357 exam Flashcards
Epidemiology / Demographics of posionings
Pharmaceutical
….Most common poisonings by pharmaceuticals differ between genders:
+ Females - non-opioid analgesics, antipyretics, antirheumatics
+ Males - anti-epileptic, sedative hypnotic, antiparkisons
Most poisonings in adult are deliberate
Most poisonings in children are accidental
Non-pharmaceutical poisoning e.g. envenomation
Non-pharmaceutical poisoning examples
Envenomation
Alcohol
Carbon monoxide
Pesticides
what type of drugs are likely to be abused
Act fast
Make you feel good
Stop you feeling bad
examples of drugs of abuse
CNS stimulants - amphetamines, nicotine , cocaine, caffeine,
CNS depressants - alcohol, opioids, benzodiazepines
Psychomimetics - cannabis, LSD, designer drugs
what type of drug is methamphetamine?
CNS stimulant
Pharmacodynamics of methamphetamine
Chemically similar to adrenaline, dopamine
Increases alertness, mental and physical capabilities, surprises appetite.
Induces psychosis, aggression
‘Fall off’ effect - hunger, lethargy, depression
Causes intense craving - high risk of addiction
Treatment of methamphetamine poisoning
support of symptoms including sedation
other names for mathamphetamine
meth, ice
other names for Methylenedioxymethamphetamine
(MDMA / Ecstacy / E / Pingers)
(MDMA / Ecstacy / E / Pingers) what does it do?
Original designed in 1914 as an appetite surpressant
Similar to Methamphetamine - with subtle changes to molecules - fewer effects of aggression, irritability and ‘fall off effect’
Triggers sense of confidence, friendliness, paranoia.
Can lead to hyperthermia, hypertension, tachycardia, thirst and over hydration
MDMA treatment
Treatment: supportive control of symptoms - no antidote
what does heroine do
Central nervous system depressant - opiate
Similar to codeine, morphine, fentanyl, oxycodone
Medical version - diamorphine
Causes sense or euphoria and well being
May lead to - rest. depression, pulmonary oedema, convulsions, hypotension, bradycardia
heroine overdose treatment
support of symptoms & naloxone
how can a paracetamol/ acetaminophen cause overdose
Commonly used drug
Readily available with no restriction on sales - responsible for 50% of all toxic ingestions in Australia
Majority (97-98%) of paracetamol readily metabolised in liver.
Small amount metabolised to NAPQI - highly hepatotoxic
NAPQI easily removed by Glutathione.
Limited amount of Glutathione produced
Overdose uses up all Glutathione - leaving NAPQI to cause liver injury
paracetamol overdose treatment
N-Acteylcysteine -
What is trauma?
the transference of energy to the body
Kinetic -
…..Blunt - falls, motor vehicle accidents…
…..Penetrating - bullet wound, stabbing..
Chemical - chemical burn, deprivation of oxygen
Thermal - scalds, burns…
Radiation - UV burns…
Electrical - electrocution..
is Trauma…an epidemic?
Epidemic - an illness, injury or disease that affects a large number of the population in a region…with apparent growth
Road fatalities in developed countries has fallen
Violence against the person and injury from falls has increased
describe the burden of injury from trauma
970 million people suffer injury globally p.a.
4.8 million die from those injuries
Total number of deaths did not decrease between 2005 - 2015
Leading cause of death ages 1 - 44 yrs
describe trauma from the australian context
Trauma responsible for 500,000 hospitalisations nationally p.a.
12,000 die due to trauma
Potential years lost = 1,207
This is greater loss of potential life than cancer and heart disease combined
common injuries that we should try prevent
Falls
Cycle injury
Motor vehicle injury
Risk taking prevention
what are the determinants of trauma
Age
Gender
Indigenous populations - more than twice the incidence of non-indigenous populations
Alcohol and drug use
Geography - remoteness and terrain
Driver behavioural factors
what is involved prehospital in the patient journey
Self care? Bystander - first aid First Responders Road ambulance Helicopter Emergency Service Royal Flying Doctor Service
what is involved in the emergency part of the patient journey
Not all patients arrive by ambulance
Triage works!
Remember the psychological effect of injury / illness on behaviour
- Anxiety or anger?
Jack of all trades - Master of…..
Key to success:
- Organisation
- Communication
- Education
- Empathy
what is involved in the intensive care unit part of the patient journey?
Patients may be sedated / anaesthetised but aware
Consider the impact on family
Patients may be conscious and ventilated
what happens in the operating room/ xray part of the patient journey ?
In some cases - direct to theatre
In theatre pt. cannot advocate for themselves - a key nursing role is advocacy
Transport to OT or to xray is hazardous for the critically ill patient - how would you manage the following in a lift:
- Airway obstruction e.g. vomit
- Haemorrhage
- Cardiac arrest
What happens in the ward part of the patients journey?
Patients and their families leaving ICU are often very fearful
Higher ratio of patients to nurses
Holistic care is key
No less acute in some cases
what happens in the rehabilitation part of the patient journey?
For some patients this can be lifelong
In injury this can often involve young patients compared to stroke rehab for example
Application of clinical reasoning is just as valid here as ED or the ward
What is a trauma system
An integrated and organised approach to care of the
injured person from the site of injury to rehab and ideal
restoration of normal functioning
key factors of the prehospital phase of trauma systems
Ambulance call taker
Ambulance dispatch
On scene care - paramedic, doctor, nurse, first responder
key factors of transport phase of trauma systems
Contingent on - distance from hospital, condition of patien
Reception - early alert, clear standard
communication
trauma systems ongoing care considerations
Evidence based care
Integrated - hospital - rehab -
community - home
primary survey abbreviation
- Control of catastrophic haemorrhage
Ac – Airway with c-spine control
B – Breathing
C – Circulation
D – Disability
E - Exposure
F farenheit
key points of consideration for primary survey
Find a life threatening problem - fix it -
move on
✤ A always trumps c (Airway over cervical
spine)
✤ Don’t get distracted by OMG injuries
✤ Don’t cause hypothermi
what is involved in the secondary survey
A detailed examination of each system
✤ Head to toe
✤ Every orifice - blood, CSF etc.
✤ Includes ECG, bloods, x-ray
Head to toe detailed examination
Look for ‘occult’ injuries
Difficult in unconscious patients
Followed by imaging e.g. POCUS, FAST scan, CT, x-ray
what is tertiary survey
Later in care ✤ Looking for development of problems: ✤ E.g. ARDS, infection, acute kidney injury ✤ Detailed scan
considerations of nursing care during trauma
Communication with patient
✤ Vital sign measurement
✤ Assist with interventions e.g. chest drain
✤ Record keeping
✤ Liaison with family / other
examples of different trauma pathophysiology
Coagulopathy
Hypothermia
Chest trauma
Abdo trauma
Pelvic injury
Skeletal injury
Penetrating trauma
what is coagulopathy
✤ This disease process of abnormal blot clotting
✤ Most trauma patients will have some form of bleed
✤ One the trauma triad - acidosis, hypothermia &
coagulopathy
causes of coagulopathy in trauma
✤ Causes:
✤ Hypothermia
✤ Haemodilution
✤ Acidosis
why is hypothermia considered trauma
Leads to vasoconstriction - reduced circulation
✤ Can cause:
✤ Arrhythmias
✤ Coagulopathy
✤ Can be caused by pre-hospital environment / within hospital
✤ Prevention is better than cur
hypothermia management
✤ Warmed IV fluids inc. blood
✤ Blankets reduce exposure
✤ Bair hugger
what are examples of thoracic trauma
✤ ATOM - FC ✤ Airway obstruction ✤ Tension pneumothorax ✤ Open pneumothorax ✤ Massive haemothorax ✤ Flail chest ✤ Cardiac tamponade
Tension pneumothora Signs and symptoms
✤ Rapid resp rate
✤ Tracheal tug
✤ Absence of lung sounds
treatment of tension pneumothorax
✤ Needle decompression
✤ Intercostal chest drain
✤ Definitive treatment of cause
Open pneumothorax
(sucking chest wound) signs and symptoms
✤ Wound on chest wall (anterior or posterior)
✤ Tachypnoea
✤ Low SaO2
✤ Reduced chest movement / unilateral movement
management of open pneumothorac
Management
✤ Three sided dressing (acts as a flap valve)
✤ Intercostal chest drain
Massive haemothorax
Signs and symptoms
✤ Tachypnoea
✤ Low SAO2
✤ Reduced air entry
✤ Differenciated on x-ray from pneumothorax
management of massive haemothorax
✤ Supplemental oxygen (if indicated)
✤ Intercostal drainage
✤ Fluid resuscitation
flail chest signs and symptoms
✤ Rib pain +++
✤ Tachypnoea, Low SaO2
✤ Segment of ribs - paradoxical movement
✤ Fracture of 2 or more adjacent ribs in two or more place
flail chest management
Analgesia +++
✤ May require tracheal intubation
✤ Physiotherapy and breathing exercise
Cardiac Tamponade signs and symptoms
(Becks Triad)
✤ Reduced heart sounds
✤ Engorged neck veins
✤ Low BP
management of cardiac tamponade
Management
✤ Pericardiocentesis
common presentations of abdominal trauma
✤ Splenic rupture
✤ Liver rupture
✤ Rupture bowel
✤ Kidney injury
diagnostic aids for abdominal trauma
✤ F.A.S.T. - Focused Abdominal Sonography for
Trauma (now available pre-hospital)
✤ CT Scanning
✤ Diagnostic Peritoneal Lavage (DPL)
why is pelvic trauma so bad
✤ Pelvis forms a ring that is extremely strong
✤ Potentially life threatening on its own
✤ Can contain at least 3 litres of blood
signs and symptoms of pelvic trauma
Pelvic pain
✤ Mechanism and history
✤ Haematuria
✤ Leg discrepancy / groin pain
management of pelvic trauma
Pelvic binder
✤ Fluid resuscitation
✤ Analgesia
✤ External fixation
Skeletal trauma signs and symptoms:
Assess with - Look, Feel, Move
✤ Swelling, bruising deformity
✤ Pain
✤ Neurovascular assessment
complications of skeletal trauma
Compartment syndrome
✤ Infection in open fractures (osteomyelitis)
✤ Loss of function (or limb)
describe penetrating injury
✤ Low velocity
✤ E.g. stabbing, impalements
✤ Low energy - minimal damage to surrounding tissue
✤ Site and depth of injury dictates severity
✤ High velocity
E.g. gunshot
-High energy
- Dispersed wide spread from site of injury
- Caliber of gun (pistol v rifle) - severity of energy
key nursing issues in trauma care
Psychological factors
✤ Trauma has a life long impact for patients and
their family
✤ It affects healthcare workers
Pain relief
✤ Be the patient’s advocate
Communication
✤ The patient will remember more of what you say
than what you do
What is Multi Organ Dysfunction Syndrome?
Previously called multi-organ failure
Continuum of abnormal physiological changes and changes in organ function that occur in critical illness
Not only affects organs e.g. acute kidney injury but also immune, blood and endocrine systems
Pathophysiology of MODS
+
Equation
Similar to sepsis
Abnormal cellular responses involving several organ systems
Usually has a trigger
eg.
Increased inflamation, coagulation + decreased fibrinolysis = endothelial dysfunction and microvascular thrombosis = hypoperfusion ischaemia
Causes of MODS
Trauma Gut failure e.g. bowel obstruction, paralytic ileum Infection Ventilator induced lung injury Burns Pancreatitis Multiple blood transfusions Cardiac bypass Heat induced illness Poisoning / toxicity …
Describe development of MODS/ worsening stages
Usually occurs in worsening stages:
- Increasing fluid requirement, mild resp. Alkalosis, oliguria, hyperglycaemia
- Tachypnoea, hypocapnia, hypoxaemia, moderate liver dysfunction, possible blood abnormalities
- Shock with increasing Azotemia (nitrogen containing compounds e.g. urea), acid based disturbance, coagulopathy
- Dependence on vasopressors with oliguria, lactic acidosis
review MODS/ sepsis flow chart
review MODS/ sepsis flow chart
How does MODS affect the cell aposis v necrosis
Apoptosis v Necrosis
Cells ‘self-destruct’ normally - damaged or aged cells - Apoptosis
Prevents abnormal function or mutations
In MODS - this process is altered - may be slowed down (in neutrophils) or sped up gut lining
This causes tissue / organ damage
Necrosis is cell death caused by hypoxia or trauma
Apoptosis v necrosis
Apoptosis does not need pro-inflammatory chemicals e.g. histamine to work
Necrosis is often caused by pro-inflammatory chemicals - and is often unregulated
Cells rupture and leak contents causing collateral damage
This then starts the surrounding cells breaking down - cascade
Necrosis caused significant and widespread tissue and organ damage
describe how MODS causes cell dysfunction
Every cell has a function
MODS causes the cell to dysfunction
For example liver, renal and cardiac cells make proteins
MODS inhibits this production
These cells stop functioning correctly
- Cardiac cells contract weaker
- Liver cells slow down metabolisation
- Renal cells cease filtering
Why is MODS so bad?
MODS is systemic
The trigger e.g. trauma - causes a body wide reaction
For some reason multiple organs are affected by an enhanced immune, hormone and metabolic response
Homeostasis starts to fail
describe MODS and inflammation
Inflammation is normal part of healing process
In MODS and Sepsis - causes problems
Cytokines produced (e.g. histamine, prostaglandin, and nitric oxid) = vasodilation
Affects BP (lower)
Affects tissue perfusion
describe MODS and odema
Inflammatory response causes leaky vessels ‘capillary leak’
Fluid shifts:
- Hypovolaemia
- Pulmonary oedema
- Acute kidney injury
describe coagulation as it relates to MODS
Coagulation is a normal process in response to tissue damage
Pro-coagulation occurs when:
- Tissue damaged
- Cytokines released from macrophages or endothelium
Normal anti-coagulation factors balance this
Procoagulants consume anti-clotting factors in MODS
This leads to abnormal clotting in areas not damaged
examples of how organs might be in dysfunction in MODS
Specific complications
Cardiovascular - Patient needs vasopressors (e.g. adrenaline) despite fluids
Respiratory - patient requires mechanical ventilation
Renal - urine output less thsn 0.5ml/kg/hr; raised creatinine
Haematological - low platelet count; abnormal clotting
Metabolic - low pH (<7.3); increased lactate
Hepatic - raised LFTs
CNS - Reduced GCS
key factors of management of organ dysfunction
Resuscitation
- Fluid restoration
- Control of hypothermia & acidosis
Early treatment of infection / injury
- Early anti-microbial therapy (broad spectrum)
Steroid therapy
- Coricosteroids ‘calm down’ immune system response
outline of mods
A complex syndrome
Abnormal host response to a trigger e.g. trauma
Early recognition is key
Similar process to sepsis
what is jacksons burn wound model
review diagram
jackson’s burn wound model is a model for understanding the local response of burns wounds.
Three zones of a burn wound :
Zone of coagulative necrosis - Area nearest to the heat source (or other injuring agent). Results in immediate coagulation of proteins leading to irreversible cellular death.
Zone of stasis - Damage in this area is less severe but there is compromised circulation. Untreated, this area undergoes necrosis as the injury progresses. Observed clinically as the progression of the depth of a burn over several days (3-5 days). The tissue in this zone is potentially salvageable.
Zone of hyperaemia - In the outermost zone inflammatory mediators cause widespread dilatation of blood vessels. Provided there is resolution of hyper-dynamic response, tissues will recover.
how do burns cause damage twice
Initial destruction of tissue
Inflammatory response causes further problems
> 30% TBSA causes release of inflammatory mediators
how burns can affect around the body
resp, metabolic, immunological, cardiov
resp- bronchoconstriction, ARDS
Metabolic- increased BMR threschhold
Immunological- reduced immune response
Cardiov- reduce myocardial contractility, increased capilary permiability, peripheral and splanatic vasoconstriction
discuss burns impact of fluid loss
Fluid shifts reduce intravascular volume.
Onset often takes 6 to 8 hours.
Results in hypovolaemic shock
Rhabdomyolysis may begin…..
Renal failure
What makes cells live?
Life needs energy
Energy = ATP (Adenosine triphosphate)
The production of energy = respiration
This occurs in the mitochondria
What keeps cells alive?…
Cells need glucose to make ATP
ATP can be made without Oxygen
…BUT…only makes 8 ATP – Anaerobic respiration
With Oxygen – makes 30 ATP - Aerobic respiration
discuss Cellular effects of shock
Mitochondrial damage begins
Lysosomes rupture – begins cell lysis
Release of cytokines, lactic acid, complement, kinins, prostaglandins…..
Metabolic acidosis
Multiple organ failure begins
Reperfusion may exacerbate toxic mediator release (may lead to SIRS)
review coagulopathy in burns
review coagulopathy in burns
what is involved in the assessment and management of burns
- Immediate care
- Assessment of severity of burn
- Fluid resuscitation
- Patient flow chart
- Vital sign assessment
- Referral and specialist management
what is the impact of airway burns
Swelling due to burns in the upper airway can be fatal.
Swelling of the vocal cords can obstruct the airway completely.
Consider early intubation
Indicators of poss. inhalation injury
Hx of fire / explosion in enclosed space
Collapse / confusion at any time
Hoarseness / change of voice
Insp. stridor / exsp. wheeze
Facial burn – singed nasal hair
Soot in sputum
how do burns affect breathing
Inhalation of hot gases to bronhcial tree:
- Damage to alveoli
- Altered gas exchange
- Pulmonary oedema
ALL cases should receive high conc. humidified O2
Senior anaesthetic help required
Tracheal tubes should be left uncut
what does smoke inhalation do
Smoke contains many harmful chemicals.
Inhalation of smoke can cause these poisons to enter the body.
why is carbon monoxide an issue
Carbon monoxide is present in almost all forms of combustion.
It attaches with great affinity to red blood cells. hb binds to CO blocking out normal oxygen
Don’t expect a “cherry red” appearance.
circulation issues with burns
Hypovolaemia due to fluid loss
Can result in acute kidney injury and widespread organ damage
Need to estimate extent of burn…
Assessment of severity of burn
Burn Severity is determined by:
Extent of burn – described as percentage of Total Body Surface Area (%TBSA)
Depth of burn.
Burn location.
Estimating the extent of burn
Serial halving
Palm of patient’s hand = 1 % (includes fingers)
Rule of nines
Lund & Browder charts
what s the burn Rule of nines
review chart
“Rule of Nines” is a methid of calculating total body surface area thst divides the body surface into areas of nine percent (%) or multiples of nine (%)
what is the lund bowder chart
review chart
used to assess the burned body surface area. Different percentages are used because the ratio of the combined surface area of the head and neck to the surface area of the limbs is typically larger in children than that of an adult.
describe erythema/ superficial burn like
Very painful – sensation throughout
Redness – good capillary refill
Skin often intact
describe partial thickness burn
Deeper than epidermis
Often blistered
Very painful
Sensation intact
describe full thickness burn
No sensation
May not be painful
Hard leathery
eschar
what are the catergories looked at for refferals for burns
extensive burns (SA), full thickness (cm), Inhalation injury, Associated problems, extremes of age, special types of burns eg. electrical, critical areas, non accidental burns, psychiatric illness
Primary management of burns
Commence fluid resuscitation
describe parkland formula
Parkland Formula
Crystalloid resuscitation with Hartmanns solution.
Volume (mls)required in first 24 hours:
4 x %TBSA x body weight in (kg)
Half the fluid given in first 8 hours
Other half given over remaining 16 hours
Time since incident (may mean ‘catch up’)
describe hypothermia
Temp less than 36.0deg C
One of the trauma triad
Can be caused by injury – skin is a thermoregulator
Can be caused by first aid – running water
Can be iatrogenic – cold hospital environment
Prevent – blankets, environment
Treat – warmed IV fluids (inc. blood), warmed blankets, Bair Hugger
systemic complications and management of burns
Renal failure may occur as a complication of renal hypoperfusion (inadequate resuscitation), septicaemia or haemoglobinuria/myoglobinuria.
Haematology Intravascular haemolysis along with wound losses will increase blood transfusion requirements.
Nutrition Patients are profoundly catabolic with a BMR peaking at 4 days. These patients require early and aggressive feeding preferably enterally to maintain intestinal mucosal integrity.
Cerebral Hyponatraemia complicating resuscitation may result in the burn encephalopathy syndrome. This is seen as cerebral irritability.
Sepsis Burn injury is associated with a generalised loss of immunocompetence, and sepsis remains a major cause of death in burns.
interventions other than fluid resus for burns patients
Analgesia
Sedation
Tetanus status?
Escharotomy?
pathophys of shock
Cells need perfusion with oxygen and glucose
Perfusion is provided by blood pressure
Where blood pressure is normal the cell is able to function normally
Mitochondria within the cell produce ATP + H2O + CO2 (Aerobic respiration)
When perfusion fails = shock
Cell switches metabolism to Anaerobic respiration = much less ATP + H2O + CO2 + Lactic acid
what does metabolic acidosis do (shock)
Metabolic acidosis causes mitochondria to fail
Cell lysis occurs
Lactic acid enters blood + inflammatory cytokines
Unless compensated – leads to metabolic acidosis systemically
Eventual multi organ involvement and dysfunction
Initial management of shock (hypov)
Catastrophic haemorrhage control
- Direct pressure / elevation
- Indirect pressure
- Tourniquet
- Haemostats
IV access – two large cannula – peripheral venous
Initial fluid bolus crystalloid 250ml and determine response
Consider blood transfusion
class 1 of shock
less than 15% blood loss, HR over 100, normal systolic, normal/ increased pulse pressure, 14-20 RR, slightly anvious
class 2 of shock
15-30% blood loss, HR over 100, normal systolic, decreased pulse pressure, 20-30 RR, mildly anxious
class 3 of shock
30-40% blood loss, HR over 120, decreased systolic, decreased pulse pressure, 30-40 RR, anxious/ confsed
class 4 of shock
over 40% blood loss, HR over 140, decreased systolic, decreased pulse pressure, over 35 RR, confused/ lethargic
what are the 3 possible response for shock treatment
rapid response, transient response, no response
rapid response to trauma characteristics
vitals return to normal. minimal fluid loss, low need for crystalloid and blood, type x- match blood prep, possible need for operative intervention,
transient response to trauma characteristics
vitals have transient improvvement , recurrence of low BP/ high HR, moderate and ongong fluid loss, high need for crystalloid, moderate to high need for blood, type specific bloo prep, likley need for operative intervention
no response to trauma characteristics
vitals remain abnormal, severe blood loss, high need for crystalloid, immediate need for blood, o neg blood prep, highly likely need for operative intervention
vascular access in shocked patients
Peripheral venous access difficult
Central access – needs skilled clinicians and takes time
options. ..
1. peripheral venous access
2. central venous cannulation ( skilled operaters needed,
3. intraosseous access
benefits of intraosseous access
Useful in difficult venous access
Landmarks easy to find
Can deliver fluids and most drugs rapidly and easily
Painful in conscious patients
examples of 2 catergories of life threatening circulation problems
External haemorrhage
- Wounds, traumatic amputations
Internal haemorrhage
- Penetrating trauma e.g stab / gunshot
- Fractures e.g. pelvis
- Abdominal e.g. liver rupture, spleen, small bowel
symptoms of life threatening circulation problems
Tachycardia Pale Oliguria Tachypnoea Diaphoresis BP……?
as we loose blood vessels….
vasoconstrict until cant and plateu
as we loose blood heart rate ….
HR increases unitil plateaus
as we loose blood bp …
stays constant due to compensation then falls rapidly
describe Trauma induced coagulopathy, what makes it worse?
Systemic anticoagulation
Fibrinolysis
Made worse by:
- Hypothermia
- Acidosis
- Haemodilution
Imbalance of procoagulant / anticoagulant / platelets and fibrinolysis
Occurs in approx. 25% of all major trauma patients
4 times more likely to die than those without the condition
Likelihood reduced by:
- Prevention of hypothermia
- Haemorrhage control
- Appropriate blood / fluid management
components of the vertebral column (cross section)
review image in word
- intravertebral foramen
- vertebral body
- intervertebral disc
intervertebral disc can become compressed in a weight bearing situation
what is c1 to c7 of the spine
cervical curvature (concave)
what is t1 to t12 of the spine?
thoracic curvature (convex)
what is l1 to l5 of the spine?
lumbar curvature (concave)
what is sacrum of the spine like
belove lumar spine above coccyx, fused, convex
what is the coccyx of the spine like
4 fused vertebrae
where is the normal weight bearing line on the spine
on the concave right side
what is kyphosis
An increased front-to-back curve of the upper spine is called kyphosis.
what is scoliosis
abnormal lateral curvature of the spine.
vertebral anatomy. what are the 3 main parts of the vertebrae
Body
Arch
Articular processes
describe body of vertebrae
Transfers weight along axis of column
Connected by ligaments
Separated by intervertebral discs
describe the vertebral arch of the vertebrae
Forms posterior margin of vertebral foramen (foramen – opening)
Walls – pedicles
Roof – laminae
All together form – vertebral canal
describe the lumbar vertebrae
Largest vertebrae
Vertebra is thicker
Bear the most weight
Spinous process – surface attachment for lower back muscles
describe joints of the vertabrae
No intervertebral disc between C1 / C2
Nucleus Pulposus – soft, elastic, gelatinous core – surrounded by Anulus Fibrosus – effectively a shock absorber
Aging process – less water content in Nucleus Pulposus
- reduced shock absorbency
- Length of vertebral column shortens
review diagram labeling joints of the spine
review diagram labeling joints of the spine
The bottom picture shows a disc prolapsing and impinging on the spinal cord – this is very common in lumbar spine area and is usually known as a slipped disc.
breifly describe physiology of the spinal cord
Different parts of the cord have different functions
Some parts are ascending – travelling from receptors to brain
Some descending - from brain to effectors
describe neurogenic shock
Caused by interruption of sympathetic stimulation at or above T6
Shock = inadequate perfusion of the vital organs
Low BP
BP = C.O. x Peripheral Resistance
Sympathethic stimulation lost due to cord injury
Results in loss of muscle tone and loss of normal vaso constriction
Reduced vasoconstriction = reduced peripheral resistance = reduced BP
Signs and symptoms:
- Hypotension, bradycardia, flushed warm extremeties…but urine output remains within normal range
It is possible to have hypovolaemic shock AND neurogenic shock
what is spinal shock
This is a temporary state – lasts days to weeks
Loss of motor and sensory function below level of cord injury.
Loss of all spinal reflexes below injury
Flaccid paralysis (including bladder and bowel)
Priapism may be present
Ends when reflex arcs
below level of injury start to return.
Different as it is related to neurological function rather than blood pressure
what is Poikilothermia
Inability to maintain core body temperature
Temperature usually regulated by hypothalamus
Results in vasodilation and loss of heat through this mechanism
Classification of spinal cord injuries
tetraplegia
paraplegia
tetraplegia vs paraplegia
Tetraplegia
- Impairment or loss of motor and / or sensory function in cervical segments of spinal cord as a result of damage to neural elements of cord
Decreased function to arms, trunk, legs and pelvic organs
Paraplegia
- Impairment or loss of motor and / or sensory function in thoracic, lumbar or sacral segments of cord as a result of damage to neural elements of cord
Arm function remains intact
Trunk, legs and pelvic organs may be involved.
breifly describe cellular respiration
Life comes from Energy = ATP
What does a cell need to make energy (ATP)?
- Oxygen and Glucose
Inadequate perfusion of Oxygen and Glucose = cell dysfunction or cell death
ATP – produced in mitochondria (internal respiration)
With normal perfusion of Oxygen = Aerobic respiration
Inadequate perfusion or no Oxygen = AnAerobic respiration
aerobic respiration vs anarobic respiration
Aerobic respiration produces:
Sufficient ATP for cell to function and survive
Waste products – water and CO2
Anaerobic respiration produces:
Much less ATP
Cell dysfunction or death
Waste products – water, CO2 and Lactic acid
3 components of the cardiovascular system
blood, vessels and heart
t or f
Provides cell with oxygen and glucose – removes waste
t
How does Oxygen and Glucose get to the cell?
Carried in Blood – which is carried in Blood vessels
How does the Blood move to the cells and perfuse them?
pushed by the heart
this push is what we know as blood pressure
t or f the body doesnt need bp to be normal
f
BP equation
Blood pressure = Cardiac Output (CO) x Peripheral Resistance (PR)
how is CO and BP changed when trying to stabalise low bp
If a drop in B.P. is detected the body will try to bring it back to normal by altering CO and PR
review physiology of the immune system
Inflammation is normal – 1st stage of healing
Caused by release of cytokines (chemicals released by the immune system that have an affect on other cells)
Cytokines include:
+Histamine from mast cells - powerful vasodilator
+Nitric oxide – powerful vasodilator
+Tumour Necrosis Factor, Interleukin1 and many others
Vasoldilation
Also triggers change in core temperature – pyrexia or hypothermia
define sepsis
“Sepsis is life threatening organ dysfunction caused by a dysregulated host response to infection”
(Singer, et al 2016)
In plain English:
Life threatening organ failure caused by an abnormal response to infection
Sepsis pathophysiology
In Sepsis release of pro-inflammatory cytokines systemically (throughout the body) – which cause:
+ Vasodilation:
- decreased Peripheral Vasc. Resistance = decreased B.P.
- Compensatory mechanisms fail (Angtiotension II & Noradrenaline)
- Causes blood vessels to become leaky
…..Causes widespread oedema
……Fluid from oedema comes from systemic circulation = relative hypovolaemia
+Drop in B.P. (if not managed) causes:
- Anaerobic respiration / Mitochonrial dysfunction
- Lactic acid production = Metabolic Acidosis
- Metabolic Acidosis – leads to cell death and further inflammatory reaction
patient assessment considerations for sepsis
A- E assessment essential Sepsis is a medical emergency Early recognition is key A, B, C, D, E assessment YOU could be the first person to spot that something is wrong
breathing signs of sepsis
Resp Rate >20
21 – 24 = Moderate risk
>24 = High risk
Or new need for >40% oxygen to maintain SaO2 more than 92% = High risk
ANY ONE HIGH RISK– INITIATE SEPSIS BUNDLE
TWO OR MORE MODERATE RISK INITIATE SEPSIS BUNDLE
(NICE, 2016)
circulation signs of sepsis (ranges)
HR >90bpm
- 91 – 130 = Moderate risk
- > 131 = High risk
Systolic B.P. <100mmHg
- 91 – 100 = Moderate risk
- <90mmHg = High Risk
Not passed urine in past 12 – 18 hours = Moderate risk
Not passed urine > 18hrs = High risk
ANY ONE HIGH RISK– INITIATE SEPSIS BUNDLE
TWO OR MORE MODERATE RISK INITIATE SEPSIS BUNDLE
(NICE, 2016)
disablility/ neurological signs of septic shock
GCS< 15 (of new onset)
ANY ONE HIGH RISK– INITIATE SEPSIS BUNDLE
TWO OR MORE MODERATE RISK INITIATE SEPSIS BUNDLE
NICE, 2016
exposure signs of septic shock
- Raised white cell count
- Temp - Pyrexia>38C or Hypothermia <36 C = Moderate Risk
- Mottled / ashen appearance / non blanching rash = High Risk
- Signs of infection – redness / swelling / discharge
- Cyanosis = High Risk
ANY ONE HIGH RISK– INITIATE SEPSIS BUNDLE
TWO OR MORE MODERATE RISK INITIATE SEPSIS BUNDLE
(NICE, 2016)
considerations when using sepsis care bundle
Recently became one single bundle
Within first hour of arrival:
- Measure lactate – remeasure if >2mmol/l
- Obtain blood cultures before administering antibiotics
- Administer broad spectrum antibiotics
- Rapid administration 30ml/kg crystalloid fluid if hypotensive / Lactate > 4mmol/l
- Give vasopressors if hypotensive during or after fluid – keep MAP >65mmHg
Time zero = time of triage
priorities of care in sepsis - airway
Airway
+ Ensure patency (esp. GCS< 8)
what are the functions of the skin
Also known as the integumentary system
Function:
- Protection
- Temperature regulation
- Water regulation
- Sensory reception
How would the loss of any of these functions affect the person?
what are the different layers of the skin?
Epidermis
Dermis
- Nerve endings
- Blood vessels
- Hair follicles
- Sebaceous glands
- Sweat glands
Subcutaneous
-Adipose tissue
review layers of the skin diagram
review layers of the skin diagram
hair pore germinal layer of epid. sebaceous g;and sensory nerve sweat gland hair follicle blood vessel subcut fat fascia muscle
What is a burn?
Comes from Old English word ‘Baernan
An injury caused by heat, or a chemical, radiological or mechanical force that simulates the action of heat
what are the types of thermal burns
Flame Scald Contact Steam Flash
types of burns
Thermal
Chemical
Electrical
Radiation
Sources of Chemical Burns
Acids Alkalines (bases) Oxidisers Phosphorous Vesicants
Chemical Burns mechanisms
Reduction
Oxidation
Corrosion
Desiccation (drying out)
Vesication (causing blister e.g. mustard gas)
types of electrical burns
Contact burns
Flash burns
Flame burns
But can travel along muscle and nerve fibres
how do lightning strikes affect people, prevention of injury strategies?
50 per year injured
10 per year die
Prevention is a priority
- Don’t be the tallest object
- Don’t stand under tall objects
- Take shelter in a substantial structure
Electrical Burn Complications
Asphyxia Cardiac arrest Neurological Convulsions Kidney damage
what are radiation burns
Radiation burns can be caused by X-rays or radiation therapy to treat cancer.
treatment of radiation burns
May be contaminated
- Decontaminate before transport
Irrigate open wounds gently to avoid further damage
- Internal radiation absorption
Contact radiation burns
- Decontaminate the wound.
- Treat it as a burn.
assessment and management of burns
- Immediate care
- Assessment of severity of burn
- Fluid resuscitation
- Patient flow chart
- Vital sign assessment
- Referral and specialist management
describe immediate care of the burn
Stop the burning process:
- Remove the heat – water / cooling pad (Water-jel)
- Remove the burning agent e.g. Chemical burns – irrigation
- Begin ABCDE approach
considerations for treatment of airway burnt patients
Swelling due to burns in the upper airway can be fatal.
Swelling of the vocal cords can obstruct the airway completely.
Consider early intubation
What is critical care nursing?
Nursing care of patients who have…Manifest or potential disturbances of vital organ functions and who need assistance, support and restoration to health or the delivery of pain management preparation for a dignified death.’
World Federation of Critical Care Nurses (2016)
Essential care of the critically ill patient- 2 factors
reducing risk to patients
provision of quality care
how to reduce risk to the critically ill patient
- recognise specific need, particlarly sedate/ unconcious or immobile pta
- recognise specific complications that may req. special obs or treatment
- vigilant monitoring
- ADPIE
manage environemntal factors affectig the pt
how to provide quality care to the critically ill pt
- developmemt of skills and knowledge for practice
- EBP
- Optimal use of protocol driven therapy
- competent, efficient and safe practice, ADPIE, monitoring consequence of nursing interventions
- continuity of care
read chap 5 of critical care text
read chap 5 of critical care text
what is Invasive Positive Pressure Ventilation
mechanical ventilation
Over half of all admissions to ICU require invasive (also called mechanical) ventilation
(invasive positive pressure ventilation, which requires delivering breaths either through an endotracheal tube or a tracheostomy tube.)
IPPV indications
Apnoea
Inability to protect airway e.g. loss of gag reflex, low GCS
Clinical signs of rest failure - such as … SOB, productive coughing,
wheezing, cyanosis
Inability to sustain oxygenation to meet metabolic demands
review phases of normal breathing and vetilator respiratory components diagrams
review phases of normal breathing and vetilator respiratory components diagrams
How does mechanical ventilation work?
Patient intubated with endotracheal tube
Modern ventilators - able to detect, respond and control pressure and gas flow
Respiratory cycle - inspiration and expiration
A ventilator ‘breath’ can be classified by:
+ The mechanism that starts inspiration - patient or ventilator
+ The parameter that is limited / controlled during inspiration
+ The parameter that cycles the breath from inspiration to expiration
For example the ventilator could be set as:
- Ventilatior initiated inspiration
- The duration of inspiration may be the controlled phase
- A tidal volume may be set and this will trigger the expiratory phase
A ventilator ‘breath’ can be classified by:
ventilator ‘breath’ can be classified by:
+ The mechanism that starts inspiration - patient or ventilator
+ The parameter that is limited / controlled during inspiration
+ The parameter that cycles the breath from inspiration to expiration
For example the ventilator could be set as:
1. Ventilatior initiated inspiration
2. The duration of inspiration may be the controlled phase
3. A tidal volume may be set and this will trigger the expiratory phase
complications of mechanical ventilation
complications related to intubation, mechanical complications related to presence of ETT, ventilator induced lung injury, complications related to oxygen, complications of mechanical ventilation
describe venous access in critical care?
difficult to cannulate shocked pt eg. veins collapsed
venous vein accsess routes
Peripheral
Central
- Jugular or subclavian
Peripherally Inserted Central Cannulaton
-Indications for PICC line insertion
parenteral delivery of nutrition, antibiotics, and analgesics, as well as chemotherapy and repeated blood transfusions.
how is picc line inserted and where does it go?
PICCs are placed in a vein of the upper arm. The right basilic vein is the vein of choice due to its larger size and superficial location.
Once a suitable vein is identified in your arm, the skin around the area is cleaned and prepared. Numbing medicine is injected into the skin to minimize pain. To place the PICC line, a needle is inserted through your skin and into the vein in your arm. Ultrasound or an X-ray might be used to confirm the placement.
small incision is made in the vein so that a catheter can be inserted.
Once the catheter is in your arm, it’s carefully advanced along the vein. The catheter continues up your arm and toward your heart.
What care does picc line need - daily and weekly
keep dressing dry and in tact bp on other arm flush befor eand after meds change dressing and ports every 7 days watch for contamination watch for signs of local infection
What possible complications are there for picc line?
Bleeding. Nerve injury. Irregular heartbeat. Damage to veins in your arm. Blood clots. Infection. A blocked or broken PICC line.
why do we need BP
Perfusion
- Circulation of blood within an organ or tissue
…..Adequate amounts to meet the cells current needs for oxygen, nutrients and waste removal
what do cells do with blood
receive needs and expel wastes, transport system
needs used to maintain organs so the body can function efficiently
Organs perfusion requirements?
The heart requires constant perfusion
Brain and spinal cord cannot go for more than 4 to 6 minutes
Kidneys will be permanently damaged after 45 minutes
Skeletal muscles cannot tolerate more than 4 hours
3 elements of the cardiovascular system
3 elements:
Heart
Blood and its components
Blood vessels
components of Cardiac output
Stroke volume
- Pre-load
- Myocardial contractility
Heart Rate
After load / Peripheral Vascular resistance have big impact
what is cardiac output
Amount of blood pumped through the circulatory system in 1 minute
Expressed in litres per minute
Cardiac Output = Stroke Volume × Heart Rate
components of stroke volume
Preload…
- Starlings law
“the ability of the heart to change its force of contraction and therefore stroke volume in response to changes in venous return…”
- Myocardial contractility
describe the sympathetic nervous system
Prepares the body to respond to various stresses
- Increases heart rate
- Strengthens the force of cardiac muscle contractions
Noradrenaline
Adrenaline
what triggers the sympathetic and parasympathetic stimulation
Cardiac centre in medulla
- Sympathetic stimulation
- Parasympathetic stimulation
Baro and chemo-receptors in Carotid and Aortic arteries
what is afterload/ peripheral vascular restatance
the force a chamber of the heart has to generate to eject blood
Usually refers to left ventricle
what is normal blood volume
Normal adult blood volume – 7% of body weight
70kg - 5,000mls
equation for oxygen delivery and influences on arterial oxygen concentration
Oxygen delivery = Cardiac output x Arterial oxygen conc.
Arterial oxygen concentration
- quantity of haemoglobin
- saturation of haemoglobin
what does hb do to o2
Once oxygen has entered the blood from the lungs, it is taken up by haemoglobin (Hb) in the red blood cells
oxygen bonded with Hb molecules travel to organs and oxygen is released to tissue cells
types of blood vessels
Arteries Arterioles and capillaries - Diffusion Veins Venules
75% of blood capacitance is within venous system – “Venous reserve”
What is blood pressure equation
Blood pressure = Peripheral resistance x Cardiac output
how is blood pressure maintained
BP = CO x PR
Maintain BP at all costs
Change CO - Heart rate - Stroke volume ...Force of contraction ...Increased pre-load
Change Periph. Resist
what causes change in PVR
Baro-receptors – Carotid and Aortic
Release of Adrenaline - Noradrenaline
- Vasoconstriction
- Increased afterload
Renin – Angiotensin- Aldosterone pathway
Anti-diuretic hormone
Pathophysiology of shock - What is shock?
“Shock is the manifestation of the rude unhinging of the machinery of life”
Samuel V. Gross 1872
OR
“Shock is an inadequate delivery of oxygen and nutritive substrates to the tissues”
what are the Metabolic effects of shock
Reduction in oxygen – anaerobic respiration
Much less energy produced
Lactic acid produced as a by-product
Cellular breakdown begins
Cellular effects of shock
Mitochondria damage begins
Lysosomes rupture – begins cell lysis
Release of cytokines, lactic acid, complement, kinins, prostaglandins…..
Metabolic acidosis
Multiple organ failure begins
Reperfusion may exacerbate toxic mediator release (may lead to SIRS)
how might the body try compensate for shock
Neurogenic
- Baroreceptors
Endocrine
- Vasopressors – Adrenaline, Noradrenaline
- Renin – Angiotensin
- Aldosterone
- ADH
Inflammatory
- Nitric Oxide
Definition of hypovolaemic shock, what fluids can be lost
Shock caused by loss of fluid volume:
Whole blood – haemorrhage
Plasma – burns
Interstitial – diaphoresis, vomiting, diarrhoea
primary survey in relation to shock
Some suggestion of change to AcBCDE in massive haemorrhage Ac B – RR, Sa02, IPPA C – Pulse, BP, Cap refill, urine output D – AVPU E – Any obvious bleeding
basics of management of shock
Control of obvious external bleeding
Splinting of long bone fractures
Supplemental oxygen
Fluid resuscitation
what is splinting
secure (a broken limb) with a splint or splints
where may massive blood loss occur leading to shock
Massive haemothorax 1500 – 2000ml
Fractured Femur 1000 – 1200 ml
Fractured pelvis - >2000ml
principles of fluid resuscitation in shock
IV Fluids... - Don’t carry oxygen (yet!) - Don’t clot MUST be warmed Dilutional coagulopathy...
principles of fluid resusitation (Blood)
Type specific takes time
Transfused blood does not initially coagulate well
Potential for transfusion reaction
Potential for TRALI – Transfusion Related Acute Lung Injury
fluid resus methods
Fluid challenge v hypotensive resuscitation
what is fluid challenge
The principle behind the fluid challenge technique is that by giving a small amount of fluid in a short period of time, the clinician can assess whether the patient has a preload reserve that can be used to increase the stroke volume with further fluids.
what is hypotensive resusitation
“Permissive hypotension”
Increased mortality assoc. with rapid fluid challenge (Geoghegan et al, 2010)
Evidence recommends withholding fluids
- Where a radial pulse is palpable
- Where a central pulse if palpable in penetrating torso trauma
- This referred to the pre-hospital setting…
Sapsford (2008) argues insufficient evidence to alter algorithm in hospital at present
Head injuries…
strategy that uses limited fluids and blood products during the early stages of treatment for hemorrhagic shock. A lower-than-normal blood pressure is maintained until operative control of the bleeding can occur.
What is Aggressive fluid challenge (ATLS)
Initial warmed IV bolus of up to 2,000ml (20ml/kg in a child) as rapidly as possible
Observe patients response…
what is the non average patient for which consideration should be taken during shock care
Athletes
Pregnancy
Extremes of age
Complicating factors:
Medicines
Pacemaker
Anaemia
Hypothermia
crystalloid or colloid for resus during shock
Crystalloid require at least 3:1 ratio of replacement
Colloids much more expensive
…what is the evidence
What is Tranexamic acid used for in shock
Anti-fibrinolytic agent i.e. blocks the action of clot dissolving enymes.
Used off label in the UK – up to the clinicians judgement as to indication
CRASH 2 trial (2011) – increased survival without increased risk of adverse events.
Recommended administration within 3 hrs
Cost +/- £6.80 per dose.
What is Tranexamic acid used for in shock
Anti-fibrinolytic agent i.e. blocks the action of clot dissolving enymes.
Used to reduce haemorrhage
Used off label in the UK – up to the clinicians judgement as to indication
CRASH 2 trial (2011) – increased survival without increased risk of adverse events.
Recommended administration within 3 hrs
Cost +/- £6.80 per dose.
the primary survey for trauma
Similar to A- E assessment
AcBCDEF
Fix a life threatening problem at each step before moving on
Can be done simultaneously with other members of the trauma team
What is involved in Catastrophic haemorrage part of the primary survey? types/ possible causes?
Relatively uncommon in hospital
Bleeding that if not stopped will lead to death rapidly
Arterial external haemorrhage
Traumatic amputations
Penetrating trauma e.g. stabbing / shooting
Rapid treatment:
- External direct pressure
- Tourniquet
- Haemostatic agents
What is catastrophic haemorrhage?
what is involved in Catastrophic haemorrage part of the primary survey?
what situations can cause it?
Relatively uncommon in hospital
Bleeding that if not stopped will lead to death rapidly
Arterial external haemorrhage
Traumatic amputations
Penetrating trauma e.g. stabbing / shooting
Rapid treatment:
- External direct pressure
- Tourniquet
- Haemostatic agents
What is involved in Airway with restriction of c-spine motion part of the primary survey
Airway take priority over all other elements
All unconscious patient suspected of having c-spine injury
All injuries above clavicles should be suspected of having c-spine injury
Collar v self-splinting (we will cover in more detail in Topic 7 - Spinal Injury)
Ability to speak?
What indicates possible airway obstruction?
Manual manoeuvres - head tilt or jaw thrust?
If moving patient - have suction available
What is involved in Breathing part of the primary survey
Remember RIPPA from Year 1? Resp rate Inspect Palpate Percuss Auscultate
What observations tell you about this? O2, RR
What immediate interventions?
BVM, ventilation
What is involved in circulation part of the primary survey
What observations tell you about the patient’s circulatory state?
oliguria- low urine output… indicates decreased renal blood flow,
What possible immediate interventions?
fluids
What is involved in disability part of the primary survey, things affecting LOC?
What are we actually assessing at this step?
LOC
What would a GCS of less than 8 mean?
intubate
List 4 things that can affect conscious state: drugs./substance abuse. medications. epilepsy. low blood sugar.
What is involved in exposure part of the primary survey
Look for any ‘OMG’ injuries
Any obvious wounds, deformed limbs, bruising
What is involved in farenheit part of the primary survey
Hypothermia results in poor outcomes for trauma patients
Blood coagulates poorly at lower temperatures
- Trauma triad - acidosis, hypothermia, coagulopathy
What does iatrogenic mean?
Hypothermia in trauma is commonly iatrogenic
It must be prevented:
- Bair hugger
- Warmed IV fluids
pharmacology used in major trauma
Tranexamic acid
- Used to reduce haemorrhage
Analgesia
Anaesthesia / sedation
eg. Fentanyl , propofol- general anaesthetic agent, rocuronium - neuro-muscular blocker
- What type of drug is Fentanyl and How is it different to morphine?
contraindications?
Fentanyl has an analgesic and sedative effect on the human body. it is an opioid analgesic
Although Morphine Sulphate and fentanyl are both opiate analgesic medications there are
some differences between the medications.
Fentanyl is considered 50 to 100 times more
potent than morphine and fentanyl is a synthetic
opioid where as morphine is pure and comes from opium. (Trescot et al., 2008).
Rapid sequence induction - what is it? example
Rapid sequence induction (RSI) is a method of achieving rapid control of the airway whilst minimising the risk of regurgitation and aspiration of gastric contents.
airway management technique that produces inducing immediate unresponsiveness (induction agent) and muscular relaxation (neuromuscular blocking agent) and is the fastest and most effective means of controlling the emergency airway
eg. Fentanyl , propofol- general anaesthetic agent, rocuronium - neuro-muscular blocker
Psychological factors following major trauma
Post –traumatic stress disorder may be common not just to trauma (injury) but to critical illness
Severity of injury does not predict a PTSD reaction
Important to follow up with patient in the long term – liaison with primary care
Consider your words
patients will remember what you say for a lot longer than what you do
Anatomy of the spine
Bony structures
- Vertebral column – cervical, thoracic, lumbar, sacral and coccyx
- Spinal Cord
- Joints
- Muscle groups
function of the spine
- Support Weight bearing (anterior -Vertebral Body)
Movement
- Muscle attachments
- Joint articulations
Nerve distribution & protection (posterior Vertebral Arch)
describe the cervical spine
The cervical spine
C1 – is called Atlas – it carries the world (head) on it’s shoulders
C2 – is called the axis – this is the bone on which the head pivots (like an axle on a car wheel)
C2 has a peg (Dens or ‘tooth’) – this stops C1 from slipping forward.
The xray shows a fracture of c1 and c2
This is usually fatal and referred to as Hangmans fracture
describe the lumbar vertebrae
Largest vertebrae
Vertebra is thicker
Bear the most weight
Spinous process – surface attachment for lower back muscles
describe the joints of the spine
No intervertebral disc between C1 / C2
Nucleus Pulposus – soft, elastic, gelatinous core – surrounded by Anulus Fibrosus – effectively a shock absorber
Aging process – less water content in Nucleus Pulposus
- reduced shock absorbency
- Length of vertebral column shortens
Common spinal cord injuries
Approx 180000 cases of spinal cord injury globally p.a.
Leading causes – Motor vehicles – followed by falls, snowboarding, rugby and diving
51% are tetraplegic – all 4 limbs
Main risk factors:
Age
Gender
Alcohol / drug use
Most common vertebra involved – C5 – 7, T12 and L1
primary spinal cord injury?
Mechanical – bone fragments, direct trauma
Damage to axons, blood vessels, cell membranes of cord
secondary spinal cord injuries?
Occurs minutes to years after primary injury
Changes in blood supply
Electrical activity
immediate assessment process following spinal cord injury
- Catastrophic haemorrhage Ac – Airway with restriction of spinal movement B - Breathing C – Circulation D - Disability E - Exposure F - Fahrenheit
immediate care following spinal cord injury
Application of cervical collar
Indications
- Alteration in sensory or motor function
- Unconscious
- Can have adverse effects e.g. increased ICP
- In line spinal control
- Observe airway – especially when moving patient
What would you do if patient vomits on route to x-ray for example?
bring suctioning and equipment along
aim of immediate care following spinal injury
Aim is to prevent secondary injury
- Observe for neurogenic shock
- Further movement causing further damage
- Reduce inflammation – swelling
- Assessment and stabilise patient
- CT / MRI scan with xray
- Consider patient pressure areas!
possible ongoing care needs following spinal injury
- May require Halo frame
- Gastrointestinal dysfunction
…..May require nasogastric tube for first 48 hra
…..Distension and inability to empty bowel
……Slow digestive processes
- Genito urinary dysfunction ....Urinary catheter required ....Loss of voluntary bladder control ....Priapism in men Impotence in men
- Pressure care crucial
how a cervical collar should be fitted and its’ purpose
Measure the distance from the top of the patient’s shoulder to the angle of the jaw with your hand (image 1)
On the collar, measure from the bottom of the rigid plastic to the “measuring post”. This should correspond to the above measurement (image 2)
Check that the collar fits correctly
The neck should not be overextended
The mouth should not be able to be fully opened
purpose - to support your neck and spinal cord, and to limit the movement of your neck and head.
Explain what a log roll is and its’ purpose
Logrolling is a common patient care procedure performed by many health care workers. The purpose of logrolling is to maintain alignment of the spine while turning and moving the patient who has had spinal surgery or suspected or documented spinal injury.
what is autonomic dysreflexia
Autonomic dysreflexia is a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above).
signs of AD include high blood pressure, pounding headache, flushed face, sweating above the level of injury, goose flesh below the level of injury, nasal stuffiness, nausea, and a slow pulse
4 signs or symptoms that would lead you to suspect your patient has a spinal cord injury
- extreme back pain
- numbness
- weakness
- loss of bladder/ bowel function
What is poisoning / intoxication?
Poisoning can be defined as an interaction between a foreign chemical (toxin) and a biological system that results in damage to a living organism.
risk assessment for poisoning/ intoxication?
Not all overdoses are deliberate / not all accidents are accidental
- What agent & formulation (e.g. tablet, slow release etc.)
- Dose (if known)
- Time since ingestion
- Clinical features and progress
- Patient factors (weight / comorbidities / ingestion of others substance e.g. alcohol
initial assessmet of poisoning/ intox
primary survey
factors to consider when caring for poisoning/ intox./ care- treatment options
Supportive care and monitoring
Investigations
- Screening and specific investigations
Decontamination
Enhanced elimination
Antidotes
Disposition
Management of common presentations of poisoning/ intox
Very few specific antidotes - Specific antidotes include: Naloxone Flumazenil for benzodiazepines N-Acetylcysteine for paracetamol
supportive care
What is ‘supportive’ care?
The goal of supportive care is to prevent or treat as early as possible the symptoms of a disease, side effects caused by treatment of a disease, and psychological, social, and spiritual problems related to a disease or its treatment.
Consider possible effects of poison, what systems?
Poisoning morbidity and mortality usually results from the acute effects of the toxin on the cardiovascular, central nervous or respiratory systems.
Monitoring is essential to detect the progress of the intoxication and to time the administration of supportive care.
If the patient deteriorates more quickly than expected, …? (intox/ poisoning)
go back to the resuscitation phase, then revise the risk assessment.
To ensure ongoing assessment is comprehensive, the patient requires regular:
- Vital signs, cardiac monitoring, neurological assessment
- Haemodynamic monitoring, psychological assessment
- General assessment for signs such as rashes, diaphoresis.
what is decontamination
The principle of decontamination is that by reducing the dose absorbed the subsequent severity and duration of clinical toxicity will be reduced.
risks of decontamination
Tendency to overestimate the potential benefits / underestimating potential hazards of gastrointestinal decontamination procedures
No longer routine, the decision to decontaminate is based on weighing up the benefits against the risks
Basic resuscitation and supportive care take precedence
poisoning decontamination options
Options include: Single dose activated charcoal Induced emesis Gastric lavage Whole bowel irrigation.
what is the aim of enhanced elimination
Aims:
- Reduce severity & duration of clinical intoxication by increasing the rate of removal of an agent.
- Indicated if they reduce mortality, length of stay, compilations or the need for other invasive interventions
- Used where agents are characterised by: severe toxicity, poor outcome despite good supportive care and antidote administration, slow endogenous rates of elimination, suitable pharmacokinetics
enhanced elimination options
Multiple dose activated charcoal
Haemodialysis and haemofiltration
Urinary alkalinisation
Charcoal haemoperfusion.
review alcohol poisoning
review alcohol poisoning
review opioid poisoning
review opioid poisoning
review methamphetamine poisoning
review methamphetamine poisoning
review paracetamol poisoning
review paracetamol poisoning
review snake bite poisoning
review snake bite poisoning
Trauma in the older person?
Only 8% return to independent living 1 year post polytrauma.
- Diminished vision, hearing and touch expose older people to increased risk of injury
- Hospital separations increase exponentially, becoming extremely high in the 85+ age group.
trauma and falls?
- Falls are the main cause for injury-related hospital separations
- The reason for the fall is likely to be complex, despite a simple explanation
- There needs to be a falls assessment and referral programs for those who do not require immediate hospitalization.
the aging process skin injury
Skin
Epidermis flattening and loss of papillae leads to decreased adhesion between layers of the skin
Loss of subcutaneous fat and wrinkling of the skin
Nails become thick and brittle.
the aging process muscoskeletal injury
Atrophy of tissue extends to muscle and bone
Decreased muscle strength and movement
Bone mass decreases, resulting in more brittle bones.
the aging process respiratory system injury
Respiratory system
•Trachea and rib cage become less flexible
•The number of alveoli reduces
•Reduction in the arterial partial-pressure of oxygen.
the ageing process circulatory system injury
Circulatory system
•The myocardium loses contractility resulting in decreased cardiac output
•Vasculature thins and stiffens
•Arrhythmias and conduction disturbances are more prevalent, harder to diagnose and not tolerated as well.
The ageing process renal system injury
Renal system
20% decrease in the size of the kidney by the age of 80
A decrease in glomerular filtration rate increases the chance of adverse drug reactions and drug-induced renal failure
Fluid overload is a real risk and fluid resuscitation must be titrated to central venous pressure and urine output.
the ageing process gastrointestinal inury
- Gastric emptying, splenic blood flow and gastrointestinal motility all decrease with age.
- A difficult presenting complaint that brings older people to the ED is abdominal pain.
- Mortality from abdominal symptoms is ten times higher in older persons when compared to young people.
what is a common fracture in older person
Colles fracture
type of fracture of the distal forearm in which the broken end of the radius is bent backwards.
describe fractured neck of femur
Major weight bearing bone
50% of body weight going through neck of femur
Blood supply to head of femur travels through neck of femur
High risk of avascular necrosis
broad classifications for neck of femur fractures
Broad classifications:
- Intracapsular - ‘true’ neck of femur fracture
- Extracapsular
- Each type requires a different management strategy
assessment of the older adult trauma
Primary survey
Secondary survey
–What could we miss
immediate nursing care following trauma in the older adult
Fluid balance and restoration - haemorrhage
Analgesia
Pressure assessment and care
What else do you think is an immediate priority?
- more at risk individuals
review surgical management of the older adult (trauma)
review surgical management of the older adult (trauma) video on lms
If a drop in B.P. is detected the body will try to bring it back to normal by …….?
If a drop in B.P. is detected the body will try to bring it back to normal by altering CO and PR
Recognising Sepsis – high risk groups
Infants (under 1 year)
Elderly (over 75 years)
Impaired immune system:
- Cancer patients – active treatment
- Immuno-therapy – organ transplant or rheumatoid arthritis
- AIDS
- Diabetes Mellitis
Recent surgery (less than 6 weeks)
Pregnancy, recent birth / termination / miscarriage (within 6 weeks)
Any breach of the skin
IV drug users
Indwelling lines or catheters
(NICE, 2016)
Recognising Sepsis - pitfalls
Young people compensate well for long periods…then crash rapidly
Beware underlying illnesses / drugs masking sepsis e.g. beta blockers masking tachycardia
Abusive behaviour could be caused by sepsis
priorities of care during sepsis care - breathing?
Breathing
+ Maintain SaO2 > 94% (88-92% in COPD)
+ Consider if cause of infection is respiratory e.g. pneumonia
+ May require ventilation
priorities of care during sepsis care - circulation?
Circulation
+ Maintain systolic B.P. >90mmHg
+ IV fluid resuscitation if hypotensive – 30ml/kg OR / AND Lactate >4mmol/litre
+ May require IV vasopressors if hypotensive despite fluids
e.g.
Adrenaline – increases force of myocardial contraction, heart rate and peripheral resistance (vaso-constrict)
Noradrenaline – increases heart rate and increases peripheral resistance
Dopamine – increases heart rate and increases peripheral resistance
Dobutamine – stimulates beta 1 adrenergic receptors in heart – increases force of myocardial contraction and heart rate
priorities of care during sepsis care - disability?
Disability \+ Decreased GCS = risk to airway \+ Determine cause of altered conscious state: -BGL? - Trauma? - Stroke? - Hypoxia? - Hypotension? - Toxins? - Medication?
priorities of care during sepsis care - exposure?
Rashes may not appear OR may be a very late sign
Log roll patient and expose all of patient – check skin folds, soles of feet
Monitor temperature – may be hyperthermic – BUT – could also be hypothermic
What is svt
Supraventricular tachycardia (SVT) is an abnormally fast heart rhythm arising from improper electrical activity in the upper part of the heart.
No.1 cause of CHD
Atherosclerosis
What is the role of apoptosis in the pathophysiology of multiple organ dysfunction syndrome (MODS) in sepsis?
Apoptosis (programmed cell death) is the principal mechanism by which dysfunctional cells are normally eliminated. The proinflammatory cytokines may delay apoptosis in activated macrophages and neutrophils, but other tissues (eg, gut epithelium), may undergo accelerated apoptosis. Therefore, derangement of apoptosis plays a critical role in the tissue injury of sepsis.
necrosis is caused by
Necrosis is cell death caused by hypoxia or trauma
hypotensive resus…
Evidence recommends withholding fluids when?
- Where a radial pulse is palpable
- Where a central pulse if palpable in penetrating torso trauma
- This referred to the pre-hospital setting…
