Unit 3: Trauma Flashcards
1
Q
What is the leading cause of unintentional injury?
A
falls
2
Q
What is the leading cause of death?
A
motor vehicle collisions (MVCs)
3
Q
Trauma Risk Factors
A
> Age
-majority of deaths from motor vehicle trauma occur in individuals between 15 and 45
-patients older than 65 years have greatest risk of dying from unintentional injury’s b/c of comorbidities
Gender
Race and socioeconomic background
Geographical location and time of year
alcohol, smoking, and substance abuse
4
Q
Connection Check: As an emergecy nurse in an inner-city ED, you are responsible for developing a trauma prevention program for your community. Who will be your priority patient population?
A. 10 to 34 year old African American males
B. 10 to 34 year old Caucasian Females
C. 75+ year olds
D. 10 to 34 year old Hispanic males
A
A. 10 to 34 year old African American males
5
Q
Trauma Center
A
- hospitals specially equipped to provide comprehensive emergency care to patients suffering from a traumatic injury
- to be designated as a trauma center, certain criteria must be met
- designated as level I, II, III, or IV
- life support equipment, blood and blood products, and diagnostic tools need to be maintained in the highest state of readiness so that they are available when the patient arrives
6
Q
How did Trauma Centers come into existence?
A
from the realization that traumatic injury is a disease process requiring specialized multidisciplinary treatment and resources
7
Q
How to be considered a designated Trauma center?
A
- must meet certain criteria
- hospital must maintain a specialty trained workforce that is prepared to provide a range of emergency care 24/7 and must also ensure access to the equipment that is needed to provide immediate lifesaving care to critically injured patients
8
Q
Higher Level Trauma Centers
A
- have trauma surgeons and other specialists, such as neurosurgeons and orthopedic surgeons
- highly sophisticated medical diagnostic equipment
9
Q
Lower Level Trauma Centers
A
may be able to provide only initial care and stabilization and arrange for transfer of the injured patient to a higher level of care
10
Q
What does the hospital have to do to maintain trauma center designation?
A
-must ensure all staff members receive ongoing education in trauma and maintain their competency is trauma care
11
Q
Level I Trauma Center
A
- Regional resource hospital that is central to the trauma care system
- Provides total care for every aspect of injury from prevention through rehabilitation
- Maintains resources and personnel for patient care, education, and research
- Meets minimum requirement for volume of trauma patients
12
Q
Level II Trauma Center
A
- Provides comprehensive trauma care, regardless of the severity of injury
- Might be most prevalent facility in a community and manages majority of trauma patients or supplements the activity of a level I trauma center
- Can be an academic institution or a public or private community facility located in an urban, suburban, or rural area
- Where no level I TC exists, is responsible for education and system leadership
13
Q
Level III Trauma Center
A
- Provides prompt assessment, resuscitation, emergency surgery, and stabilization and arranges transfer to a higher level facility when necessary
- Maintains continuous general survey coverage
- Has transfer agreements and standardization treatment protocols to plan for care of injured patients
- Provides back-up care for rural and/or community hospitals
14
Q
Level IV Trauma Center
A
- Rural facility that supplements care within the larger trauma system
- Provides initial evaluation and assessment of injured patients
- Must have 24-hour emergency coverage by a provider
- Has transfer agreements and a good working relationship with the nearest level I, II, or III TC
15
Q
Golden Hour/Golden Period
A
- the critical time between when an injury occurs, and definitive care is initiated
- during this period, if bleeding is uncontrolled and there is inadequate tissue perfusion, damage occurs throughout the entire body
- if bleeding and tissue oxygenation are not quickly controlled, chances of survival drop
- this period varies; may be much less than an hour for some patients, while others have more time
16
Q
What are the priorities of Prehospital Care?
A
- Stabilization
- Transport
17
Q
What is the Systematic Method to rapidly assess patients presenting with traumatic injury?
A
ABCDs
>Airway, Breathing, Circulation, and Disability
18
Q
Airway
A
- airway must be checked to make sure it is open and clear while maintaining C-spine stabilization
- if a patient is able to vocalize, there is likely a stable airway
- gasping, gurgling, or no respirations at all; compromised airway in need of emergent definitive management
19
Q
Breathing
A
- Ventilation and oxygenation
- assessed by auscultating for breath sounds in both lung fields
- checking O2 saturation via pulse oximetry
- all patients must be placed on O2
- for patients who are not breathing on their own, prehospital provider must start assisting ventilation with a bag-valve mask device with supplemental O2
20
Q
Circulation
A
- checking perfusion
- assessing for hemorrhage and circulatory system compromise or failure
- palpating pulses and measuring blood pressure can determine adequacy of circulation
- HR, skin color, capillary refill, and any obvious signs of bleeding (internal or external)
- management of circulatory compromise includes hemorrhage control
- direct pressure is most effective way of stopping external hemorrhage
- may also need IV insertion to provide IV fluids while in transport
21
Q
Disability
A
- neurological function
- goal is to determine level of consciousness (LOC)
- Glasgow Coma Scale (GCS)
22
Q
C-spine Stabilization
A
- when a patient is in a supine position with the spine in neural alignment (no rotation or bending of the spine)
- protects the patient from spinal cord damage and minimizes further damage
23
Q
Prehospital Care: Transport
A
if life-threatening conditions are identified, the patient should receive necessary emergency care, be rapidly “packaged” (process of preparing a patient for transport), and transported to the nearest appropriate trauma facility
-recommended to notify the receiving hospital in advance so that the trauma team can assemble before patient arrival
24
Q
Important Factors to be considered in determining appropriate transportation type and destination
A
- mechanism of injury
- transportation time to the medical facility
- if transportation by ground is too long, air transportation
- if no air transportation or close trauma facility, patient taken to the closets facility for stabilization then transported to a trauma center
- others: age, pregnancy > 20 weeks, and bleeding disorders
- if in doubt, EMS can consult the trauma center and closest facility to obtain guidance on the best initial treatment location of the patient
25
Connection Check: The nurse understands priority prehospital interventions include which of the following?
A. Transporting the patient as quickly as possible to the nearest trauma center
B. Treating all injuries found and then transporting the patient
C. Notify the local hospital of the transport of a trauma patient and transporting the patient quickly
D. Assessing the patient using ABCs, treating life-threatening conditions, then transport to the hospital
D. Assessing the patient using ABCs, treating life-threatening conditions, the transport to the hospital
>always stabilize first (ABCs)
26
Hospital Care
- Hospital personnel
- Triage
- Trauma Assessment
- Interventions
27
Once the patient has arrived to the trauma center, the aim of the trauma team is what?
- provide safe and efficient evaluation and treatment
- team must identify all injuries and initiate definitive management of such injuries in an expedient manner
- the staff at trauma centers are specially trained to function smoothly in the most challenging and chaotic circumstances
28
Trauma Team
- Trauma team leader
- Airway provider
- Surgical provider
- Nurses
- Respiratory therapy
- Radiologist
- Clinical technician (highly trained nursing assistant or EMT)
- Social work and/or Pastoral care
- Ancillary support staff
29
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Connection Check: The nurse caring for a trauma patient understands which team member will establish priorities for the patient's care and authorize the interventions and procedures?
A. Trauma surgeon
B. Trauma team leader
C. Anesthesiologist
D. Radiologist
```
B. Trauma Team Leader
30
Role: Trauma Team Leader
- does not physically touch the patient
- orchestrates the care of the patient through delegation and supervision of the other providers and staff in the room
- establishes priorities for the patient's care
- authorizes interventions based on the assessment of the patient and all diagnostic results
- must be clear and in control of the situation; the captain of the team
- the trauma room should be quiet so that all members of the team can heat the voice of the team leader
31
Role: The airway, surgical, and ED providers
- responsible for establishing and maintaining an airway, ordering medications, and performing surgical procedures at the direction of the team leader
- primary survey
- some overlap in roles is necessary between the general surgeons and ED providers to ensure that tasks continue simultaneously, and no time is lost
32
Role: The airway, surgical, and ED providers
- responsible for establishing and maintaining an airway, ordering medications, and performing surgical procedures at the direction of the team leader
- primary survey
- some overlap in roles is necessary between the general surgeons and ED providers to ensure that tasks continue simultaneously, and no time is lost
33
Primary Survey
- the first quick assessment and initial management of life-threatening injuries
- performed by airway, surgical, or ED provider
34
Role: Nurses
- administration of all medications and IV fluids
- set up of equipment for wound management and surgical procedures
- a nurse can serve as a scribe; responsible for full documentation of trauma assessment and care
- after stabilization, provide updates to the family
35
Rapid Fluid Volume Infuser
- used to administer blood or boluses of fluid to the injured patient who has lost large volumes of blood
- when in use, nurse is dedicated to its management, ensuring empty fluid bags are replaced as necessary and fluid intake is closely monitored
36
Nurses role as a scribe
- responsible for full documentation of the trauma assessment and care
- records must include: the details of the patients care, such as time of arrival, personnel present at call, physical findings, and fluids and drugs administered
37
Role: Clinical technicians, EMTs, or Paramedics
delegated duties within their scope of practice: establishing IV access, performing chest compressions during CPR, preparing equipment, obtaining vital signs, and placing patient on cardiac monitor
38
Role: Clinical Pharmacists
-provide expert support in the pharmacological management of the patient
39
Role: Radiologist
-evaluates the many x-rays and scans typically performed in the trauma assessment
40
Role: Social Workers and ED case management
serve as liaisons with the families who are often in need of support as their loved one is cared for by the team
41
Role: Ancillary Staff
- retrieve equipment and supplies
| - run blood samples to the lab
42
Triage
- the sorting of patients based on their need for treatment and the resources available to provide that treatment
- triage nurse must quickly identify patients who need to be seen immediately and those who can safely wait for treatment; based on quick assessment (vital signs)
- Triage and acuity level is based on ABCs
43
Trauma Assessment
- primary and secondary survey
- performed on all trauma patients even if they do not appear to be seriously injured
- obtain subjective information about major injuries and mechanism of injury from the prehospital providers, patient, or family members
- more detailed report in secondary survey
44
Primary Survey
- begins immediately on the patient's arrival to the hospital
- helps identify life-threatening conditions and simultaneously institute management of these conditions
- follows the ABCDs, in addition to E (exposure/environment)
- Exposure ("E") means to completely undress the patient so that obvious and potential injuries, both front and back, can be quickly identified
- Exposure includes measure to prevent hypothermia
- Glasgow Coma Scale when assessing disability
- Pupils should also be assessed for size, shape, equality, and reaction to light
45
Glasgow Coma Scale
- provides a quick assessment of neurological abilities and disabilities
- best score = 15 (no deficits or injuries)
- lowest score = 3 (nonresponsive or is intubated and heavily sedated)
46
Secondary Survey
- performed after the primary survey is complete and lifesaving interventions have been initiated
- identifies the other injuries that the primary survey did not assess along with pertinent information about the patient such as comorbidities
- pain should be assessed
- at the start of the secondary survey, vital signs taken again; if abnormal, need to return to the primary survey and reassess; if normal, head-to-toe assessment
- trauma team gathers critical information about the event from the patient, prehospital providers, witnesses, and family
47
Priority Interventions
>ABCDs + E
- Airway
- Breathing
- Circulation
- Disability
- Exposure/Environment
48
Priority Interventions for Airway
(A) open airway
(B) provide oxygen
(C) prepare for an advanced airway
-if the airway is not patent, open and clear the airway using the jaw thrust maneuver and suction; can also use chin-lift maneuver
-if patients tongue has fallen backward and obstructed the airway, both maneuvers allow the airway to become unobstructed; jaw thrust always used for spinal cord injury
-care must be taken to not hyperextend the neck w/ either maneuver
-an oropharyngeal or nasopharyngeal airway can be placed; at this stage, preparations for endotracheal intubation or a surgical airway, cricothyroidotomy, should be implemented
49
Safety Alert: Assessing airway in a trauma patient
- there is always a high index of suspicion for C-spine injury after trauma
- maintain C-spine precautions
- use the jaw thrust maneuver when assessing airway and breathing when when placing a definitive airway
50
Priority Interventions for Breathing
(A) providing oxygen
(B) diagnosing and treating life-threatening breathing injuries
-all trauma patients should receive O2 via face mask and placed on pulse oximetry to measure oxygenation changes
-chest x-rays should be done to check for life-threatening chest injuries
-laboratory studies (ABGs)
51
A patient in respiratory distress, hemodynamic instability and/or decreased breath sounds on the injured side should raise the suspicion for what?
Pneumothorax; should be confirmed by chest x-ray (CXR), treated w/ chest tube
52
Pneumothorax
- occurs when air enters the pleural space partially collapsing the lung
- if evolves quickly or untreated, can lead to tension pneumothorax
53
Tension Pneumothorax
- caused when the air entering the pleural space cannot escape on expiration, increasing intrathoracic pressure
- results in fully collapsed lung and a mediastinal shift that compresses the heart, trachea, great vessels, and uninjured lung
- may need a needle thoracostomy (needle decompression); insertion of a needle into the pleural space on the side of the pneumothorax
- needle thoracostomy: allows that air that has accumulated in the pleural space to escape; this is followed by chest tube placement and confirmed by CXR
54
Priority Interventions for Circulation
(A) IV access
(B) Fluid resuscitation
-needs one or two large-bore (18-gauge or larger) IV catheters to allow for fluid and medication administration
-if venous access difficult; prepared for central line
-intraosseous catheter (catheter placed into the marrow cavity of a bone), is an option for fluid or medication administration when peripheral blood vessels are inaccessible
-last resort, surgical cutdown; emergency procedure that surgically exposes a vein allowing placement of an IV catheter under direct visualization of the vessel
55
Fluid Resuscitation
- dictated by patient's condition
- starts with the judicious infusion use of warmed isotonic crystalloid solution
- blood products are indicated if there is excessive bleeding
- if severely hypotensive or has suffered extensive blood loss, fluids may be placed in pressure bags or administered through a rapid infusion device that can infuse about 1000 mL of warmed fluid/min
56
Priority Interventions for Disability
- maintaining spinal immobilization
- if during primary survey the patient is found to have a decreased LOC; further investigation in the secondary survey including a detailed neurological evaluation and imaging of the brain and spinal cord
57
Priority Interventions for Exposure/Environment
- control the environment to prevent hypothermia
| - warming blankets, warmed fluids, and continual temperature monitoring helps prevent the trauma triad of death
58
Trauma Triad of Death
-term describing the lethal combination of hypothermia, metabolic acidosis, and coagulopathy (bleeding)
59
Secondary Survey Interventions
- further laboratory, radiographical, ultrasound, and other diagnostic tests
- focused assessment with sonography for trauma (FAST) tool
- insertion of Foley catheter to monitor urine output and renal function
- insertion of a gastric tube to empty stomach and prevent aspiration
- NG tubes not used in facial trauma
- once secondary survey is completed, definitive interventions are performed, or initial surgical stabilization is performed if the patient is too ill to tolerate definitive procedures
60
Focused Assessment with Sonography for Trauma (FAST) tool
- diagnostic tool
- ultrasound that looks for free fluid in the abdominal cavity, pericardium, or pelvis
- if positive = presence of blood
- positive = emergency surgery to find the source of bleeding and repair the injury
61
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Connection Check: The nurse understands the purpose of damage control surgery is which of the following? Select all that apply
A. Control hemorrhage
B. Prevent renal failure
C. Prevent contamination
D. Avoid further surgery
E. Control hypoxia
```
A. Control Hemorrhage
| C. Prevent Contamination
62
Mechanism of Injury
- transference of energy from an external force to the body of the patient
- blunt or penetrating
63
Blunt Trauma
- when the energy transference does not cause disruption to the skin making these injuries more difficult to see
- mechanisms of energy transference that cause blunt trauma injuries are: deceleration, acceleration, compression, and shearing
64
Mechanism of injury: Deceleration
when the body has been moving and comes to an abrupt stop
| -ex: motor vehicle traveling at 50 mph that hits a brick wall, causing the vehicle to come to a sudden stop
65
Mechanism of injury: Acceleration
- sudden increase in speed
- often followed by deceleration
- ex: a pedestrian standing at the side of the road who is hit by a moving vehicle, causing the pedestrian to be thrown 20 feet
- deceleration forces are applied when the pedestrian hits the ground
66
Mechanism of injury: Compression
-organs or tissues compressed between two immovable surfaces such as bones or a steering wheel
67
Mechanism of Injury: Shearing
-occurs when skin or tissue slides in opposite but parallel directions
68
Blunt Abdominal Trauma
- abdominal organs are more vulnerable to injury than those in the thorax b/c of the lack of protection from the sternum and ribcage
- results from compression, shearing, and acceleration/deceleration
- may be associated with damage to the viscera (internal organs), which can result in massive blood loss or the spilling of intestinal contents in the peritoneal space, and peritonitis
69
Solid Abdominal Organs
>dense masses of very vascular tissue
- Liver (RUQ)
- Spleen (LUQ)
- Kidneys
- Pancreas (LUQ)
- Adrenal Glands
- Ovaries
70
Hollow Abdominal Organs
>less dense b/c of presence of a cavity that is filled with air or digestive matter
- Bladder
- Large Intestines
- Small intestines
- Stomach
- Uterus
71
Penetrating Trauma
- injuries produced by a foreign object penetrating the tissue
- knives, guns, or ice picks most common cause
- anything that penetrates the skin, such as glass from a broken windshield, can be a cause of trauma
- low-energy, medium-energy, or high-energy
- the energy created by the foreign object dissipates into the surrounding tissues, causing injury
- extent of the damage is affected by: character of the wounding object, its velocity, and the characteristics of the tissues that it passes through
- the injury one sees on the skin may be minor compared to the significant injury beneath the surface
72
Velocity
the speed of the traveling object
73
Profile
describes the initial size of the projectile and changes, if any, at the time of impact
74
Connection Check: A 30-year-old female driver who was in a front-end, high-speed MVC is admitted to the ED. She had a seat belt on, but the car did not have any airbags. There was severe front-end damage with spidering of the windshield in front of the drivers seat and a bent steering wheel. The nurse caring for this patient should anticipate and monitor for which injuries?
A. Sternal/rib, T-spine, pelvic fracture injuries
B. Head, cervical-spine (C-spine), sternal/rib, cardiac contusion, hollow abdominal organ injuries
C. Head, C-spine, solid abdominal organ injuries
D. Sternal/rib, collarbone fracture, pelvic fracture, facial fracture injuries
B. Head, cervical spine (C-spine), sternal/rub, cardiac contusion, hollow abdominal organs
75
Tumble of a bullet
-when the bullet assumes a different angle once inside the body
76
Yaw
"wobble of bullet"
- deviation of the tip of the bullet from the straight axis of flight as it comes out of the barrel
- it should come out going straight but spinning
77
Fragmentation of Bullet
-when the missile/bullet breaks up to produce multiple parts which causes more drag and energy exchange
78
Complications of Trauma
- Hemorrhage
- Airway Compromise
- Sepsis
79
Complications: Hemorrhage
- causes: abdominal or chest trauma injuring organs or vessels
- major sources of abdominal bleeding in blunt trauma are injuries to the liver or spleen; both organs are very vascular and prone to shearing and laceration
- chest damage resulting in a massive hemothorax causes blood loss and tension pneumothorax d/t airway compression
- can also result from fractures
80
Complications: Airway Compromise
- can occur b/c of direct damage to the airway, injury to the surrounding tissue, or secondary issues such as decreased LOC
- may require insertion of an artificial airway
- trauma to surrounding tissue such as facial and neck trauma that result in excessive bleeding or swelling may also result in airway compromise requiring intubation to maintain patent airway
- decreased LOC, administration of a sedative or pain medication, hypovolemia, or hypoxemia may result in the patient's inability to protect his/her airway or in an ineffective breathing pattern, requiring intubation
- other causes: rib fractures and flat supine patient positioning; both increase work of breathing
81
Complications: Sepsis
- the injuries themselves and the invasive interventions necessary to treat the injuries put the patient at risk for infection
- trauma itself is one of the causes of the initiation of systemic inflammatory response
82
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Connection Check: The trauma nurse anticipates which of the following complications when treating an intoxicated homeless patient after he was hit by a car in the snow? the patient is in C-spine immobilization, has an open femur fracture, a pelvic fracture, abdominal tenderness, and a GCS of 12. Select all that apply
A. Decreased hemoglobin and hematocrit
B. Decreased SpO2
C. Tension pneumothorax
D. Sepsis
E. Decreased PaCO2
```
A. Decreased hemoglobin and hematocrit
B. Decreased SpO2
D. Sepsis
83
Nursing Management: Assessment and Analysis
- clinical manifestations seen in a trauma patient are dictated by the mechanism of injury and area of the body impacted
- blunt trauma of the chest can result in compression, shearing, deceleration, or acceleration injuries
- penetrating trauma to the abdomen can result excessive bleeding especially when a very vascular organ such as the liver is impacted
84
Nursing Diagnoses
- impaired tissue perfusion
- ineffective breathing patterns
- impaired gas exchange
85
Nursing Assesment
- airway
- breathing
- circulation
- disability
- expose
86
Nursing Assessment
- airway
- breathing
- circulation
- disability
- expose
87
Assessment: Airway
assess for possible airway obstruction that would impair ventilation
88
Assessment: Breathing
assess for the ineffective breathing patterns that may indicate life-threatening injuries
89
Assessment: Circulation
assess pulses, heart rate, skin color, blood pressure, capillary refill, and any obvious signs of bleeding; internal or external that would indicate ineffective perfusion
90
Assessment: Disability
assess the GCS to determine the patients LOC and determine if further evaluation and treatment are necessary
91
Assessment: Expose/Environment
completely undress the patient so that obvious and potential injuries, both front and back, can be quickly identified
92
Nursing Actions
- Open airway using C-spine precautions
- Provide oxygen
- Prepare for an advanced airway
- Establish IV access; fluid and drug administration
- Fluid resuscitation as ordered w/ warmed fluids
- Monitor temperature; prevent hypothermia
- Provide warm blankets
93
Nursing Teachings
>Safe lifestyle skills
| -avoid high-risk behaviors and/or potential situations that may result in unintentional injuries
