Trauma

Question 1

an external force of energy that impacts the body and causes structural or physiologic alterations or injury.
External Forces of injury

Answer 1

Trauma:

Question 2

Multiple sources
Lack of Oxygen - drowning, combustion products: smoke
Electrical: lightning, wires, cords, outlets
Chemicals - insect bites (most not too bad unless allergic), drugs, snake bites (not wait until venomous - activate trauma team - surgical emergency - neurotoxin where just twitching, liquitive where everything digested), pesticides with wind, poisons: solid, liquid, gases
Thermal (Heat) - fires
Mechanical

Answer 2

External Forces of injury

Question 3

Classic
Most common mechanical injuries: blunt trauma and penetrating trauma.
Cars, bikes, motorcycles
Guns, knives
Falls
Crush
Machines: factory, farm
Humans: bites, assaults, battery

Answer 3

Mechanical

Question 4

Blunt trauma:
Penetrating trauma:
Acceleration:
Deceleration:

Answer 4

Types of Mechanical injury

Question 5

Physical trauma to a body part, either by impact injury or physical attack.
Struck with
Severity of injury depends on the mechanism – not always obvious.

Answer 5

Blunt trauma:

Question 6

Injuries that puncture the body and result in damage to internal structures
Size of the entry wound does not always reflect the underlying damage to the body.
Anything beyond an abrasion

Answer 6

Penetrating trauma:

Question 7

The force that increases the velocity of a person or object.
Whatever comes in contact with the person is moving.
Force increases before comes in contact with you
Baseball to the arm - you are not moving - ball is
A stationary or slow-moving pedestrian who is struck by a car. A slow moving or stopped car is struck from by another faster-moving car. Standing (minding your own business) and struck by a baseball bat. Getting hit by a falling tree branch is another example.
An increase in speed
Walking across crosswalk and get hit by a car
Gets out car and hit with door

Answer 7

Acceleration:

Question 8

The force that stops or decreases the velocity of a moving person or object.
Running head on and face plant into tree - you are moving - tree is not
Whatever comes in contact with the person is not moving.
A motor vehicle decelerates and comes to a complete stop as a result of hitting a brick wall. The driver will also come to a stop, dissipating additional energy when he/she comes in contact with an immovable surface.
If you’re in a car and rear end another car, you will have a deceleration injury. If your body continues to move and hits the windshield, it is also a deceleration injury.
After getting hit by door, throw on ground

Answer 8

Deceleration:

Question 9

Occurs at the time of the injury.
Occurs at time of accident

Answer 9

Primary Injury:

Question 10

The biochemical and cellular response to the initial trauma. Presents hours, days, weeks later.
Later on - body trying fix injuries and is another injury - could be edema causing peripheral perfusion probs; bleeding out later; secondary to injury
Not happen at time of accident

Answer 10

Secondary injury:

Question 11

Essential priorities are:
Airway maintenance
Recognition and control of external bleeding and shock
Immobilization of the patient
Vital components also include:
Initiation of a peripheral intravenous (IV) line
Splinting of fractures
Pain management
Prehospital personnel should communicate information needed for triage before arrival at the hospital. Advanced planning for multiple-injured patients by trauma teams is essential.

Answer 11

The goal of prehospital care is immediate identification of life-threatening injuries and transport to the closest appropriate medical facility.

Question 12

Chemical?
Yes, stung 4 times
Mechanical?
Yes, fell on his right upper leg and small limb is embedded in the left lower leg

Answer 12

The ED nurse is ready to receive patient from the scene:
EMS radio report: Pt fell from tree: Once on the ground, the tree limb he was trimming fell on his right upper leg. As the tree limb was falling, it dislodged a small hornet’s nest and the pt is stung 4 times. A small limb is embedded in the left lower leg. Pt. A&O x 4. Vital signs: BP 94/50, HR 110, RR 22, SpO2 90%.
What is/are the forces of injury?

Question 13

Acceleration?
Tree limb that fell on top of him
Deceleration?
Falling to ground
Blunt?
Pt fell from tree: Once on the ground, the tree limb he was trimming fell on his right upper leg
Penetrating?
A small limb is embedded in the left lower leg

Answer 13

What is/are types of mechanical injury?

Question 14

How fast going
Seatbelt
Need know whole story
Big tree limb - cannot lift - chainsaw to get off - more severe of injury than tiny limb
Embedded in leg - where at - lower leg past popliteal - bleed out from that - near artery, oozing blood, pulsatile flow, get control of it
Helps prepare room for the pt

Answer 14

The story matters. Listen to the details.

Question 15

Assessing pt is very structured - very fast assessment
Airway: Is this patient maintaining his airway?
Recognize & control of external bleeding & shock: Is there a concern for bleeding?
Immobilization: Did this patient require immobilization?
IV access
Splinting of Fractures: Does this patient require anything to be splinted?
Pain management

Answer 15

Prehospital Care (What care would you anticipate the EMS to have completed?)

Question 16

Make sure maintaining this
Face, trachea, bronchus, make sure exchanging air
Talking to you - airway patent
Hoarse voice
Barely have enough forced voice speak above whisper - airway compromised
No more than 2 seconds

Answer 16

Airway: Is this patient maintaining his airway?

Question 17

Before get to ED
Not done perfectly

Answer 17

Recognize & control of external bleeding & shock: Is there a concern for bleeding?

Question 18

Immobilize for spine injuries
Put on back boards

Answer 18

Immobilization: Did this patient require immobilization?

Question 19

Will have this
If not - could not - get central line ready

Answer 19

IV access

Question 20

Not set it
Prevent movement and more soft tissue damage

Answer 20

Splinting of Fractures: Does this patient require anything to be splinted?

Question 21

Can receive these orders in route

Answer 21

Pain management

Question 22

Immediately assess patient’s ability to speak
Look: are there obvious signs of airway trauma, tachypnea, accessory muscle use?
Listen: can you hear the patient breathing?
Immediate care: immobilize spine; nondefinitive airway management - oropharyngeal (unconscious patient) and nasopharyngeal (conscious patient); when in doubt secure the airway (endotracheal intubation and emergency cricothyrotomy)
Feel: for air exchange through the mouth; palpate for tracheal deviation
The patient’s airway is assessed for patency and possible airway obstruction.
Trauma patients are at risk for ineffective airway clearance, especially in the presence of altered consciousness, effects of drugs and/or alcohol, and maxillofacial or thoracic injuries.
Airway obstruction can be caused by foreign bodies, blood clots, or broken teeth.
Airway patency is assessed by inspecting the oropharynx for foreign body obstruction and listening for air movement at the nose and mouth.
If the patient can verbally communicate, it is likely that the airway is patent.
Patients who have a Glasgow Coma Scale (GCS) score of 8 or less or are unable to protect their own airway often require placement of a definitive airway.
Airway placement must incorporate cervical spine immobilization.
The patient’s head and neck should not be rotated, hyperflexed, or hyperextended.
The cervical spine must be immobilized at all times in all trauma patients until a cervical spinal cord injury (SCI) has been ruled out.

Answer 22

A - Airway:

Question 23

Is the patient breathing
Look: is the patient’s chest rising and falling; respiratory rate, rhythm, and symmetry; is there any evidence of thoracic trauma
Listen: quickly auscultate air entry; is there air entry in all lobes
Palpate: chest wall integrity
Immediate care: administer supplemental O2; for life-threatening conditions (tension pneumothorax), immediate needle decompression or chest tube insertion; full support mechanical ventilation (as required)
The patient is assessed for signs of visible chest movement.
An open, clear airway does not always ensure adequate ventilation and gas exchange.
Assessment includes a visual inspection of chest wall integrity and respiratory rate, depth, and symmetry.
Auscultation is performed to assess the presence or absence of breath sounds.
Decreased or absent breath sounds or alteration in chest wall integrity may necessitate chest tube placement.
Supplemental oxygen is administered to some injured patients but may not be required in the spontaneously breathing trauma patient who is awake, alert, and talking and has an oxygen saturation with pulse oximetry (SpO2) greater than 92%.
Endotracheal intubation may be required for patients who have compromised airways caused by mechanical factors, who are unconscious, or who have ventilatory problems.
Needle or surgical cricothyroidotomy may be necessary when severe maxillofacial trauma exists and endotracheal intubation is not an option.

Answer 23

Breathing:

Question 24

Assess pulse quality and rate
Assess for life-threateng conditions (uncontrolled bleeding, shock)
Examine and feel patient’s skin (warm and dry; cool, pale, clammy)
Immediate care: signs and symptoms of poor tissue perfusion; initiate IV access; administer 1 L of isotonic IV fluid, then reassess hemodynamic status; if no pulse, CPR
The patient is assessed for the presence of a palpable pulse, any evidence of external or internal hemorrhage.
Rapid evaluation of circulatory status includes assessment of level of consciousness (LOC), skin color, and pulse.
If possible, obtain a baseline measurement of the patient’s vital signs.
LOC provides data on cerebral perfusion.
Facial color that is ashen or gray and extremities that are pale or slightly mottled may be ominous signs of hypovolemia and shock.
Central pulses (femoral or carotid artery) are assessed bilaterally for rate, regularity, and quality. If a pulse is not present, cardiopulmonary resuscitation (CPR) must be initiated immediately. All trauma patients are considered to be in shock.
Trauma patients may or may not exhibit significant deterioration in hemodynamic stability; vital signs can initially remain stable even in the face of hemorrhage.
Measurement and trending of systolic and diastolic blood pressure, mean arterial pressure (MAP), and SpO2 readings are more important than individual values.
Hypotension in trauma should be attributed to hypovolemia until proven otherwise.
External exsanguination is identified and controlled by direct manual pressure on the wound.
Internal hemorrhage in trauma requires urgent surgical consultation and transport to interventional radiology for diagnostic imaging or the operating room for immediate surgery.

Answer 24

Circulation:

Question 25

A rapid neurologic assessment of the patient’s baseline LOC and pupil size and reaction are assessed and documented.
The GCS score can be used to quickly describe the patient’s LOC
Neurologic assessment
GCS score
Pupils: size and reactivity
Is the patient moving all 4 limbs to command
Evidence of panting
Immediate care: consider early neurosurgical consultation
Consider early CT scan

Answer 25

Disability:

Question 26

A thorough examination of all body surfaces assesses for the presence of injury.
All of the patient’s clothing is removed for the assessment.
The patient is turned (logrolled) while full spinal precautions are maintained.
The spine is carefully palpated for obvious deformity.
The occipital lobe, neck, back, buttocks, and extremities are quickly examined for wounds, impaled objects, and bleeding.
After clothing is removed, the patient must be protected from hypothermia. This can be accomplished through warm blankets, increasing room temperature, and warm intravenous (IV) fluids.
All clothing removed to inspect all body regions
Any lacerations, abrasions, bruises?
Stab wounds: Entrance?
Gunshot wounds: Entrance? Exit?
Immediate care: prevent hypothermia, warm blankets, warm IV fluids, increase room temperature

Answer 26

Exposure:

Question 27

The secondary survey begins when the primary survey is completed, potentially life-threatening injuries have been identified, and resuscitation initiated. In reality, both primary and secondary surveys may seem to occur almost simultaneously.
F- Full set of Vitals, focused adjuncts, and family presence:
G – Get Monitoring Devices and Give Comfort:
H- Head-to-toe & History:
I – Inspect posterior surfaces:
Do not get the vitals first
Interdisciplinary team - radiology, respiratory therapy, trauma surgeons, residents, fellows, team effort; nurse - need what in your scope prace - what can be delegated and what must be done by provider; things going quickly hard determine - need solid understanding of protocols of the facility
Aggressive fluid resuscitation - lots fluid
If require blood - uncrossed matched; bleeding out - no time to cross and match and wait for it to be meant for pt - get cooler of uncrosed matched blood
Balance IV fluids with blood
What can be delegated to unlicensed assistive personnel (UAP)

Answer 27

Secondary survey (Anticipated findings)

Question 28

1. Obtain and trend readings for blood pressure, pulse, respiratory rate, peripheral oxygen saturation (SpO2), and temperature at regular intervals. Focused adjuncts: Complete diagnostic testing. Ensure the completion of all necessary procedures, such as an electrocardiogram, radiographic studies (chest, cervical spine, thorax, and pelvis), ultrasonography, and insertion of gastric and urinary catheters.… 3. Offer the family the opportunity to be with the patient in the treatment area if appropriate. Provide a support person to be with them to answer questions and explain procedures
   Full set of vitals
   Up until now using EMS’ VS - not going blind
   Can get delegated but if alone not priority

Answer 28

F- Full set of Vitals, focused adjuncts, and family presence:

Question 29

Laboratory Studies: 1. Obtain appropriate laboratory tests, such as arterial blood gas (ABG) analysis, lactic acid level, and type and crossmatch if indicated.
2. In the presence of the patient, label the specimen(s) per the organization’s practice.4
3. Prepare each specimen for transport.
a. Place the labeled specimen in a biohazard bag.
b. If the specimen requires ice for transport, place the specimen in a biohazard bag, then place the bag with the specimen into a second biohazard bag filled with ice slurry.
Monitoring (Cardiac)
1.Monitor cardiac rate and rhythm. Arrhythmias, such as premature ventricular contractions (PVCs), atrial fibrillation, or S-T segment changes, may indicate a blunt cardiac injury. Pulseless electrical activity may suggest cardiac tamponade, tension pneumothorax, or profound hypovolemia.
Nasogastric or Orogastric Tube: 1. Insert a nasogastric or orogastric tube if indicated or prescribed to relieve gastric distention, which helps optimize lung inflation, and to prevent vomiting and aspiration. Avoid the nasogastric route in patients with a suspected head injury or mid-face fractures.
Oxygenation and Ventilation (SpO2, End-Tidal Carbon Dioxide [ETCO2]): 1. Monitor oxygenation by implementing pulse oximetry (if not performed previously). Remember that pulse oximetry is a measurement of SpO2 and is not evidence of ventilation. An SpO2 of 94% or greater is considered adequate oxygenation.
2. Assess ventilation by monitoring ETCO2 levels via capnography. Normal values range from 35 to 45 mm Hg.
Pain Assessment and Management: 1. Assess and treat pain with pharmacologic and nonpharmacologic interventions as indicated.
Get monitoring devices and Get comfort
Address pain
Do comfort type stuff
Monitor: Dynamap and if need art line - hooked up

Answer 29

G – Get Monitoring Devices and Give Comfort:

Question 30

1. Obtain a prehospital report of the incident or illness. A helpful mnemonic is M-I-S-T: M = mechanism of injury; I = injuries sustained; S = signs and symptoms before arrival; T = treatment before arrival
2. Obtain the patient’s history. A helpful mnemonic is S-A-M-P-L-E. S = symptoms associated with the injury or illness A = allergies and tetanus status M = medications currently used, especially anticoagulants P = past medical history (including hospitalizations and surgeries) L = last oral intake and output (last menstrual period if female of childbearing age) E = events and environmental factors related to the injury or illness
3. Assess the patient from head to toe
   Head to toe - real one
   Done fairly quickly and focus in on problem areas - all done and focus in on problem areas

Answer 30

H- Head-to-toe & History:

Question 31

1. In the injured patient, obtain assistance to maintain cervical spine alignment and support injured extremities while log rolling the patient to the side.
   Avoid rolling the patient onto an injured extremity or side if possible. If necessary for adequate assessment of posterior surfaces, roll the patient to both sides.
2. Inspect the posterior surfaces for wounds, deformities, or discolorations. Palpate all posterior surfaces for wounds, deformities, or muscle spasms.
3. At this point, the practitioner may perform a rectal examination to assess sphincter tone, presence of injury to the pelvis or rectal mucosa, and the presence of gross or occult blood.
   Prostate position as determined by rectal examination is not a reliable indicator of urethral injury.
4. Remove the backboard or transferring device as indicated.
   Inspect posterior surfaces
   Team gets together - Not know if SCI
   Get team and spinal precautions - goes down back see if pain or feels it all way down - looking for exit and entrance wounds

Answer 31

I – Inspect posterior surfaces:

Question 32

Too many traumas - not delegate if unable
Full set of vitals - first; still in room in them
Comfort measures (blankets)
Transport to other departments
In the event of death, transport to the morgue
Do not delegate any notifications/consults

Answer 32

What can be delegated to unlicensed assistive personnel (UAP)

Question 33

A: no breath sounds, what do hear is referred - from another lobe, big enough - unequal chest rise
Pneumo and hemothorax same presentation but look diff on CXR
Part of lung not expanding
Breathing

Answer 33

Right pneumothorax

Question 34

A: pant because not want expand ripcage; shallow, rapid respirations
Breathing

Answer 34

4 broken ribs

Question 35

A: swollen, reddened, first look benign

Answer 35

Crush injury right upper leg

Question 36

A: thing sticking out dermis

Answer 36

Imbedded tree bark right upper leg and left lower leg

Question 37

A: look like puncture; stick still there - we do not remove stuff because not know what damaged on way in

Answer 37

Puncture wound left mid-calf

Question 38

A: package deal with crush injury - force was enough to break big bone; bruising; lot blood lost

Answer 38

Fractured right femur

Question 39

Goal prevent further damage
In ER Stabilize thing sticking out body
Prevent more damage
Prevent collapse ABCs - assessing it before becomes an issue
Once up to unit/floor - not all require ICU - prevent secondary injuries: DVTs, pressure ulcers

Answer 39

Nursing Interventions?

Question 40

Infection
Near an artery or had to fix vessel that was transected or lacerated - assess for bleeding too - always oozing because soft tissue damage

Answer 40

Penetrating injury - Assessment of possible complications

Question 41

Broken ribs: pneumothorax
Atelectasis - not want take in nice, normal breathe - not want turn cough deep breathe

Answer 41

Thoracic injury - Assessment of possible complications

Question 42

Rhabdomyolysis: myoglobin - raspberry iced tea urine; Cr increased
Compartment syndrome - swelling and big artery vein in upper leg - smush it so not adequate flow - distal stuff - muscle bundle swells to point where sheath where have cell death
Lot muscle damage - rhabdo and swell - fascia keeps it contained and muscle bundle dies - compartment syndrome

Answer 42

Crush injury - Assessment of possible complications

Question 43

Fat embolism
s&s: sudden SOB, restless - not have adequate oxygen exchange, weird petechial rash on upper chest

Answer 43

Fracture femur - Assessment of possible complications

Question 44

Allergic rxn/anaphylaxis

Answer 44

Hornet Sting - Assessment of possible complications

Question 45

Penetrating injury
Anything that goes through the dermis

Answer 45

Which injury has the highest risk for infection?

Question 46

Mechanical

Answer 46

EMS calls to notify the ED they are bringing in 1 trauma patient.
Driver of the car hit a power pole. The package in the passenger seat became airborne and hit the driver on the side of the head.
“seat belt” sign
Bruising and bright red where seatbelt was because where blood vessels broken
What is the force of injury?

Question 47

Rotated and shorter

Answer 47

Right leg deformity

Question 48

Electrical?
Potential because hit a power poll - lines down - come in contact with person or car
Mechanical?
“seat belt” sign
Right leg deformity
Bleeding from mouth & nose
Right forehead laceration

Answer 48

What is/are the forces of injury?

Question 49

Acceleration?
The package in the passenger seat became airborne and hit the driver on the side of the head.
Deceleration?
Driver of car hit a power poll
Blunt?
“seat belt” sign
Right leg deformity
Lots Bleeding from mouth & nose
Penetrating?
Right forehead laceration - open dermis

Answer 49

What is/are types of mechanical injury?

Question 50

Driving at a high rate of speed (approx. 70 mph) and hit a power pole
Was drinking a Starbucks iced mocha at the time of the accident, and the straw is lodged in the back of their throat. - secure so not move and cause more soft tissue damage

Answer 50

Other information should the nurse receive in report?
History of the trauma (need to know the story)

Question 51

PT/INR - high -

Answer 51

emergent lab; fix right now; bleeding out

Question 52

A: edematous, blood in there too, quantify how much edema so can watch for compartment syndrome - more discrepancy; coloration: edema or blood; dependent - settle in back

Answer 52

Right femur fracture

Question 53

A: chest pain; worse when take in a breath; difference between coronary artery narrowing vs chest wall; can have cardiac issues heart against sternal wall - can have cardiac contusion - arrhythmias or ischemic events
Pericardial effusion to pericardial tamponade - care because pericardial sac not flexible - filling with fluid not letting LV expanding so CO diminished and as fills no fill at all = cardiac arrest - nice rhythm because electrical fine - just mechanical
Listening to heart tones - if more muffled or not
Having to focus more - first sign: heart tones more muffled

Answer 53

Mid sternum fracture

Question 54

A: swelling and tenderness; pelvic cavity hold lot blood - fill space; supine - bruise in back first; first in front - heck fracture and lot soft tissue/vessel damage
Affects pelvis location
Anything connects into it distorted - be messed up - messed up leg and shortened leg

Answer 54

Pelvic fracture

Question 55

A: stridor, difficulty breathing, rapid respirations, pain when swallowing; Trouble starting a swallow; Coughing or wheezing after eating

Answer 55

Straw embedded in pharynx

Question 56

Face fracture - maxilla
Mid face
Soft palate and teeth mobile - holding it is soft tissue
Really high risk for losing airway - swelling all soft tissue on inside mouth - swells = lost airway; sinuses hold lot blood - can have issues with circulation - blood pool in back get clot and go down to occlude airway
Nose is out too
Medically managed: call OMF, move around until right spot, reduce it/fix it/stabilize it; twisty tie it until go to surgery so not moving around causing more soft tissue damage; through with needle and suture with wire, umph to get through bone
Nursing: conscious sedation and fentanyl; holding lip up out way during sewing
a separation of the hard palate from the upper maxilla due to a transverse fracture running through the maxilla and pterygoid plates at a level just above the floor of the nose.

Answer 56

Le Fort 1 fracture

Question 57

A: abdominal pain (bruise from seatbelt) but higher up, bleeding, swollen abdomen - recumbant position - not in pelvic floor as fast, bruising seen quickly because liver superficial
Not terrible
Still has potential

Answer 57

Grade 1 liver laceration

Question 58

Checking distal pulses to ensure have adequate blood flow distal to the wound, ensure not bleeding by assessment and labs
Pin care so no infection if have to have external fixator
CMS

Answer 58

Right femur fracture: - N, interventions

Question 59

Monitor for arrhythmias, heart behind sternum
Ensure breathing well

Answer 59

Mid sternum fracture: - N, interventions

Question 60

Read radiology report - see if stable or not; see if bones moving/fixed
Check distal pulses
Enough swelling, blood, fluid to push on it to affect distal flow
Dressing change, pain management

Answer 60

Pelvic fracture: - N, interventions

Question 61

Ensure not oozing again after med wears off
Edema
Assess airway
Must speak to you - not nod and shake head

Answer 61

Straw embedded in pharynx: - N, interventions

Question 62

OG placed - cannot chew if maxilla floating - not put in by nursing - put in by OMF - pulled out - not whoopsie often sutured in; addressed must come in and harder get in after because swelling
Giving meds - ensure flush them with 20 mL
HOB up esp with pelvic fracture - not want sit up, need = not want blood pool in sinuses - need come out
Assess for oral cavity edema
Need get pieces out mouth and flush mouth to ensure cleaned out
Population pts - nauseated - give PRN antiemetics immediately
Wire cutters for vomiting at bedside
Nursing In control of: keeping OG tube in, patent, HOB up, assessing
Do not stabilize or reduce fractures - want know if has been done

Answer 62

Le Fort 1 fracture: - N, interventions

Question 63

Monitor abdominal pain (bruise from seatbelt) but higher up
Monitor for a swollen abdomen - recumbant position - not in pelvic floor as fast, bruising seen quickly because liver superficial

Answer 63

Liver Laceration - N, interventions

Question 64

Leg squeezers

Answer 64

Being in the hospital: - N, interventions

Question 65

compartment syndrome

Answer 65

Right femur fracture: - Possible complications

Question 66

heart irritated = arrhythmias - ensure not cardiac tamponade

Answer 66

Mid sternum fracture: - Possible complications

Question 67

Affects pelvis location
Anything connects into it distorted - be messed up - messed up leg and shortened leg
Moving - causing soft tissue damage and bleeding
Usually lose lot blood

Answer 67

Pelvic fracture: - Possible complications

Question 68

difficulty breathing
Losing airway

Answer 68

Straw embedded in pharynx: - Possible complications

Question 69

losing airway
blood pool in back get clot and go down to occlude airway

Answer 69

Le Fort 1 fracture: - Possible complications

Question 70

Potential to become worse liver laceration

Answer 70

Liver Laceration - Possible complications

Question 71

atelectasis, pressure ulcers

Answer 71

Being in the hospital: - Possible complications

Question 72

Extremes in ages - over 80 and suspicious; minors
Accident that caused death
MVCs - can and cannot tell officer at bedside
Reporting trauma from abuse/neglect - must report it

Answer 72

What types of deaths are required to be reported to the coroner?

Question 73

RN: Notify the coroner - answer questions
RN, UAP: Cover the body
RN, UAP: Transport to the morgue

Answer 73

Do’s - Care of the deceased who died of a reportable death.

Question 74

Spit shine pt and presentable
Not remove tubes and drains
Missed on IV - not take out in beginning - still hanging out
Not taking anything out
Not do last suction
Leave everything just way is
Not redo chest tube
Do not make presentable for family

Answer 74

Do Not - Care of the deceased who died of a reportable death.

Question 75

The patient’s airway is assessed for patency and possible airway obstruction.
Trauma patients are at risk for ineffective airway clearance, especially in the presence of altered consciousness, effects of drugs and/or alcohol, and maxillofacial or thoracic injuries.
Airway obstruction can be caused by foreign bodies, blood clots, or broken teeth.
Airway patency is assessed by inspecting the oropharynx for foreign body obstruction and listening for air movement at the nose and mouth.
If the patient can verbally communicate, it is likely that the airway is patent.
Patients who have a Glasgow Coma Scale (GCS) score of 8 or less or are unable to protect their own airway often require placement of a definitive airway.
Airway placement must incorporate cervical spine immobilization.
The patient’s head and neck should not be rotated, hyperflexed, or hyperextended.
The cervical spine must be immobilized at all times in all trauma patients until a cervical spinal cord injury (SCI) has been ruled out.
Trauma team assessment
Immediately assess patient’s ability to speak
Look: are there obvious signs of airway trauma, tachypnea, accessory muscle use?
Listen: can you hear the patient breathing?
Feel: for air exchange through the mouth; palpate for tracheal deviation
Immediate care
Immobilize spine
Nondefinitive airway management
Oropharyngeal (unconscious patient)
Nasopharyngeal (conscious patient)
When in doubt secure the airway: endotracheal intubation; emergency cricothyrotomy

Answer 75

Survey component: A = airway

Question 76

The patient is assessed for signs of visible chest movement.
An open, clear airway does not always ensure adequate ventilation and gas exchange.
Assessment includes a visual inspection of chest wall integrity and respiratory rate, depth, and symmetry.
Auscultation is performed to assess the presence or absence of breath sounds.
Decreased or absent breath sounds or alteration in chest wall integrity may necessitate chest tube placement.
Supplemental oxygen is administered to some injured patients but may not be required in the spontaneously breathing trauma patient who is awake, alert, and talking and has an oxygen saturation with pulse oximetry (SpO2) greater than 92%.
Endotracheal intubation may be required for patients who have compromised airways caused by mechanical factors, who are unconscious, or who have ventilatory problems.
Needle or surgical cricothyroidotomy may be necessary when severe maxillofacial trauma exists and endotracheal intubation is not an option.
Trauma team assessment
Is the patient breathing?
Look: is the patient’s chest rising and falling; RR, respiratory rhythm and symmetry; is there any evidence of thoracic trauma
Listen: quickly auscultate air entry; is there air entry in all lobes
Palpate: chest wall integrity
Immediate care
Administer supplemental oxygen
For life-threatening conditions (tension pneumothorax), immediate needle decompression or chest tube insertion
Full support mechanical ventilation (as required)

Answer 76

Survey component: B = breathing

Question 77

The patient is assessed for the presence of a palpable pulse, any evidence of external or internal hemorrhage.
Rapid evaluation of circulatory status includes assessment of level of consciousness (LOC), skin color, and pulse.10
If possible, obtain a baseline measurement of the patient’s vital signs.
LOC provides data on cerebral perfusion.
Facial color that is ashen or gray and extremities that are pale or slightly mottled may be ominous signs of hypovolemia and shock.
Central pulses (femoral or carotid artery) are assessed bilaterally for rate, regularity, and quality. If a pulse is not present, cardiopulmonary resuscitation (CPR) must be initiated immediately. All trauma patients are considered to be in shock.
Trauma patients may or may not exhibit significant deterioration in hemodynamic stability; vital signs can initially remain stable even in the face of hemorrhage.
Measurement and trending of systolic and diastolic blood pressure, mean arterial pressure (MAP), and SpO2 readings are more important than individual values.
Hypotension in trauma should be attributed to hypovolemia until proven otherwise.
External exsanguination is identified and controlled by direct manual pressure on the wound.
Internal hemorrhage in trauma requires urgent surgical consultation and transport to interventional radiology for diagnostic imaging or the operating room for immediate surgery.
Trauma team assessment
Assess pulse quality and rate
Assess for life-threatening conditions (uncontrolled bleeding, shock)
Examine and feel patient’s skin - warm and dry; cool, pale, and clammy
Immediate care
Signs and sx of poor tissue perfusion
Initiate IV access
Administer 1 L of isotonic IV fluid, then reassess hemodynamic status
No pulse, begin CPR

Answer 77

Survey component: C = circulation

Question 78

A rapid neurologic assessment of the patient’s baseline LOC and pupil size and reaction are assessed and documented.
The GCS score can be used to quickly describe the patient’s LOC (see Table 22.1).
Trauma team assessment
Neurologic assessment
GCS score
Pupils: size and reactivity
Is the patient moving all 4 limbs to command
Any evidence of posturing
Immediate care
Consider early neurosurgical consultation
Consider early CT scan

Answer 78

Survey component: D = disability

Question 79

A thorough examination of all body surfaces assesses for the presence of injury.
All of the patient’s clothing is removed for the assessment.
The patient is turned (logrolled) while full spinal precautions are maintained.
The spine is carefully palpated for obvious deformity.
The occipital lobe, neck, back, buttocks, and extremities are quickly examined for wounds, impaled objects, and bleeding.
After clothing is removed, the patient must be protected from hypothermia. This can be accomplished through warm blankets, increasing room temperature, and warm intravenous (IV) fluids.
Trauma team assessment
All clothing removed to inspect all body regions
Any lacerations, abrasions, bruises?
Stab wounds: entrance?
Gunshot wounds: entrance? Exit?
Immediate care
Prevent hypothermia
Warm blankets
Warm IV fluids
Increase room temp

Answer 79

Survey component: E = exposure

Question 80

Driving fast/slow
In body - near vital organ or artery
Hx of anticoag or not
VAD and just hit sternum against steering wheel - more emergent

Answer 80

Get the whole story

Question 81

Primary & secondary assessments
Injuries based on body system
Complications
Assessment
Prevention

Answer 81

Know

Question 82

Clinical manifestations: s&s
Fractures of the maxilla are diagnosed according to the Le Fort classification.
Le Fort fractures are classified in three broad categories, depending on the level of the fracture
Often associated with severe skull and brain injuries, CSF frequently leaks with these fractures because there is usually communication between the cranial base and the cribriform plate.

Answer 82

Maxillofacial injuries

Question 83

Rib fractures.
Flail chest.
Lung injuries: Pulmonary contusion. Open pneumothorax. Tension pneumothorax. Massive hemothorax. Cardiac tamponade. Blunt traumatic aortic injury.

Answer 83

Thoracic (chest wall, pulmonary, cardiac & vascular)

Question 84

can be minimal and cause minor discomfort or be serious and life-threatening
Because arteries and veins are protected by the scapula, clavicle, humerus, and muscles, vascular injury signifies a very high degree of force applied to the thorax.
Localized pain that increases with respiration or that is elicited by rib compression may indicate rib fractures. The pain associated with rib fractures can be aggravated by chest wall movement.
Interventions include pain control to improve chest expansion and facilitate gas exchange, chest physiotherapy, and early mobilization. Nonsteroidal antiinflammatory drugs, intercostal nerve blocks, thoracic epidural analgesia, and opiates may be considered.

Answer 84

Rib fractures.

Question 85

caused by blunt trauma, disrupts the continuity of chest wall structures.
decreased tidal volume and vital capacity and impaired cough that lead to hypoventilation and atelectasis.
paradoxical chest movement.
crepitus and tenderness near fractured ribs.
Interventions focus on ensuring adequate oxygenation and analgesia to improve ventilation.
Intubation and mechanical ventilation may be required.

Answer 85

Flail chest.

Question 86

is a bruise of the lung. Pulmonary contusion is often associated with blunt trauma and other chest injuries
results in progressive hypoxemia and poor ventilation.
Clinical manifestations of pulmonary contusion may take up to 24 hours after injury to develop. Inspection of the chest wall may reveal ecchymosis at the site of impact. Diminished breath sounds and coarse crackles may be auscultated over the contused lung.
Interventions include deep-breathing exercises, incentive spirometry, early mobilization, or noninvasive positive pressure ventilation.
Adequate pain control is achieved with nonsteroidal antiinflammatory drugs, opiates, intercostal nerve blocks, or thoracic epidural analgesia.

Answer 86

Pulmonary contusion.

Question 87

As air moves in and out of the hole in the chest, a sucking sound can be heard on inspiration.
Dyspnea, tachycardia, and hypotension may be observed.
Subcutaneous emphysema
inserting a chest tube.

Answer 87

Open pneumothorax.

Question 88

the shift exerts pressure on the heart and thoracic aorta, which results in decreased venous return and decreased cardiac output
Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to the back, neck, or shoulders.
On the injured side, breath sounds may be decreased or absent.

Answer 88

Tension pneumothorax.

Question 89

Increasing vascular blood loss into the pleural space causes decreased venous return and decreased cardiac output.
assessment findings reveal diminished or absent breath sounds over the affected lung and collapsed neck veins (hypovolemia) or distended neck veins (coexisting tension pneumothorax)
Hypovolemic shock may be present.

Answer 89

Massive hemothorax.

Question 90

Classic assessment findings associated with cardiac tamponade include the presence of elevated central venous pressure (with neck vein distention), muffled heart sounds, and hypotension. This is known as Beck’s triad.
Immediate treatment is required to remove the accumulated fluid in the pericardial sac - Pericardiocentesis

Answer 90

Cardiac tamponade.

Question 91

one of the most lethal thoracic injuries
The critical care nurse must assess blood pressure in both arms, because a tear in the aortic arch may create a pressure gradient resulting in blood pressure changes between upper extremities. Additional clinical assessment findings include a pulse deficit at any site, unexplained hypotension, sternal pain, precordial systolic murmur, hoarseness, dyspnea, and lower extremity sensory deficits.
The critical care nurse monitors for bowel ischemia (e.g., tube feeding intolerance, lactic acidosis) and acute kidney injury, which may manifest by low urine output and rising serum creatinine

Answer 91

Blunt traumatic aortic injury.

Question 92

Liver injuries.
Spleen injuries.
Hollow viscus injuries.

Answer 92

Specific abdominal organ injuries

Question 93

Hemorrhage is common with liver injuries
ligation of the hepatic arteries or veins may be required.

Answer 93

Liver injuries.

Question 94

Hemodynamically stable patients may be monitored in the critical care unit, trending serial hematocrit and hemoglobin values and vital signs.
Embolization therapy

Answer 94

Spleen injuries.

Question 95

Surgical resection and repair is almost always required.

Answer 95

Hollow viscus injuries.

Question 96

Blunt trauma to the pelvis can be caused by MVCs, falls, or a crush injury.
Signs of pelvic fracture include swelling, tenderness, and bruising around the pubis, iliac bones, hips, or sacrum. Perianal ecchymosis (scrotum or vulva), indicating extravasation of urine or blood, may be present. Pain or crepitus on palpation, or “rocking” of the iliac crests, suggests a fractured pelvis, but this is not conclusive.
Lower extremity rotation or leg shortening is also suspicious for a pelvic injury. Other possible assessment findings are lower limb paresis; swollen testicles; and vaginal, rectal, or urethral bleeding, which may or may not be accompanied by hematuria.
Medical Management: prevent or control life-threatening hemorrhage; Temporary pelvic binders
Nursing Management: Before the patient is moved, the nurse should know whether the physician has classified the pelvic fracture as stable or unstable; IV fluid resuscitation and hemorrhage control are mainstays of pelvic fracture management; Essential nursing care includes neurovascular assessment of the lower extremities; The patient is at high risk for several different postinjury problems, including development of venous thromboembolism (VTE), ARDS, wound infection, and sepsis.

Answer 96

Pelvic Fractures - Musculoskeletal injuries

Question 97

Primary injuries include those injuries that directly damage the brain parenchyma.
Secondary injury. - the biochemical and cellular response to the initial trauma that can exacerbate the primary injury and cause additional damage and impairment in brain recovery. - caused by ischemia, hypotension, hypercapnia, cerebral edema, seizures, or metabolic derangements. Hypoxia and hypotension, the best-known culprits for secondary injury, typically are the result of extracranial trauma.
Classification of Skull and Brain Injuries
Skull fracture.
Concussion.
Contusion.
Cerebral hematoma.
Neurologic Assessment of Traumatic Brain Injury
Nursing assessment of a patient with traumatic brain injury.
Diagnostic procedures.
Medical Management
Nursing Management

Answer 97

Traumatic Brain Injuries (i.e. neuro trauma)

Question 98

are common, but they do not by themselves cause neurologic deficits.
Assessment findings may include cerebrospinal fluid (CSF) leakage—described as rhinorrhea (from nose) or otorrhea (from ear), Battle sign (ecchymosis overlying the mastoid process behind the ear), “raccoon eyes” (subconjunctival and periorbital ecchymosis)
The significance of a skull fracture is that it identifies a patient with a higher probability of having or developing an intracranial hematoma.
Major complications of basilar skull fractures are cranial nerve injury and CSF leakage.

Answer 98

Skull fracture.

Question 99

Neurologic dysfunctions include confusion, disorientation, and sometimes a period of anterograde or retrograde amnesia. Other clinical manifestations that occur after concussion are headache, dizziness, nausea, irritability, inability to concentrate, impaired memory, and fatigue.

Answer 99

Concussion.

Question 100

Coup injury affects the cerebral tissue directly under the point of impact.
Contrecoup injury occurs in a line directly opposite the point of impact
Clinical manifestations of a contusion are related to the location of the injury, the degree of contusion, and the presence of associated lesions.

Answer 100

Contusion.

Question 101

Extravasation of blood creates a space-occupying lesion within the cranial vault that can lead to increased ICP.
Traumatic intracerebral hemorrhage (ICH) directly damages neural tissue and can produce further injury as a result of pressure and displacement of intracranial contents.
Epidural hematoma.
Intracerebral hemorrhage and hematoma.

Answer 101

Cerebral hematoma.

Question 102

is a collection of blood between the inner skull and the outermost layer of the dura mater
occurs as a result of trauma to the skull and meninges
The classic clinical manifestations of EDH include brief loss of consciousness followed by a period of lucidity. Rapid deterioration in the LOC should be anticipated
complain of a severe, localized headache and may be sleepy
A dilated and fixed pupil on the same side as the impact area is a hallmark
Treatment of EDH requires urgent surgical intervention to remove the blood and to cauterize the bleeding vessels.

Answer 102

Epidural hematoma.

Question 103

Results when bleeding occurs deep within cerebral tissue. Traumatic causes of ICH include depressed skull fractures, penetrating injuries (bullet, knife), or sudden acceleration deceleration motion.
Sudden clinical deterioration of a patient 6 to 10 days after trauma may be the result of ICH.

Answer 103

Intracerebral hemorrhage and hematoma.

Question 104

Neurologic assessment is the most important tool for evaluating a patient with a severe TBI, because it can provide information about the severity of injury, offer prognostic information, and dictate the speed with which further evaluation and treatment must proceed.
Pupillary and motor strength assessment must be incorporated into early and ongoing assessments. After specific injuries are identified, a more thorough, focused neurologic assessment, such as examination of the cranial nerves, is warranted

Answer 104

Neurologic Assessment of Traumatic Brain Injury

Question 105

Immediate assessments of airway, breathing, and circulation (ABCs) are the first steps in patient assessment. Patients with moderate to severe TBI may require endotracheal intubation with mechanical ventilation to reduce the risk of hypoxia and hypercapnia.
LOC, motor movements, pupillary response, respiratory function, and vital signs all are part of a complete neurologic assessment of a patient with TBI. LOC is a patient’s degree of responsiveness and awareness.

Answer 105

Nursing assessment of a patient with traumatic brain injury.

Question 106

The cornerstone of diagnostic procedures for evaluation of TBI is the CT scan.

Answer 106

Diagnostic procedures.

Question 107

Surgical management.
If a lesion identified on CT scan is causing a shift of intracranial contents or increasing ICP, surgical intervention is necessary. A craniotomy is performed to remove the EDH, SDH, or large ICH.
Nonsurgical management.
Nonsurgical management includes management of ICP, maintenance of adequate CPP, ensuring adequate oxygenation, and prevention and treatment of complications such as pneumonia or infection.

Answer 107

Medical Management

Question 108

Nursing interventions focus on recognition and reduction of increased ICP, limiting or preventing secondary brain injury, and stabilization of vital signs. Ongoing neurologic assessments are the foundation of care for patients with TBI.
If secondary injury is to be prevented, the critical care nurse (in collaboration with the physicians), must respond immediately to events that increase ICP, reduce MAP, and reduce CPP.
In patients with TBI, changes in cardiovascular function and circulating catecholamines may contribute to hemodynamic instability.
Of utmost importance is ensuring that the TBI patient is not hypoxemic.

Answer 108

Nursing Management

Question 109

Cranium/brain injuries
Traumatic subarachnoid hemorrhage (SAH)
Traumatic intracerebral hemorrhage (ICH)
Epidural hematoma (EDH)
Subdural hematoma (SDH)
Cerebral Contusion
Skull Fracture
Traumatic brain injuries
Head trauma patients (SAH, SDH, ICH, EDH, skull fx) are often forgetful. They should be reoriented starting with where they are and why they are in the hospital
Head trauma patients (SAH, SDH, ICH, EDH, skull fx) may present unconscious and regain consciousness hours/days/weeks later. They also should be reoriented starting with where they are and why they are in the hospital

Answer 109

What kinds of injuries are considered neuro trauma?

Question 110

Blunt trauma. Arterial bleed – a large artery is dissected/ruptured. Blood in the arachnoid space (in the cerebral spinal fluid) .Abrupt onset of symptoms that do not change from the time of the event. Symptoms will slowly change as the blood is reabsorbed by the body or with an intervention such as an EVD placement.

Answer 110

Traumatic subarachnoid hemorrhage (SAH)

Question 111

Blunt trauma. Arterial bleed in the brain tissue (ruptured tiny arteries). Abrupt onset of symptoms that do not change from the time of the event. Symptoms will slowly change as the blood is reabsorbed by the body.

Answer 111

Traumatic intracerebral hemorrhage (ICH)

Question 112

Classically a sports related injury. Blunt trauma. Arterial bleed. The pt. passes out then regains consciousness. Then passes out again. Many pts with an epidural hematoma do not make it to surgery in time.

Answer 112

Epidural hematoma (EDH)

Question 113

Blunt trauma: Venous bleed. Symptoms typically present days, weeks, or months later. The symptoms get progressively worse over time.

Answer 113

Subdural hematoma (SDH)

Question 114

Secondary injury can be caused by ischemia, hypotension, hypercapnia, cerebral edema, or metabolic derangements.
Ischemia: secondary to hypotension or hypoxia. Increased ICP causes decreased cerebral perfusion which leads to cerebral ischemia.
Hypotension: causes decreased cerebral perfusion.
Hypercapnia: Caused by hypoventilation & hypoxia. Causes vasodilation which causes increased cerebral blood flow which causes increased ICP.
Cerebral edema: can be localized around the injury. Need to manage aspects of secondary injury: oxygenation, ventilation, perfusion.
The book does not mention hemorrhage/hemorrhagic conversion as a secondary injury, but it is commonly seen. The hemorrhage increases ICP.

Answer 114

Secondary injury

Question 115

Same sx as ICH - not know until imaging
Arterial bleed
Onset of symptoms: Fast
Symptoms continue to get worse until treated

Answer 115

Traumatic subarachnoid hemorrhage (SAH)

Question 116

Same sx as SAH - not know until imaging
Arterial bleed
Onset of symptoms: Fast
Symptoms continue to get worse until treated?

Answer 116

Traumatic intracerebral hemorrhage (ICH)

Question 117

Arterial bleed
Onset of symptoms: slow
Symptoms wax & wane
Middle meningial artery - can affect this artery that under temporal and parietal bone and damage it and make it bleed

Answer 117

Epidural hematoma (EDH)

Question 118

Venous bleed
Onset of symptoms: slow
Symptoms continue to get worse until treated

Answer 118

Subdural hematoma (SDH)

Question 119

Can be benign and incidental finding
Little bruise
Small vessel (bruise) - tiny arteries - self-limiting - progressively better; with head CTs see dissipating over time
Onset of symptoms: Fast - onsite then better; fast if do have sx
Symptoms should get better with time. Commonly seen with coup/countercoup injuries - hit head brain move - brain slam into front and back or side to side - direct path

Answer 119

Cerebral contusion

Question 120

4
Spontaneous: eyes open spontaneously without stimulation
3
To speech: eyes open with verbal stimulation but not necessarily to command
2
To pain: eyes open with noxious stimuli
1
None: no eye opening regardless of stimulation

Answer 120

Eyes

Question 121

5
Oriented: accurate information about person, place, time, reason for hospitalization and personal data
4
Confused: answers not appropriate to question but use of language is correct
3
Inappropriate words: disorganized, random speech, no sustained conversation
2
Incomprehensible sounds: moans, groans, and incomprehensible mumbles
1
None: no verbalization despite stimatulation

Answer 121

Verbal response - higher func; motor and sensory strip in brain

Question 122

6
Obeys commands: performs simple tasks on command; able to repeat performance
5
Localizes to pain: organized attempt to localize and remove painful stimuli
4
Withdraws from pain: withdraws extremity from source of painful stimuli
3
Abnormal flexion: decorticate posturing spontaneously or in response to noxious stimuli
2
Extension: decerebrate posturing spontaneously or in response to noxious stimuli
1
None: no response to noxious stimuli, flaccid

Answer 122

Best motor response - higher func; motor and sensory strip in brain

Question 123

waiting day to come in; slow bleed and taken while to be symptomatic
Will be slow
Always have a delay

Answer 123

Subdural

Question 124

Reassess
Stat noncontrast CT - not know what causing sx - swelling or bleeding - see what going on in head

Answer 124

Neuro change

Question 125

Periorbital
Tympanic membrane - classic s&s
Sinuses hold lot blood

Answer 125

Classic s&s of Basilar skull fracture

Question 126

Medical management - must go to OR
No other way address
Surgical emergency
From CT suite to OR
Afterwards: intracranial pressure issues and do appropriate nursing interventions
Positioning
↑ HOB
Head in neutral position
Fluid management
I & O
Fluid restriction
Stool softener - increases ICP
Aggressive about controlling cough - every time cough - increase ICP secondary intrathoracic pressure affecting venous return down from brain
Avoidance of vomiting - increases intracranial pressure - Nausea - antiemetics - prevent increase ICP with vomiting can cause death, expand hemorrhage
Avoidance of fever - increases metabolic demand.
Comfort & emotional support
Promote arterial oxygenation (airway & breathing)
Avoid increasing metabolic demand (htn, anxiety, pain, elevated temp., infection, seizures)
Source identified and treated effectively
Aware metabolic demand
Based on neuronal demand affects metabolic rate
May administer sedation
PRN P.O./IV benzodiazepines
Titrate continuous IV sedation
Assess for complications: infection, corneal abrasions, injury

Answer 126

How is this condition treated? - Epidural bleed

Question 127

Swelling; Bleeding - Two big ones
SAH - blood circulating in CSF - CSF and blood
Usually cerebral edema and bleeding occupying space

Answer 127

What causes the ICP to increase in a trauma pt?

Question 128

Difference is the mechanism of injury
Stroke - pathological response by the body - HTN causing intracranial bleed, aneurysm causing intracranial bleed
Trauma - mechanism of injury = trauma
Treated close to same
In ER - two diff paths and matrixes
Knowing cause imp - required doc diff

Answer 128

What is the difference between a subarachnoid hemorrhage caused by a stroke vs by trauma?

Question 129

Prevent secondary injury
Assess and reassess ABCDEs - can be fine and then go downhill quickly - monitor them
Manage ABC’s
Avoid complications of prolonged immobility
Same Primary and Secondary assessment
ABCDE

Answer 129

Neuro trauma summary -Management of neuro trauma