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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.