Trauma Flashcards
Trauma: Pre-arrival to Hospital
- EMS in the field reports what is coming in, the ABCs/GCS of pt to charge nurse
- Trauma team is notified
- CT is made available
- Bed made ready
- Trauma team dons standard or higher precautions
- Equipment is ready: fluids (warm NS), monitoring (BP cuff, SPO2), meds (inotropes, vasopressors), blood products
Primary Survey
Airway Breathing Circulation Disability Exposure
Airway
assessing for patency and protection:
- can they talk?
- what is your name?
- are they breathing? (if no, anticipate intubation if not intubated in field)
RSI - rapid sequence intubation
-involves 3 drugs pushing quickly: sedation (versed), anesthesia (etomidate), paralysis (succinylcholine)
Breathing
once airway is secured, assess that breathing is adequate (rate and depth)
draw ABGs to look for adequate oxygenations
inspect, palpate, auscultate lungs (looking for bilateral breath sounds and good effort)
in chest trauma, anticipate/prepare for chest tube
Circulation
- assess pulses: starting w/ most central pulses and then move forward (femoral and carotid first)
- assess capillary refill
- control bleeding, infuse products and fluid
- access via two large bore IVs (18 gauge is ideal), possible central line
- rapid infuser
-look for hypotension and shock signs
BPs by Pulse
carotid pulse: systolic must be at least 30-40
femoral pulse: systolic must be at least 50-60
radial pulse: systolic must be at minimum 60-70
Disability
focused neuro exam:
- LOC
- GCS
- PERRLA
- Gross motor function
- sensation in 4 extremities
Glascow Coma Scale
looks at:
- eye opening response
- verbal response
- motor response
best score = 15
comatose = 8
unresponsive = 3
Exposure
completely undress pt and examine entire body
- maintain C-spine precautions
- assess scalp, axillary folds, skin folds, perineum
- prevent hypothermia during work up (warm fluids, blood products, warming blankets)
*hypothermia can lead to coagulopathy and MODS
ABC’s rest of alphabet
Facilitate adjuncts/Family - full set of VS, notify familly
Get adjuncts (LMNOP)
- Labs
- Monitoring
- NG to decompress
- O2 if needed
- Pain (address)
Trauma: Dx Tools
- Head CT: for head trauma
- Chest X-ray: for chest trauma (can do chest CT, but chest x-ray is portable and faster)
- FAST U/S: for abdominal trauma looking for free air/fluid, intestinal damage
- X-ray for trauma in limbs
- Lab work: CBC, chemistries (electrolytes), coags (clotting factors), abdominal labs (BUN/creatinine/CK), blood type and screen, lactate, urine for presence of blood and pregnancy and/or toxicology, ETOH level, troponin
Trauma: Commonly Missed Injuries
blunt abdominal trauma:
- hollow viscus injury
- diaphragmatic rupture
penetrating abdominal trauma:
-rectal and ureteral injuries
thoracic trauma:
- aortic injuries
- pericardial tamponade
- esophageal perforation
extremity trauma
- fractures
- vascular injury
- compartment syndrome
Secondary Survey
if pt is stable and not immediately taken to the OR:
- assess thoroughly for signs of injury
- obtain full set of vitals
- detailed history via SAMPLE
- head to toe assessment
Fluid Resuscitation
use hemodynamic parameters such as HR/BP and physical assessment to determine fluid needs
usually start with 2 L NS/LR (NS is usually standard)
Blood Products
part of fluid resuscitation if needed
-considered when trauma pt remains HD unstable, has signs of tissue hypoxia despite crystalloid infusion
RBCs increase O2 carrying capacity and allow volume expansion
O negative given before type and screen is complete
platelets and fresh frozen plasma can be given as needed
Trauma: Additional Considerations
tetanus: if pt injury involves dirt, gravel, metal
(need to have had 3 or more tetanus boosters in less than 10 years, then you do not need another booster)
hepatitis: if pt was exposed to used needles
Head Trauma
priority: Airway
signs: battle’s sign, raccoon eyes, presence of CSF
assess neuro status (if neurologically compromised, can’t protect airway)
Basilar Skull Fracture
anticipate that head injury is severe
look for CSF leak via halo sign, battle’s sign, raccoon eyes
management: strict bedrest, HOB > 30 degrees, no coughing, no sneezing, no straining, no nasal tubes
herniation and death can occur if undetected or if pt takes a while to get to hospital
Facial Fractures
priority: airway
may not be able to use traditional airways b/c of trauma to nose or mouth
nutrition is priority and difficult to address when you can’t use mouth for nutrition
Lefort = nasal bone fractures, can involve orbital area
Facial Fractures: Nursing Care
- assess symmetry
- palpate bones and soft tissue
- tetanus status
- pain
- anxiety
- remove debris
Chest Trauma: Blunt
harder to distinguish damage b/c it’s difficult to see what’s effected
could have:
- cardiac complication
- contusions
- aortic dissection
- hypoxemia from pneumothorax or disrupted airway
adequate ventilation and circulation is priority
Chest Trauma: Penetrating
result of sharp objects
tx depends on area affected
adequate ventilation and circulation is priority
Chest Trauma
typically ribs 4-10 are the ones that are broken
pain worsens w/ cough, deep breathing, movement
crepitus w/ palpation
atelectasis and diminished breath sounds
flail chest: multiple rib fractures, creates free segment of the ribs > paradoxical chest wall movement
Chest Trauma: Dx and Clinical Manifestations
- decreased O2 and ventilation
- tachypnea (early)
- SOB
- subq emphysema
- pain
- splinting is clinical sign of chest trauma
Dx:
- chest x-ray
- CT
- FAST
- ABGs
- Lactate
- H&H (look at O2 capacity)
Chest Trauma: Tx
- ABCs
- small rib fractures can be treated outpatient
- pain management
- cough/deep breathe (educate pt to splint chest)
- pneumonia risk r/t atelectasis
- 3-6 wks to heal
Pneumothorax
air in the pleural space results in a lung collapse
happens more slowly than a tension pneumothorax
Pneumothorax: Causes
thoracentesis
chest trauma
ruptured blebs (COPD)
infection
Pneumothorax: Sx
- dyspnea
- cyanosis
- tracheal deviation
- asymmetrical chest wall expansion
- anxiety
- tachycardia
- diminished breath sounds
Pneumothorax: Dx
chest x-ray
ABGs
Hemothorax
bleeding into chest cavity
blood increases pressure and collapses lung in that area
Tension Penumothorax
happens vey quickly
air in chest cavity/pleural space (just like a pneumothorax)
ex) knife between ribs, when you breath in knife is dislodged slightly and air leaks into negative pleural space and stays there > tracheal deviation, depresses diaphragm, pressure on other lung
Abdominal Trauma
can also be blunt or penetrating
hypovolemia is a big concern with abdominal trauma b/c of major organs in abdomen
risk for peritonitis, sepsis, abdominal compartment syndrome
dysfunction of liver, spleen, kidneys, bladder
Abdominal Trauma: S/Sx
splinting hard, distended abdomen decreased/diminished bowel sounds abrasions/bruising hematuria hematemesis shock
Abdominal Trauma: Nursing Care
- anticipate bedside FAST and/or CT scan
- NG tube (assess for presence of blood, decompress stomach, slow down bowel function in acute phase)
- foley catheter (assess for presence of blood, decompress bladder, bladder pressure)
- anticipate need to go to OR for exploratory surgery
Abdominal Compartment Syndrome
- result of increased abdominal pressure
- tissue, fluid, blood compress the abdominal wall > bowel death or vital organ death
Tx: surgical decompression (fasciotomy), but pt must be stable
Musculoskeletal Injury
dislocations
amputations (clean cut, crush, avulsion)
soft tissue injury (affects skin, muscle, cartilage, ligaments)
Musculoskeletal Injury: Nursing Care
- CMS checks to affected extremity
- sensation, ability to move
- Pain management
- immobilization
- compression
- elevate if possible
Pelvic Fractures
high mortality because of bleeding
may result in intra-abdominal injury such as paralytic ileus, laceration of colon, bladder, urethra
Pelvic Fractures: Complications
- hypovolemic shock
- sepsis
- embolus
- compartment syndrome (fasciotomies)
- DVT (> pulmonary embolus if it moves)
- Fat embolus
Pelvic Fractures: Nursing Care
- assess: pelvic stability, pain, hemodynamic stability
- stabilize
- prepare for intervention (emoblization, OR)
- if open, monitor for infection
Fat Embolus
24-72 hours after initial injury of long bone or pelvic fracture
s/sx of pulmonary emboli
look for petechial rash
Heat Injuries
emergency when person is unable to sweat after a certain amount
influenced by: age environment pre-existing conditions medications street drugs
Heat Injuries: Tx
stabilize ABCs 100% O2 EKG electrolytes cool pt (fan, cooling blankets, spray w/ water)
Cold Injuries
frostbite:
- gently rewarm
- avoid friction
hypothermia:
- temp less than 95 degrees F
- mental status deterioration
- cold blood puts pt at risk for clots
- severely hypothermic pts appear dead - rewarm!
Triage
Priority 1: Red = Immediate
Priority 2: Yellow = Delayed
Priority 3: Green = Minimal
Priority 4: Black = Expectant
Emergent: need immediate care - increased risk of death/threat to limb
Urgent: seen w/in 1 hr condition may deteriorate
Non-Urgent: can wait at least 2 hrs
