CH 25: Trauma (p. 487 - 516)

8 Complications of Trauma

Hypermetabolism Infection Sepsis/Septic Shock Fat Embolism Renal Complications Compartment Syndrome Missed Injury MODS

Constant blood transfusions can put a patient at risk for what electrolyte imbalance?

Hypocalcemia

During damage control surgery (DCS), the goals are to ________ and ____ bleeding; resuscitate and correct _________, ___________, and ____________; and if all goes well, return to _________ ____ for definitive care.

Identify and Stop Acidosis, Hypothermia, Coagulopathy Operating Room

Type of shock that results from injury to the descending sympathetic pathways in the spinal cord, causing irreversible damage to the neurons.

Neurogenic Shock (Urden, 2016, p. 499)

The injury of what organ is associated with blood at the meatus with high riding prostate?

Urethral Injury

Primary Survey in Emergency Department Resuscitation (A through H)

A- Airway B- Breathing C- Circulation D- Da neuro E- Expose them F- Fahrenheit (Temp control) G- Get vitals and tubes in H- History

Medical emergency in spinal cord injury that results from stimulation below the level of the injury such as pain, distended bladder or rectum. A. Autonomic dysreflexia B. Neurogenic shock C. Spinal shock D. Flaccid paralysis

A. Autonomic dysreflexia Rationale: Signs and symptoms include bradycardia, hypertension, facial flushing, and headache. Alleviate noxious stimuli and elevate HOB to prevent cerebral hemorrhage, seizures, and acute pulmonary edema.

The orthopedic nurse is aware that traumatic dislocations are treated as orthopedic emergencies due to the risk of diminished blood supply and subsequent tissue death. Tissue death due to anoxia and diminished blood supply is referred to as: A. Avascular necrosis B. Nerve palsy C. Subluxation D. Compartment syndrome

A. Avascular Necrosis

Fracture of cervical vertebrae C3-C5 can have serious respiratory complications. Why?

Innervated by phrenic nerve

Referred pain to the left shoulder resulting from injury to the spleen or irritation of the diaphragm

Kehr's Sign (Urden, 2016, p. 509)

Injury to the _______ may be reflected by flank ecchymosis and may be caused by the fracture of inferior ____. This ecchymosis in the flank area is refereed to as ____ ______ sign.

Kidneys Ribs Grey Turner (Urden, 2016, p. 509 and 512)

Fractures of the right and left lower ribs are associated with injury to what 2 organs?

Liver (Right) and Spleen (Left)

Common forms of Blunt Trauma (4)

Motor vehicle accidents Assaults Sports Injuries Falls (Urden, 2016, p. 487)

Five P's of compartment syndrome

Pain Paresthesia Pallor Pulse (late) Paralysis

When the primary survey is complete and vitals are reaching their norm in ER, the secondary survey beings. What 5 interventions take place during a secondary survey? (Typical day of the nurse taking care of an admitted patient; You as the nursing student do the majority of these things)

Head to toe assessment (rectal in males) Full set of vitals Complete diagnostic/Radiology exams Emotional Support Pain management

6 Phase of Trauma Care (Care from start to finish)

Pre-hospital resuscitation (EMS to hospital) Hospital resuscitation (In ER) Definitive Care (Specific care identified) Critical Care (Actual admission to hospital) Intermediate Care Rehabilitation

Most common cause of death for all individuals between the ages of 1 and 44 years and is the third most common cause of death regardless of age

Trauma

True or False: Aortic injuries can happen as a result of first or second rib fractures, as well as sternal or clavicular fracture.

True (Urden, 2016, p. 509)

What will be placed in the patient during the Hospital Resuscitation (ER) phase to help provide fluid replacement?

Two large-bore IVs

Hallmark symptom of compartment syndrome

Unrelenting pain out of proportion to the injury/Unrelenting pain

Your patient is brought to the ER with a pneumothorax. You have just intubated your patient in attempt to stabilize them when suddenly they deteriorate further. What has likely happened?

Your intubation has inadvertently caused a tension pneumothorax.

Syndrome associated with damage to one side of the spinal cord; Loss of function on side of injury but loss of sensation on the other side

Brown-Séquard syndrome

Potentially life-threatening complication of spinal cord injury caused by massive sympathetic response to noxious stimuli (like fecal impaction) that results in bradycardia, hypertension, and headache.

Autonomic Dysreflexia

A massive hemothorax results from the accumulation of more than ____ mL of blood in the chest cavity.

1500 mL

Normal Pulsus Paradoxus (mmHg)

2 - 4 mmHg

_ to _ liters of blood can be lost in an open book fracture

4 to 6

How many units of blood would one expect to lose with a pelvic fracture? Femur fracture?

4 to 6 units 2 units

__% of thoracic injuries are caused by motor vehicle accidents. __% are caused by stabbings.

70 30

Wearing a helmet reduces your risk of head injury from a bicycle accident by __%. (Class question)

75

Neurogenic shock is considered what type of shock? A. Distributive B. Cardiogenic C. Hypovolemic D. Spinal

A. Distributive

A trauma patient arrives in the critical care unit. Pertinent history includes report of a prolonged extrication time from a motor vehicle. The nurse knows to expect potential complications related mostly to: A. Hypotension and hypothermia B. Sacral and occipital breakdown C. Anoxic injury D. Acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS)

A. Hypotension and Hypothermia Rationale: Prolonged extrication time gives an indication of the length of time the patient may have been hypotensive or hypothermic before medical care. The period of respiratory or cardiac arrest provides information on the effects of loss of perfusion to the brain (anoxic injury), kidneys, and other vital organs. The time on the backboard potentiates the risk of sacral or occipital breakdown. The number of units of blood, whether any were not fully cross-matched, and packed cells versus whole blood used potentiates the risk of ARDS and MODS.

End-organ dysfunction caused by intraabdominal hypertension (or abnormally increased pressure in the abdomen) (hint: Can occur in the leg)

Abdominal Compartment Syndrome

Fractures to the lower ribs are associated with injuries to what organs? (2)

Abdominal Injuries (Liver and Spleen)

Why is physical exam alone unreliable in a patient with an abdominal trauma?

Abdominal injuries are not always obvious

A patient is admitted for a spinal cord injury (SCI) after a 10-foot fall from a rooftop where he landed on his buttocks. The type of injury that the nurse can expect to see with this SCI is: A. rotation B. axial loading C. hyperflexion D. hyperextension

B. Axial loading Rationale: Axial loading, or vertical compression, injuries occur from vertical force along the spinal cord. This is most commonly seen in a fall from a height in which the person lands on the feet or buttocks. Compression injuries cause burst fractures of the vertebral bodies that often send bony fragments into the spinal canal or directly into the spinal cord. (Evolve)

Occurs when excessive pressure builds up inside an enclosed space in the body, resulting in compromised circulation and eventual ischemia/necrosis of affected tissues after an injury.

Compartment Syndrome (Urden, 2016, p. 514)

5 potential Breathing interventions during ER resuscitation (How are you gonna help them breath, other than applying oxygen?)

Cover chest wounds Needle Thoracostomy (decompression) Open Thoracotomy (open the chest) Chest Tube Intubation

Blood component prepared from plasma that help restore fibrinogen levels

Cryoprecipitate

Purplish discoloration of the flanks or umbilicus in abdominal trauma are referred to as _______ sign.

Cullen's Sign

160lb man is traveling down a busy highway at 60 mph. He hits a pole, get ejected through the windshield and hits the pole head first. How many pounds of force did the man hit the pole with in milliseconds? A. 60 lbs B. 600 lbs C. 1600 lbs D. 9600 lbs

D. 9600 lbs (Class question) To estimate this, multiply the persons weight by the miles per hour. 160 X 60 = 9,600 (Urden, 2016, p. 487)

Select the true statement about aortic injury: A. Greatest risk from shearing forces from rapid deceleration B. Vulnerable area is the proximal aorta where mobile arch meets fixed descending aorta at point where ligamentum arteriosum "tethers" C. Occurs with frontal or side impacts and fall from significant height D. All of the above

D. All of the above

Patient with high index of suspicion for extensive trauma: A. Death in the compartment B. Mechanism of injury consistent with extensive deceleration, acceleration, or rotational injury such as high speed MVC or fall from above 20 feet. C. Fracture of first and second rib D. All of the above

D. All of the above Rationale: Recall that significant forces were in play to have fractures of first and second rib. They are normally well protected by clavicle.

Which of these signs of compartment syndrome is the earliest and most reliable? A. Pallor B. Pulseless C. Paresthesias D. Unrelenting pain

D. Unrelenting pain

Foot drop, paresthesia, and inability to void can all be the result of what kind of injury?

Spinal Cord

Condition that can occur shortly after traumatic injury to the spinal cord in which the TEMPORARY complete loss of all muscle tone and normal reflex activity below the level of injury occurs (hint: Not paralysis, which is more CHRONIC)

Spinal Shock (Urden, 2016, p. 499)

Common forms of Penetrating Trauma (3)

Stabbing Gun Shot Wounds Impalement (Urden, 2016, p. 487)

____________ injury occurs when the skull is hit by a force that causes the brain to move forward toward the point of impact. When the brain reverses direction and the brain hits the other side of the skull, ____________ injuries occur.

Acceleration Deceleration

When obtaining the patients history regarding the injury that brought them in AND past information, it is referred to by the mnemonic AMPLE. What does AMPLE stand for?

Allergies Medications Past medical history/Pregnancy Last Meal Events leading to the injury/Environment

Construction worker presents to the ER after falling face front off of a roof. He appears to have a wide mediastinum secondary to a chest injury. What might this assessment finding be indicative of?

Aortic Dissection/Rupture

In a complete spinal cord injury, which type of paralysis occurs when injury to C1- T1 occurs? A. Paraplegia B. Tetra/Quadriplegia C. Hemiplegia

B. Tetra/Quadriplegia Rationale: Paraplegia, also called leg paraylsis, occurs after injury from T2-L1 (Urden, 2016, p. 498)

A large percentage of _________ and intraabdominal injuries result from _________ fractures.

Bladder Pelvic (Urden, 2016, p. 512)

Which of the following interventions would be included in the primary survey of a trauma patient? (Select all that apply.) A. Open the airway to look for loose teeth, vomit, or foreign objects using a head-tilt, chin-lift technique. B. Evaluate ventilation and gas exchange by inspection, palpation, and auscultation. C. Locate peripheral and central pulses. D. Assess patient's level of consciousness. E. Remove all clothing to inspect body surfaces and cover to provide warmth.

B, C, D, E Rationale: The airway should not be opened. Jaw thrust with cervical spine immobilization should be performed until spinal cord injury has been ruled out. The rest of the interventions listed are included in the primary survey.

A spinal cord injured patient is complaining of numbness on the left side and is unable to move the right and left arms. The nurse notes that the patient can feel temperature and pain only on the left side during a neurologic assessment. The nurse suspects this patients injury is: A. Anterior cord syndrome B. Brown-Séquard syndrome C. Central cord syndrome D. Posterior cord syndrome (Evolve)

B. Brown-Sequard Syndrome Rationale: Brown-Séquard syndrome is associated with damage to one side of the spinal cord, which explains the ipsilateral functional damage with contralateral sensation. Anterior cord syndrome results in motor function, pain, and temperature loss below the level of the injury; position sense and pressure remain intact. Central cord syndrome produces motor and sensory loss that is more pronounced in the upper extremities. Posterior cord syndrome results in loss of position sense, pressure, and vibration below the level of the injury, but motor function, pain, and pressure sensation remain intact.

A patient experiencing a hemothorax is at risk for what type of shock? A. Distributive Shock B. Hypovolemic Shock C. Neurogenic Shock D. Cardiogenic Shock

B. Hypovolemic Shock (Urden, 2016, p. 507)

A nurse is caring for a patient with blunt chest trauma after a motor vehicle accident. The patient starts to complain of pain from the chest to the shoulder and a sense of impending doom. Upon assessing the patient, the nurse notes that the patient has diminished breath sounds on the left side, jugular vein distention, and tracheal deviation to the right. The nurse anticipates: A. insertion of an indwelling urinary catheter. B. insertion of a chest tube. C. a chest radiograph. D. administration of pain medications.

B. Insertion of a chest tube Rationale: It appears that the patient is experiencing a tension pneumothorax and is in immediate need of needle decompression or insertion of a chest tube. This is a life-threatening emergency that will take precedence over the radiographs and pain medications. Inserting an indwelling urinary catheter is not indicated here.

Standard measures for optimal care of the spinal cord injury patient. A. Methylprednisolone B. Prevention of hypotension and search for associated injuries C. Fractures are always stabilized with four point device if expertise available D. All of the above

B. Prevention of hypotension and search for associated injuries Rationale: It is a fatal flaw to assume that the spinal cord injury patient has only one injury. The patient may have accompanying intra abdominal injuries that become difficult to diagnose because of patients motor sensory deficit. Prednisone is no longer the standard of care

A nurse is developing a plan of care for a patient with a T5 spinal cord injury that includes a bowel and bladder regimen because these patients are at risk for: A. neurogenic shock. B. spinal shock. C. autonomic dysreflexia. D. hemorrhagic shock

C. Autonomic dysreflexia Rationale: Autonomic dysreflexia is a life-threatening emergency that can be brought about by a full bladder or constipation. Although spinal cord injured patients are also at risk for neurogenic shock (loss of vasomotor tone resulting in hypotension and bradycardia) and spinal shock (loss of muscle and reflex activity below the level of the injury), the purpose for the bowel and bladder training is for the prevention of autonomic dysreflexia. Spinal cord injury itself does not necessarily lead to hemorrhagic shock (which would be hypovolemic).

Highest level of cervical spine cord injury patient with ability to feed himself: A. C4 B. C2 C. C7 D. T2

C. C7 Rationale: Muscles remain intact for C7 fracture; Feeding and grooming are more independent

A 75-year-old man is admitted for transient ischemic attack, left-sided weakness. During the admission assessment, the patient states he is also experiencing absentmindedness, vomiting, and intermittent photophobia. The patient is on warfarin (Coumadin) therapy. The patient cannot recall any significant injury involving a blow to his head. Based on this information, what is the most likely cause of his symptoms? A. Acute subdural hematoma B. Subacute subdural hematoma C. Chronic subdural hematoma D. Epidural hematoma

C. Chronic subdural hematoma Rationale: Chronic subdural hematoma is diagnosed when symptoms appear days or months after injury. Most patients with chronic subdural hematoma are older. Patients at risk for chronic subdural hematoma include those with balance disturbances, older adults, and those receiving anticoagulation therapy. The patient may report a variety of symptoms, such as lethargy, absentmindedness, headache, vomiting, stiff neck, and photophobia and may show signs of transient ischemic attack, seizures, pupillary changes, or hemiparesis. (Evolve)

The Battle sign in a patient with head trauma most likely indicates a: A. contusion B. concussion C. skull fracture D. cerebral hematoma (Evolve)

C. Skull fracture

Why is a rectal exam done in males during a secondary survey?

Can determine high riding prostate indicative of urethral damage

Progressive accumulation of blood in the pericardial sac, increasing intracardiac pressure, which can cause obstructive shock, and eventual lead to cardiogenic shock if not treated

Cardiac Tamponade (Urden, 2016, p. 508)

Common signs and symptoms associated with rib and sternal fractures (5)

Dyspnea Localized Pain Ecchymosis over chest Sternal Contusion Deformity

Classic assessment findings associated with cardiac tamponade are called Beck's Triad. What does Beck's Triad include?

Elevated central venous pressure and neck veins Muffled Heart Sounds Hypotension

7 potential Circulation interventions during ER resuscitation (How are you gonna stop bleeding, non-pharmacologically?)

External pressure Pressure dressing Elevate injured part Arterial Pressure point Apply traction Temp Control Patient Positioning

True or False: Diagnostic Peritoneal Lavage (DPL) is a widely used diagnostic procedure.

False

True or False: Ruptured Diaphragm is more likely associated with sharp epigastric/chest pain radiating to left shoulder (Kehr's Sign) than a ruptured spleen.

False Rationale: Blunt trauma to the abdomen can produce injuries to the liver, spleen, and diaphragm. Referred pain to the left shoulder (Kehr sign) may indicate a ruptured spleen or irritation of the diaphragm from bile or other material in the peritoneum, but more likely a ruptured spleen.

True or False: A patient arrives with multiple gunshot wounds to the abdomen. The surgeon will remain in OR until all major and minor bleeding is controlled and all injuries are identified.

False Rationale: Damage control surgery is an option to avoid hypothermia, coagulopathies,and metabolic acidosis. Stop the bleeding, resuscitate the patient and return to the OR for definitive care

Life-threatening complication that can occur as a complication of orthopedic trauma; Develops from fat droplets in small blood vessels that leak from fractured bone to lungs How fast can symptoms from this occur?

Fat Embolism Within a few hours to 3 or 4 days

Occurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall, letting a part of the chest wall move independently from the other side

Flail Chest

Blood component infused with PRBC's used to replace depleted clotting factors but not an intravascular volume expander

Fresh Frozen Plasma

Blood component infused with PRBC's that participate in the formation of fibrin, and adhere to damaged blood vessel walls forming a "plug"

Platelets

4 potential Airway interventions during ER resuscitation (What might you have to do to give them an airway, for instance if it was blocked?)

Position head Suctioning Intubation Cricothyrotomy

Exaggeration of normal decrease in systolic blood pressure occurring during inspiration; Seen in asthma and cardiac tamponade

Pulsus Paradoxus