Care of the person who experiences trauma (BIG MOTHER FUCKING DECK) Flashcards
What is the purpose of the triage system?
To ensure that the level and quality of care that is delivered to the community is commensurate with objective clinical criteria
Explain the Australasian triage scale and the 5 categories
- Immediately life-threatening (category1)
- Imminently life-threatening (category2)
- Potentially life-threatening or important time- critical treatment or severe pain (category 3)
- Potentially life-serious or situational urgency or significant complexity (category 4)
- Less urgent (category5)
Name factors that influence the triage role
Physical environment Time constraints Language use Nonverbal behaviours Cultural diversity Nature of the health concern Expectations and assumptions Emotions
What are impartant factors when checking airways?
Check patency
Check obstruction
What are important factors when checking Breathing?
Check for respiratory distress
What should you look out for when checking circulation?
Heart rate Pulse characteristics Skin indicators Oral intake Output
What should you look out for when checking Disability?
GCS
what is AVPU and when is it used?
when checking disability A = alert V = Responds to voice P = Responds to pain - purposefully, non-purposefully, withdrawal/flexor response, extensor response U = Unresponsive
What happens in a secondary survey?
Full set or vital signs Give comfort measures History and head to toe Individualised aspects IDC BGL physical
What differs between rural and remote triage?
Lack of safety net
Time issues
Triage process may occur outside hospital setting
Personal safety
Lack of anonymity
Decisions may carry enormous financial or social ramifications to patients and family
Knowledge of the community
What are the different types of emergency presentations
Burns Submersion Environmental emergencies Spinal and head injuries Anaphylaxis
what are the 3 Types of burns
not thickness
- Thermal
- Chemical
- Electrical
Explain the characteristics and the thickness of different burns
– Superficial (epidermis): skin may pink to red and
dry, painful
– Partial thickness (epidermis and dermis): skin bright pink and blisters, painful
– Full thickness (epidermis, dermis, underlying tissues): skin appears waxy, dry, leathery, charred, no pain
What are the predisposing factors of burns
Age
- under 3 yrs.- safety issues
- 3-14 yrs. – flame burns most common - 15-60 yrs. – domestic or industrial
- over 60 yrs. – medical problems
Describe a primary survey of a burn
- Airway – possible smoke inhalation
- Breathing – possible carbon monoxide poisoning
- Circulation – haemodynamic stability
- Disability – neurological and spinal status
- Exposure – temperature, wound severity (size, depth, location, patients age
Explain a secondary survey of a burn
- Nature of the incident
- Mechanisms of injury
- Pertinent medical history – pre-existing disease
- Current medications
- Allergies
- Tetanus immunisation
How do we measure the extent of a burn?
Every body part is broken down into a percentage
The rule of 9’s
The Lund and browder method is the recommended method as there is a table for different ages
Why is the burn percentage important to us?
The Australian nz burns association relies on accurate burn measurement for referral
What are some burns referral criteria?
Burns greater than 10% Burns of special areas Full thickness burs greater than 5% Electrical burns Chemical burns Burns associated with inhalation injury Burns at the extremes of age Burns on people with pre existing medical disorders Any burn patient with associated trauma
How is a partial thickness burn assessed for depth?
Sensation - Normal or increased sensitivity to pain and temperature
Colour - Red, will blanch with pressure indicating good capillary return
Blisters - Large, thick walled, will increase in size
Texture - Normal to firm
How is a full thickness burn assessed for depth?
Sensation - Anaesthetic to pain and temperature
Colour - White, brown, black, red. If red, does not blanch with pressure
Blisters - Usually none. If present, thin walled and do not increase with size
Texture - Firm to leathery. Eschar
What are some types of minor burns?
Sunburn
Scald burn - exposure to moist heat
What are some types of a major burns?
- Includes all burns of the hands, face, eyes, ears, feet, and perineum, all electrical injuries, multiple traumas, and all clients that are considered high risk
- Partial thickness burns of greater than 25% of the total body surface
- Full thickness burns of 10% or greater of the total body surface area
Explain what happens in the Integumentary system in a major burn event
Integumentary
- skin loss
- sensory loss
- decreased temp
How can you tell if a burn wound is infected or at risk of infection?
– Increased sloughing of burn tissue
– Increased edema around wound edges
– Partial-thickness wound converting to full- thickness wound
– Black or brown areas of discoloration
What is the recommended parameters for fluid resuscitation and for what burns is this necessary?
- Necessary in all burns >15% TBSA
- Hourly urine0.5mL-1mL/kg/hr
- HR <120 beats/min
What needs to be considered for respiratory management for a burn?
• TCDB every 2 hours - Prepare for intubation • Maintain adequate tissue oxygenation with least amount of inspired oxygen necessary • Continuous assessment of ABGS • PEEP may be used
What do we do for pain management if a burn?
- Do not administer IM analgesia
- IV/CVC inserted
- sliding scale order – e.g. Morphine infusion 5-25mg/hr with 2mg bolus prn – PCA
- Change to oral medication when tolerating food and fluids
What types of surgery is done for burns?
- Escharotomy
- SurgicalDebridement
- Grafting
Explain escharotomy
A scalpel or electrocautery incision through the full thickness eschar, usually performed at a burn centre, to restore circulation to compromised extremities
Removal of eschar
Explain burn contracture
Skin and scaring heals to tight
What nursing issues are associated with burns?
Distancing oneself from patients pain
Engaging with the patients pain
Seeking social support
Core role reconstruction
What is a submersion injury?
Results when a person becomes hypoxia due to submersion
What is the pathogenisis of submersion?
Immediate struggle sometimes surprise inhalation or breath holding
What is a wet drowning?
Vigorous breathing and water down into the lungs leads to aspiration
What is a dry drowning?
The laryngeal spasm closes the airway leads to aspiration
What happens when fresh water is aspirated?
Water leaks rapidly to the capillary bed
What happens when salt water is aspirated?
Fluid is dragged into the the alveoli
What does surfactant destruction lead to?
Pulmonary oedema
What is the treatment and assessment of a submersion?
• Manage and maintain ABC
• If ABC secure assess
– Tachycardia is common after near drowning
– CNS can range from coma to agitation to alert some may be lethargic, confused or irritable
– Resp assessment note rate rhythm cyanosis, frothy sputum
– Temp can be low grade in the first few hours
– Exclude other possible pathologies such as MI, Arrhythmia, Neurological epilepsy, head injury ,spinal injury, Alcohol and drug intox, Environmental hypothermia
What is a thermoregulation issue?
Imbalance of temp
What is internal heat input?
Eating or drinking
Muscle contraction
What is external heat input?
Shower
engines
What are the types of heat output?
Conduction
Convection
Radiation
Evaporation
Where is the thermoregulation centre?
The hypothalamus
How does the thermoregulation centre work?
Peripheral receptors send signals to the essential receptors in the hypothalamus which then sends the reponse
In smooth muscles what happens in thermoregulation?
Describe the difference between cold and hot
Cold
- muscles contract causing vasoconstriction
- Less heat is carried from core to surface
- extremities can turn blue and get frostbite
Hot
- muscles relax causing vasodilatation
- more heat is carried from core to surface
- surface heat is lost by convection and radiation
- skin turns red
What happens in sweat glands in thermoregulation?
Describe the difference between cold and hot
Cold
- no sweat
Hot
- Glands excrete sweat to suface
- sweat cools body and evaporates
In erector pili muscles what happens in thermoregulation?
Describe the difference between cold and hot
Cold
- Muscles contract raising the skin hairs which traps an insulating layer of still warm air next to the skin (goosebumps)
Hot
- muscles relax lowering skin hairs allowing air to flow over skin
What do skeletal muscles do for thermoregulation?
Describe the difference between cold and hot
Cold
- shivering, muscles contract and relax repeatedly generating heat by friction
Hot
- no shivering
Explain hypothermia
Hypothermia is a marked cooling of core body temperature
It produces depression of the • CNS and respiratory systems, • vasoconstriction • alterations in micro circulation coagulation • and ischemia tissue damage
What happens to metabolism the in hypothermia?
- Initial ↑ in basal metabolic rate which results in tachycardia, vasoconstriction and shivering
- As metabolism slows oxygen deprivation occurs
- The metabolism movesto anaerobic producing lactate and resulting in metabolic acidosis
What happens in the CVS in hypothermia?
- ↑ HR, ↑ B/P, ↑ CO
- Shunting of blood from peripheries to central organs
- As temp falls to 32°C myocardial activity is suppressed resulting in bradycardia
- As myocardial activity is further depressed CO falls with the result less perfusion to vital organs
What happens in the respiratory system in hypothermia?
increased resp rate
as hypothermia worsens the medulla becomes depressed and respiratory function is depressed
Metabolically there is less CO2 being produced but there is less capacity to remove CO2 via the lungs and respiratory acidosis results
What is the management of hypothermia?
Rewarming to raise temperature by 0.5 - 1 degree Celsius /hour
What are the different types of rewarming?
Passive and active
Explain Passive rewarming
- Remove wet clothing
- Replace with warm blankets
- Increase room temperature
- Eliminate drafts
- Minimal handling
- Warm oral fluids
Explain Active rewarming
- Immersion in heated water
- Use of radiant heat
- Devices such as Bair hugger
- Use of space blankets
- Cover the persons head (50 -60% of radiant heat loss occurs above the shoulders)
What is hyperthermia?
Diagnosed when the core body temp is higher than 40
What is the signs and symptoms of hyperthermia?
Heat cramps
• Severe muscle cramps
• Thirst
Heat exhaustion • Pale or grey skin • Fatigue weakness • Sweating++ • Altered mental state • Hypotension • Tachycardia • Thready pulse • Temp >37.8 but <40C
What is the management of hyperthermia?
Remove from danger Stabilise ABC, record temp Remove excessive clothing Cool – cold packs to axial / groin spray with water and fan Immerse part of body in cool/iced water Continue to monitor ABC may need Oxygen and / or ventilation, cardiac monitor Slow re hydration to prevent hyponatraemia
How are head injuries described?
Open or closed
What happens in raised ICP?
Blood or CSF or brain tissue swell and raise the pressure in the skull
What is used to regulate and maintain ICP?
• Monro-Kellie doctrine
– If one component increases, another must decrease to maintain ICP.
• Normal ICP 5 to 15 mmHg
– Elevated if >20 mm Hg sustained
What compensatory actions does the body do for increased ICP?
– Changes in CSF volume
– Changes in intracranial blood volume
– Changes in tissue brain volume
Explain what happens in the cardiovascular system in a major burn event
Third spacing decreased BP Increased HR Decreased RBC's Decreased cardiac output Decreased tissue perfusion
Explain what happens in the respiratory system in a major burn event
Hypoxia Increased respiration Rhonchi Decreased ciliary movement Airway obstruction
Explain what happens in the GI system in a major burn event
Hyperacidity Ileus Melena Hematemesis Increased abdominal girth
Explain what happens in the urinary system in a major burn event
Decreased GFR Increased creatinin increased BUN Increased Specific gravity increased uric acid increased myoglobinuria
Explain what happens in the immune system in a major burn event
Decreased T-Cells Decreased B-cells Increased WBC's Decreased proteins Phagacytosis
Explain what happens in the metabolic system in a major burn event
increased catabolism decreased anabolism weightloss acidosis hyperglycemia
What do the adrenal and thyroid glands do for thermoregulation?
Describe the difference between cold and hot
Cold
- Glands excrete adrenaline and thyroxine which increased metabolic rate
Hot
- glands stop secreting adrenaline and thyroxine
What behaviours do people do for thermoregulation?
Cold
- huddling up
- curling up
- finding shelter
- putting on more clothes
Hot
- Stretching out
- finding shade
- swimming
- removing clothes
What happens to the neurological system in hypothermia
alteration in mentalstate, ↑anxiety, muscle incoordination, weakness and confusion
What treatment can you do to actively internally rewarm a hypothermic patient?
- Heated humidified air or oxygen
- Heated/warmed IV fluids
- CP bypass diverts blood flow via a pump oxygenator and heat exchanger
- Continuous arteriovenous rewarming via a femoral catheter
Explain the 4 stages of increased ICP
– Stage 1:total compensation
– Stage 2: ↓compensation; risk for ↑ICP
– Stage 3: failing compensation; clinical manifestations of ↑ICP (Cushing’s triad)
– Stage 4: imminent → death
What are the clinical manifestations of raised ICP?
Give 3 examples
• Change in level of consciousness
• Change in vital signs
– Cushing’s triad (widened pulse pressure, bradycardia, irregular respirations)
– Change in body temperature
• Ocular signs – Unilateral pupil dilation – Sluggish or no response to light – Inability to move eye upward – Eyelid ptosis
Headache
Vomiting
Regarding increased ICP what motor manifestations can occur?
↓ In motor function
– Hemiparesis/hemiplegia
– Decerebrate posturing (extensor) • Indicates more serious damage
– Decorticate posturing (flexor)
What diagnostic studies are done for determining head and spinal injuries?
- CTscan/MRI/PET
- EEG
- Cerebral angiography
GCS
Where can you place an ICP monitoring device?
Epidural intraparenchymal subarachnoid ventricular subdural
What treatments are used for spinal or head injuries?
• Treat under lying cause. • Adequate oxygenation –PaO2 >100mmHg – PaCO2 35-45 mm Hg – Intubation – Mechanical ventilation • Surgery
Give an example of 3 drug therapies that are used for head injuries?
– Mannitol (Osmitrol)
• Plasma expansion
• Osmotic effect
• Monitor fluid and electrolyte status.
– Hypertonic saline
• Moves water out of cells and into blood.
• Monitor BP and serum sodium levels.
– Corticosteroids
• Vasogenic edema
• Monitor fluid intake, serum sodium and glucose levels.
• Concurrent antacids, H2 receptor blockers, proton pump inhibitors
– Antiseizure medications – Antipyretics – Sedatives – Analgesics – Barbiturates
What nursing assessments can you do for a patient affected by a head injury?
• Subjective data • Level of consciousness (LOC) • Glasgow Coma Scale – Eye opening – Best verbal response – Best motor response
What does one dilated and one normal pupil mean?
compressed cranial nerve 3
What do bilateral dilation of pupils mean?
Ominous sign
What do pinpoint pupils mean?
Damage to pons or drugs
What cranial nerve assessments can you do?
– Eye movements
– Corneal reflex
– Oculocephalic reflex (doll’s eye reflex)
– Oculovestibular (caloric stimulation)
What nursing interventions can you do for respiratory functioning of head injuries?
– Maintain patent airway. – Elevate head of bed 30 degrees. – Suctioning needs – Minimize abdominal distention. – Monitor ABGs. – Maintain ventilatory support.
What nursing interventions can you do for pain management of head and spinal injuries?
– Opioids – Propofol (Diprivan) – Dexmedetomidine (Precedex) – Neuromuscular blocking agents – Benzodiazepines
What nursing interventions can you do for fluid and electrolyte imbalances patients with head and spinal injuries?
– Monitor IV fluids.
– Daily electrolytes
– Monitor for DI or SIADH
How can you visually assess for a head injury?
- Bruising
- Swelling
- Lacerations
- Bleeding
What are the different classifications of spinal cord injuries?
Traumatic and non traumatic
What can cause a traumatic spinal injury?
vehicle accidents, sporting accidents, falls and assaults with weapons.
What can cause a non-traumatic spinal injury?
- cervical spondylosis
- myelitis
- osteoporosis
- tumours
- vascular disease
What nursing management can you do for a spinal cord injury?
- Immobilisation to prevent further injury.
- Thermoregulation.
- Bowel and bladder management.
- Reduce spascity.
- Prevent pressure areas.
- Prevent resp complications
- Assist with nutritional needs.
- Control pain
- Promote mobility and maintain suppleness of joints and muscle tone.
- Psychological support
What is a hypersensitive reaction?
Hypersensitivity describes an increased immune response to the presence of an allergen known as an antigen, which can potentially cause harm to the person
What are the signs and symptoms of anaphylactic shock?
- Rapid onset from seconds (can be up to one hour).
- Rash, urticaria, pruritus.
- Angioedema especially of the head, face, neck and upper airway.
- Flushing
- Chills
- Diaphoresis
- Laryngeal spasm (hoarseness, stridor)
- Bronchospasm (wheeze or poor air entry)
- Hypotension
- Tachycardia
- Arrhythmias
- Cardio- pulmonary arrest
What is the treatment and management of anaphylactic shock?
- Secure patent airway, relieve obstruction
- Remove allergen i.e. stinger, infusion etc
- Adrenaline
- Administer high flow oxygen via a non rebreather mask may require nebulised bronchodilator
- Provide warmth
- Corticosteroid
- Administer histamine
- Maintain BP with fluid, volume expanders, vasopressors
Explain the triad of death
Sever blood loss leads to
- low body temp
which leads to decreased coagulation which leads to
- Blood clotting problems
which increase lactic acid in the blood which leads to
- Acidic blood
which decreases heart performance
And repeat steps 1-3 indefinitely until you save the patient
