Unintentional Injury & Trauma

Question 1

Unintentional Injury

Answer 1

Leading cause of death for people 1-44
Leading causes of unintentional fatalities:
Motor vehicle traffic (MVA, pedestrian, bicyclists)
Poisoning
Falls

Question 2

triad of death : a lethal cascade

Answer 2

predictor of poor outcome
Coagulopathy: excessive fluid dilution, metabolic events, hyperthermia, DIC
Acidosis: build-up of lactic acidosis, build up of Co2 from poor lung functioning, slow breathing
Hypothermia: wet clothing, IV fluids=shivering, decreased tissue perfusion, decreases removal of lactic acid
hypothermia, coagulopathy, acidosis***.

Question 3

Emergency room nurse

Answer 3

Prompt recognition of patients requiring immediate intervention => triage
Team assembling: roles and responsibilities for trauma patient on admission to ER
PPE
Stressful environment
Triage-takes a lot of experience to triage appropriately
“Code Trauma”: have specific responsibilities/role

Question 4

triage “ to sort”

Answer 4

Process of sorting or quickly determining victim acuity
Categorizes patients so that most critical are treated first based on illness severity and resource utilization
Emergency Severity Index (ESI): Five levels of triage (1-5)
ESI-1 & ESI-2 most critical
ESI-3, ESI-4, ESI-5 patients are stable
How sick, how soon need to be seen? With the ESI, patients are assigned to triage levels based on both their acuity and their anticipated resource needs. ESI-1 any threats to life (cardiac arrest) ESI-2 high risk situation ESI-3,4,5(nL vs) depends on # of resources(ECG, labs, radiology studies, IV fluids)

Question 5

Primary Survey

Answer 5

A: airway
B: breathing
C: circulation
D: disability
E: exposure and environmental control
When a trauma patient first comes in. Trauma resuscitation requires immediate treatment, these five things to prevent death. Trauma viewed as multisystem disease. Identify and treat life-threatening conditions first. Primary (ABCDE) & secondary (FGHI) survey for all trauma patients

Question 6

Second Survey

Answer 6

F: full set of vital signs & family
G: give comfort measures
H: head to toe assessment & history
I: Inspection of posterior surfaces

Question 7

Airway with simultaneous cervical spine stabilization and/or immobilization

Answer 7

Open airway
Always assume injury to cervical spine
Stabilize/immobilize cervical spine
Remove or sx foreign bodies
Insert airway or prepare for intubation
Nearly all trauma deaths that occur immediately, due to airway obstruction.
S/Sx of compromised airway:
Suspect cervical spine trauma in any patient with face, head, or neck trauma and/or significant upper chest injuries; open airway with modified jaw thrust maneuver

Question 8

Breathing

Answer 8

Assess adequacy of ventilation
Look, listen, and feel parameters
All trauma patients should receive high-flow oxygen (NRB) during initial evaluation/may need BVM
If we must intubate, it is preferred rapid sequence intubation, induce unresponsiveness followed by neuromuscular blockade to cause muscular relaxation(sedate and paralyze). If unable to intubate due to injury or edema or a failed intubation: emergency cricothyrotomy or a tracheostomy, which is a lifesaving measure.

Question 9

End tidal CO2 monitoring

Answer 9

Increased use of end tidal CO2 monitoring (capnography) in trauma patients-why?

Question 10

Circulation

Answer 10

Check central pulse (quality)
Blood pressure, HR, skin color, oxygen saturation, cap refill
If absent pulse, start CPR
STOP THE BLEED!
Determine source of blood loss
Hemorrhage is cause of early post-injury deaths; can occur in several areas:, pelvis, femur, liver, spleen, kidney, head, chest (organs that are vascular or areas that can hold a lot of blood)

Question 11

Circulation continued

Answer 11

2 large bore IVs
Type and cross match
Administer fluid/blood products
Aggressive fluid resuscitation: LR or NS
What does type and cross match mean?
What blood type would we use if type and cross match taking too long (for example, someone is bleeding out)?

Question 12

Circulation (fluids)

Answer 12

Warm Lactated Ringer’s solution
Isotonic
The components of LR are the closest to our blood crystalloids
Not usually used as a maintenance fluid because of added electrolytes such as Na+ and K+
What would failure to respond to fluids possibly indicate? rapid surgical intervention is required (hypovolemic shock)

Question 13

Disability

Answer 13

Brief neuro exam
Determine patient’s level of consciousness:
A –Alert
V – Responsive to voice
P – Responsive to pain
U – Unresponsive
or
Glasgow coma scale
PERRL
posturing
Agitation is common in the early stages of shock, fight or flight response. As shock progresses their LOC decreases.
Amnesia about an event suggests an altered loc

Question 14

Exposure

Answer 14

Patient completely disrobed in preparation for secondary survey
Exposure to: cold ambient temperatures, large volumes of room temperature IV fluids, cold blood products, and wet clothing  hypothermia
Prevention and early recognition of correctable issues
Heated blankets, overhead warmers, warmed fluids, warmed room, and Bair hugger
Maintain privacy
Preservation of evidence
Hypothermia: core temp 35 C or 95 F or less. Hypothermia is the easiest to treat of the trauma triad.

Question 15

Second Survey

Answer 15

Full set VS, focused adjuncts, facilitate family presence: continuous ECG,O2 sat, end-tidal CO2 monitoring; urinary catheter/NGT if indicated; tetanus; labs, X-rays; designate team member to support family
Give comfort measures: assess and reassess pain/anxiety
Finished primary
Labs you would anticipate:?
Blood at meatus-what would you suspect?
Facial fractures - NGT with US guidance

Question 16

History and Head to Toe Assessment Inspection

Answer 16

Obtain details of incident/illness, mechanism and pattern of injury, length of time since incident, injuries suspected, treatment provided and pt’s response, LOC
Head to toe assessment
AMPLE: allergies, meds, past health hx, last meal, events/environment preceding injury or illness
Log roll and inspect back for deformity, bleeding, lacerations, and bruises
What did happen? Mechanism of injury is important when obtaining history can help predict the types and combinations of injuries ie. If a fall, how high? if MVA, driver? Seatbelt? Airbag deployed?
May need to remove anterior portion of c-collar to see if any tracheal deviation or JVD

Question 17

Diphtheria, Tetanus & PertussisVaccinations

Answer 17

DTaP (given to children under age 7)
Tdap (one dose age 11-64 years)
Td (once every ten years after one Tdap)
TIG
When would you give TIG (tetanus immunoglobulin)?

Question 18

Tetanus, diphtheria, and acellular pertussis(Tdap)

Answer 18

Only for individuals older than 7 years of age
Now routinely given around 11 or 12 years of age
Healthcare professionals should all have this vaccine
Pregnant women should get one dose of Tdap during every pregnancy (CDC, 2022)* “whooping cough”
Td is a derivative of Tdap…but without the pertussis.
Td boosters should be given every 10 years
*CDC recommends all women receive a Tdap vaccine during the 27th through 36th week ofeachpregnancy, preferably during the earlier part of this time period. Why?

Question 19

Trauma Signs

Answer 19

1. Battle’s sign
2. Raccoon eyes
3. Liver laceration
4. Grey Turner’s sign
5. Cullen’s sign
   Battle’s: post-auricular ecchymosis, behind the ear, over the mastoid bone- basilar skull fx

Question 20

Chest trauma

Answer 20

Penetrating
Blunt
Sternal and rib fractures
Pulmonary contusion (mortality rate >50%)
Flail chest
Sternal fx usually by steering wheel, can cause pulmonary contusion. Increases mortality 50%, present like an ARDS presentation. Hypoxemia refractory to oxygen.

Question 21

Flail Chest

Answer 21

Fracture of several consecutive ribs in two or more separate places causing unstable segment
Paradoxical breathing
Rapid, shallow respirations and tachycardia
Supportive therapy is key while the ribs heal
Paradoxical breathing-the opposite of what it should be.
Rarely need surgery (external device), supportive therapy-taping, splinting.
Causes: severe blunt injury – crushing roll-over injury due to a flipped ATV, MVA or a fall might cause it.
If major injury, may be intubated

Question 22

Thoracic Injuries

Answer 22

Pneumothorax: air enters the pleural space causing a total or partial collapse of the lung
Loss of negative pressure
Signs and symptoms depend on size
Types:
Simple or spontaneous
Traumatic
Tension
Hemothorax: may require autotransfusion
Insert CT into pleural space: to drain fluid, blood or air; re-establish the negative pressure, and re-expand the lungs

Question 23

Spontaneous pneumothorax

Answer 23

Rupture of small blebs
Primary: healthy young individuals
Secondary: as a result of lung disease
Risk factors
Treatment
VATS procedure: video-assisted thoracic surgery

Question 24

Traumatic Pneumothorax

Answer 24

Closed- can occur during invasive thoracic procedures (“drop a lung”) like CVC insertion
Open pneumothorax- “sucking chest wound” (mediastinal shift)
Causes?
Open (flap may act as one-way valve) occurs with a penetrating wound.

Question 25

Tension Pneumothorax

Answer 25

Progressive build-up of air within the pleural space and cannot escape
Increased intrathoracic pressure
compression of lung on affected side
mediastinum shifts to unaffected side
decreased venous return
decreased cardiac output
We want to prevent a tension pneumothorax (trapped air causes pressure on the heart and lungs)

Question 26

Tension pneumothorax on CXR

Answer 26

Tension pneumo on left with mediastinal shift to right
Tension pneumo on right with mediastinal shift to the left
What do you think you would hear on affected side?

Question 27

Tension pneumo s/sx

Answer 27

Sudden pleuritic pain
Air hunger, decreased pulse ox
Marked tachycardia, delayed cap refill
Tracheal deviation
Decreased or absent breath sounds on affected side
Neck vein distention
Cyanosis
Profuse diaphoresis

Question 28

Tension Pneumo

Answer 28

Remember tension pneumothorax is one of your “t’s “ in causes of PEA
Medical emergency!
Possible circulatory collapse w/ hypotension and traumatic arrest
Not getting blood returning to the heart…what are we gonna do

Question 29

Tension pneumo treatment

Answer 29

Act fast!
Prepare patient for needle decompression followed by chest tube insertion to water seal drainage
First action, second action: needle decompression (angiocath inserted to release air, everything goes back into normal place); follow with CT insertion and connect to pleurovac drainage system

Question 30

Cardiac Tamponade

Answer 30

Causes
blunt or penetrating trauma (hemorrhage)
diagnostic cardiac procedures
pericardial effusions from metastasis
Tx
Pericardiocentesis using echocardiography – immediate relief
Also another one of your “t’s “
in causes of PEA!
Must treat underlying treatment

Question 31

Cardiac Tamponade Beck’s Triad

Answer 31

Jugular Venous Distension
Muffled or Distant Heart Sounds
Low Blood Pressure

Question 32

Abdominal Trauma

Answer 32

. Blunt
compression & shearing injuries
may not be obvious - no open wound
2. Penetrating
0pen wound
Blunt: MVA usually; assoc with: low rib fx, femur fx, pelvic fx, thoracic injuries
Abdominal trauma can cause massive life-threatening blood loss into abdominal cavity.

Question 33

Clinical Manifestations

Answer 33

abdominal pain
guarding/splinting of abdominal wall
hard, distended abdomen
decreased or absent bowel sounds
contusions, abrasions, or bruising over abdomen
scapular pain
hematemesis/hematuria
signs of hypovolemic shock
MUST lift your patient’s gown to accurately assess abdomen!
“Rigidity”: hard, distended, “board-like”
Assess for referred pain which may indicate spleen, liver, or intraperitoneal injury. Blood/fluid irritating in the abdominal cavity and phrenic nerve involved
What is hematemesis/hematuria?

Question 34

Abdominal Trauma Complications

Answer 34

When solid organs injured (liver, spleen) bleeding can be profuse  hypovolemic shock (requires aggressive fluid resuscitation)

When hollow organs (bladder, stomach) spill into peritoneal cavity  risk for peritonitis and abdominal compartment syndrome
Liver /spleen vascular
Bacterial peritonitis or abd comp. synd. Just like you can have compartment syndrome in your extremities, you can also have fluid in your abd. Compartments = can put pressure on diaphragm and lungs causing respiratory compromise

Question 35

Abdominal Diagnostic Studies

Answer 35

labs
urinalysis
CT
diagnostic peritoneal lavage (DPT)
focused assessment with sonography in trauma (FAST) on next slide
Labs: T &CM, BMP, CBC, liver fx tests, UA, CT, US
DPT-accurate, quick bedside assessment: checking for blood and bowel contents
10-15 min.

Question 36

Focused Assessment with Sonography for Trauma

Answer 36

Bedside ultrasound - used to rapidly examine all four abdominal quadrants and the pericardium to identify the presence of free fluid, usually blood. Used in high risk injury of mechanism
Unstable and +FAST goes straight to OR
Stable and +FAST goes to CT for better localization of the problem

Question 37

Management of the patient with intra-abdominal injuries

Answer 37

Primary survey
Document all wounds
If viscera are protruding, cover with sterile, moist saline dressing
Pelvic binder
Hold oral fluids
NG to aspirate stomach contents
Tetanus and antibiotic prophylaxis
Continuous monitoring and reassessment
Rapid transport to surgery if indicated
Impaled objects should never be removed except by skilled provider.
Pelvic binder used in suspected pelvic trauma to prevent from further injury. To help stabilize
Ab for open wound or a peritonitis
Who would use an oral gastric tube instead of NGT?

Question 38

Head/face trauma

Answer 38

Any injury or trauma to the scalp, skull, or brain
MVA & falls most common cause
Factors that predict a poor outcome
Suspect cervical spine injury with face, head, neck trauma
TBI more likely in males

Question 39

Glasgow Comma Scale

Answer 39

GCS scores on arrival to hospital strong predictor
the lower the GCS score, the less chance of survival
Minor 13-15 GCS
Moderate 9-12 GCS
Severe 3-8 GCS
On a continuum: general approach
IMPT: baseline, monitor and detect early changes!

Question 40

Scalp lacerations

Answer 40

Profuse bleeding
Tx: staple or suture closed
Pressure bandage fell off.

Question 41

Skull fractures

Answer 41

Can cause CSF leaks (basilar fracture)
Manifestations
Battles sign
Periorbital ecchymosis (raccoon eyes)
Halo sign
Complications
Intracranial infections, hematoma,
Meningeal and brain tissue damage

Skull fx frequently occur with head trauma. Type and fx depends on velocity, momentum, site of impact.
Basilar fracture are assoc. with a tear in the dura, leaking of CSF.
May have CSF leak-may have rhinorrhea (clear fluid from nose or pt c/o of postnasal drip) or can have fluid draining from ear.

Question 42

Traumatic Brain Injury (TBI)

Answer 42

Concussion
Diffuse axonal injury
Contusion (coup contre coup)
Hematoma
TBIs in 114
Concussion: local injury; sports-soccer, boxing, football. Repeated concussions are cumulative effect-autopsies show chronic encephalopathy. Concussion syndrome: irritable, difficulty concentrating, reading, math skills. We do better with post concussion return to game protocol now.
DAI-poor prognosis. All over brain injury. 90 % in a persistent vegetative state
Contusion: minor to severe. Coup contre coup: two injuries, assoc. with closed head injury, seizures common. Increased mortality with anticoagulant.
Epidural bleed is a medical emergency, usually arterial bleed. Classic signs: Disoriented, then have a lucid interval, brain compensates at first, but it’s s fixed structure, can only tolerate so much bleeding before they decompensate. Headache, n/v, unresponsive. Need surgery, craniotomy to evacuate hematoma
Subdural bleed is usually a slower bleed, venous in nature. Acute and chronic. Difficult to distinguish from a mentally declining older person or someone with Alzheimer’s.

Question 43

TBI Nursing Management

Answer 43

ABC:
Administer O2 via non rebreather mask
Intubate if GCS <8
Control external bleeding w/ sterile pressure dressing
IV access x 2 large bore
Stabilize cervical spine
Goals:
Maintain cerebral oxygenation & perfusion
Prevent secondary cerebral ischemia
CT and MRI scans
Cushings triad: worsening head injury; the body’s response to increased ICP
Widening pulse pressure (Inc SBP and dec. DBP), bradycardia, irregular resp= brain herniation leading to cardiac and resp arrest.

Question 44

Complications of Crush Injuries

Answer 44

Hypovolemic shock
Paralysis of body part
Erythema and blistering
Damage to body part
Renal dysfunction
When a person is caught between opposing forces (for example, you’re standing behind a car that backs up on you, trapping your lower extremities)

Question 45

Fractures

Answer 45

Disruption or break in continuity or structure of the bone
Some are “pathologic” in nature
2 Types
1. Open (compound)
Skin is broken and bone is exposed
2. Closed (simple)
Skin has not been ruptured and bone is not exposed
Open vs. Closed

Question 46

Emergency Management of Fractures

Answer 46

Treat life threatening injuries first
Ensure ABCs
Control external bleeding with:
Direct pressure
Sterile pressure dressing
Elevation of extremity
Check neurovascular status distal to injury
Elevate injury if possible
Apply ice packs to affected area
X-rays
Last tetanus?

Question 47

Traction

Answer 47

Skin Traction
Short term (48-72 hrs) treatment
Nothing penetrates the skin
Skeletal traction
Longer periods…long term pull
Pin (Steinmann pin) or wire is inserted into the bone to align and immobilize the part
Traction helps prevent or reduce pain and muscle spasms, and immobilization, helps to reduce the fracture (restore a fx bone to its normal anatomical position).ORIF
With skeletal traction: risk for infection at pin site(s) and pulleys must be able to move freely

Question 48

Complications of fractures

Answer 48

Compartment Syndrome
2 basic causes
remember 6 P’s
Treatment
emergency fasciotomy
neurovascular assessments
urine output
Compartment syndrome usually involves the leg, but can occur in arm, shoulder, abdomen, and buttock;
Causes: 1.) decreased compartment size (cast too soon, then edema, or drsg, burn around the leg, like a tourniquet) 2.) increased compartment contents(d/t edema, bleeding or both) remember 6 P’s: pain (disproportionate to injury to passive motion, despite pain med administration), increasing pressure in the compartment, paresthesia (numbness, tingling), pallor, paralysis, pulseless (late sign, check cap refill) or diminished pulses

If you can’t feel a pulse?

Worried about rhabdomyolysis

Tx: if it’s the cast, remove, if no improvement, may need fasciotomy, cut through fascia so we can restore circulation, otherwise will lose extremity
UO: with muscle damage in crush injuries, myoglobin released can clog tubules in kidney and get acute tubular necrosis (ATN)

Question 49

Complications of fx

Answer 49

Fat Embolism Syndrome
Symptoms, if present,
typically occur 24 to 72 hours after the trauma; shortness of breath, confusion, and a transient petechial rash

Treatment
Reduce long bone fractures
Intravascular fluid resuscitation with fluids/albumin, may require intubation
Esp. with long bone fx or pelvic fx or multiple fx. Fat emboli released from the bone marrow at the fracture site into the venous system
Petechial=coagulopathy
Similar to ARDS presentation

Question 50

Complications of FX. cont.

Answer 50

. Infection
Open fractures->aggressive surgical debridement + antibiotic therapy + tetanus & diphtheria prophylaxis
4. Venous Thromboembolism

Question 51

Management of the Patient With Poisoning

Answer 51

Treatment goals
Remove or inactivate the poison before it is absorbed
Provide supportive care in maintaining vital organs systems
Administer specific antidotes
Hasten the elimination of the poison
Poison Control Center

Question 52

Poisons

Answer 52

ABCs
Monitor VS, LOC, ECG, UO
Laboratory specimens
Determine what, when, and how much substance was ingested
Signs and symptoms of poisoning and tissue damage
Health history
Age and weight

Question 53

Management of the Patient with Ingested Poisons

Answer 53

Measures to remove the toxin or decrease its absorption
Use of emetics* (do not induce vomiting with corrosive agents)
Gastric lavage
Activated charcoal
Administration of specific antagonist as early as possible (i.e what for acetaminophen OD?)
May include diuresis, dialysis
*Emetics (induce vomiting)not used as much anymore. Gastric lavage if done within the first hour; activated charcoal to help absorb poison and eliminate it from your body.
Corrosive going down, just as corrosive coming up
Possible psychiatric consultation if suicidal or self-harm attempt; accidental poison ingestion=>education on prevention & poison proofing instructions, esp. with children

Question 54

NC Venomous snakes

Answer 54

1.) copperhead 2.) cottonmouth 3.) pigmy rattlesnake (most severe reaction from bite; medical emergency)

Question 55

Venomous vs Nonvenomous

Answer 55

Venomous Snake Characteristics
triangular or diamond-shaped headelliptical or “cat-like”long, movable fangsfacial pits located below the eyes
Venomous snakes leave one or two puncture wounds
Non-venomous snake characteristics
smooth, tapered headround pupilsno fangs, have small teethno pits

Question 56

Snake Bite Treatment

Answer 56

S/sx of envenomation: edema, ecchymosis, hemorrhagic bullae–necrosis, lymph node tenderness, n/v, metallic taste in mouth
May progress without treatment
Lie down, remove constrictive items, clean and cover wound, immobilize the injured body part below the level of the heart; mark the area with pen to monitor progression
Tetanus, analgesia, possible fluid or vasopressors
Possible administration of antivenom (between 4-12 hrs)
DO NOT leave patient unattended
What don’t you do?

Question 57

Poisonous spiders in NC

Answer 57

Black widow
Brown Recluse

Question 58

Manifestations & treatment for spider bites

Answer 58

Black Widow
Bites feel like pinpricks
Systemic effects within 30 min: abd. rigidity, N/V, HTN, tachy, paresthesia’s
Severe pain

TX: ice, elevation, last tetanus, analgesic, benzos, antivenom if necessary
Continuous monitoring!
Brown Recluse
Bites are painless
Systemic effects; within 24 to 72 hours, fever, chills, N/V, malaise, joint pain, reddish to purple in color site, necrosis

TX: clean with soap and water, possible hyperbaric O2 or surgical debridement
found in dark places: closets, woodpiles, shoes

Question 59

Tick Bites/Lyme disease

Answer 59

Occur in grassy or wooded areas
Pathogen (bacteriumBorrelia burgdorferi) transmitted by tick can cause: Rocky Mountain Spotted Fever, West Nile virus, Lyme disease
Steps to prevent Lyme disease:
using insect repellant, remove ticks promptly, avoid tick-infested areas, check for ticks on self and pets

Question 60

Stages of Lyme disease

Answer 60

Stage I
S/Sx: flulike, bull’s-eye rash (not always)
TX: antibiotics (10-21 days)
Stage II
S/Sx: facial nerve palsy, joint pain, memory loss, poor motor coordination, adenopathy, cardiac issues
Stage III
S/Sx: arthritis, neuropathy, myalgia and myocarditis
Diagnosis
Progresses to stage 2 and 3 if not treated; even with treatment, 10-20% of patients experience long-term effects (post treatment lyme disease syndrome)