Unintentional Injury & Trauma Flashcards
Unintentional Injury
Leading cause of death for people 1-44
Leading causes of unintentional fatalities:
Motor vehicle traffic (MVA, pedestrian, bicyclists)
Poisoning
Falls
triad of death : a lethal cascade
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***.
Emergency room nurse
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
triage “ to sort”
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)
Primary Survey
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
Second Survey
F: full set of vital signs & family
G: give comfort measures
H: head to toe assessment & history
I: Inspection of posterior surfaces
Airway with simultaneous cervical spine stabilization and/or immobilization
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
Breathing
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.
End tidal CO2 monitoring
Increased use of end tidal CO2 monitoring (capnography) in trauma patients-why?
Circulation
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)
Circulation continued
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)?
Circulation (fluids)
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)
Disability
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
Exposure
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.
Second Survey
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
History and Head to Toe Assessment Inspection
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
Diphtheria, Tetanus & PertussisVaccinations
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)?
Tetanus, diphtheria, and acellular pertussis(Tdap)
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?
Trauma Signs
- Battle’s sign
- Raccoon eyes
- Liver laceration
- Grey Turner’s sign
- Cullen’s sign
Battle’s: post-auricular ecchymosis, behind the ear, over the mastoid bone- basilar skull fx
Chest trauma
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.
Flail Chest
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
Thoracic Injuries
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
Spontaneous pneumothorax
Rupture of small blebs
Primary: healthy young individuals
Secondary: as a result of lung disease
Risk factors
Treatment
VATS procedure: video-assisted thoracic surgery
Traumatic Pneumothorax
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.
Tension Pneumothorax
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)
Tension pneumothorax on CXR
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?
Tension pneumo s/sx
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
Tension Pneumo
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
Tension pneumo treatment
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
Cardiac Tamponade
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
Cardiac Tamponade Beck’s Triad
Jugular Venous Distension
Muffled or Distant Heart Sounds
Low Blood Pressure
Abdominal Trauma
. 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.
Clinical Manifestations
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?
Abdominal Trauma Complications
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
Abdominal Diagnostic Studies
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.
Focused Assessment with Sonography for Trauma
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
Management of the patient with intra-abdominal injuries
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?
Head/face trauma
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
Glasgow Comma Scale
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!
Scalp lacerations
Profuse bleeding
Tx: staple or suture closed
Pressure bandage fell off.
Skull fractures
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.
Traumatic Brain Injury (TBI)
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.
TBI Nursing Management
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.
Complications of Crush Injuries
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)
Fractures
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
Emergency Management of Fractures
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?
Traction
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
Complications of fractures
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)
Complications of fx
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
Complications of FX. cont.
. Infection
Open fractures->aggressive surgical debridement + antibiotic therapy + tetanus & diphtheria prophylaxis
4. Venous Thromboembolism
Management of the Patient With Poisoning
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
Poisons
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
Management of the Patient with Ingested Poisons
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
NC Venomous snakes
1.) copperhead 2.) cottonmouth 3.) pigmy rattlesnake (most severe reaction from bite; medical emergency)
Venomous vs Nonvenomous
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
Snake Bite Treatment
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?
Poisonous spiders in NC
Black widow
Brown Recluse
Manifestations & treatment for spider bites
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
Tick Bites/Lyme disease
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
Stages of Lyme disease
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)
