Multi-System Trauma Part 1 Flashcards
Spinal Cord Injuries, Care of the Emergency Patient beside bites
Spinal Cord Injury cells do / do not regenerate
DO NOT regenerate
Spinal Cord Injury results from
trauma
- partial or complete damage to the spinal cord
SCI is the
degenerative loss of motor, sensory and autonomic function
What happens during SCI to the cells?
Apoptosis (programmed cell death)
- days to months after initial injury
- **sudden reoval of survival signals or disassociation from neighboring cells
T/F: SPINAL SHOCK is a true shock.
False
What can not be regained after a SCI?
central nervous system function
What 2 factors cause the SCI to excel
Edema secondary to inflammatory response is harmful because of lack of space for tissue expansion
Edema and inflammation of SCI result in
compression of cord and extension of edema above and below injury increase ischemic damage
The extent of injury and prognosis for recovery most accurately determined
at least 72 hours or more after injury
- up to 1 year after
Spinal Shock is
Temporary neurologic syndrome
Spinal Shock characterized by
loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury.
Spinal shock masks
postinjury neurologic function** can have more mvmt ability later than when they first come in
- resolved when you get the reflexes back
Neurogenic shock occur where in the spine
T6 and higher
Neurogenic Shock occurs from
unopposed parasympathetic response due to loss of sympathetic nervous system (SNS) innervation
Neurogenic shock causes
peripheral vasodilation, venous pooling, and decreased cardiac output
Neurogenic shock s/s
significant hypotension (< 90 mmHg), bradycardia, and temperature dysregulation
- Warm and dry (PINK) due to blood in periphery
Neurogenic shock lasts
1-3 weeks
Neurogenic shock’s hypotension can cause
poor perfusion and oxygenation to the spinal cord and worsen spinal cord ischemia
Neurogenic shock is what type of problem
pipe problem
- vessel vasodilate into periphery
- low HR and BP
- no resistance
What can you do to determine if it is a neurogenic shock issue?
500 -1000mL OF FLUID if it does not work then you know it is neurogenic shock then give vasopressors but don’t drown them
What can you use to help the neurogenic shock pt with orders
TED hose, compression socks, SCD, belly binder and vasopressors
SCI is classified by the
(1) mechanism of injury, (2) level of injury, and
(3) degree of injury
Major mechanisms of SCI
flexion, flexion-rotation, hyperextension, vertical compression, extension-rotation, and lateral flexion
Flexion-rotation injury is the
most unstable because ligaments that stabilize the spine are torn. This injury most often contributes to severe neurologic deficits
Flexion injury of the cervical spine ruptures the
posterior ligaments
Hyperextension injury of the cervical spine ruptures the
anterior ligaments
Compression fractures
crush the vertebrae and force bony fragments into the spinal canal
Flexion-rotation injury of the cervical spine often results in
cervical spine often results in tearing of ligamentous structures that normally stabilize the spine - spinning car crash
In a MVA what should check first for a fx of the spinal column
Calcaneus heal bone as it is the “toughest” in the body
Skeletal level of injury
vertebral level where there is most damage to vertebral bones and ligaments
Neurologic level of injury
Lowest segment of spinal cord with normal sensory and motor function on both sides of the body
What injuries are most common in the spine?
cervical and lumbar
- greatest flexibility and mvmt
If the cervical cord is involved then paralysis
all four extremities occurs, resulting intetraplegia(formerly termedquadriplegia).
The lower the level of injury to the spine,
the more function is retained in the arms
If the thoracic, lumbar, or sacral spinal cord is damaged, the result
paraplegia(paralysis and loss of sensation in the legs).
C4 injury
tetraplegia
complete paralysis below the neck
C6 injury
partial paralysis of hands and arms and lower body
- tetraplegia
T6 injury
paraplegia
= paralysis below the waist
L1 injury
paraplegia
Which is shorter the spinal cord or the vertebral column?
spinal cord
Cervical vertebrae
7
Thoracic vertebrae
12
Lumbar vertebrae
5
Sacral vertebrae
5
Cervical cord
first cervical vertebra (the atlas) and the second cervical vertebra (the axis
Complete cord involvement injury
(decapitation – internal, GSW, stab, penetrating all the way across)
= Results in total loss of sensory and motor function below level of lesion (injury)
Incomplete (partial) cord involvement
Results in
Results in a mixed loss of voluntary motor activity and sensation and leaves some tracts intact
What is associated with incomplete injuries?
central cord syndrome, anterior cord syndrome, Brown-Séquard syndrome
Central cord syndrome damage to
Damage to central spinal cord
Central cord syndrome occurs most commonly in
cervical cord region
Central cord syndrome s/s
Motor weakness and sensory loss are present in both upper and lower extremities
- bone abnormality
- lower not affected
- burning pain in upper
- cant bear own weight
Central cord syndrome loss in
Greater loss in arms than in legs
Central cord syndrome is common in
older adults
Farmers
Does central cord syndrome last forever?
no, rehab can help them walk again with arm or leg braces sometimes
not able to feed themselves or button a shirt
Brown-Séquard syndrome damage to
one half of spinal cord
Brown-Séquard syndrome characterized by
loss of motor function and position and vibration sense on same side of injury
Paralysis on the same side as lesion
Opposite side has loss of pain and temperature sensation below level of lesion
Brown-Séquard syndrome caused by
penetrating injury to spinal cord
Proprioception
I cant tell you wear my arms are or how they look when not in my view (position)
Higher the injury, the
more serious the sequelae
- Proximity of cervical cord to medulla and brainstem
Patient with an incomplete lesion may demonstrate a
mixture of symptoms
S/S of SCI
direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection.
Sequalae – 2nd things = complications
pneumonia, bed sores,
Priority to take care of in SCI
atelectasis = partial portion = IS, forced FiO2 if unable on their own, turn, suction, cough out
SCI S/S - respiratory system
C1-3
Apnea, inability to cough
Need intubation quickly
SCI S/S - respiratory system
C4
Poor cough, diaphragmatic breathing, hypoventilation
Assisted cough
SCI S/S - respiratory system
C5-6
↓ Respiratory reserve
Teaching
The most likely cause of death when a spinal cord injury occurs
respiratory arrest
Above C3 Loss of
phrenic nerve function
SCI @ C4-C5 loss
loss of diaphragmatic innervation
Spinal cord edema and hemorrhage can affect function of phrenic nerve and cause respiratory insufficiency
Hypoventilation almost always occurs with diaphragmatic breathing
SCI Between C6-T8 loss of
intercostals
Presents special problems because of total loss of respiratory muscle function
Mechanical ventilation is required to keep patient alive
Artificial airways have an increase of
direct access for pathogens
Important to ↓ infections
Pulmonary edema may occur in response
fluid overload
Forced assisted cough –
lay flat on their back then place hands under their diaphragm, when they take try to cough then press to help them to cough
SCI S/S - CV system
Above level T6 reduce influence of the sympathetic nervous system
Heart rate is slow (<60 beats per minute) because of unopposed vagal response
- DECREASE VAGAL STIM.
SCI Bradycardia tx
Vasopressors and IV fluids, atropine – temporary, pacemaker
SCI increase of vagal stimulation result in
cardiac arrest
SCI has peripheral vasodilation resulting in
hypotension
- ↓ Venous return of blood to heart, ↓ Cardiac output
IV fluids or vasopressor drugs may be required to support BP
Any increase of vagal stimulation help by
Turning
Suctioning, cough (but could arrest)
Temporary/permanent pacemaker
Tx for CV SCI
Compression gradient stockings, Remove q 8 hours for skin care
Prophylactic heparin or low-molecular-weight heparin
Frequently assess vital signs
Anticholinergic for bradycardia
Phrenic nerve stimulators or electronic diaphragmatic pacemakers increase mobility
Teach cervical-level injury patients who are not ventilator dependent
Assisted coughing
Regular use of spirometry or deep breathing exercises
S/S of SCI in the GU system
Urinary retention common
Bladder may become hyperirritable
- Loss of autonomic and reflex control of bladder and sphincter
- reflux into kidney with eventual renal failure
SCI in the GU system Tx
INT cath program
prevent UTIs
Suprapubic cath
S/S of SCI GI
above T5
primary GI problems related to hypomotility
- paralytic ileus
- gastric distension
- stress ulcers HCl excess
S/S of SCI GI
T12 or lower
decreased sphincter tone
As GI reflexes return, then
Bowel becomes reflexic
Sphincter tone is enhanced
Reflex emptying occurs
bowel program with laxative at desired routine time
Dysphagia may be present in patients who need
mechanical ventilation, tracheostomy, and anterior spine surgery.
Combined with increased anal sphincter tone and the inability to sense a full rectum, this causes
stool retention and constipation
SCI at or below the conus medullaris causes the bowel to be
areflexic.
The defecation reflex may be damaged and anal sphincter tone relaxed. This leads to
constipation, increased risk for incontinence, and possible impaction, ileus, or megacolon. Hemorrhoids can occur over time.
What is a great way to get the pt GI system moving?
early ambulation
- stable and with help
S/S of SCI skin system
Consequence of lack of movement is skin breakdown
- bony prominences and decreased/absent sensation of immobility
Pressure ulcers can occur quickly
Can lead to major infection or sepsis
SCI skin breakdown prevention
Turn them and teach the support system
Case mgmt. gets them the correct supplies
Poikilothermism
- inability to maintain a constant core temperature, with the patient assuming the temperature of the environment.
Thermoregulation of spinal cord disruption
Decreased ability to sweat
Decreased ability to shiver
SNS prevents peripheral temperature sensations from reaching
hypothalamus
___________ are associated with a greater loss of ability to regulate temperature than are thoracic or lumbar injuries.
cervical
If temp gets high due to going outside, antipyretics
do not help this type of hyperthermia
- manage temp
if hot give cool drinks and fluids visa versa
Nonoperative stabilization
traction or realignment
Eliminate damaging motion at injury site
Intended to prevent secondary damage
ABC for SCI
A with C collar
Airway
Breathing
Circulation
Criteria for SCI surgery
Evidence of cord compression
Progressive neurologic deficit
Compound fracture
Bony fragments
Penetrating wounds of spinal cord or surrounding structures
What surgery is better compared to the other for a SCI?
Anterior first due to no access during a code in posterior
the bone graft for the SCI surgery is taken from
iliac crest
Proper immobilization involves maintenance of a neutral position
Skeletal traction
Kinetic therapy
Halo jackets
Immobilization devices mgmt
correctly aligned
turn to prevent spinal mvmt
Clean twice daily
Realignment or reduction of injury
Provided by rope, pulley and weights
Traction must be maintained at all times
Stabilize head if dislodged and then call for help
Kinetic Therapy
Uses a continual side-to-side slow rotation
Decreases pressure ulcers and cardiopulmonary complications
Autonomic DYSREFLEXIA
spinal cord at T6 or higher/lower?
Autonomic DYSREFLEXIA triggered by sustained stimuli from
restrictive clothing
full bladder
UTI
pressure areas
fecal impaction
Nursing Interventions for Autonomic DYSREFLEXIA
Elevate head of bed at 45 degrees or sit patient upright (HIGH FOWLERS)
Notify physician
Assess cause
Immediate catheterization
Teach patient and family causes and symptoms
DIGITAL RECTAL FOR IMPACTION
Autonomic DYSREFLEXIA S/S
high BP - severe and rapid
flushed and fever
HA
distended neck veins
low HR
high sweating
Vasodilation Above
Vasoconstriction Below
*pale.cool, no sweating
Rehab and Home CARE
Organized around individual patient’s goals and needs
Patient expected
To be involved in therapies
To learn self-care
Can be very stressful
Frequent encouragement
SEXUAL ISSUES IN YOUNG AND ELDERLY - counseling
Return of reflexes may complicate rehabilitation
Hyperactive
Exaggerated responses
Spasms
Patient or family may see this as return of function
Grief and Depression for SCI
May feel an overwhelming sense of loss
May believe they are useless and burdens to their families
Patient’s family may also require counseling – hopeless, wish they died
Patient should be
Treated in an adult manner
Involved in decision-making process
- allow mourning and reality to set in but not hopelessness
- sympathy not helpful
Scope of emergency nursing
Recognizing life-threatening illness or injury
- interventions to reverse or prevent
An emergency is whatever the patient or family considers it to be
The emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations
factors result in chronic overcrowding and long wait times in ED
(1) the inability to see an HCP, (2) an aging population, (3) shorter hospital stays resulting in frequent readmissions, (4) acute mental health crises, (5) ED closures, and (6) lack of or inadequate health insurance or an HCP
It is not your crisis, it is
their crisis = need help from personal events as you do not know their story
Triage
Process of rapidly determining patient acuity
Represents a critical assessment skill
The triage system identifies and categorizes so the most critical are treated first.
First impressions are made here
EMERGENT (ASAP), URGENT, JUST NEED TO BE SEEN
Initial Assessment - primary
– things that kill you the fastest –ABCD(NEURO) and environment/exposure, <Catastrophic></Catastrophic>
Initial Assessment - secondary
Head-to-Toe, Hx, fractures, meshy spots, back
catastrophic hemorrhage
Apply direct pressure with a sterile dressing followed by a pressure dressing to any obvious bleeding sites.
Pediatric assessment triagle
Appearance - tone, interactions, consolability, gaze, speech
Breathing - sounds positioning, retractions, flaring, apnea
Circulation - pallor, mottling, cyanosis
Target Temp MGMT is done within
at least 24 hours after the return of spontaneous circulation (ROSC) decreases mortality rates and improves neurologic outcomes in many patients
3 Phases of TTM
induction, maintenance, and rewarming.
Induction phase of of TTM
ED
- goal temp 89.6° to 96.8°F (32° to 36°C)
Ways to cool down a pt in ED
cold saline infusions and surface cooling devices (e.g., Arctic Sun).
need intubation, mechanical ventilation, and invasive monitoring and require continuous assessment**
Life before limb excluding
vision
Who would you see first
Abdominal pain
22yo fracture wrist
Sore throat for 3 days 60yo
Chest pain
Chest pain
Abdominal pain
Sore throat for 3 days 60yo
22yo fracture wrist
Death in the ED
importance of hospital rituals in preparing the bereaved to grieve
- comfort
private area
- chaplain visit
- personal belongings
- mortuary arrangements
- Determine if patient could be candidate for non–heart beating donation
= Have another person not providing care to the pt to as about organ donation
- Medical examiner: nothing removed if placed invasively only tidy up the area for the family
An autopsy may be done at
family’s request, or if death occurred within 24 hours of ED admission, from suspected trauma or violence, or in an unusual way.
Elderly are at high risk for injury due to
Decreased visual acuity and peripheral vision
Hearing loss
Especially to high frequency sounds
Pre-existing disease and medication use
R/O others before going to Dementia and cognitive impairment**
- generalized weakness, envirnoment hazards, syncope, orthostaic hypotension
Heat Exhaustion
Prolonged exposure to heat
Occurs when the body is unable to cool itself
Symptoms may be vague
S/S od heat exhaustion
Fatigue,
nausea,
vomiting,
extreme thirst,
feelings of anxiety
Hypotension,
tachycardia,
elevated body temperature 99.6° to 105.8° F [37.5° to 41° C]
dilated pupils,
mild confusion,
ashen color,
profuse diaphoresis
Heat exhaustion usually occurs in
strenuous activity in hot, humid weather, but it also occurs in sedentary individuals
Tx of heat exhaustion
- cool area and removing constrictive clothing
- ABCs, including heart dysrhythmias (caused by electrolyte imbalances
- oral fluid and electrolyte replacement unless the patient is nauseated
- Do not use salt tablets because of potential gastric irritation and hypernatremia
- 0.9% normal saline IV solution if oral solutions are not tolerated
- Always correlate fluid replacement to clinical and laboratory findings. - Place a moist sheet over the patient to decrease core temperature through evaporative heat loss
Heat Exhaustion hospital admission if
the chronically ill, or those who do not improve within 3 to 4 hours.
Heat Exhaustion if untx leads to
heat stroke
Heat stroke s/s
anxiety
confusion AMA
no sweating
circulatory cllapse
hot, dry, and ashen skin
skin dry and hot
Na and K depletion
impaired sweating
listlessness
cerebral edema and hemorrhage
increase HR and RR
low BP
Cerebral edema s/s
seizures
delirium
coma
Heatstroke
failure of the hypothalamic thermoregulatory processes
the body’s attempt to lower temperature depleteS
fluids and electrolytes, specifically sodium. Eventually, sweat glands stop functioning, and core temperature increases rapidly, within 10 to 15 minutes.
Heatstroke temp
core temperature greater than 105.8° F (41° C)
Who is more vulnerable to heatstroke?
Older adults and those with diabetes mellitus, chronic kidney disease, cardiovascular disease, pulmonary disease, or other physiologic compromise
Mgmt of Heatstroke
- stabilizing the patient’s ABCs and rapidly - reducing the core temperature.
-Give 100% O2to compensate for the patient’s hypermetabolic state. - Ventilation with a BVM or intubation and mechanical ventilation may be needed.
- Correct fluid and electrolyte imbalances and start continuous ECG - monitoring for dysrhythmias.
Cooling methods for Heatstrokes
1 removing clothing, covering with wet sheets, and placing the patient in front of a large fan (evaporative cooling);
2 immersing the patient in a cool water bath (conductive cooling);
3 applying ice packs to the groins and axillae; and, in refractory cases,
4 peritoneal lavaging with iced fluids. Closely monitor the patient’s temperature and control shivering.
5 Shivering increases core temperature due to the heat generated by muscle activity. This complicates cooling efforts
Give chlorpromazine IV to control shivering
Antipyretics are not effective in this situation because the elevated temperature is not related to infection.
What is given to control shivering?
chlorpromazine IV
What should be monitored during heatstroke tx?
rhabdomyolysis
- Get a CK and CK-MB
The muscle breakdown leads to myoglobinuria. This places the kidneys at risk for acute kidney injury.
- Carefully monitor the urine for color (e.g., tea colored), amount, pH, and myoglobin.
- myoglubinuria
- clotting for DIC
- INSTRUCT ON S/S and hydration
Rhabdomyolysis
a serious syndrome caused by the breakdown of skeletal muscle
- CK and CK-MB
- tea urine
Aggressive temperature reduction until core temperature reaches
102º F
Frostbite
true tissue freezing that results in the formation of ice crystals in the tissues and cells
Initial repsonse to cold stress
Peripheral vasoconstriction
- results in a decrease in blood flow and vascular stasis
As cellular temp decreases then ice crystals do
ice crystals form in intracellular spaces, the organelles are damaged, and the cell membrane destroyed
This results in edema.
Superficial frostbiteinvolves
skin and subcutaneous tissue, usually the ears, nose, fingers, and toes.
S/S of frostbite
edema
waxy pale yellow to blue to mottled
crunchy and frozen feel
tingleing
numbness
bruning
Never do what when fristbite
never squeeze, massage, or scrub the injured tissue because it is easily damaged.
- no blankets
Tx of frostbite
Immerse the affected area in circulating water that is temperature controlled (98.6° to 104° F) [37° to 40° C]) - till flush distal to area. Use warm soaks for the face. The patient often experiences a warm, stinging sensation as tissue thaws. Blisters form within a few hours. The blisters should be debrided and a sterile dressing applied. Avoid heavy blankets and clothing because friction and weight can lead to sloughing of damaged tissue. Rewarming is extremely painful. Residual pain may last weeks or even years. Give analgesia and tetanus prophylaxis as appropriate. Evaluate the patient with superficial frostbite for systemic hypothermia.
Bed cradle for blankets
What should be given to the frostbite pt before rewarming them
analgesics on medical control warming
Deep frostbiteinvolves
muscle, bone, and tendon
- gangrene
- insensitive to touch
Mild hypothermia temp
(93° to 95°F [33.9° to 35°C])
- body can not compensate for heat lost
- s/s = shivering, lethargy, confusion, rational to irrational behavior, and minor heart rate changes.
Moderate hypothermia temp
(86º to 93.º F [30º to 33.9º C])
- rigidity, bradycardia, slowed respiratory rate, BP obtainable only by Doppler, metabolic and respiratory acidosis, and hypovolemia.
Severe hypothermia temp
(<86º F [30º C])
- S/S: appear dead and is a potentially life-threatening situation. Metabolic rate, heart rate, and respirations are so slow that they may be hard to detect. Reflexes are absent, and the pupils fixed and dilated. Profound bradycardia, ventricular fibrillation, or pulseless electrical activity
Death usually occurs when core temperature is
<78º F (25.6º C)
Most body heat is lost as ________ energy, with the greatest loss from the head, thorax, and lungs (with each breath).
radiant
Shivering diminishes or disappears when core temp is at
86 degrees F
Tx of hypothermia
Put a monitor on them for rewarming, give a tetanus shot, analegics, antibiotics maybe, get risd of wet clothes and apply warm blankets
Hypothermia mimicks
metabolic and cerebral illnesses
Physician Can not pronounce a patient dead until they are
> 90 degrees
Mild hypothermia Tx
Passive or active external rewarming
Moderate to Severe hypothermia Tx:
Active core rewarming
Rewarming should be discontinued once the core temperature reaches
95º F (35º C)
Passiveorspontaneous rewarminginvolves
moving the patient to a warm, dry place; removing damp clothing; using radiant lights; and placing warm blankets on the patient
Active externalorsurface rewarminginvolves
fluid- or air-filled warming blankets,. Closely monitor the patient for marked vasodilation and hypotension during rewarming. - BLANKETS
active internalorcore rewarming refers to
heat directly to the core. Techniques include (1) heated humidified O2; (2) warmed IV (3) peritoneal lavage with warmed fluids and (4) extracorporeal circulation with cardiopulmonary bypass, rapid fluid infuser, or hemodialysis. – enema and warm fluids in IV, NG
**Rewarming places the patient at risk for
afterdrop**
cold peripheral blood returns to the central circulation. Rewarming shock can produce hypotension and dysrhythmias. – NEED MONITORS
Hypothermic Pt teachings include
dressing in layers for cold weather, covering the head, carrying high-carbohydrate foods for extra calories, and developing a plan for survival should an injury occur when in an extreme environment.
Submersion injury the pt becomes
hypoxic due to submersion in water
Drowning:
Death from suffocation after submersion in water
Immersion syndrome occurs with immersion in cold water, which **leads to
stimulation of the vagus nerve and potentially fatal dysrhythmias**
Submersion in cold water (below 32° F [0° C]) may
slow the progression of hypoxic brain injury.
Most drowning victims do not aspirate any liquid due to
laryngospasm
If drowning victims do aspirate it is due to
lose consciousness
aspirate water can develop
pulmonary edema
- leading to ARDS
Near-drowning victims stay in hospital for
4-6 hours = pulmonary edema dry drowning
Submersion injury Tx
Treatment ABCD, C-collar immobilization, rewarming, establish patent airway PRIORITY!
correcting hypoxia and fluid imbalances, supporting basic physiologic functions, and rewarming when hypothermia is present
- MECH VENT OR peep, CPAP
What meds can be given to treat cerebral edema in submersion injuries
Mannitol (Osmitrol) or furosemide (Lasix)
- decrease free water
Observe all victims of drowning for a minimum of
23 hours
Submersion injury pt teachings
water safety and how to reduce the risks for drowning. Remind patients and caregivers to lock all swimming pool gates; use life jackets on all watercrafts, including inner tubes and rafts; and learn water survival skills (e.g., swimming lessons). Emphasize the dangers of combining alcohol and drugs with swimming and other water sports.
Aspiration of any water develops
surfactant destruction and destruction of alveolar and capillary membranes
- noncardiogenic pulmonary edema and ARDS
Aspiration of freshwater
water rapidly leaks to capillary bed and circualtion
Aspiration of saltwater
draws fluid into alveoli
Violence
The acting out of emotions of fear and/or anger
Emergency Departments are high-risk areas for workplace violence
Family and intimate partner violence
Human trafficking
