Trauma Flashcards by Kelsey Klipfel

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

Trauma:

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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

External Forces of injury

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

Mechanical

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Blunt trauma:
Penetrating trauma:
Acceleration:
Deceleration:

Types of Mechanical injury

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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.

Blunt trauma:

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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

Penetrating trauma:

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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

Acceleration:

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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

Deceleration:

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

Primary Injury:

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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

Secondary injury:

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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.

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

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

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?

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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

What is/are types of mechanical injury?

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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

The story matters. Listen to the details.

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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

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

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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

Airway: Is this patient maintaining his airway?

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Before get to ED
Not done perfectly

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

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Immobilize for spine injuries
Put on back boards

Immobilization: Did this patient require immobilization?

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

IV access

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Not set it
Prevent movement and more soft tissue damage

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

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Can receive these orders in route

Pain management

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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.

A - Airway:

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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.

Breathing:

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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.

Circulation:

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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

Disability:

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

Exposure:

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)

Secondary survey (Anticipated findings)

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

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

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

G – Get Monitoring Devices and Give Comfort:

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

H- Head-to-toe & History:

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

I – Inspect posterior surfaces:

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

What can be delegated to unlicensed assistive personnel (UAP)

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

Right pneumothorax

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

4 broken ribs

A: swollen, reddened, first look benign

Crush injury right upper leg

A: thing sticking out dermis

Imbedded tree bark right upper leg and left lower leg

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

Puncture wound left mid-calf

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

Fractured right femur

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

Nursing Interventions?

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

Penetrating injury - Assessment of possible complications

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

Thoracic injury - Assessment of possible complications

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

Crush injury - Assessment of possible complications

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

Fracture femur - Assessment of possible complications

Allergic rxn/anaphylaxis

Hornet Sting - Assessment of possible complications

Penetrating injury Anything that goes through the dermis

Which injury has the highest risk for infection?

Mechanical

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?

Rotated and shorter

Right leg deformity

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

What is/are the forces of injury?

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

What is/are types of mechanical injury?

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

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

PT/INR - high -

emergent lab; fix right now; bleeding out

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

Right femur fracture

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

Mid sternum fracture

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

Pelvic fracture

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

Straw embedded in pharynx

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.

Le Fort 1 fracture

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

Grade 1 liver laceration

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

Right femur fracture: - N, interventions

Monitor for arrhythmias, heart behind sternum Ensure breathing well

Mid sternum fracture: - N, interventions

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

Pelvic fracture: - N, interventions

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

Straw embedded in pharynx: - N, interventions

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

Le Fort 1 fracture: - N, interventions

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

Liver Laceration - N, interventions

Leg squeezers

Being in the hospital: - N, interventions

compartment syndrome

Right femur fracture: - Possible complications

heart irritated = arrhythmias - ensure not cardiac tamponade

Mid sternum fracture: - Possible complications

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

Pelvic fracture: - Possible complications

difficulty breathing Losing airway

Straw embedded in pharynx: - Possible complications

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

Le Fort 1 fracture: - Possible complications

Potential to become worse liver laceration

Liver Laceration - Possible complications

atelectasis, pressure ulcers

Being in the hospital: - Possible complications

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

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

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

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

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

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

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

Survey component: A = airway

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)

Survey component: B = breathing

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

Survey component: C = circulation

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

Survey component: D = disability

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

Survey component: E = exposure

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

Get the whole story

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

Know

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.

Maxillofacial injuries

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

Thoracic (chest wall, pulmonary, cardiac & vascular)

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.

Rib fractures.

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.

Flail chest.

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.

Pulmonary contusion.

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.

Open pneumothorax.

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.

Tension pneumothorax.

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.

Massive hemothorax.

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

Cardiac tamponade.

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

Blunt traumatic aortic injury.

Liver injuries. Spleen injuries. Hollow viscus injuries.

Specific abdominal organ injuries

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

Liver injuries.

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

Spleen injuries.

Surgical resection and repair is almost always required.

Hollow viscus injuries.

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.

Pelvic Fractures - Musculoskeletal injuries

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

Traumatic Brain Injuries (i.e. neuro trauma)

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.

Skull fracture.

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.

Concussion.

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.

Contusion.

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.

Cerebral hematoma.

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.

Epidural hematoma.

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.

Intracerebral hemorrhage and hematoma.

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

Neurologic Assessment of Traumatic Brain Injury

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.

Nursing assessment of a patient with traumatic brain injury.

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

Diagnostic procedures.

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.

Medical Management

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.

Nursing Management

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

What kinds of injuries are considered neuro trauma?

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.

Traumatic subarachnoid hemorrhage (SAH)

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.

Traumatic intracerebral hemorrhage (ICH)

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.

Epidural hematoma (EDH)

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

Subdural hematoma (SDH)

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.

Secondary injury

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

Traumatic subarachnoid hemorrhage (SAH)

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

Traumatic intracerebral hemorrhage (ICH)

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

Epidural hematoma (EDH)

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

Subdural hematoma (SDH)

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

Cerebral contusion

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

Eyes

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

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

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

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

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

Subdural

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

Neuro change

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

Classic s&s of Basilar skull fracture

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

How is this condition treated? - Epidural bleed

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

What causes the ICP to increase in a trauma pt?

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

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

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

Neuro trauma summary -Management of neuro trauma