When Bad Things Happen When Bad Things Happen To Good Patients: To Good Patients:
Managing The Managing The Complications of TraumaComplications of Trauma
Janice Delgiorno MSN, CCRN, ACNP-BCJanice Delgiorno MSN, CCRN, ACNP-BCAcute Care Nurse PractitionerAcute Care Nurse Practitioner
Department of SurgeryDepartment of SurgeryDivision of Trauma and Surgical Critical Division of Trauma and Surgical Critical
CareCareCooper University Medical CenterCooper University Medical Center
Cooper TraumaCooper Trauma
Typical Trauma PatientTypical Trauma Patient 37 Y/O male37 Y/O male ETOHETOH Intubated, L SC TLC, NGT, FlexisealIntubated, L SC TLC, NGT, Flexiseal Grade II Liver, Grade III SpleenGrade II Liver, Grade III Spleen L Traumatic AKAL Traumatic AKA R Grade 3-4 C Open Tibia fx with R Grade 3-4 C Open Tibia fx with
external fixatorexternal fixator OR Q Other Day for Wash outsOR Q Other Day for Wash outs
AirwayAirway Emergent Airways/ Loss of Emergent Airways/ Loss of
AirwayAirway Obstruction from loss of Obstruction from loss of
consciousness is the most consciousness is the most common causecommon cause
Facial FracturesFacial Fractures BurnsBurns Laryngeal FractureLaryngeal Fracture
Laryngeal FractureLaryngeal Fracture
CricothyroidotomyCricothyroidotomy
Inappropriate NGTInappropriate NGT Raccoon eyes Raccoon eyes
suggest basilar suggest basilar skull fractureskull fracture
NGT placedNGT placed Could go through Could go through
cribiform plate!!cribiform plate!!
RespiratoryRespiratory ARDSARDS Pneumonia/ VAPPneumonia/ VAP AtelectasisAtelectasis Respiratory FailureRespiratory Failure Iatrogenic PneumothoraxIatrogenic Pneumothorax EmpyemaEmpyema
EmpyemaEmpyema Collection of pus in Collection of pus in
pleural spacepleural space Caused by infection in Caused by infection in
the lung the lung Fluid builds up to a Fluid builds up to a
pint or more and puts pint or more and puts pressure on the lungpressure on the lung
Causes SOB and painCauses SOB and pain TX: thoracentesisTX: thoracentesis
Iatrogenic PneumothoraxIatrogenic Pneumothorax Air in the pleural Air in the pleural
spacespace Caused by: Trans-Caused by: Trans-
thoracic needle thoracic needle aspiration procedures aspiration procedures (37%), central line (37%), central line insertion, mechanical insertion, mechanical ventilation, ventilation, thoracentesisthoracentesis
Can cause substantial Can cause substantial morbidity: rarely morbidity: rarely deathdeath
ARDSARDS
ARDSARDS Causes: Injury (inhalation, Causes: Injury (inhalation,
trauma), or as a result of MODStrauma), or as a result of MODS Causes lung swelling and fluid Causes lung swelling and fluid
build up in the alveolibuild up in the alveoli Lungs become “stiff” and unable Lungs become “stiff” and unable
to ventilateto ventilate Fluid build up inhibits oxygen Fluid build up inhibits oxygen
passing into the bloodstreampassing into the bloodstream Mechanical ventilation with PEEP, Mechanical ventilation with PEEP,
diureticsdiuretics
Respiratory InfectionRespiratory Infection Primary loss of defense when Primary loss of defense when
patient is intubatedpatient is intubated Flail Chest, rib fractures, surgical Flail Chest, rib fractures, surgical
incisions…can’t cough and deep incisions…can’t cough and deep breathebreathe
Aspiration : Streptococcus most Aspiration : Streptococcus most commoncommon
Respiratory InfectionRespiratory Infection NG tubes and Nasal-tracheal NG tubes and Nasal-tracheal
tubes can obstruct the drainage tubes can obstruct the drainage of the sinuses and result in of the sinuses and result in nosocomial sinusitisnosocomial sinusitis
Can obstruct eustachian tubes Can obstruct eustachian tubes and cause otitis mediaand cause otitis media
Chest tubes have been shown to Chest tubes have been shown to be a factor in developing be a factor in developing nosocomial empyemanosocomial empyema
VAPVAP ETT/ Trach provide a direct route ETT/ Trach provide a direct route
to the lungs for bacteriato the lungs for bacteria Gram negative bacilli and Staph Gram negative bacilli and Staph
aureus are the most common aureus are the most common bacteriabacteria
Compartment SyndromeCompartment Syndrome ChestChest AbdomenAbdomen ExtremitiesExtremities
Compartment SyndromeCompartment Syndrome
Compartment SyndromeCompartment Syndrome Can affect any body compartmentCan affect any body compartment Most commonly affected are the Most commonly affected are the
lower leg and forearmlower leg and forearm Body has 46 compartments, 36 are Body has 46 compartments, 36 are
found in the extremitiesfound in the extremities Closed spaces containing muscles, Closed spaces containing muscles,
nerves, vascular structures nerves, vascular structures enclosed within bone or fasciaenclosed within bone or fascia
Can result from internal or external Can result from internal or external forces increasing compartment forces increasing compartment pressurespressures
Abdominal Compartment Abdominal Compartment SyndromeSyndrome
Secondary to resuscitation edema, Secondary to resuscitation edema, ileus, bowel obstruction, post op ileus, bowel obstruction, post op hemorrhage or abdominal packinghemorrhage or abdominal packing
Increased abdominal pressure Increased abdominal pressure affects ventilation, urinary output, affects ventilation, urinary output, and the CV system (hypotension, and the CV system (hypotension, decrease CO)decrease CO)
Normal IAP is 0 IAP >20 produces Normal IAP is 0 IAP >20 produces adverse physiologic effectsadverse physiologic effects
Abdominal Compartment Abdominal Compartment SyndromeSyndrome
Compartment SyndromeCompartment Syndrome
Compartment SyndromeCompartment Syndrome Any injury to an extremity has the Any injury to an extremity has the
potential to cause a compartment potential to cause a compartment sydromesydrome
Tibial and forearm fracturesTibial and forearm fractures Severe crush injury to muscleSevere crush injury to muscle Localized, prolonged external pressure Localized, prolonged external pressure
to an extremityto an extremity Increased capillary permeability Increased capillary permeability
secondary to ischemic musclesecondary to ischemic muscle BurnsBurns Excessive exerciseExcessive exercise
Compartment Sydrome: Compartment Sydrome: 6 P’s6 P’s
PainPain ParasthesiaParasthesia PallorPallor ParalysisParalysis Pulse loss (late sign)Pulse loss (late sign) Tissue Pressures >35 to 45 Tissue Pressures >35 to 45
mmHgmmHg
ManagementManagement All constricting dressings, casts, and All constricting dressings, casts, and
splints applied over the affected splints applied over the affected extremity must be releasedextremity must be released
Patient must be carefully monitored Patient must be carefully monitored for the next 30-60minfor the next 30-60min
Anticipate OR for muscle compartment Anticipate OR for muscle compartment pressures greater than 35-45mm Hgpressures greater than 35-45mm Hg
FasciotomyFasciotomy
Compartment SyndromeCompartment Syndrome
Compartment SyndromeCompartment Syndrome
Compartment SyndromeCompartment Syndrome
Compartment SyndromeCompartment Syndrome
RhabdomylosisRhabdomylosis From crush injuries, electrical From crush injuries, electrical
shock, severe burns, excessive shock, severe burns, excessive muscle use, drugs (ethanol, muscle use, drugs (ethanol, cocaine, ecstacy, snake venom, cocaine, ecstacy, snake venom, tetanus)tetanus)
Damaged muscle cells release Damaged muscle cells release potassium and Phosphorus potassium and Phosphorus
High myoglobin levels in the urineHigh myoglobin levels in the urine CK climbs to > 5x normal CK climbs to > 5x normal
RhabdomyolysisRhabdomyolysis Most common muscles involved Most common muscles involved
are the calves and lower backare the calves and lower back Signs/ Symptoms: Tachycardia, Signs/ Symptoms: Tachycardia,
pain, malaise, nausea/ vomiting, pain, malaise, nausea/ vomiting, and feverand fever
RhabdomyolysisRhabdomyolysis Aggressive IVF administration to Aggressive IVF administration to
“flush” kidneys“flush” kidneys NaHCO3, Insulin, and Glucose to NaHCO3, Insulin, and Glucose to
alkalinize urine and push alkalinize urine and push potassium back into cellspotassium back into cells
Maintain urine output by using Maintain urine output by using mannitol or lasixmannitol or lasix
CRRT if necessary CRRT if necessary
InfectionInfection SepsisSepsis SinusitisSinusitis OsteomylitisOsteomylitis Urinary Tract InfectionUrinary Tract Infection VAPVAP Skin/ Wound InfectionSkin/ Wound Infection
Infection…Infection… Trauma patients are a breeding Trauma patients are a breeding
ground…think of all the tubes…ground…think of all the tubes…tube in every orifice…tube in every orifice…
Sepsis, urinary tract infection, Sepsis, urinary tract infection, blood stream infection, wound/ blood stream infection, wound/ skin infection…skin infection…
Skeevy…Skeevy…
InfectionInfection Pathogens bypass the first line Pathogens bypass the first line
defense, when broken skin and defense, when broken skin and mucosal membranes are mucosal membranes are contaminated during injury and contaminated during injury and later by surgery and debridement later by surgery and debridement
Surgical Drains, external fixators, Surgical Drains, external fixators, IV catheters, ICP monitors, IV catheters, ICP monitors, urinary catheters, woundsurinary catheters, wounds
Nosocomial InfectionsNosocomial Infections
SIRSSIRS Caused by endogenous mediatorsCaused by endogenous mediators Overall inflammatory response Overall inflammatory response
that effects multiple organs with that effects multiple organs with or without infectionor without infection
SIRS can compromise the function SIRS can compromise the function of various organ systems of various organ systems resulting in MODSresulting in MODS
SIRS with a confirmed infection is SIRS with a confirmed infection is SepsisSepsis
SIRSSIRS 2 or more of the following:2 or more of the following: Fever >38 c or < 36 cFever >38 c or < 36 c HR >90HR >90 RR >20 or CO2 <32RR >20 or CO2 <32 WBC > 12K or < 4K or > 10% WBC > 12K or < 4K or > 10%
bandsbands
SepsisSepsis High Mortality Rates: 40% for High Mortality Rates: 40% for
uncomplicated sepsis…80% for uncomplicated sepsis…80% for cases of septic shock and MODScases of septic shock and MODS
Severe Sepsis: Sepsis with organ Severe Sepsis: Sepsis with organ hypoperfusionhypoperfusion
Septic Shock: Severe sepsis with Septic Shock: Severe sepsis with hypotension…requires fuids, hypotension…requires fuids, vasopressorsvasopressors
SepsisSepsis Early, Goal Directed TherapyEarly, Goal Directed Therapy OxygenateOxygenate Central Venous Oximetry monitor and A-Central Venous Oximetry monitor and A-
lineline CVP <8 Crystalloid, ColloidCVP <8 Crystalloid, Colloid MAP <65 or >90 Vasoactive agentsMAP <65 or >90 Vasoactive agents ScVO2 <70% Transfuse PRBC’s to Hct ScVO2 <70% Transfuse PRBC’s to Hct
>30>30 ScVO2 still <70% start DobutamineScVO2 still <70% start Dobutamine Antibiotics within one hourAntibiotics within one hour
SpleenSpleen
SpleenSpleen Filtration of aging or deformed Filtration of aging or deformed
blood cellsblood cells Antibody synthesisAntibody synthesis Promotion of phagocytosisPromotion of phagocytosis Asplenic patients have Asplenic patients have
significantly decreased levels of significantly decreased levels of IgM, lack the ability to swithch IgM, lack the ability to swithch from IgM to IgG antibody from IgM to IgG antibody productionproduction
SpleenSpleen The net effect is a decrease in The net effect is a decrease in
opsonizationopsonization Opsonization facilitates the Opsonization facilitates the
adherence of a phagocyte to a adherence of a phagocyte to a bacteriabacteria
Important for phagocytosis of Important for phagocytosis of encapsulated bacteria such as encapsulated bacteria such as pneumococci, salmonellae, pneumococci, salmonellae, haemophilus, meningococci and haemophilus, meningococci and staph aureusstaph aureus
Post Splenectomy SepsisPost Splenectomy Sepsis Well documented in children and Well documented in children and
becoming more common in adultsbecoming more common in adults Fulminant and usually fatalFulminant and usually fatal 1.4% of patients1.4% of patients Early antibiotics and hemodynamic Early antibiotics and hemodynamic
supportsupport Prevention is imperativePrevention is imperative Pneumococcal Vaccine Pneumococcal Vaccine
(Pneumovax) within 72hrs of (Pneumovax) within 72hrs of splenectomysplenectomy
Post Splenectomy Post Splenectomy InfectionInfection
Encapsulated bacteria: Encapsulated bacteria: S. S. pneumoniae, H. influenza, N. pneumoniae, H. influenza, N. meningitidismeningitidis
· · S. aureusS. aureus · Numerous gram negatives · Numerous gram negatives
including including E. coli, K. pneumoniae,E. coli, K. pneumoniae, Salmonella spSalmonella sp. and . and Capnotcytophagia spCapnotcytophagia sp. (the latter . (the latter usually acquired from a dog bite)usually acquired from a dog bite)
Post Splenectomy Post Splenectomy InfectionsInfections
· Malaria· Malaria · Babesia (acquired from ticks in · Babesia (acquired from ticks in
the Eastern seaboard particularly the Eastern seaboard particularly Cape Cod, Martha’s Vineyard, Cape Cod, Martha’s Vineyard, Nantucket, Block Island)Nantucket, Block Island)
VaccinationsVaccinations PneumococcalPneumococcal MeningococcalMeningococcal H Influenza H Influenza
As soon as possible after As soon as possible after splenectomysplenectomy
OsteomylitisOsteomylitis Lots of ortho injuries…almost Lots of ortho injuries…almost
80% of trauma patients have an 80% of trauma patients have an ortho injuryortho injury
Open fractures, fixators, Open fractures, fixators, procrastination of amputationprocrastination of amputation
OsteomyelitisOsteomyelitis Infection involving bone and marrowInfection involving bone and marrow Can occur weeks, months or years Can occur weeks, months or years
after injuryafter injury Infected hardware, overlying wound Infected hardware, overlying wound
infection, inadequate debridement infection, inadequate debridement of a hematoma at the time of injuryof a hematoma at the time of injury
Pain, erythema, heat, tenderness, Pain, erythema, heat, tenderness, drainage drainage
OsteomyelitisOsteomyelitis Remove infected hardwareRemove infected hardware Surgical debridementSurgical debridement IV antibiotics for a minimum of 4 IV antibiotics for a minimum of 4
weeksweeks
Deep Vein ThrombosisDeep Vein Thrombosis Approximately 630,000 pts develop DVT Approximately 630,000 pts develop DVT
annually resulting in 200,000 deathsannually resulting in 200,000 deaths In surgical patients over the age of 40 In surgical patients over the age of 40
DVT occurs in 16%-30% with PE DVT occurs in 16%-30% with PE episodes in 1.6% Fatal PE..1%episodes in 1.6% Fatal PE..1%
20% of young trauma patients develop 20% of young trauma patients develop DVTDVT
More than 40% of elderly trauma More than 40% of elderly trauma patients with hip fractures develop DVT patients with hip fractures develop DVT and 14% have a fatal PE episodeand 14% have a fatal PE episode
Deep Vein ThrombosisDeep Vein Thrombosis Head and Spinal Cord Patients Head and Spinal Cord Patients
40% and fatal PE of 5%40% and fatal PE of 5% Prevention is keyPrevention is key Pre disposing factors: Venous Pre disposing factors: Venous
stasis, vascular damage, hyper-stasis, vascular damage, hyper-coagulabilitycoagulability
Examples: Sepsis, bed rest, long Examples: Sepsis, bed rest, long bone or pelvic fractures, spinal bone or pelvic fractures, spinal cord injuries, obesity, age >40, cord injuries, obesity, age >40, previous DVT or PE, prolonged previous DVT or PE, prolonged use of MAST trousersuse of MAST trousers
Deep Vein ThrombosisDeep Vein Thrombosis Pneumatic Compression DevicePneumatic Compression Device TEDSTEDS Low Molecular Weight HeparinLow Molecular Weight Heparin Vena Cava FilterVena Cava Filter Doppler ScreeningDoppler Screening
Deep Vein ThrombosisDeep Vein Thrombosis ProphylaxisProphylaxis Sequential Compression DevicesSequential Compression Devices Low Molecular Weight HeparinLow Molecular Weight Heparin TEDSTEDS
Deep Vein ThrombosisDeep Vein Thrombosis Calf pain on forced dorsiflexion Calf pain on forced dorsiflexion
of foot (Homan’s sign)of foot (Homan’s sign) Subtle to obvious swelling of the Subtle to obvious swelling of the
involved areainvolved area TachycardiaTachycardia FeverFever Distal Skin color and temp. Distal Skin color and temp.
changeschanges
Deep Vein ThrombosisDeep Vein Thrombosis If a DVT is diagnosed:If a DVT is diagnosed: Bedrest to lower risk of clot Bedrest to lower risk of clot
dislodgmentdislodgment AnticoagulationAnticoagulation ThrombolysisThrombolysis Surgery may be necessary to Surgery may be necessary to
prevent PEprevent PE
DVT TreatmentDVT Treatment Anticoagulation if Possible: Anticoagulation if Possible:
Therapeutic Lovenox: 1mg/kgTherapeutic Lovenox: 1mg/kg Transition to CoumadinTransition to Coumadin 3 Months of treatment: Needs a 3 Months of treatment: Needs a
new ultrasound before new ultrasound before discontinuing anti-coagulationdiscontinuing anti-coagulation
Pulmonary EmbolusPulmonary Embolus Embolus lodges in a pulmonary Embolus lodges in a pulmonary
artery or smaller pulmonary artery or smaller pulmonary vessel and prevents blood flowvessel and prevents blood flow
Life threatening conditionLife threatening condition
Pulmonary EmbolusPulmonary Embolus
Pulmonary EmbolusPulmonary Embolus Substernal Chest PainSubsternal Chest Pain Rapid, shallow respirationsRapid, shallow respirations Shortness of breathShortness of breath Pale, dusky or cyanotic skin coloringPale, dusky or cyanotic skin coloring Anxiety, feeling of impending doomAnxiety, feeling of impending doom Altered or decreased level of Altered or decreased level of
consciousnessconsciousness Low grade feverLow grade fever
Pulmonary EmbolusPulmonary Embolus Cardiopulmonary SupportCardiopulmonary Support Pain ControlPain Control AnticoagulationAnticoagulation Operative intervention may be Operative intervention may be
necessarynecessary 6 months tx6 months tx
Fat EmboliFat Emboli Can occur with any type of Can occur with any type of
fracturefracture especially pelvis and long bonesespecially pelvis and long bones
Fat globules released from bone Fat globules released from bone marrow into injured veinsmarrow into injured veins become trapped in pulmonary become trapped in pulmonary
vasculaturevasculature
Fat EmboliFat Emboli Signs and Signs and
symptomssymptoms DyspneaDyspnea TachypneaTachypnea Altered LOCAltered LOC Decreased PaO2 Decreased PaO2
and SpO2and SpO2 PetechiaePetechiae Retinal Retinal
HemorrhageHemorrhage Chest painChest pain
Normal RetinaNormal Retina
Fat EmboliFat EmboliRetinal HemorrhageRetinal Hemorrhage
Fat EmboliFat EmboliPetechiaePetechiae
Unrelieved Pain/ Chronic Unrelieved Pain/ Chronic PainPain
Pain is under managed in the Pain is under managed in the majority of trauma patientsmajority of trauma patients
Increases morbidity…potentially Increases morbidity…potentially increases mortalityincreases mortality
Can delay and intensify rehabCan delay and intensify rehab
PainPain Nociception: tissue damage-induced Nociception: tissue damage-induced
pain from the peripheral receptor pain from the peripheral receptor through the spinal cord to the brainthrough the spinal cord to the brain
Central Pain: Traumatic amputationsCentral Pain: Traumatic amputations Psychologic Pain: feelings of anxiety or Psychologic Pain: feelings of anxiety or
depression mislabeled as paindepression mislabeled as pain Behavioral Pain: For attention, Behavioral Pain: For attention,
sympathy, time off from work…pt c/o sympathy, time off from work…pt c/o painpain
Nerve Pain: Burning, shooting painNerve Pain: Burning, shooting pain
PainPain Team approach is bestTeam approach is best Aggressive Pain Management to Aggressive Pain Management to
prevent complicationsprevent complications Chronic pain can become the Chronic pain can become the
focal point of a patient’s lifefocal point of a patient’s life Chronic pain often goes hand in Chronic pain often goes hand in
hand with depressionhand with depression
Chronic PainChronic Pain
Secondary Brain InjurySecondary Brain Injury Lack of oxygen/ perfusion to the Lack of oxygen/ perfusion to the
brain after an injurybrain after an injury Causes: hypotension, hypoxia, Causes: hypotension, hypoxia,
hypercapnia, hypocapnia, hypercapnia, hypocapnia, anemia, hyperthermia, anemia, hyperthermia, hypoglycemia, hyperglycemia, hypoglycemia, hyperglycemia, elctrolyte abnormalities, elctrolyte abnormalities, increased ICP, seizures, increased ICP, seizures, vasospasm…vasospasm…
Secondary Brain InjurySecondary Brain Injury Systemic hypoxia and hypotension Systemic hypoxia and hypotension
are the most commonare the most common Contribute significantly to Contribute significantly to
morbidity and mortalitymorbidity and mortality If SBP is <90 or PaO2 <60 on If SBP is <90 or PaO2 <60 on
hospital admission a patient’s hospital admission a patient’s mortality doublesmortality doubles
Complications that cause Complications that cause secondary brain injury are usually secondary brain injury are usually easily treatableeasily treatable
Acute Acalculous Acute Acalculous CholecystitisCholecystitis
Acute inflammation of the gallbladder Acute inflammation of the gallbladder in the absence of gallstonesin the absence of gallstones
Affected patients are often critically Affected patients are often critically illill
Cause is uncertainCause is uncertain Contributing factors include TPN, lack Contributing factors include TPN, lack
of oral intake and narcoticsof oral intake and narcotics Gallbladder ischemia also a cause in Gallbladder ischemia also a cause in
patients who were hypotensive or patients who were hypotensive or had low blood flow during surgeryhad low blood flow during surgery
ACCACC Does not differ from the calculous type Does not differ from the calculous type
except the incidence of gangrene and except the incidence of gangrene and perforation is higherperforation is higher
Fever, N/V, RUQ tendernessFever, N/V, RUQ tenderness Difficult to diagnose in critically ill trauma Difficult to diagnose in critically ill trauma
patient…sedated, intubated, associated patient…sedated, intubated, associated injuriesinjuries
Increased WBC in 70% and increased AST Increased WBC in 70% and increased AST in 50%in 50%
Imaging: Ultrasound and Imaging: Ultrasound and cholescintigraphy cholescintigraphy
Post Traumatic Stress Post Traumatic Stress SyndromeSyndrome
Trauma is a crisis…life changing Trauma is a crisis…life changing event for most patientsevent for most patients
Event itself was probably terrifyingEvent itself was probably terrifying Now lots of life changesNow lots of life changes PTSD is often mis-diagnosedPTSD is often mis-diagnosed Spinal Cord injury and facial Spinal Cord injury and facial
injuries put patients at great risk injuries put patients at great risk for PTSDfor PTSD
PTSDPTSD Experience sudden, vivid Experience sudden, vivid
flashbacks of the eventflashbacks of the event Emotions such as fear, grief and Emotions such as fear, grief and
angeranger May demonstrate avoidance: May demonstrate avoidance:
relationships disintegrate relationships disintegrate Chronic hyper-arousal and a Chronic hyper-arousal and a
biologic alarm reaction ex: GSW biologic alarm reaction ex: GSW victim responds to a car back victim responds to a car back firing firing
PTSDPTSD GI upset, headaches, irritability, GI upset, headaches, irritability,
insomnia, difficulty concentratinginsomnia, difficulty concentrating Tx with benzos, SSRI’s Tx with benzos, SSRI’s Many patients also benefit from Many patients also benefit from
non-pharmacological therapynon-pharmacological therapy
DeathDeath
DeathDeath Some patients are not Some patients are not
salvageablesalvageable Some patients die from initial Some patients die from initial
injuriesinjuries Some patients die from Some patients die from
complications complications