Trauma part 1 Flashcards
How is the extent of injury calculated in children with burns?
Different body proportions such as the infant head being bigger than the body change the rule of nines, and so we do it by age surface area.
Depth of injury/burn categories?
Why we need to differentiate these?
Superficial
Partial thickness
Full-thickness
Different depths require different plans of care
Explain superficial depth
What is healing like?
Just the epidermis or top layer of the skin which will be dry, erythemic, and painful.
Can heal in a couple days without scarring
Explain partial thickness depth
What is healing like?
Includes the epidermis and dermis parts of the skin which will appear as mottled, red, blistered, and painful.
Will heal within 14 days and could have a scar
Explain full - thickness depth
The epidermis, dermis, and subq/muscle tissue are affected. Skin may be dry and leathery without stretch ability and without sensation due to nerve damage.
Healing takes longer and can have complications.
If the severity of the burn is extensive, what are some complications to consider?
Scarring & contractures Loss of ability/function of body parts affected Cosmetic appearance Infection Ischemia Respiratory complications Fluid shifts
What is a common reason children get circumferential burns?
What sort of complications can occur from circumferential burns around the trunk?
What other circumferential complications can happen to any part of the body?
Due to hot water burns when bathing.
The burn can develop eschar which doesn’t allow lungs to stretch which affects respiratory system. It also may just hurt to breath as well.
If a burn is circumferential, it may cut off circulation to distal parts.
How is severity of injury determined
Extent and depth of burn, body parts involved, patient’s age, and concomitant injury and illnesses
What system can be affected if the neck and face are burned?
Respiratory issues bc the airway may be burned too and cause edema and obstruction
Why is an infant and elderly person’s skin a concern when it comes to burns?
Both infants and elderly have thinner skin that is more fragile which can be more damaged from burns. Skin is an important organ
What are infant’s protein stores like and how can that impact a burn they have? What is the care here?
Infants have less protein stores. And they would need the protein to recover from a burn. To help them, we’d need to provide nutritional support.
What is an infant’s immune response like? How does that affect them if they have a burn?
An infant’s immune response is immature. And it can lead to increased risk of infection from a burn site.
So give antibiotics if necessary.
What is an infants fluid proportional like?
What about renal functioning?
They have more fluid compared to size which makes fluid shifts have more of an impact on them and make them more out of balance. A burn can definitely throw them out of balance here.
Infant renal function is also immature. If there’s more fluid shifting, that hurts the blood volume and ultimately hurts the kidneys perfusion
Three zones of injury
Zone of coagulation
Zone of stasis
Zone of hyperemia
Zone of coagulation
The necrotic, destroyed portion of the burn. No coming back from this, and so just needs to be removed/sloughed off.
Zone of stasis
Middle zone where the area is still alive but very injured and abnormal. Will do watchful waiting to see how this zone does.
Zone of hyperemia
The alive zone that has remained metabolically active and gets blood flow still. This is the zone we need to really focus on bc we want to make sure it stays this way and we have the most control over it.
It may even be hyperactive from working to keep itself alive. Still viable.
Order of body’s local response to a burn that explain fluid shifting due to a wound
What is the deciding factor on how much fluid shifting will happen
1) Vasodilation of vessels and increased hydrostatic pressure
2) More permeability
3) Water and electrolytes move into the interstitial
4) Oncotic pressure is lost and so edema develops
Depends on the SA of the wound. If it is bigger = more shifting
If fluid shifting is going on due to a wound/burn, what does that do to blood?
How do we treat this?
How long will the fluid shift last? And how will we know?
Blood volume of vasculature will lose volume and so perfusion/cardiovascular can be affected leading to decreased CO
Need to replace the fluids asap.
Fluid shift lasts around 72 hours.
Once it’s over, the I&O may increase, weight loss, and loss of edema occur.
What is the renal system directly tied to?
The cardiovascular system. If the heart’s CO isn’t enough, the kidneys will stop functioning adequately.
What does an electrical burn do to muscles?
What does this have to do with the kidneys ability to function? How do we intervene?
An electrical burns travels through the whole body affecting muscles by releasing Myoglobin protein.
Myoglobin has large molecules that can plug the kidneys if too much enters.
We need to make sure we are flushing kidneys with enough fluid to make sure the plug doesn’t happen.
What is compartment syndrome?
How does this occur in burns and cause neurovascular changes?
What makes this more likely to happen?
Compartment syndrome is when there’s too much pressure that it turns inward and affects its surroundings like organs, muscles, fascia, etc.
The burn can cause the edema to occur, within 18-48 hours and the fluid can accumulate so much in the tissues that Compartment syndrome occurs which damages nerve pathways and restrict blood flow.
More likely if you have eschar tissue involved bc the tissue doesn’t stretch and so the pressure build up sooner.
How is compartment syndrome treated?
They can do a tissue release where they cut the fascia/eschar open with a scalpel so whatever is adding pressure can expand.
- only issue here is you’d have to treat the incision as a wound , watch for infection, and even sometimes they can’t even do this bc the area is so invasive
BC if they don’t do this, its gonna hurts nerves.
How is the GI affected by burns/wounds? Risks? Tx?
The decrease in perfusion can lead to ischemia of GI tract and therefore erosion, necrosis, and perforation can happen.
There’s also a risk for ileum and ulcerations from stress.
Can give PPI for these
May need to decompress the GI before they vomit
What does the body experience due to a burn:
hyper-metabolism or hypo-metabolism?
Nutritional needs?
Both actually. First hypo-metabolism for 72 hrs and then hyper-metabolism bc the body recognizes it needs to get to work to help itself heal.
High protein with fat. High calories as well.
- could be IV parental for intra-lipids or fat
- tube feedings if they really can’t do enteral or mouth feedings
What will cortisol and BG levels be like in burn patients? Treatment?
High cortisol and blood sugar due to stress!
Treatment may be insulin drip but you won’t want to overcorrect past 100 bc that puts them at risk for hypoglycemia. Shooting for 150.
When there’s a burn around the the neck/face what is the risk again?
As a nurse, what should you anticipate?
What is the risk with a mechanical intubator?
Obstruction risk due to the edema occurring.
Anticipate doing a planned artificial airway. It is much easier to get a chest tube in ahead of the time rather than when the the throat is obstructed.
Mechanical vents can cause pneumonia and so we need to be aware of oral care.
If a wound infection persists due to a child’s decreases immune system, what complication can that lead to?
Sepsis ! So we want to be assessing for infection early on. REEDA
How can the CNS be affected by a burn?
What can this ICP cause?
Management?
A burn can cause edema and increased pressure in the head can occur. ICP.
So be aware of a secondary seizure and treat with anticonvulsants.
First step in a burn situation that we need to educate about
Stop the burning!
Chemical burns - if liquid, use a liquid flush. If powder, do not add water!!! it will make it worse
Electrical burns - remove the current
Metal burns - get the. metal off the skin!
Cover w clean cloth and get them help
Cement can also burn someone.
Toddlers are risk bc they are clumsy!
What meds can be used to help with airway edema?
Bronchodilators
Escharotomy
When you open up deep burns covered in eschar for compartment syndrome release
How should fluid be replaced to restore blood volume and thus perfusion?
Formula?
Best way to tell if perfusion is fixed?
What if it has been 48 hours and perfusion is still an issue?
Gradually! Do so over 24-48 hours bc otherwise, you just add to the problem.
PARKLAND FORMULA can help
Check UO. It should be at least 30 ml/hr for older kids and calculate the appropriate amount for younger kids the 0.5-1 ml/kg in younger kids
After 48 hrs, use blood and albumin
What should pain med administration be like for interventions?
The child will need more pain meds for things like wound care or other interventions like showers so give meds in advance.
As always , watch for respiratory depression.
Primary excision of wound
Done early to decrease wound sepsis
Debridement of wound
Bathe, soak, and clean the wound to remove dead tissue
- a requirement for graft replacement too since it has to be clean and healthy
Dressings for the wound
What do we need for any graft?
Skin graft substitute like cadaver
Synthetic dressings
Porcine grafts from pigs
Split thickness grafts
And gauze to support the dressing
We need the debridement to clean it so that the graft to adhere and attach.
Topical agents for wound care
Silver sulfa
Santyl
Mafenide acetate
all these inhibit bacterial growth but they won’t treat if its already happening
They can even come packaged on the gauze to help with healing
Which is more painful with a graft - donor site or graft site?
donor site actually
Things to avoid with graft
How soon does healing begin?
infection
trauma
fluid accumulation
Healing begins within hours of graft due to release of fibrin so it vascularizes in 3 days and heals up in 2 weeks.
What can be used to prevent significant scarring of graft or burn?
Contracture prevention?
other needs for long term rehab?
Elastic Jobst stockings for compression and to keep tissue from accumulating
splinting for contractures
PT
Plastic surgery if desired
Are burns always accidents?
No , sometimes they are abuse.
Why do we need child resistant containers?
To help with ingestion poisoning
What age group is most at risk of ingestion poisoning?
Those under 6 years old
- they are curious
- pills look like candy
- mislabeled bottles may make them think it is ok to drink
Why is it important for parents to understand that even if their child who ingested an excess of acetaminophen or other toxic substance to them is not allowed to go home right away?
They may feel and look fine currently but give it 72 hours and they will start to have an organ crash
- same with iron or other substances just different time lengths
Acetaminophen antidote
Muconist?
When providing treatment for poisons, what does then nurse need to remember?
Treat the child first ! How are they doing NOW?
then treat the poison.
- terminate exposure, identify , and prevent absorption
Best treatments for poisoning?
Charcoal
Emetic
Gastric Lavage
What is charcoal method?
Black powder that inactivates substances.
Need t use in first hour or two though for best absorption.
Could cause vomit or vagal response.
Emetic method for poisoning?
Not recommended in home setting anymore. Might be used in medical field.
Gastric lavage method for poisoning?
Risk?
Use bore to insert fluid and then suction out the pieces along with fluid.
Can increase aspiration risk tho
How common are trauma deaths?
Leading cause of death
- due to small children’s curiosity
- older kids and MVA
FIRST assessments on trauma patient?
Airway
Breathing
Circulation
Disability or what impact the trauma will have on the body
Initial management of airway
Keep immobilized with C spine. Jaw thrust and chin lift.
Place airway if unconscious.
- Bag and mask works fine until at hospital
What Glasgow coma scale may occur in trauma?
How to assess for perfusion in trauma?
Below 8 - and if its at this , person can’t protect their airway.
If unconscious, check cap refill, skin color, temp. Good indicator of airway due to perfusion.
Or even blood gases
IV placement with initial trauma?
2 large bores or use intraosseous device.
Type of fluids with trauma?
Isotonic. may warm.
What if trauma has led to a lot of blood loss?
Colloids
If in shock, how does the body try to compensate?
Hypotension and tachycardia
- check cap refill
When working with a trauma patient, and they have their clothes on, what should you do
Cut the clothes away to do what you have to do but remember to maintain body temperature
- warm fluids, heat lamps, blankets
Why do a type and cross for a trauma patient?
Bc they might need blood replacement/infusions
Why check amylase?
Helps investigate organ damage of pancreas
Why check AST? metabolic profile?
Helps know how liver is functioning
metabolic profile to show the whole picture of everything
All expected labs with trauma patients?
Tests?
Diagnostic tests?
CBC
amylase
AST
metabolic profile
drug screening
Type/cross
CT scan for head
Abdominal sonogram
Why can abdominal trauma be a sign of abuse?
Common nonuse reason to get abdomen trauma?
Kidney protection?
It isn’t always but abdominal traumas are easy to conceal.
Small child with seat belt trauma
Kidneys have very little protection.
When there is an unconscious patient with an abdominal trauma possibility, what should the nurse keep in mind?
Be careful with palpation bc if there’s discomfort pain , you won’t be able to tell and make things worse.
- look for bruisings or marks instead
Abnormal abdominal palpation signs on assessment?
A rigid abdomen OR the free air/fluid in cavity.
If an abdominal trauma occurs & the organs are affected, where will it be felt?
Referred should pain
- right = hepatic
- left = splenic (kehr’s sign)
Flank pain = from kidneys. may also see blood in the urine
What if there’s a possible rib fracture?
A rib fracture can make it hard to breathe and the pt can develop atelectasis.
The bone can also lacerate the organs.
In an abdominal injury what can happen to the genital/groin area?
Swelling due to the blood accumulating from gravity.
What will liver enzymes and amylase trends be in abdominal trauma?
Increased AST/ALT due to liver
Increase amylase due to small bowel, pancreas
How often should assessments be if there is an abdominal trauma?
What happens if the assessment shows the condition is just getting worse for the organs involved in abdominal trauma?
Ongoing!
If it’s an organ like a spleen, then will take it out with splenectomy.
If there’s compartment syndrome going on can do the Escharotomy.
Types of renal injuries?
Contusion like a bruise
Laceration so like a tear
Transection is in the very center
Fragmentation is outwards fragment
Parts of the urinary/GU tract that can be damaged?
What to observe for ?
Bladder
Ureters
Urethra
Pelvic fracture which can damage the surroundings
Observe their pee when they go the bathroom for hematuria and amount if it is anuria or no pee, then scan the bladder.
Types of chest trauma
What can they cause ?
Blunt
Penetrating
Rib fx
Bleeding into nearby areas
Air leaking no expansion
Lack of perfusion
What will a pulmonary contusion look like on X-ray? CT?
Local opacity on x ray
Increased density on CT
just a bruise really
Most common complications of chest trauma?
Hemothorax
Pneumothorax
What is a Hemothorax?
When there is bleeding that builds up and stops the lung expansion is decreased bc its compartmentalized by the blood
What is Pneumothorax?
When an air keeps the lungs from being able to expand.
High tube in chest means___
Pneumonthorax
Low tube in chest means____
Requirement with this?
Hemothorax
Might need to figure out where the bleeding is coming from to stop it.
How are hemothorax and pneumothorax treated?
With chest tubes draining.
signs of hemothorax or pneumothorax?
Dyspnea
Uneven breathing
Unequal breathe sounds
How do you know the air is being drained with pneumothorax?
What if they don’t slow?
the bubbles will show in the machine
If bubbles don’t slow you may have a leak or chest tube malfunction.
- pinch the tubing to find the leak
Tidaling
What if this stops?
Water being pulled up motion by the chest tube drainage system.
If it stops, then there could be a clot OR the problem has gone away.
Main focus of treatment with head injuries?
Secondary prevention from the primary event
What is an acceleration injury
Moving object hits the head and causes injury in acceleration injury
What is a deceleration injury
A deceleration injury involves the human skull hitting something
- like a fall
What is a concussion
Alteration in mental status immediately following head injury and can sometimes lose consciousness but not required for dx
Symptoms of concussion
Confusion, amnesia
headache
n/v
post concussion syndrome up to 1 year
Contusion and laceration of the skull
A bruise or tear of the cerebral tissue essentially
What is coup
What is countercoup
The initial hit of the brain
Countrecoup is the brain hitting a second time
T/F
Those with concussion may feel a lot of pressure in their head
True they can. The bleeding can accumulate and cause IOP and determines the extent of symptoms sometimes too.
Basal skull fractures locations
anterior, middle, and posterior fossa areas with a break in the skull
What can leak in skull fractures?
Battle’s sign?
Around eyes?
spinal fluid and blood
bleeding/bruising around ears
Orbital ecchymosis
Epidural hematoma and subdural hematoma are caused by _____ .
trauma
Epidural hematoma
Symptom onset?
Bleeding between dura and skull from arterial vessel which can lead to brain compression
Very quick. fine one minute, crashing the next.
Subdural hematoma
Symptom onset?
Bleeding between the arachnoid and dura from venous vessel or tear. It can be a slow , gradual process.
Slow onset. Person may go home and feel nothing but shows up later with symptoms.
Epidural and Subdural hematoma treatment?
Burr hole or drilling the hole into the skull to drain blood
Subarachnoid injuries are usually from ______.
Where is the subarachnoid injury located?
type of injuries?
treatment?
Shaking injuries.
Located between arachnoid and brain bc the brain moves a lot.
Will have diffuse injury issues.
can’t remove the fluid/blood.
Diffuse atonal injury
White matter tracts are sheared and upset neuro functioning as time goes on due to diffuse edema
Cerebral edema calculation
Why do we do this?
MAP - ICP = CPP
Cerebral edema is expected with a brain tissue injury. But we want to help control it. And so we measure
An increase in ICP decreased CPP.
CPP measures how much mean arterial pressure is being pumped in order to perfuse the brain to overcome pressure
Osmotic agents to reduce edema?
Hypertonic saline 3%
Mannitol pulls into renal tubules
Why will a person with cerebral edema be on anticonvulsants?
Due to ICP causing seizures
Why will they put a patient with cerebral edema under sedation?
Control of behavior if needed
But also because inducing an unconscious state can help with healing
How do we avoid a stroke in cerebral edema patients?
Maintain adequate perfusion
