Assessment & Management of Patients with Chest, Abdominal and Eye Trauma Flashcards
Describe what you would do in the primary survey of a trauma patient
- Assess airway for patency, obstruction; use chin-lift or jaw-thrust maneuvers
- Protect the cervical spine by not overextending, hyper-flexing or rotating the head and neck. Use immobilization devices. Stabilize the patient’s head/neck if they must be removed temporarily
- Administer high flow oxygen, ventilate with a bag-valve-mask device if necessary. Assess carefully for pneumothorax, especially tension pneumothorax
- Assess the patient’s circulation and control hemorrhages by applying direct pressure to external bleeding sites. Insert at least 2 large bore IVs, consult surgery STAT if internal bleeding is suspected
- Assess neurological status. Determine the level of consciousness using the Glascow Coma scale.
- Completely undress the patient for a quick assessment then cover with warm blankets to prevent hypothermia
What additional labs/tests will you perform initially on a trauma patient?
- Full panel of labs: Chem-10, CBC, coags, ABG, lactate and type & screen
- Place patient on EKG monitor
- Insert indwelling urinary catheter for strict and accurate measurement of I & O
- Insert an NG tube for gastric decompression
- Assess need for x-ray, flat plate exam of chest and pelvis
- Consider a peritoneal lavage or focused assessment with sonography (FAST) exam
- Re-examine ABGs before beginning secondary survey
Describe what you would do in the secondary survey of a trauma patient
- Complete a thorough head to toe examination. The sequence is head, maxillofacial structures, cervical spine and neck, chest, abdomen, perineum/rectum/vagina, musculoskeletal system and neurological system
- Take a complete history using the mnemonic AMPLE: allergies, medications, past illnesses/pregnancy, last meal and events that led to the trauma
What are the subjective/objective findings associated with chest trauma?
- Patients experience pain with coughing, movement and even breathing.
- You can reproduce pain during your physical exam.
- The pain may cause the patient to take shallow breaths, splint or protect the area when examined.
- You may note crepitus and decreased breath sounds on the affected side
What labs/diagnostic tests are ordered for patients with chest trauma?
- CXR may reveal the fracture and atelectasis.
- ABGs may reveal respiratory acidosis if the patient is hypoventilating due to pain. If the patient is hyperventilating, the opposite will be seen (respiratory alkalosis).
- CBC may show decreased H&H if a hemothorax occurred due to severe contusions
How do you manage a patient with chest trauma?
Need to make sure that the underlying structures are intact.
- Possible additional injuries include a lacerated subclavian artery or vein, lacerated liver or spleen or pneumothorax.
Pain management
- Minor pain: Aspirin, acetaminophen or non-steroidal anti-inflammatory drugs but evidence of/risk for bleeding needs to be determined first.
- Severe pain: Ketorolac (Toradol) 30 mg IV Q6H, Morphine Sulfate 2 – 4 mg IV initially then titrate for affect. If patients are requiring very high doses, watch for respiratory depression and consider change to Dilaudid 0.2 mg IV initially (every 15 minutes to break the pain) then 0.5 mg IV Q4H.
- Consult Pain Services for their input and recommendations. Intercostal nerve blocks may be needed if the pain is severe and exceeds your ability to control their pain without side effects of medications.
Pulmonary considerations:
- Monitor oxygenation closely; order 2L O2 per NC to maintain oxygen saturations > 92%, keep patient turned or mobile, use aggressive pulmonary toilet (will likely need pain medications before treatments).
- Patients may need aerosol therapy with albuterol (Ventolin) if they develop shortness of breath or wheezing
What is and what causes a flail chest?
Definition:
- Fracture of at least two adjacent ribs at two sites that results in a “floating” segment or sternum
- This is the chest wall injury that most frequently causes damage to the underlying structures.
Cause:
- It is caused by blunt force/trauma
What are the subjective/objective findings associated with a flail chest?
- The patient will exhibit pain, shortness of breath with rapid, shallow breaths.
- Upon physical exam, due to the unstable section of the chest wall, you may note paradoxical chest wall movement, cyanosis, crepitus
- decreased breath sounds on the affected side
- The pain may appear groggy with a decreased LOC due to hypoxemia
How do you manage patients with a flail chest?
- Administer oxygen to improve hypoxia
- Consider ventilatory support with positive end-expiratory pressure and pressure support if the patient’s ventilatory restriction is severe.
- Induced paralysis may be needed.
- IVF should include crystalloids such as lactated Ringers or NS.
- A 1liter bolus should be given followed by maintenance of 100 cc/hr.
- Remember, the patient’s pre-existing conditions should always be considered.
- Pain management: Morphine sulfate 2 mg IV initially then titrate. Dilaudid may also be considered. If the patient is not mechanically ventilated, observe closely for respiratory compromise
What is a Hemothorax?
Blood accumulates in the pleural space. If there is at least 1500 cc of drainage, it is a massive Hemothorax.
What is a Open pneumothorax?
“Sucking chest wound”. Air flows from the atmosphere to the pleural space and back again. It can lead to a tension pneumothorax if the wound is covered with an occlusive dressing This type of pneumothorax can be caused by a penetrating trauma such as a gunshot wound or knife wounds
What is a tension pneumothorax?
one way entrance of air flow into the pleural space results in increased pressure on the heart, mediastinal shift to the unaffected side and eventually circulatory collapse. It can be caused by blunt or chest trauma, open pneumothorax, fractured rib, mechanical ventilation and clamped chest tube
What are the signs and symptoms of a collapsed lung?
respiratory distress, hypoxia, decreased LOC, hypotension, chest pain, decreased or absent breath sounds on the affected side and deviation of the trachea to the unaffected side
How do you manage patients with a pneumothorax?
- For open pneumothorax, apply a 3 sided dressing, leaving one side unsecured to allow air to escape
- If the patient has a massive Hemothorax, fluid resuscitation with lactated Ringers or auto transfusion after thoracostomy
- If tension pneumothorax, rapid insertion of large bored (14 to 16 gauge) needle into the second intercostal space, midclavicular line of the affected side to decompress. An obese person or a patient with a large amount of breast tissue may not have complete resolution with a standard catheter due to inability to reach the area. These patients may require a longer needle or larger gauge needle to stent the area open to allow air to escape
- Chest tube insertion to low wall suction (- 20 cm) for a pneumothorax or Hemothorax
- Consider mechanical ventilation with a positive end expiratory pressure of + 5, a pressure support of 10 and a tidal volume set at 6 ml/kg
What is and what causes aortic rupture?
Definition:
- It is an interruption of the wall of the aorta caused by blunt traumatic deceleration injuries.
Cause:
- It can occur in an MVC (most often without use of a seat belt), falls, auto-ped accident.
- In patients wearing a lap belt only, no shoulder attachment, they can sustain injury when the belt forcefully compresses the abdomen in a collision.
- This injury has a high mortality rate in general with patients often dying before they reach the hospital for care.
What are the subjective/objective findings associated with aortic rupture?
- Shortness of breath, weakness and chest or back pain
- The patient can quickly progress to total circulatory collapse
What diagnostic tests are done to diagnose an aortic rupture?
- A CXR may show a widened mediastinum, deviation of the trachea to the right, obliteration of the aortic know and fractures of the first or second rib or scapula.
- An aortagram may be done to confirm diagnosis and may reveal a widened mediastinum.
What are the subjective/objective findings associated with a liver laceration?
- RUQ pain
- Guarding
- Signs of hypovolemic shock from hemorrhage, hypoactive or absent bowel sounds.
- There can be abdominal distention and abdominal wall ecchymosis.
- Important historical data to obtain in the BAT occurred in a MVC include vehicle type and velocity, rollover, patients location in the vehicle, extent of damage to the vehicle, steering wheel deformity, whether front or side air bags were deployed
What diagnostic/lab tests are done to diagnose liver trauma?
Diagnostic:
- FAST ultrasound or positive diagnostic peritoneal lavage (DPL) indicate BAT although this procedure has largely been replaced by CT scans
- Radiologic studies can provide invaluable information in the patient with BAT.
- CT scans can better define the organ injury and can detect the presence of and source of bleeding in the peritoneum.
- Plain radiographs of the abdomen are generally not helpful.
Labs:
- decreased H&H (hematocrit below 30 increases the likelihood of an abdominal injury
- elevated pancreatic enzymes
- elevated liver enzymes
- increased PT
What are some subjective/objective findings associated with a ruptured spleen?
- Pain - Kehr’s sign (acute pain in the tip of the shoulder when lying down with legs elevated)
- The patient may also demonstrate guarding when being examined
- VS and PE may show signs consistent with hypovolemic shock
What diagnostic tests are done to diagnose a pelvic fracture?
Pelvic x-ray shows a disruption of the pelvic ring, a widened sacroiliac joint, widened pubic symphysis and rami fractures
What is an Open globe rupture eye trauma?
occurs following blunt eye injury typically near the equator and directly behind the insertion of the rectus muscles
What is an open globe eye laceration?
a penetrating injury to the eye by a sharp object or projectile. It can be penetrating (there is an entry wound but no exit wound) or perforating (both entry and exit wounds).
