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Trauma
· Trauma - caused by injury or external force
o 3 types
▪ Blunt
· Most common type
· When something hits the body. Ex. Car accidents, falls, beatings.
· Problem: Is you don’t always see the extent of the injury. Don’t know what’s going on under the surface.
· FAST Scan (Focused Assessment with Sonography for Trauma)
o Quick ultrasound of organs in the abdomen to determine any internal injuries
· Abdominal injury most commonly associated with blunt forced trauma.
▪ Penetrating
· Anything that penetrates the body. Ex. Gunshot, stabbing, anything that piercing the skin and is sticking out of you, ice picks. Less Common.
· 2 Problems:
o High infection risk. Especially with injuries to the abdomen.
o Did object hit any vital/internal organs?
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▪ Depending on what organ is hit it can leak into the body (i.e stomach/GI con- tents). We look at this when someone gets shot. Did it hit anything vital?
▪ Blasts
· 3 concerns
o What got blasted? What kind of shrapnel what is exploding? Anything that explodes.
o Injury to internal hollow organ from shockwaves. Depends on how close you are to the blast. What is blasted out of the bomb maybe a chemical or object ex: screws
o First concern : Whatever is being blasted out, chemicals from the bomb. Second con- cern: Trauma to our hollow internal organs from the shock waves. Final Concern: Sec- ondary injuries related to how close you were to the blast. Ex: Could be thrown a distance injuring spinal cord.
o Secondary (tertiary) injuries (Blunt, head, spinal cord, burns, bleeding)
Triage
· Means to sort – based on the need of each patient.
· Any time you have multiple people in a large trauma. We triage patients by color.
· Color coding system
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o One to two minute evaluation tool in which we assess establish priorities and treat at the very same time.
o Airway comes first always EXCEPT when patient was a spinal cord injury toy would FIRST stabilize spine before airway if suspected spinal injury.
o Drug and alcohols effect on the trauma
▪ Treatment, causes of trauma, withdrawals.
▪ If you make it to secondary survey and your patient starts to be unstable what do you do? START OVER, go back to A
Primary Survey:
Survey Rationale Abnormal Assessment Findings
Treatment/Actions
A=Airway – is our pa- tient airways intact if so move on to B, if not per- form an intervention.
Assess airway patency
Obstructions can occur due to edema, posterior dis- placement of the tongue, in- ability to protect airway due to neurological impairment or high level spinal cord in- jury, vomit, blood or a for-
Shallow, noisy breathing, stridor , central cyanosis, nasal flaring, accessory mus- cle use, anxiety, inability to speak or swallow, drooling, decreased level of con- sciousness , facial/head
First: Opening the airway with a head- tilt-chin-lift or jaw-thrust maneuver Insertion of an oral or nasal airway Endotracheal intubation Tracheostomy of crycoidthyrotomy
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eign object trauma Airway always comes first EXCEPT read above!!
B=Breathing
Assess for breathing ef- fectiveness
Breathing problems can oc- cur due to altered mental status, tension pneumotho- rax, pneumothorax (open or closed), hemothorax, pul- monary contusion, flail chest and spinal cord injury
Asymmetrical chest expan- sion, absent, decreased or unequal breath sounds, chest wounds, accessory muscle use, anxiety, tracheal shift, decreased level of con- sciousness, tracheal devia- tion, cyanosis, increased resp rate,
If patient has trouble breathing give them oxygen or give them a ventilator. You also need to think about the lung them. Some- times you might place: (Listed Below) Needle decompression, chest tube inser- tion, early intubation and mechanical ven- tilation, cervical spine stabilization
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E= Expose Patient and Warm the Patient
Environmental Control (Warm environment and prevention of hypother- mia)
Remove the patient’s clothing to assess for in- juries
Due to traumatic injuries Exposure the cold environ- ment, wet, Hypothermic – risk for dys- rhythmias and coagu- lopathies.
Soft tissue injuries such as edema, deformities, crepitus, ecchymosis
Remove clothing and assess for injuries, provide warming measures, look for any. Hypothermia is dangerous in trauma pa- tients because it can lead to decreased blood clotting. Assess for specific organ injuries such as cardiac tamponade, car- diac contusions, aortic disruption, tension pneumothorax, hemothorax, rib fractures and flail chest, abdominal injuries, mus- culoskeletal injuries,
Rewarm the patient with warm blankets, warm lights, warm IV fluids
Warm fluids, heating lamps, warm blan- kets, bear huggers, warm room. Coldness due to loss of blood of exposure to outside elements, brain injury, exposure to water – lakes, rivers, or pools, room temp being too cold, fluids are cold can be cold due to this. We want to warm our patients because they will have clotting problems, will take longer to clot espe- cially if you come in with a bleed, patient can develop dysthymia when they are cold.
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Secondary Survey -^ by the time you hit F you should have your pa-tient stabilized.
F= Full set of vital signs, Focused Interventions, Family Presence
Vital signs alterations de- pend on the injuries that oc- curred
Assess for a complete set of vital signs
Actions in this portion of the survey in- clude insertion of a urinary catheter un- less bladder trauma has occurred, insert a nasogastric tube, obtain laboratory stud- ies, connect to a cardiac monitor, identify family and provide updates. Always have a right to ask family to leave
G= Give comfort mea- sures
Trauma is both physically and emotionally painful
Pain, Anxiety, Grief, Fear, nonpharmacological Ex: someone from pastoral care sitting with patient.
Provide emotional reassurance, adminis- ter narcotics/antianxiety as needed, pro- vide therapeutic touch, family present, pastoral care.
H= History
Obtain a complete history and physical as long as the patient is stable. Head to toe Assessment.
Need to determine the cause to determine possible in- juries
Evidence of abnormal find- ings from injuries
Perform a head to toe assessment, obtain a history of the events as well as the pa- tient’s past medical history
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only done by doctor
Open Chest Wound Severe respiratory distress, chest pain, hypotension, tachycardia, ab- sent breath sounds
Seal the wound with an occlusive dressing and tape on three sides (So air can get back, if you tape on all 4 sides patient can get a tension pneu- mothorax. Prepare for chest tube insertion.
Massive Hemothorax – blood in the lung cavity
Decreased breath sounds, dullness to percussion on the affected side, hy- potension, and respiratory distress
Prepare for blood transfusions, type and crossmatch, IV insertion, prepare for chest tube insertion
Pulmonary Contusion – bruise in lung. That part of the lung will not be able to participate in gas ex- change and that part of the lung that becomes bruised will become stiff. High risk then for developing ARDS.
Chest wall abrasions, ecchymosis, bloody secretions, decreased PaO 2 , bruise of the lung. Bruised part will not participate in gas exchange, lung becomes stiff leading to ARDS.
Prepare for early intubation and mechanical ventila- tion early. -
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Flail Chest Cardinal sign: Paradoxical chest movement/Respirations. where the chest wall decreases in size with in- spiration and increases in size with expiration. Fracture of 2- 3 consec- utive rib
Prepare for early intubation and mechanical venti- lation, avoid hyperextension or rotation of the neck, administer analgesics as prescribed (lots and lots) , pulmonary hygiene. For proper gas exchange and lots and lots of meds.
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Aortic Disruption also known as aortic dissection. If a patient has that and lives they need surgery.
Weak femoral pulses, dysphagia, hoarseness, dyspnea and pain. Chest X-ray will demonstrate a wide medi- astinum, tracheal deviation, rib frac- tures Aortic dissection – tear in wall of artery creating a false lumen, weaken- ing of arterial wall. No manifestations until rupture.
Prepare the patient for the OR for repair of the aorta
Gastric and bowel injuries Abdominal^ pain,^ rigid^ abdomen, absent bowel sounds or decreased. Bowel has high infection rate.
Surgical intervention.
Liver Injuries Right upper quadrant pain, ecchymo- sis, hypotension, rigid abdomen, can cause hemorrhage. Will complain of abdominal pain.
Minor injuries are treated conservatively by monitor- ing H&H and bed rest for five days, major injuries or hemodynamically unstable require surgical repair, flu- ids also given. Liver injury can cause hemorrhage. Only will do surgery if injury was severe.
Injuries to the Spleen Left upper quadrant pain, peritoneal ir- ritation, referred left shoulder pain (Kehr’s sign) but problem in the spleen. Will complain of abdominal pain.
Same as liver injuries. In addition patients may re- quire immunizations. Every effort is made to save the spleen. Only will do surgery if injury was severe.
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Renal trauma Costavertebral^ tenderness, microscopic or gross hematuria, bruising and ecchy- mosis Associated with blunt trauma.
For minor injuries bed rest, hydration and monitoring of renal function Major injuries may require surgical interventions such as surgeries to control bleeding, repair the injury or nephrectomy
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people who over use their mushcles., elevated BUN and creatinine), fat embolism syn- drome (signs and symptoms are similar to ARDS) and for DVT,
· Alcohol and Drugs can be a cause of Trauma. A nurse needs to know any ingestion due to possible withdrawal – this can af- fect healing process.
· Trauma high risk for infection or sespsis.
Palliative Care and End of life
· Important things for patients to have
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o Advanced directives
o Power of Attorney, 95% of decisions in ICU made by surrogates.
o 95% decisions are made by surrogates not actually themselves that is why it is important to have Will’s and Power or Attorney, You need to know what the patient wants and who will appoint care.
Dimension Definition
Palliative Care Interventions to relieve symptoms of illness or injury that will negatively affect pa- tient. Symptoms include pain, anxiety, hunger, thirst, dyspnea, diarrhea, nausea, confusion agitation and sleep disturbances. Often includes basic nursing interven- tions such as repositioning, hygiene, skincare and creation of a peaceful environ-
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Hemodynamics
· Used to assess:
o Patients tissue profusion
· Cardiac output
o Stroke Volume x HR
o Normal output 4-8L/min
o How much blood is ejected from the heart in one minute.
· Cardiac Index
o Cardiac Output divided by Body Surface Area
o Better estimate of profusion in relation to a person’s size (size is important)
o 2-4L/min
o Ex: Shaq cardiac output is 6 and so is Danny Devito, but they are both different sizes.
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· HR
o Too quick (tachy) ventricles do not have enough time to fill
▪ Need to slow down the heart (cardioversion, cadizem, adenosine)
o Too slow (brady) not enough blood is being pumped to the body
▪ Speed the heart up (pacemaker, epi, dopamine, atropine)
Components of Cardiac Output
· Increases in heart rate affect cardiac output. If heart is too slow affects heart rate output.
· Cardiac output will be affected by 4 specific things:
· Preload (Volume)
o Amount of blood in your ventricles at the end of diastole. Blood in your heart before it contracts
o Frank-starling:
▪ Greater the volume, the greater the stretch on the hear/ventricles (normal physiological stretch), the greater/stronger the contraction
▪ The amount of volume, which the heart can handle, is only good.
▪ Overly stretched is not good! (CHF, cardiomegaly, HTN). We get more volume in heart, but the heart beats less effective.
o Increased Preload
