Acute trauma Flashcards
The nurse in the emergency room has received report from EMS of an incoming patient who was the victim of a high-speed, roll-over motor vehicle accident and sustained multiple injuries. Which of the following should the nurse assess first?
A) Pedal pulses
B) Chest rise and fall
C) Blood pressure
D) Head and neck pain
B) Chest rise and fall
Always your abc
Nursing care and mgmt of trauma
- Spinal immobilization until cleared
- Accurate and thorough history as able
- Determine mechanism of injury
- Locate and document all wounds
- Withhold oral fluids
- Tetanus and antibiotic prophylaxis as ordered
- Continuous monitoring and assessment
Mechanism of injury
Forces and energy that causes trauma
1. Falls
2. Blast
3. MVC
4. GSW
5. Pedestrian struck
Significant MOI
- Ejection from vehicle
- Death of someone in the same vehicle
- Rollover motor vehicle accident
- High speed collisions (40+mph)
- Pedestrian struck
- Falls from 20+ feet
- Motorcycle accident with rider separation
- Penetrating trauma to head, neck, torsos and proximal extremity
- Significant blunt force trauma to head neck or torso
Motor vehicle accidents (MVA): Seat belts and air bags
- Airbags without seatbelts only slightly reduce risk of fatality
- Assessment of injury pattern will coincide with type of seatbelt (Skin will have an injury that is the same shape as the belt)
- In 30+ mph MVA with an unbelted occupant slams into the internal compartment of the vehicle is the same impact as falling from a 3 story building
MVA: Over the dash
- Upper torso injuries
- Chest moves forward and hits the steering wheel and dash
- Fractured Ribs
- Flail chest
- Contusions
- Intra-abdominal injuries
- Head hits windshield
- Skull fractures
- Brain injury
- Neck injury
- Lacerations
MVA: Under the dash
- Lower torso injuries
- Body slides under the steering wheel and dash
- Hip dislocation and fracture
- Femur fracture
- Knee dislocation
- Tibia/fibula fracture
- Ankle injury , dislocation, fracture
MVA: Rear end collision
- Accelerated forward motion (whiplash)
- Neck injuries
- Chest wall injuries
MVA: side impact injury (Tbone)
- Lateral movement of the vehicle
- Head and neck injuries
- Chest injuries
- Pelvic injuries
MVA: Roll over accidents
- Number of injuries as well as severity of injuries is increased
- Multiple impact points
- Ejection from vehicle
- UFO/Sun roof
Chest Trauma
- Blunt trauma occurs more frequently than penetrating chest trama
- Can be life threatening
- hypoxemia
- Hypovolemia
- Cardiac failure
Chest trauma assessment: history
- Time elapsed sience injury
- Mechanism of injury
- LOC
- Specific Injuries
- Estimated blood loss
- Recent drug/alc use
- any pre hospital care
Flail chest
- More than 2 ribs fractured in at least 2 places each
- Causes paradoxical movement
- Inspiration causing the chest (lungs) to sink in
- Expiration causing the chest (lung) to go out
Chest trauma assessment: Look
- RR
- depth of respirations
- Equal chest wall expansion, paradoxical chest wall motion (Flail chest)
- Look for bruising, seat belt or steering wheel injures, any penetrating wounds, foreign objects
Done first
Chest trauma assessment: Listen
Listen for normal and equal breath sounds on each side
Done second
Chest trauma assessment: Feel
- Palpate for chest wall tenderness
- Palpate for subQ emphysema (air bubbles under the skin)
- Assess for tracheal alignment
Chest trauma mgmt: assess
- Pain
- Anxiety
- Resp distress
Chest trauma mgmt: Treatment
- Goal is to evacuate blood and air from pleural space
- Chest Tube
- Fill chest wound
- O2
Tension pneumothorax
- Trachea: Deviated (side of injury)
- Chest expansion:Decreased
- Breath sounds: Diminished or absent
- Percussion: Hyper resonant
Simple Pneumothorax
- Trachea: Midline
- Chest expansion: Decreased
- Breath sounds: May be diminished
- Percussion:Usually normal may be hyper resonant
Hemothorax
- Trachea: Midline
- Chest expansion: Decreased
- Breath sounds: Diminished if large, normal if small
- Percussion: Dull
A patient is brought to the emergency room after sustaining a penetrating injury to the abdomen. Which of the following would the nurse identify as a possible cause?
Impact of a steering wheel
Fall to the ground from a ladder
Stabbing with a knife
Concrete debris from an explosion
Stabbing with a knife
Probably
Abdominal/pelvic trauma
- History of injury
- Inspection: Sharp or blunt? examine pelvis and perineum
- Auscultate: Bowel sounds
- Palpate: Tenderness, including rebound tenderness
- Muscle rigidity
- Pain
- Distension
- Labs and diagnostics
- UA,CBC, preg, PT/INR
- Pelvic X ray, ct
Abdominal/pelvic trauma: Blunt injury
- Look at
- the speed of impact
- Location of wound
- Intrusion of vehicle
Abdominal/pelvic trauma: Penetrating injury
- Look at
- Type of weapon
- Distance
- Speed
- Location of wound
The nurse is admitting the patient with a penetrating abdominal injury from a knife wound. What should the nursing measures for a penetrating abdominal injury include: (Select all that apply)
1. Assessing for manifestations of hemorrhage
2. Covering any protruding viscera with sterile dressings soaked in normal saline solution
3. Looking for any associated chest injuries
4. Exploring the abdominal wound with a gloved finger
5. Irrigating the wound with normal saline
- Assessing for manifestations of hemorrhage
- Covering any protruding viscera with sterile dressings soaked in normal saline solution
- Looking for any associated chest injuries
- Irrigating the wound with normal saline
Musculoskeletal trauma: Fractures
ABC’s, including pulse in extremities
Musculoskeletal trauma: Pulseless extremity
- Reposition
- If ineffective, be quick and complete exam and then transfer to OR: ortho emergency
Musculoskeletal trauma:
- Fractures
- If pulseless, reposition
- Life vs limb injuries
- Compartment syndrome
Musculoskeletal trauma: Life or limb, life
- femur or pelvic fractures (lots of good arteries there)
- Can die from associated blood loss of up to 2-3 liters
Musculoskeletal trauma: Limb
- Fractures associated with vascular dmg
- open wounds or compartment syndrome
Musculoskeletal trauma: Compartment syndrome
- Extreme swelling to the point it impedes blood flow to the distal end of the extremity
- Loss of pulse is a late sign
- Disproportionately high pain
- Pain on passive stretch of affected muscle
- Palpable tenseness
- Altered sensation
- Delayed capillary refill
Mgmt of compartment syndrome
fasciotomy: relieve the pressure by making an incision
Musculoskeletal trauma mgmt:
- Control the bleeding
- Assess and recognize vascular compromise
- Consider comparment syndrome
- pain control
- Reduce and immobilize fractures and dislocations
Blast or explosion injuries:
- Combination of mechanisms
- Blunt and penetrating (Shrapnel)
- Consider proximity, enclosed space, multiple fragments and secondary impacts (Throw or fall from height)
Initial assessment of a pt
- Priorities stay the same no matter the cause of injury
- A: Airway and C spine protection
- B: Breathing and ventilation
- C: Circulation and bleeding control
- D: Disability (Neurology)
- E: Environment and exposures
Initial assessment of a pt: Airway
- Establish a patent airway
- C spine stabilization
- May need adjunctive therapy to maintain airway
Initial assessment of a pt: Breathing and vent
- Assess for adequate breathing and vent
- RR
- Chest movement
- O2 sat
- Mechanical vent
Initial assessment of a pt: Circulation and bleeding control
- Assess organ perfusion
- LOC
- Skin color and temp
- Pulses: rate and character
- Control bleeding
- Restore volume
Initial assessment of a pt: Disability
- LOC
- GCS
- Motor and sensory to limbs
It is actually just neuro
Initial assessment of a pt: Environment and exposure
- Expose the pt
- Look for wounds, rashes, contusions, injuries
- Check temp
Initial assessment of a pt: Neuro status
- Baseline neuro status
- GCS
- Pupillary response
- Observe for neuro deterioration
GCS
- Scale used to determine neuro function. assess LOC
- Score ranges 3-15 with 15 being the best
- Composed of 3 test (Motor, speech, eye)
- Important to consider the individual scores as well as total score
- Consider if the pt received narcotics or sedated
GCS: Motor
- No response
- Decerb
- Decort
- Withdrawal from pain
- Localizes to pain
- Obeys commands
GCS: Eye
- No response
- To pain
- To speech
- Spontaneously
GCS: Speech
- None
- Incomprehensible (Grunting)
- Inappropriate
- Confused
- Orientated
Pupillary response
- Check for symmetry
- Check size
- Check reaction
- Are pupils dilated
When are eyes no longer considered symmetrical
Greater than 1mm between them
Fixed pupils
No response to light
Dilated pupils
> 4 mm
What else goes on during the initial assessment
- All happening at once
- Initial assessment
- Resuscitation
- Prevent hypothermia
- Blood work and diagnostics
- Vitals
- Urine output
What labs are done during the initial assessment
- ABG
- CBC
- PT/PTT/INR
- Chemistries
- Lactate
- Pregnancy
- Cardiac enzymes
- X ray
- CT
- Ultrasound
What after the initial assessment
- Initial assessment is ongoing, continually assess your pt
- Monitor for changes
- Identify and treat deterioration
Starting a secondary assessment
- Complete history
- Complete head to toe physical
- Complete neuro assessment
- Further diagnostic testing
- Continuoius reevaluation
Secondary assessment: History
- Sample history
- S+S
- Allergies
- Meds
- past medical history
- Last oral intake
- Events leading up to the injury
Secondary assessment: Detailed physical exam: Head and face
- External exam
- Scalp, palpation and examination
- Exam nose, ears auditory canal
- Visual exam
- Facial deformities
Secondary assessment: Detailed physical exam: Neck
- Soft tissue injuries
- Hematoma
- Bruit
Secondary assessment: Detailed physical exam: Chest
- Inspect
- Auscultate
- Palpate
- Percuss
Secondary assessment: Detailed physical exam: Abdomen/pelvis
- Inspect
- Auscultate
- Palpate
- Percuss
- X-rays
- Pain on palpation
- Pelvic instability
Secondary assessment: Detailed physical exam: Genitalia
- Blood
- Lacerations
Secondary assessment: Detailed physical exam:Perineum
- Contusions
- Abrasions
- Lacerations
Secondary assessment: Detailed physical exam: Extremities
- Deformities
- Lacerations
- Pain
- Perfusion
- X-ray (Soft tissue injuries, missed fractures)
Secondary assessment: Detailed physical exam: Neuro
- Cranial nerves
- GCS
- Pupillary response
Secondary assessment: Detailed physical exam: Back and spine
- Palpation
- Deformity
- Tenderness
- Swelling
- Sensation
- Urinary output
- Immobilization
Brain death criteria:Coma
- No evidence of responsiveness
- Absent eye movements or eye opening with noxious stimuli
Brain death criteria
- Coma
- Absent brainstem reflexes
- Apnea
Brain death criteria: Absent brainstem reflexes
- Absent pupillary response, ocular movement, corneal reflexes
- Absence of facial movements, gag reflex
Special considerations: Peds
- Big Head
- Soft head
- Large tongue
- Soft chest wall
- Soft thinner muscular wall
- Smaller blood volume
- Age specific vitals
Kids compensate really well, deterioration is sudden
Special considerations: Geriatric
- Vision
- Diminshed hearing
- Respiratory vital capacity
- Renal disease
- Joint pain and degeneration
- Peripheral neuropathy
- Vascular disease (impaired blood flow to legs)
- HD
- High BP
- Stroke
- Diabetes
- Meds (polypharm)
When do you transfer pt
- Multisystem or complex injuries
- Patients with comorbidities
- Pts with age extremes
- Hospital does not have specialty care that patient requires
what do you document
- Description of all wounds
- mechanism of injury
- Time of events
- Collection of any and all evidence, such as clothing
