, lethargy, confusion, decreased LOC
Hemopneumothorax
intrapleural air / blood collections
Pneumothorax
intrapleural air collection
Hemothorax
intrapleural bleeding
Complications of Trauma to the Kidneys
may include infection, hemorrhage, infarction, acute kidney injury
Skull fracture: Linear
nondisplaced, associated w/ low-velocity impact
Secondary brain injuries: Cerebral edema
occurs within 24-48 hrs of injury; peaks at 72 hrs. May result in herniation if not treated
Compartment syndrome signs and symptoms
swelling, tightness, paresis, pain; decreased pulses & delayed CRT are late signs!
Intracerebral Hematoma
-Collection of blood within brain tissue caused by disrupted blood vessels -May be treated surgically or nonsurgically depending on size, mass effect, & displacement of other structures
Complications of Trauma: Missed injury
-Commonly discovered 24-48 hours after admission -Can include unknown/undiagnosed preexisting medical conditions (i.e. endocrine disorders) -Thorough assessment is key!
Complications of Trauma: Vascular complications
-Compartment syndrome: Increased pressure within a limited space compromises circulation resulting in ischemia & necrosis -Venous thromboembolism: DVT & pulmonary emboli; very high risk!
Thoracic Trauma - Penetrating Cardiac Injury
-Bullets, knives, impalements -Mortality rate is 50-85% -R ventricle is injured most often due to it's anterior location -Most deaths occur within minutes due to blood loss or tamponade
Cardiac Contusion Symptoms
-Chest pain -Dyspnea -Chest wall ecchymosis -Flail chest, sternal fracture -EKG changes -Symptoms may vary from none to severe CHF and cardiogenic shock!! -In the patient who has had severe anterior blunt trauma and chest wall bruising, -Most patients w/ cardiac contusions have EKG abnormalities.
Open Pneumothorax management
-Closure of wound at end expiration with a sterile occlusive dressing (plastic wrap or petroleum gauze); dressing taped on 3 sides to create a valve effect -Valve effect: when patient breathes in, the dressing is sucked in & occludes the wound to prevent entry of air; but air can still get out of the chest. -Chest tube asap with possible surgical intervention
Emergency Department Resuscitation: Primary Survey
-"ABCDEs" of trauma; identification of life-threatening conditions 1. Airway & Alertness with spinal immobilization 2. Breathing and ventilation 3. Circulation with hemorrhage control 4. Disability: neuro status (use GCS) 5. Exposure and environmental control -Each component of the primary survey is dealt with in order before moving on to the next component. For example breathing and ventilation cannot be established if there is no airway -During the primary survey, if the patient does not have a patent airway then intubation will be performed; chest tube insertion & CVL placement (for fluid resuscitation) may also take place during primary survey. IV fluids and blood products may be administered to maintain adequate circulation. -DO remember that during resuscitation, you want to keep your patient warm w/ warm blankets and warmed IV fluids, in order to prevent hypothermia.
Prehospital Resuscitation: The golden hour
-60 minute time frame from injury to definitive care -If a patient is admitted to a trauma center and specialized care is begun within 1 hour of the injury, then there is a greater chance of a positive patient outcome. The more organized and specialized the care is, the lower the mortality rate. -Emergency practitioners pretty well agree that if transport time to a trauma center is short, then few interventions should be performed at the scene. If transport time to a trauma center is longer, then more interventions should be performed at the scene
Basilar skull fracture Nursing interventions
-AVOID USE OF NGTs to prevent passage of tube through the fractured area & into the brain. -Drainage of CSF from nose or ear (may be mixed with blood); look for "halo sign" to identify CSF. -CSF leaks usually heal on their own with rest. May require surgical repair if it persists.
Blunt Injury is Caused by a combination of Forces such as:
-Acceleration: increase in the velocity of a moving object -Deceleration: decrease in the velocity of a moving object -Shearing: structures slip relative to each other -Crushing: continuous pressure is applied to a body part -Compressive resistance: ability of an object to resist squeezing forces or inward pressure
Complications of Trauma: Kidney Complications
-Acute kidney injury (AKI) -Rhabdomyolysis: Associated with crush injuries which compromise blood flow resulting in loss of oxygen transport & tissue ischemia leading to necrosis of cells; necrotic cells spill contents (potassium & myoglobin) which can lead to development of kidney failure
Emergency Department Resuscitation: Damage control surgery
-All injuries are not addressed in one surgery; goal is control of hemorrhage & contamination -Exploratory laparotomy to identify & control bleeding and sources of contamination; followed by abdominal packing & temporary wound closure then transported to ICU -Other injuries are addressed after the client is stable (during definitive care phase)
Concussion
-Altered mental status r/t trauma; no structural damage. Tx: observation -Usually recovery is quick & complete. However, some patients experience post-concussive syndrome (headaches, decreased short term memory, dizziness, fatigue, and other symptoms) for months to 1 year following the injury.
Thoracic Trauma - Pulmonary Contusion
-Bruising of the lung, unilateral or bilateral -Diagnostics: Chest x-ray or CT -Suspect if pt has bony fractures of thorax -Results in atelectasis & consolidation -Manifests initially as hemorrhage followed by alveolar & interstitial edema; this inflammation affects alveolar-capillary units resulting in a ventilation-perfusion imbalance that results in progressive hypoxemia over 24-48 hour period -The greater the severity of pulmonary contusion, the worse ventilation becomes. -Usually worsen over 24-48 hour period then slowly resolve unless complications occur (ARDS, infection, etc.)
Cushing's Triad
3 late signs of herniation: *-increased systolic blood pressure* *-decreased heart rate* *-irregular respiratory pattern*
Cardiac contusions
Cardiac contusions occur because the heart hits the sternum during rapid deceleration or because the heart is compressed between the spine and sternum.
most common causes of blunt trauma
Acceleration-deceleration injuries
Abdominal injuries "fun facts"
Blunt trauma is associated with more fatalities than penetrating trauma. Abdominal injuries are often missed due to the focus being placed on more visible but less severe injuries. Usually more than one organ system is affected in abdominal trauma.
Secondary Survey F-H
F - full set of VS & facilitate family presence G - Get resuscitation adjuncts L - laboratory studies M - Monitor heart rate & rhythm N - naso- or oro-gastric tube O - oxygenation & ventilation assessment P - pain assessment & intervention H - history (interview paramedics, EMTs, witnesses, etc.)
the principal factor influencing prehospital care
Literature concludes that transport time to trauma center (Level I to IV) is the principal factor influencing prehospital care
How to calculate the force of an injury
MASS x ACCELERATION= FORCE -Ex:130 lb x 60 mph= 7, 800 lbs of force -Ex: 200 lb man driving a car at 70 mph when it strikes a tree or a nonmoving car = 14000 lbs of force applied to that driver's body. *It is important to remember that prior to the crash, the car & the person inside are both traveling at the same velocity. During the crash, both the occupant and the car decelerate to zero.
What may happen if pleural space injuries do not get treated in a timely manner?
May progress to Tension Pneumothorax or Tension Hemothorax if air & blood continue to build up.
Trauma to the Spleen treatment
Minor injury: observation; serial H/H & CT; NGT Major injury: surgical intervention
Diagnostic tests for pleural space injuries
Pleural space injuries are usually diagnosed by chest x-ray. But if the pneumothorax is less than 20% of the chest cavity, it may not be detectable on the initial x-ray. A chest CT scan often shows the smaller pleural space injuries.
When is an abdominal injury assessed and diagnosed?
Secondary Survey
What is more deadly, small or large cars?
Small cars are more deadly than large ones. (Also, pedestrian vs. car - consider size of person, size of car)
Genitourinary Injuries
Suspect in any patient with pelvic fracture, blunt trauma to lower chest or flank, lower abdomen, genital swelling or discoloration, blood at the urethral meatus, hematuria
Complications of Trauma: Multiple Organ Dysfunction Syndrome
Trauma pts are high risk for SIRS & MODS
Cardiac Contusion treatment
Treatment is mainly supportive and focused on symptom management.
Early signs of increased ICP
decreased LOC, confusion, agitation, drowsiness
