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CHAPTER 19
TRAUMA AND SURGICAL MANAGEMENT
Introduction:
o Trauma is defined as physical injury caused by external forces or violence.o Fifth leading CODo Motor vehicle crashes (MVCs) are the most common cause of traumatic death and often
involve the use of alcohol, drugs, or other substance abuse.
o Majority of injured persons range in age from 16-44o Goal in trauma is prevention, however when traumatic injuries do occur, the priority is early
and aggressive interventions to save life and limb
Trauma Demographics:
o Major health care and economic concern b/c of the loss of life, societal burden in terms of lostproductivity and increased disability of injured persons, as well as the consumption of health
care resources
o MVCs and firearm incidents are the leading COD for persons 16 to 24 years of age.o Males are twice as likely as females to experience unintentional injury or deatho MVCs peak at 19 yearso Falls account for 27% of unintentional injuries, occurring primarily in the elderly populationo Direct costs are related to the actual expense of acute hospitalization and rehabilitative care
an individual receives as a result of a traumatic incident
o Indirect costs are associated with loss of work, physical disability, psychological disability andlost productivity
o 10% of total U.S. medical expenditures is attributable to trauma care costs
SYSTEMS APPROACH TO TRAUMA CARE
Trauma System:
A model trauma system provides an organized approach to trauma care that includes components of
prevention, rapid access, acute hospital care, rehabilitation, and research activities. Levels of a
trauma system are a differentiation of medical care, but are defined by resources available within the
specific hospital.
A. Levels ofTrauma Care:~ The American College of Surgeons Committee on Trauma (ACS-COT) developed a program of
external review and verification of hospitals for trauma care to ensure that certain standards in trauma
management were met within hospitals that obtained the trauma verification
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~ In 1992, under the direction of the Health Resources and Services Administration, the Trauma Care
Systems Plan was developed, providing a framework for the current trauma system and a verification
process in the United States.
~ The ACS-COT trauma system identifies a trauma centers expected level of care based on
categories: Level I, II, III, or IV
~Level I through Level IV designated hospitals collaborate to develop transfer agreements and
treatment protocols that maximize pt survival.
~the lead hospital is usually the Level I trauma center.
LEVEL I LEVEL III
Regional resource trauma centers that are tertiary
care hospitals. Level I has maximal resources
across the spectrum of trauma care including
prevention programs, acute treatment,
rehabilitation, and trauma-related research; most
are university-based teaching hospitals. Pts who
are most severely injured go here.
Facilitates prompt assessment, resuscitation,
emergency surgery and stabilization of a pt until
transfer of the pt to a higher level of trauma care
is arranged.
LEVEL II LEVEL IV
Provide definitive care to severely injured
patients, but have a limited amount of resources.
It may be able to care for complex pts, yet may
transport pts to a Level I if advanced and
extended surgical care is required.
Provide advanced trauma life support and prepare
for immediate transport of the pt.
B. Trauma Continuum:~ Death caused by traumatic injury is described as a trimodal distribution occurring in one of threeperiods
First Peak Seconds to minutes
from the time of
injury
Apnea from severe brain or high spinal
cord injury, or exsanguinating
hemorrhage Only prevention will
decrease deaths in the first peak.
Rupture of the heart,
aorta, other large blood
vessels
Second
Peak
Minutes to several
hours
Injuries associated with significant
blood loss. This first hour of care is the
golden hour focuses on rapid
assessment, resuscitation and
treatment of life threatening injuries.
Subdural and epidural
hematomas,
hemopneumothorax,
ruptured spleen, liver
lacerations, pelvicfractures
Third
Peak
Days to weeks Pt outcomes in this time frame are
affected by the care provided early in
the management of traumatic injury.
Sepsis, ARDS, MODS
C. Injury Prevention:
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~Research explored antecedents of traumatic events found that traumatic injuries are not random
events
~An individuals knowledge, risk taking behaviors, beliefs, and decision to engage in a certain activity
influence the outcome of actions
~ Because most traumatic events are considered preventable, the word accident has been removed
from discussion of traumatic injury, such as motor vehicle accident. Current verbiage is motor
vehicle crash.
~Nurses must teach to prevent trauma
Primary Prevention Interventions to prevent the
event
Driving safety classes, speed
limits, campaigns to not drink and
drive
Secondary Prevention Entails strategies to minimize the
impact of the traumatic event
Seat belt use, airbags, automobile
construction, car seats, helmets
Tertiary Prevention Interventions to maximize pt
outcomes after a traumatic event
Emergency response systems, medical
care, rehabilitation
D. Trauma Team Concept:~the term trauma team, similar to a code team, refers to health care professionals who respond
immediately to and participate in the initial resuscitation and stabilization of the trauma pt.
~trauma care begins in the field when the emergency medical response (EMS) team responds to an
event.~when the pt is transported to the hospital, the acute care trauma team is activated
~each member is pre-assigned and understands their specific responsibilities inherent in a particular
team role.
~the trauma surgeon is ultimately responsible for the activities of the trauma team and acts as the
team leader in establishing rapid assessment, resuscitation, stabilization, and intervention priorities.
~Emergency department physicians, consulting physicians, nurses, respiratory therapists, social
workers, pastoral care providers, and interventional radiologists all have specific duties.
MULTIDISCIPLINARY TRAUMA TEAM
EMS team Trauma surgeon (team leader) Emergency physician Anesthesiologist Trauma nurse team leader Trauma resuscitation nurse Trauma scribe
Laboratory phlebotomist Radiological tech Respiratory therapist Social worker/pastoral services Hospital security guard Physician specialists
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E. Prehospital Care and Transport:~When the EMS personnel arrive, they direct the situation and prepare the pt for transport.
~ Time is very important especially for pts with issues like major internal hemorrhage
~Airways with c/spine stabilization, breathing, circulation at initial trauma site
~Interventions:
y Establish an airwayy Provide ventilationy Apply pressure to control hemorrhagey Immobilize the complete spiney Stabilize fracturesy Get pt to the right level of hospital
care (EMS goal)
y Occlusive dressing to open chestwound
y Endotracheal intubationy Needle thoracotomyy Large bore venous access
y POSSIBLE administration ofcrystalloids to restore blood volume
o Research has shown the pt withisolated penetrating trauma and a
short transit time to a hospital is
more likely to survive if IV fluids are
limited or withheld. Isolated
penetrating vascular injury/extra fluid
may dislodge a clot and increase
bleeding.
o The current standard is to infuse acrystalloid solution like NSS or LR
both of which can precipitate
complications such as hyperchloremic
metabolic acidosis and inflammatory
organ injury (ARDS and MODS)
~ground or air transport: depends on travel time, terrain, availability of air and ground units,
capabilities of transport personnel, weather conditions
~optimally, the trauma team responds at the hospital before the pts arrival and prepares based on the
report of injuries
~some pts may go straight to the OR for resuscitation and immediate surgical intervention
F. Trauma Triage:~Triage mean sorting the pts to determine which pts need specialized care for actual or potential
injuries
~Triage decisions are often made by prehospital personnel based on knowledge of the mechanisms of
injury and rapid assessment of the pts clinical statuso Minor trauma: single system injury that does not pose a threat to life or limb and can be
appropriately treated in a basic emergency facility
o Major trauma: refers to serious multiple system injuries that require immediate intervention toprevent disability, loss of limb, or death.
The Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS): divide the body into
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seven regions and use a severity score from 1 to 6 for each injury. The AIS score is calculated from
the three most severely injured body regions. The ISS is the sum of scores of the highest AIS score in
three body regions. The risk of mortality increases with a higher ISS. Score of 1 indicates minor injury,
score of 6 is fatal.
Glasgow Coma Scale: The lower the score, based on three assessment parameters, the more severe
the neurological injury, suggesting the need for emergent transport to a trauma center.
The Revised Trauma Score (RTS): prospective physiological scoring system based on initial
assessment of the pt. Variable that make up the RTS include BP, RR, and GCS (see above). The lower
scores are associated with a higher mortality rate..
G. Disaster and Mass Casualty Management:~A disaster is a sudden event in which local EMS services, hospitals, and community resources are
overwhelmed by the demands placed on them
~they are caused by: fire, weather (earthquake, hurricane, floods, and tornado), explosions, terrorist
activity, radiation or chemical spills, epidemic outbreaks, and human error (car/ airplane crash)
~Disasters are classified by the number of victims
Mass patient incident refers to fewer than 10 victims Multiple casualty incident refers to 10-100 victims Multiple casualty incident refers to 100 victims
~Effective, consistent and accurate communication of the activities at the disaster site and effective
management of the severity and volume of incoming victims at the hospitals are crucial to successful
disaster and mass casualty management
~All hospital personnel are required to be familiar with the disaster response policy. All health care
personnel are required to respond, and all hospitals have well developed disaster plans that outline
specific health care provider responses during an event. These outline the roles and responsibilities of
every role in the hospital.
~Hospitals maintain disaster phone call lists that are activated during a disaster. Health care
professionals are frequently rotated to minimize fatigue.
~upon arrival, pts are triaged by physicians the most useful method of triaging involves treatment
based on three gross category assessments:
1. Pts who are dead or who have no possibility to survive2. Pts with survivable injuries needing immediate care3. Pts who are moderately to minimally injured and can wait several hours for definitive
medical care
~disasters cause psychological stress, especially for health care professionals. Resources to debriefhealth care professionals involved in disaster and mass casualty response are needed to help process
the psychological stress and trauma experience during the event
MECHANISMS OF INJURY
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Mechanism of Injury: how a traumatic event occurred, the injuring agent, and informationabout the type and amt of energy exchanged during the event.
Knowledge of the mechanism of injury can assist in early identification and management ofinjuries that may not be apparent on initial assessment (organ contusions)
Questions regarding the mechanism of injury (MOI) are directed to the pt, prehospital careproviders, law enforcement personnel, or bystanders in an attempt to reenact the scene of the
trauma
Personal and environmental risk factors include pt age, sex, race, alcohol or substance abuse,geography and temporal variation. Temporal variation describes the pattern and timing of
trauma. For example, injury deaths occur most frequently on weekends, unintentional injuries
occur during recreational activities, and suicides occur more frequently on Mondays. Injury
may also occur when pts are deficient in oxygen, such as drowning or suffocation; or, in
response to cold, leading to frostbite.
Energy may be kinetic (crashes, falls, blast or penetrating injuries), thermal, electrical,chemical, or from radiation exposure. The effects of the energy released and the resultant
injuries depend on the force of impact, the duration of impact, the body part involved the
injuring agent and the presence of associated risk factors.
BLUNT TRAUMA
Blunt trauma is the most common mechanism of injury; usually most common is MVCs, but canalso occur from assaults with blunt objects, falls from heights, sports related injuries and
pedestrians struck by a car
The severity of injury depends on the amt of kinetic energy dissipated to the body and itsunderlying structures. Blunt trauma may be caused by accelerated, decelerating, shearing,
crushing, and compressing forces.
Vehicular trauma often results from mechanisms of acceleration-deceleration force. When thevehicle stops abruptly, the body continues to travel until it comes into contact with a
stationary object like the dash, windshield or steering column.
When the pt strikes their head against a stationary object, the brain tissue hits the craniumand is thrown back against the opposite side, causing coup-contrecoup injury. In addition,
shearing forces of the cerebral tissue and the skull cause vessels to stretch and exceed their
elasticity, resulting in tears, dissection, or rupture.
Low density porous tissues and structures like lungs tolerate energy transfer and oftenexperience little damage b/c of their elasticity.
Organs such as the heart, spleen, and liver are less resilient b/c of the high density tissue andthe decreased ability to release energy without resultant tissue damage.
The severity of injury resulting from a blunt force is contingent on the duration of energyexposure, the body part involved, and the underlying structures.
PENETRATING TRAUMA
Result from the impalement of foreign objects (knives, bullets, debris) Easily diagnosed andtreated because of the obvious signs of injury
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Stab wounds are low-velocity injuries b/c the velocity is equal only to the speed with which theobject is thrust into the body
The impaled object comes into contact with underlying vessels and tissues. Importantconsiderations include the length and width of the impaling object, and the presence of vital
organs in the area of the stab wound
Women tend to stab with a downward thrust, whereas male assailants use an upward thrust. Ballistic trauma is either medium or high velocity Medium velocity weapons are handguns and some rifles High velocity include assault weapons and hunting rifles As the missile penetrates the tissues, vessels are stretched and compressed, creating tissue
damage known as cavitation
Depending on the range, the distance from the weapon to the point of bodily impact, and thevelocity of the missile, the cavitation may be as great as 30x the diameter of the bullet
Knowledge of the type of bullet (size, hollow, shotgun pellet bullets) influences the assessmentas to the type of internal tissue damage that may have occur
The entrance wound is usually smaller than the exit wound Penetrating injuries are monitored for subsequent complications including organ damage,
hemorrhage and infection.
BLAST INJURIES
Blast injuries are forms of blunt and penetrating trauma. Energy exchanged from the blastcauses tissue and organ damage. Penetrating injury may occur as a result of debris
impalement into the body.
PRIMARY explosive blast generates shock waves that create changes in air pressure, causingtissue damage. Initially after an explosion, there is a rapid increase in positive pressure for a
short time, followed by a longer period of negative pressure. The increase in positive pressure
injures gas containing organs. The tympanic membrane ruptures, and the lungs may show
evidence of contusion, acute edema, or rupture. Intraocular hemorrhage and intestinal rupture
may occur from the first shock wave after an explosion.
SECONDARY injuries occur from increased negative pressure from the shock wave causingdebris to impale the body, creating organ and tissue damage.
TERTIARY blast injuries are the result of the body being thrown by the force of the explosion,resulting in blunt tissue trauma including closed head injuries, fractures, and visceral organ
injury.
QUATERNARY blast injuries occur from chemical, thermal, and biological exposure._____________________________________________________________________________________________________
EMERGENCY CARE PHASE
Trauma rooms provide a central location for the team to provide a quick initial assessment,stabilization, and determination of the immediate medical needs of the pt.
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The resuscitation area must always be in a state of readiness for the next trauma pt Equipment needed for management of the airway with cervical spine immobilization,
breathing, circulatory support, and hemorrhage control must be immediately available and
easily accessible.
The nurse plays an essential role in assisting with assessment, advocating for the pt, andanticipating the needs of the trauma team and pt.
The Initial Patient Assessment
Pt survival after a serious traumatic event depends on prompt, rapid, and systematicassessment in conjunction with immediate resuscitative interventions.
Priorities of care are based on the pts clinical presentation, physical assessment, hx of thetraumatic event (MOI), and knowledge of preexisting disease.
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The Primary Survey
Most crucial assessment tool in trauma care. It is a rapid 1-2 minute evaluation designed toidentify life threatening injuries accurately, establish priorities, and provide simultaneous
therapeutic interventions.
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During the primary survey, life threatening conditions are identified and management isinstituted simultaneously.
All major life threatening conditions must be treated before one proceeds to the secondarysurvey.
The Secondary Survey
The secondary survey is a methodical head to toe evaluation of the pt using the assessmenttechniques of inspection, palpation, percussion, and auscultation to identify all injuries. The
secondary survey is initiated after the primary survey has been completed and all actual or
potential life threatening injuries have been identified and addressed.
HR, auscultated BP, core body temperature, respiratory effort and LOC are obtained as abaseline for analysis of trends during the resuscitation phase.
F through I is a mnemonic to remember the features of the secondary assessment. F-full set ofvitals, five interventions (cardiac monitor, pulse ox, urinary cath, NG, laboratory tests), and
facilitate family presence; G-give comfort; H-history, and head to toe assessment; I-inspect
posterior
information about actual and potential injuries are noted and used to establish diagnostic andtreatment priorities
Radiological studies are completed according to a standardized trauma protocol or anassessment of suspected injuries. The sequence of diagnostic procedures is influenced by the
pts LOC, the stability of the pts condition, the MOI, and identified injuries.
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as data are obtained, the team leader determines the need for consultation with specialtyphysicians
Supportive interventions include splinting of the extremities, wound care, and administrationof tetanus prophylaxis and antibiotics are completed.
RESUSCITATION PHASE
Resuscitation in trauma refers to reestablishing an effective circulatory volume and a stablehemodynamic status in the patient.
Effective resuscitation is a central component of the primary and secondary survey
1. Establishing Airway Patency An effective airway allows for adequate ventilation and optimal oxygenation. T
he tongue is the most common cause of airway obstruction; other causes are foreign debris(blood or vomitus), and anatomical obstruction from maxillofacial fractures.
Direct injuries to throat or neck can structurally impair the airway Pts with an altered sensorium or high spinal cord injury may not be able to protect their
airway.
Jaw thrust or chin lift is used to open the airway. These maneuvers do not hyperextend theneck or compromise integrity of c/spine.
The airway must be cleared of any foreign material such as blood, vomitus, bone fragments, orteeth by gentle suction by a tonsillar tip catheter.
Nasopharyngeal and oropharyngeal are the simplest artificial airway both devices preventposterior displacement of the tongue.
The oropharyngeal airway is not used in the conscious pt b/c it can induce gagging, vomiting,and aspiration.
Endotracheal intubation is the definitive nonsurgical airway management technique and allowsfor complete control of the airway.
Nasotracheal intubation is indicated for the spontaneously breathing pt and is used when theurgency of the situation does not allow time for preliminary c/spine studies.
Nasotracheal intubation is contraindicated for pts with facial, frontal sinus, basilar skull orcribiform plate fractures.
Disadvantages of naso epistaxis, injury to the nasal turbinates and increase risk for infection Oral tracheal intubation must be performed in the presence of documented or suspected
s/spine injury to prevent manipulation of the neck.
Disadvantages of oral possible manipulation of c/spine, incorrect tube placement, vocal cordtrauma and injury to oral structures
Before intubation, preoxygenate with 100% oxygen via bag valve mask. A sedative may be used to facilitate the procedure Correct tube position must be verified
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Sometimes, it is impossible to intubate the pt, so a cricothyrotomy is performed to make theairway. May be required with facial trauma, laryngeal fractures, facial or upper airway burns,
airway edema or severe oropharyngeal hemorrhage.
2. Maintaining Effective Breathing Interventions to restore breathing are directed toward the specific injury or underlying cause of
resp distress with the goal of improving ventilation and oxygenation
BASIC nursing interventions are administering supplemental oxygen with vent assistance (ifapplicable), effective positioning, and evaluation
Pt is assessed frequently for respiratory rate and effort, HR and rhythm, breath sounds,sensorium, skin color, temperature, tracheal position and jugular vein distention
If spontaneous breathing is present but ineffective, a life threatening condition is considered ifthe pt has: an altered mental status, central cyanosis, asymmetrical expansion of the chest
wall; use of accessory or abdominal muscles, or both; paradoxical movement of the chest wall
during inspiration and expiration; diminished or absent breath sounds; tracheal shifts from
midline position; decreasing oxygen sat via pulse ox or distended jugular veins
ABGs and chest x ray/CTmay be completed to determined effectiveness of interventions Impaired gas exchange can be a result from ineffective ventilation, an inability to exchange
gases at the alveoli, or both: possible causes are: decrease in inspired air, retained secretions,
lung collapse or compression, atelectasis or accumulation of blood in the thoracic cavity
3. Maintaining Circulation The most common cause of hypotension is hypovolemic shock from acute blood loss Initial interventions include applying pressure to control bleeding, replacing volume, determine
definitive treatment
In the face of hypovolemic shock from hemorrhage, early, rapid surgical intervention islifesaving and limb saving
Sympathetic compensatory mechanisms in the body respond to states of hypoperfusion thrutachycardia, narrow pulse pressure, tachypnea, and decreased u.o.
As a result of hypovolemia and hypoxemia, metabolic acidosis occurs secondary to a shift fromaerobic to anaerobic metabolism and the production of lactic acid
The serum arterial lactate level and base deficit are markers of effective tissue perfusion4. Diagnostic Testing
Determine the cause of bleeding with chest and pelvic X ray, abdominal u/s, and X ray ofextremity fractures
CT scan can identify intraperitoneal bleeding, but it is NOTTHE DX TESTOF CHOICE in thepresence of hemodynamic instability. We use the focused assessment with sonography for
trauma (FAST) it is non invasive way to dx peritoneal hemorrhage at pts bedside
Diagnostic peritoneal lavage frank blood, emergency laparotomy, - - - if no frank blood, asample is sent to the lab for eval of red blood cells, WBC, amylase, bile, bacteria, fecal material
or food material if so, immediate operative intervention
Occasionally pts with pelvic and long bone fractures get a pneumatic antishock garment(PASG) - an awesome pair of pants that inflate and compress to reduce bleeding during
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transport can create increased intraabdominal and thoracic pressure, compromising effective
ventilation, oxygenation and circulation
Additional causes of diminished CO include tension pneumothorax, pericardial tamponade,cardiac contusions, and myocardial infarction
A chest tube is placed to relieve the pneumo. Tx of pericardial tamponade requires aspirationof fluid from pericardial sac if more fluid accumulates, surgery is indicated
5. Adequacy of ResuscitationSublingual capnometry Noninvasive technology that provides info about degree of
hypovolemia and adequacy of fluid resuscitation based on the
sublingual PC02. A probe is placed under the pts tongue.
During shock, elevated sublingual PC02 indicates poor tissue
perfusion similar to pulse ox
Near-infrared
spectroscopy (NIRS)
Continuous noninvasive technology that uses light
transmission to measure skeletal muscle oxygenation as an
indicator of shock. Probe is placed on the thenar muscle,
located on the palm of hand. The probe measures oxygen sat
state of tissue. Low values (
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Minimal or No Responders: fail to respond to crystalloid and blood administration in theemergency department and surgical intervention is needed immediately to control
hemorrhage.
Current practice tolerates lower hemoglobin levels research has shown massive transfusionshave poorer outcomes.
If blood loss and coagulopathy are life threatening, massive transfusion may be required (10units/24 hours) in a 1:1:1 fashion. 1 unit RBC, 1 unit platelets, 1 unit fresh frozen plasma
While fluid resuscitating, monitor for dilution coagulopathies, excessive 3rd spacing,hypocalcemia, hypomagnesemia, hyper/hypokalemia. These changes may lead to changes in
myocardial function, laryngeal spasm, and neuromuscular and central nervous system
hyperirritability.
Dilution coagulopathy may occur with excessive IV fluid resuscitation and extensive blood loss.Blood banked products have high levels of citrate, which may induce transient hypocalcemia
leading to ineffective coagulation b/c calcium is a necessary cofactor in the coag cascade.
Further inhibition of the clotting cascade is observed when platelet dysfunction developssecondary to hypothermia or metabolic acidosis.
Management focuses on improving perfusion to the body tissues, increasing the pts bodytemperature and administering clotting factors.
MONITOR hemoglobin, Hematocrit, plasma fibrinogen level, platelet count, PT, PTT 3rd spacing is a problem with aggressive fluid resuscitation. During states of hypoperfusion
and acidosis, inflammation occurs and vessels become more permeable to fluid and molecules,
allow 3rd spacing to happen. Hypovolemia thus occurs in the intravascular space and require a
larger volume of fluids. This creates a cycle that causes excessive edema and predisposes the
pt to abdominal compartment syndrome, ARDs, acute renal failure and MODS.
The GOAL is to provide adequate fluid resuscitation to prevent hypoxemia.7. Assessment of Neurological Disabilities
Assessment includes pts LOC, papillary size and reaction, spontaneous and reflexive spinalmovement
Hypotension decreases cerebral perfusion, therefore the pts response to interventions, and thedegree of tissue ischemia are considered in the neuro exam
Recreational drugs/alcohol are also put into consideration can mask neuro symptoms Management priorities focus on the primary injury from the traumatic event and the
subsequent secondary injury that occurs as a result of cerebral hypoperfusion, increase ICP,
and/or cerebral edema.
Primary: blunt trauma, presence of acceleration, deceleration, or rotational forces. Injury isfocal or diffuse
Secondary: refers to the systemic (hypotension, hypoxia, anemia, hyperthermia) orintracranial changes (edema, intracranial HTN, seizures, vasospasm) that result in alterations
in the nervous system tissue pts with secondary have poorer outcomes
Nursing interventions: maintain adequate BP to meet cerebral perfusion needs, maximizeventilation and oxygenation, maintain head in a midline position to enhance cerebral blood
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flow, administer sedatives to address agitation and increased ICP and conducting frequent
neuro checks.
Lacerations to scalp may result in significant bleeding. Wounds are cleansed, debrided, andsutured.
The diagnosis of a basilar skull fracture includes CSF in the nose, ears or both, ecchymosis ofthe mastoid area (Battles sign) or hemotympanum. Raccoons eyes are present after a
cribiform plate fracture. Two complications include meningitis and cranial nerve injury
Spinal cord injury (SCI) hyperflexion, hyperextension, axial loading, rotation, and penetratingtrauma.
Initial tx with suspected SCI includes ABCS with spinal immobilization and prevention offurther injury with spine stabilization a complete sensory and neuro exam is performed, and
X ray studies or c/spine are obtained. A spinal CTmay also be done.
SCI causes a loss of sympathetic output, resulting in distributive shock with low BP andbradycardia. BP may respond to IV fluids, but vasopressor therapy is often required to
compensate for the loss of sympathetic innervating and resultant vasodilation
8. Exposure and Environmental Considerations A person is susceptible to hypothermia after severe injury, excessive blood loss, alcohol use,
and massive fluid resuscitation.
Prolonged exposure to hypothermia is associated with the development of myocardialdysfunction, coagulopathies, reduced perfusion, dysrhythmias, and decreased metabolic rate.
(dysrhythmias include brady and atria/ventricular fib)
Other environmental considerations include farming accidents, impalement with machinery orcontaminated industrial equipment, exposure to contaminated water, or wound contamination
with soil and road dirt.
Initial attempts to cleanse the wound are not priority in the emergent phase of traumamanagement, but the once the pt is stabilized, the wounds are cleansed and debrided, and
antibiotics are initiated.
ASSESSMENT AND MANAGEMENT OF SPECIFIC ORGAN INJURIES
Thoracic Injuries
CARDIAC TAMPONADE
Rapid accumulation of fluid (usually blood) in the pericardia sac. As the intrapericardial pressure
increases, cardiac output is impaired b/c of decreased venous return.
CAUSES ASSESSMENT
Penetrating trauma to the chest Suspected in any pt with blunt trauma to
the chest or multisystem injury who
presents in shock and does not respond to
Pulsus paradoxus Increased right atrial pressure distended
neck veins
Becks Triad: hypotension, muffled or
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aggressive fluid treatment distant heart sounds and elevated venous
pressure
DIAGNOSIS TREATMENT
FAST Pericardiocentesis (blood aspirated from
the pericardial sac usually does not clot
unless the heart itself has been
penetrated)
Pericardiocentesis After pericardiocentesis, immediate
operative intervention is required for
definitive repair
INTERVENTIONS
Nurses should anticipate and obtain equipment for an emergency thoracotomy in the event ofcardiac arrest.
CARDIAC CONTUSION
Bruised heart muscle the force of the traumatic event bruises the heart muscle and can compromise
effective heart functioning
CAUSES ASSESSMENT
Blunt trauma Assess for dysrhytmiasDIAGNOSIS TREATMENT
Inotropic agentsINTERVENTIONS
ECG for 48-72 hours Serum levels of cardiac isoenzymes and troponin
AORT
IC DISRUPT
IONDissection of the aorta; often the outer two layers of the aorta are torn, leaving the outermost layer
intact
CAUSES ASSESSMENT
Blunt trauma to the chest Rapid deceleration produced by head on
MVC, ejection or falls
Decreased BP Increased pulse
Weak femoral pulse Dysphagia Dyspnea
Hoarseness pain
S/s of decreased perfusionDIAGNOSIS TREATMENT
Chest x ray widened mediastinum,tracheal deviation to the right, depressed
left mainstem bronchus, first and second
rib fx and left hemothorax
Immediate surgery
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Diagnosis is confirmed by an aortogramINTERVENTIONS
TENSION PNEUMOTHORAX
Injury to the chest allows air to enter the pleural cavity without a route for escape. With each
inspiration, additional air accumulates in the pleural space, increasing intrathoracic pressure and
leading to lung collapse. The increased pressure causes compression of the heart and great vessels
toward the unaffected side. This created decreased CO and alterations in gas exchange.
CAUSES ASSESSMENT
Injury to the chest Distended neck veins Severe respiratory distress
Chest pain Hypotension Tachycardia
Absence of breath sounds on 1 side Tracheal deviation
Cyanosis is a late signDIAGNOSIS TREATMENT
Clinical presentation Tx not delayed for x ray Immediate decompression by needle
thoracostomy 2nd intercostals space at
midclavicular line this converts a
tension pneumo to a simple pneumo
Definitive tx is required with placement ofchest tube.
INTERVENTIONS
Supplemental oxygen and assist doctor
HEMOTHORAX
Collection of blood in the pleural space
CAUSES ASSESSMENT
Injuries to the heart, great vessels, or thepulmonary parenchyma
Decreased breath sounds Dullness to percussion on the affected
side
Hypotension Respiratory distress may be severe
DIAGNOSIS TREATMENT
Placement of chest tubeINTERVENTIONS
Management of chest tube
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Monitor pts hemodynamic response
**** Open pneumothorax results from a penetrated trauma pts present with hypoxia and
hemodynamic instability. Management includes a three sided occlusive dressing. Chest tube is
inserted***
PULMONARY CONTUSION
Parenchymal injury to the lung that often results in some degree of hemorrhage and edema with a
subsequent inflammatory process extending beyond the point of injury. Bruised lung becomes
edematous, resulting in hypoxia and respiratory distress.
CAUSES ASSESSMENT
Blunt or penetrating trauma to the chest Rapid deceleration or blast forces with
resulting multiple rib fractures or flail
chest
Chest wall abrasions Ecchymosis
Bloody secretions PA02 < 60
DIAGNOSIS TREATMENT
Initial X ray may not show anything Infiltrates on chest x ray and hypoxemia
will eventually be seen
Ventilatory support fluids
Narcotics!INTERVENTIONS
Administer fluids Assist with ventilatory support
Relieve pain
RIB FRACTURES AND FLAIL CHESTMost commonly associated with chest trauma may be lead significant respiratory dysfunction and
serious injury to organs and structures below and near the rib cage. Injury to the liver, spleen, or
kidney may accompany fx of ribs 10 thru 12. A flail chest occurs when two or more adjacent ribs are
broken in two or more places, creating a free floating segment of the rib cage.
CAUSES ASSESSMENT
Chest trauma Pain (Flail chest) paradoxical chest movement,
increased WOB, tachypnea, hypoxemia
DIAGNOSIS TREATMENT
Chest x ray Clinical assessment
Depends on number of rib fx, degree ofunderlying injury, and age.
INTERVENTIONS
Hemodynamic monitoring Assessing pts ventilation and oxygenation
Effective pain management Education on pillow splinting, incentive spirometry, coughing and deep breathing, benefits of
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early ambulation, and pain management.
ABDOMINAL INJURIES
The classic sign of abdominal injury is pain, but that cant be used if the pt has an alteredsensorium, drug intoxication, or SCI with impaired sensation
LIVER INJURIES
Most commonly injured organ after blunt or penetrating trauma
CAUSES ASSESSMENT
Blunt/penetrating injury Right lower thoracic pain Fractured lower right ribs
RUQ ecchymosis RUQ tenderness hypotension
DIAGNOSIS TREATMENT
FAST Abdominal CT
Peritoneal lavage
Grade I thru III close monitoring (regularabdominal assessment and H&H and best
rest x 5 days)
Trade IV thru VI get angiographicembolization
INTERVENTIONS
Assess for hemorrhage Abdominal assessment
SPENIC INJURIES
Penetrating trauma to the LUQ of the abdomen of fx of the anterior left lower rib
CAUSES ASSESSMENT
Blunt trauma to abdomen LUQ tenderness Peritoneal irritation
Referred pain to L shoulder (Kehrs sign) hypotension
DIAGNOSIS TREATMENT
FAST Abdominal CT
Peritoneal lavage
Close monitoring is vital Bed rest for 5 days is appropriate for
grade I to III.
Operative intervention for IV and VINTERVENTIONS
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Close monitoring Assessment includes: presence of guarding, rebound tenderness, rigidity, or distention of the
abdomen, alterations in H&H,
Look for ruptured spleen, it may not happen immediately. Pt is very susceptible to pneumococcal infections after splenectomy
GASTRIC AND SMALL BOWEL INJURIES
CAUSES ASSESSMENT
Penetrating trauma Gunshot wounds Blast injuries
Pain
DIAGNOSIS TREATMENT
FAST Peritoneal lavage
Surgical intervention is usually required
INTERVENTIONS
(POSTOP) Monitor for infection Maintain nutrition
KIDNEY INJURIES
Usually only one kidney is affected. Minor, major, or critical
CAUSES ASSESSMENT
Blunt trauma Costovertebral tenderness Hematuria
Bruising over 11th or 12th ribs Hemorrhage
shockDIAGNOSIS TREATMENT
FAST CT
Angiography IV pyelogram cystoscopy
minor bed rest, hydration, monitor renalfunction (u.o., UA, hematuria, BUN,
creatinine, electrolyte levels, CBC)
Major surgical intervention, control ofbleeding, repair, nephrectomy
INTERVENTIONS
Monitor for post surgical complications refractory hypertension, hemorrhage, fistulaformation, and infection
PELVIC INJURIES
This is a problem b/c of the large vascular supply, nervous system pathways, location of urological
structures, and articulation of the hip joint in the pelvic ring.
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CAUSES ASSESSMENT
Blunt trauma High deceleration MVCs pedestrian
vehicle impacts
Falls
hypotension
DIAGNOSIS TREATMENT
x ray Stabilize the pelvis Aggressive fluid resuscitation
Typing a large sheet or pelvic binder cansometimes control the bleeding
Interventional radiology techniques thatuse embolization or coil techniques to
stop bleeding.
Surgery may be required for internal orexternal fixation of complex fx.
INTERVENTIONS
Monitor hemodynamic status
MUSCULOSKELETAL INJURIES
Rarely a priority in emergent management of the pt unless the injury results in significanthemodynamic instability
Knowing the MOI is important in evaluating musculoskeletal injuries b/c kinetic energy can bedistributed from the bony impact to other areas of the body. Ex: fall from heights may break
an ankle but also cause lumbar spine and pelvic fx
Limb swelling, ecchymosis and deformity are assessed in the secondary survey The five Ps for assessment includepain, pallor, pulses, parasthesias, paralysis this describes
the neurovascular status and circulation. Loss of pulses is a late sign of diminished perfusion.
Fractures are diagnosed with x Rays. The extremity is immobilized. If skin is open, the fracture is an open fracture. If no skin is broken and is intact, it is a
closed fracture
Traumatic soft tissue injuries are categorized as contusions, abrasions, lacerations, puncturewounds, crush injuries, amputations, or avulsion injuries.
Assessment of the soft tissue injury is part of the secondary survey unless the loss of tissue ishemodynamically compromising to the pt. Secondary complications to skin and soft tissue
predispose the pt to localized and systemic infection, hypoproteinemia, and hypothermia.
A traumatic amputation produces a well defined wound edge with localized injury to softtissue, nerves and vessels this typically requires debridement and surgical closure
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Avulsion injuries result in stretching and tearing of the soft tissue and may tear nerves andvessels at different levels other than the actual site of bone and tissue trauma.
Crush injury may produce local soft tissue trauma or extensive damage distant from the site ofinjury. Crush injuries of the pelvis and/or both lower extremities or a prolonged entrapment
may be life threatening b/c prolonged compression produces ischemia and anoxia. 3rd spacing
of fluid, localized edema, and increased compartment pressures cause secondary ischemia.
Contusions do not cause a break in the skin, but do cause localized edema, ecchymosis, andpain.
Abrasions occur when the skin experiences friction can be superficial or deep. Traumaticabrasions are frequently contaminated with debris implanted into the skin can take hours or
days to effectively remove the debris from the wound.
Lacerations are usually caused by sharp objects and are treated with cleansing and suturing Puncture wounds carry a heightened risk for infection can cause aggressive infection b/c the
deliver bacteria and foreign inoculums deep into the body these should not be surgically
closed until treatment for infection has been completed. Ex: animal bite
All traumatic wounds are considered contaminated wounds must be cleansed and debridedto reduce the risk of infection, so monitor for s/s of infection
COMPLICATIONS
Compartment Syndrome Fat Embolism
Occurs when a muscle compartmentexperiences increased pressure from
internal and external sources. Internal
sources include edema and/or
hemorrhage. External sources include
splints, immobilizers, or dressings.
The closed muscle compartment of anextremity contains neurovascular bundles
that are tightly covered by fascia. If the
pressure is not relieved, compression of
the nerves, blood vessels and muscle
occurs, resulting in ischemia and necrosis
of muscle and nerve tissue.
s/s include throbbing paindisproportionate to the injury and
narcotics do not relieve the pain. Pain islocalized and increases with muscle
stretching. The area is firm
Parasthesia distal to the compartment,pulselessness, and paralysis are late signs
Elevate the affected limb to heart level topromote venous outflow and prevent
Accompanies traumatic injury of longbones and pelvis developing 24 to 48 hrs
after injury.
Long bone injuries release fat globulesinto torn vessels and into systemic
circulation embolus travels thru great
vessels and into pulmonary system,
obstructing flow and causing hypoxia.
Hallmark signs begin with low grade feverfollowed by a new onset tachycardia,
dyspnea, and increased RR and effort,
hypoxemia, sudden thrombocytopenia,
and petechial rash.
Late s/s includes ECG changes, lipuria,and changes in LOC.
Prevention is the best treatment.
Stabilization minimizes bone movementand release of fatty products do this
early.
Treatment of fat embolism is directedtoward the preservation of pulmonary
function and maintenance of CV stability.
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further swelling
Treatment is immediate fasciotomy torelieve pressure
Administration of supplemental oxygenand intubation and mech vent with PEEP
may be required to restore or maintain
pulm function. Monitor CV stability is
monitored.
Rhabdomyolysis Deep Vein Thrombosis
Syndrome of hypoperfusion and ischemia,followed by reperfusion, in which the
injured muscle tissue releases myoglobin
into the circulation compromising renal
blood flow.
Causes include crush injuries,compartment syndrome, burns, and
lightning strikes
Myloglobinuria is an effective marker causes urine to be a dark tea color
Mylogobin is toxic to the renal tubule,causing acute tubular necrosis, e- and
acid base imbalances, and eventually
acute renal failure.
Treatment includes aggressive fluidresuscitation to flush the myloglobin. IV is
titrated to achieve a urine output of 100-
200 mL/hr.
Administering osmotic diuretics andadding sodium bicarb to IV fluids may be
used to protect renal tubules in pts with
myoglobinuria.
Risk is dependent on severity of injury,the type, the presence of shock, recent
surgeries, vascular injury, and immobility.
Usually occurs in the lower extremities Thrombus formation is enhanced with
Virchows triad: vessel damage, venous
stasis and hypercoagulability.
Has the potential to become a PE. Prevention is essential: if not medically
contraindicated, pt should receive
pharmacological prophylaxis.
Nurses should encourage ambulation,evaluate hydration, and ensure SCD use
CRITICAL CARE PHASE
DAMAGE CONTROL SURGERY: Pt with multiple injuries from traumatic event is most likely to die
from hemorrhage. Emergent surgery is the gold standard to stop hemorrhage and stabilize life
threatening injuries. Surgical intervention may require several surgeries and phases. The initial
surgery focuses on cessation of the bleeding (long and extensive surgeries can lead to severe
complications that contribute to the pts ultimate death these complications now recognized as the
leading COD in pts who sustain multitraumatic injuries include the triad ofhypothermia, acidosis, and
coagulopathy). These complications and resultant mortality have changed the current surgical focus
known as damage control surgery or staged surgical repair.
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This strategy sacrifices the completeness of immediate repair, yet provides early surgical
stabilization and management of active hemorrhage associated with injury. The first stage includes
operative repair of life threatening injuries only. The pt goes to the CCU (second stage) for aggressive
rewarming, ongoing resuscitation, and attainment of hemodynamic stability. The third stage usually
occurs with 24 to 48 hrs of the first surgery and the pt returns to the O.R. for definitive repair of
intraabdominal injuries. This 3 stage approach allows for cardiovascular stabilization, correction of
metabolic acidosis and coagulopathy, rewarming, and optimization of pulmonary function. This
concept improves outcomes of critically ill pts with severe intraabdominal injuries.
POSTOPERATIVE MANAGEMENT: The pt usually bypasses the PACU and are admitted directly to
the CCU
Room temp is increased, IV pumps are accessed, respiratory therapy is contacted about avent, monitoring equipment and room supplies are double checked, the bed is zeroed before
the pt arrives from the O.R.
A thorough report is obtained including review of systems, PMH, description of the injury,intraoperative procedures, pts tolerance of procedures, vital signs during surgery and current,
intake and output, medications administered, IV access, and location of chest tubes and other
drains.
The initial intervention upon admission is a rapid assessment of ABCs followed by connectingthe pt to the bedside monitor and ventilator and completion of an assessment of vitals, cardiac
rhythm, pulse ox, LOC, pupil reactivity, and temperature.
Posterior surface and change of soiled linens is completed early. The nurse reassesses IV access and evaluates the patency of IV catheters as they may have
become dislodged during transport.
IV infusions are traced from the fluid to the pump to the pt. All drainage devices are emptied and the chest tube drainage is marked. Admission lab studies are obtained (CBC, CMP, coag studies, arterial lactate level, and ABG) The pt is then weight and the family is notified. Postoperative management involves a systemic and thorough assessment and the monitoring
of respiratory and CV function, neuromuscular abilities, mental status, temperature, pain,
drainage and bleeding, urine output and resuscitation efforts.
After ensuring the stability of pts airway and adequacy of ventilation, attention is focused onCV. This includes HR, rhythm, blood pressure, RR, pulse ox, temp, drainage, urine output, IV
fluids, and vasoactive medications.
Temperature is measured at regular intervals. Shivering is avoided b/c it increases metabolicrate and results in increased oxygen demands and potential for hemodynamic instability.
A complete physical exam is performed and rechecked often. The nurse ensures nutritionalsupport, DVTprophylaxis, and glycemic control during the post operative period.
SPECIAL CONSIDERATIONS AND POPULATIONS
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Effects of Aging:
Increased risk of complications; incidence of trauma in geriatric pts is significantly less than inyounger pts; however, these pts are more likely to require hospitalization and have
significantly higher costs for care associated with their injuries
Delirium should be investigated if any acute change in elderly pts cognition or consciousness isnoted.
Nursing interventions focus on establishing the cause of delirium, including e- imbalances,infection, and sleep deprivation. Sedative meds and restraints should be avoided. Pt is
frequently reoriented.
Pneumonia is a life threatening complication with aging, the pulm system is less able tocompensate when stressed
Age related changes in pulmonary structure and function affect the pts ability to effectivelyventilate and exchange gases.
Pain management is aggressive and pulmonary exercise (incentive spirometry, ambulating,coughing and deep breathing) and strategies that prevent aspiration (evaluate swallowing,
HOB elevation to 30 degrees) are imperative in the care of the older trauma pt.
Alcohol and Drug Abuse:
Up to 40% of all traumatic events involve alcohol, and additions 20% include drugs. Overall complications, morbidity and mortality are higher in traumatically injured pts who
tested positive for alcohol, drugs or both at the time of admission.
MOI associated with drug use include jumping from buildings and running thru traffic. Nursing care of the trauma pt with drug or alcohol addiction includes assessment for
withdrawal. s/s of withdrawal include increased agitation, anxiety, auditory and visual
hallucinations, disorientation, h/a, n/v, diaphoresis, and tremors.
Sedating agents may be used to easy physiological and behavioral symptoms. The pts is observed hourly or more often for presence of worsening anxiety, hallucinations, fall
risk and disorientation.
It is important that drug and alcohol prevention interventions begin before d/c.Family and Patient Coping:
Traumatic injury is frequently unexpected and potentially devastating event that leaves pt andfamily feeling overwhelmed, vulnerable and ill prepared to cope.
Trauma team can assist by helping the family establish a designated person as thespokesperson and to facilitate open communication about the situation and expectations.
Involve social worker and family conferences. Research has shown that pts with traumatic injury who discussed their perceptions, fears, and
emotions soon after sustaining the physical injury have more effective coping and injury
related distress.
REHABILITATION
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Begins the moment the pt is admitted to the trauma center Involve case manager and d/c planner Nursing interventions influence the pts rehab needs Ex: splints to prevent foot drop and
provide emotional support.