Trauma Nursing

By: Diana Blum RN MSNMetropolitan Community College

Priority Emergency Measures for All Patients

Make safety the first priority Preplan to ensure security and a safe environment Closely observe patient and family members in

the event that they respond to stress with physical violence

Assess the patient and family for psychological function

Patient and family-focused interventions Relieve anxiety and provide a sense of security Allow family to stay with patient, if possible, to

alleviate anxiety Provide explanations and information Provide additional interventions depending

upon the stage of crisis

Common TraumaHeat BitesCold ElectricalAltitudeNear drowningSpinalHeadMusculoskeletalStab/gunshot woundsrape

Requirements to work in ER Graduated RN program Med/Surg and or ICU experience BLS ACLS PALS Some facilities require ER certification

Triage is from a French word meaning to sort. Emergency services regularly face patient loads that overwhelm resources. To better serve patients and make sure the worst patients get treatment as quickly as possible, emergency medical providers use a method of prioritizing patients by medical severity

Triage Nurse has 2-3 minutes to decide how long each patient should wait for medical care and assign a corresponding Triage Category

The nurse will use their expertise to process data obtained from the presenting problem, physiological observations, general appearance and all important gut feelings

urgency based on vital signs, complaints, appearance, and history

Coming by ambulance think of the following Code 1 did not need ambulance Code 2 minor injuries Code 3 serious injury Code blue =coding

A client arrives in the emergency room with multiple crushing wounds of the chest, abdomen, and legs. The assessments that assume the greatest priority are: select all that apply:

A. Level of consciousness and pupil size B. Abdominal contusions and other wounds C. Pain, respiratory rate, and blood pressure D. Quality of respirations and presence of pulses

The charge nurse is overseeing care of 10 clients on a general obstetrical floor. Concerning which of the following patient-care situations should the nurse notify the physician FIRST?

a. Prenatal client at 7 weeks gestation with nausea and vomiting and a whitish vaginal discharge.

b. A gravida 2 para 1 client at 28 weeks gestation with brownish facial blotches and +1 glucose and trace protein in a random urinalysis.

c. Seventeen-year-old client at 15 weeks gestation with missed abortion and bleeding from IV site.

d. Rh-negative client at 38 weeks gestation with blood pressure of 150/105, brisk reflexes, and generalized edema in hands and ankles.

You are asked what the correct steps in CPR are. Number them in the correct order. ___ initiate breathing ___ Open the client airway ___ Determine breathlessness ___ Perform chest compressions ___ determine unconsciousness by shaking

the client and asking “ Are you Okay?”

You are preparing to suction a client with a trach. List the order of priority for the actions to take during this procedure. ____ hyperoxygenate the client ____ Place the client in a semi fowler position ____ turn the suction on and set regulator to 80

mmHG ____ Apply gloves and attach the suction tubing to

the suction catheter ____ Insert the Catheter into the trach until resistance

is met and pull back 1 cm ____ Apply intermittent suction and slowly withdraw

while rotating it back and forth

You are the triage nurse coming on duty. The following patients come in to be seen. This is all the info you have. How would you triage them and why? 54/m c/o chest pain 2/10 had a CABG 6 months

ago. Hr 92 BP 140/90 RR32 SAO2 95% on 4 liters

7 /F mom states has been vomiting and diarrhea x 2 days. She has not voided for 12 hours and can not keep fluids down. HR 112 RR24 lips and mouth dry, skin cool

70/m with general weakness and unable to due ADL. He is SOB and c/o abd pain. Bibasilar crackles, HR 123 irregular BP 150/72 sat 88% RA

Hyperthermia Acute Medical Emergency Failure of heat regulating mechanisms Elderly and young at risk Exceptional heat exhaustion Stems from heavy perspiration

Need to stay hydrated! Causes thermal injury at cellular level

Treatment Lower temp as quickly as possible(102 and

lower) How can this be done? ABC’s Give 02, Start large bore IV Insert foley Labs:

Lytes, CBC, myoglobin. Cardiac enzymes

AssessmentMental status…Seizure may occurMonitor vitals frequentlyRenal status Monitor temp continuously EKG, Neuro status

Hypermetabolism due to increased body temp Increases 02 demand

Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

Heat Exhaustion Stroke

Heat ExhaustionCaused by dehydration

Stems from heavy perspiration Poor electrolyte consumption

Signs/Symptoms Normal mental status Flu like Headache Weakness N/V Orthostatic hypotension Tachycardia

Heat ExhaustionTreatment

Outside hospital Stop activity Move to cool place Cold packs Remove constrictive clothing Re-hydrate (water, sports drinks) If remains call 911

In hospital IV 0.9% saline Frequent vitals Draw serum electrolyte level

Heat Stroke Assessment

Monitor mental status Monitor vitals Monitor renal status

Treatment At site

ensure patent airway Move to cool

environment Pour water on scalp and

body Fan the client Ice the client Call 911

At hospital O2 Start IV Administer normal

saline Use cooling blanket DO NOT give ASA Monitor rectal temp q15

minutes Insert foley to monitor

I/Os closely and measure specific gravity of urine

Check CBC, Cardiac enzymes, serum electrolytes, liver enzymes ASAP

Assess ABGs Monitor vitals q 15

minutes Administer muscle

relaxants if the client shivers

Slow interventions when core temp is 102 degrees or less

Management of Patients With Heat Stroke Remember ABCs (decrease temp to 39° C as

quickly as possible Cooling methods

Cooling blankets, cool sheets, towels, or sponging with cool water

Apply ice to neck, groin, chest, and axillae Iced lavage of the stomach or colon Immersion in cold water bath

Monitor temp, VS, ECG, CVP, LOC, urine output Use IVs to replace fluid losses

– Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

Patient teaching Ensure adequate fluid and foods intake Prevent overexposure to sun Use sunscreen with at least SPF 30 Rest frequently when in hot environment Gradually expose self to heat Wear light weight, light colored, loose

clothing Pay attention to personal limitations: modify

accordingly

Cold InjuriesMost common

Hypothermia Frostbite

Synthetic clothing is best because it wicks away moisture and dries fast

“cotton kills” it holds moisture and promotes frostbite

A hat is essential to prevent heat loss though head

Keep water, extra clothing, and food in car in case of break down

Hypothermia

Internal core temperate is 35° C or less Elderly, infants, persons with concurrent illness,

the homeless, and trauma victims are at risk Alcohol ingestion increases susceptibility Hypothermia may be seen with frostbite;

treatment of hypothermia takes precedence Physiologic changes in all organ systems Monitor continuously

Assessment Apathy, drowsiness, pulmonary edema,

coagulopathies Weak HR and BP Hypoxemia Continuous temperature and EKG Watch for dysrhythmias

Frost Bite Inadequate insulation is the culprit 3 stages

Superficial (frost nip) Mild Severe

Frostnip produces mild pain, numbness, pallor of affected skin

NOW for the Bugs and Creatures

Snake Bites Most species non venomous and harmless Poisonous snakes found in each state except

Maine, Alaska, and Hawaii Fatalities are few Children 1-9 yrs old victims during daylight hours AWARENESS is KEY Most bites between April and October

Peak in July and August 2 main types in North America are

pit vipers (look for warm blooded prey) Water moccasins, copperheads, rattlesnakes Most of bites

Coral snakes From North Carolina to Florida and in the Gulf states, Arizona,

and Texas

Pit Vipers Depression between eye and nostril Triangular head indicative of venom

Venom function is to immbolize, kill and aid in digestion of prey (systemic effects happen with in 8 hours of puncture) impairs blood clotting Breaks down tissue protein Alters membrane integrity Necrosis of tissues Swelling Hypovolemic shock Pulmonary edema, renal failure DIC

2 retractable curved fangs with canals Rattlers have horny rings in tail that vibrates as a

warning

Treatment At site

Move person to safe area

Encourage rest to decrease venom circulation

Remove jewelry and restrictive clothing

Splint limb below level of heart

Be calm and reassuring No alcohol or caffeine

2nd to speed of venom absorption

At hospital Constrict extremity but

not to tight Do NOT incise or suck

wound Do NOT apply ice Use Sawyer extractor if

available if used within 3 minutes of bite and leave for 30 minutes in place

At hospital continued O2 2 large bore IV sites Crystalloid fluids (NS or LR) Continuous tele and bp

monitoring Opiod pain management Tetanus shot Broad spectrum antibx Lab draw (coagulation

studies, CBC, creatinine kinase, T and C, UA)

ECG Obtain history of wound

and pre-hospital tx measure circumference of

bite every 15-30 minutes Possibly give antivenom if

ordered (see page 177) Monitor for anaphylaxis Notify poison control

Coral Snakes Corals burrow in the ground Bands of black, red, yellow

“red on yellow can kill a fellow” “red on black venom lack”

Are generally non aggressive Ability to inject venom is less efficient Maxillary fangs are small and fixed Use chewing motion to inject Venom is neurotoxic and myotoxic

Enough in adult coral to kill human

Action of venom Blocks binding of acetylcholine at post synaptic junction

S/S pain mild and transient Fang marks may be hard to see Effects may be delayed 12 hours but then act rapidly after N/V Headache Pallor, abd pain Late stage: parathesias, numbness, mental status change,

crainal and peripheral nerve deficit , flaccid, difficulty speaking, swallowing, breathing

elevated creatinine kinase

Coral Treatment At site

Try to ID snake Same as pit viper

without concern of necrosis

At Hospital Continuous tele Continuous bp and

pulse ox Provide airway

management (possible ET tube)

Provide antivenom treatment as ordered

Monitor for anaphylaxis from antivenom

Notify poison control

Patient teaching Avoid venomous snakes as pets Be cautious in areas that harbour snakes like tall

grass, rock piles, ledges, crevices, caaves, swamps

Don protective attire like boots, heavy pants and leather gloves. Use a walking stick

Inspect areas before placing hands or feet in them

Do not harass snakes….striking distance is the length of the snake

Snakes can bite even 20—60 minutes after death due to bite reflex

Use caution when transporting snake with victim to hospital…make sure it is in a sealed container.

Arthropod Bites and StingsSpiders: carnivorous

Almost all are venomous Most not harmful to humans Brown recluse, black widow, and

tarantula are dangerous for exampleScorpions: not in Midwest or New

England Sting with tail Bark scorpion is most dangerous

Bees and Wasps Wide range of reactions African or killer bees are very aggressive

found in southwest stateshttp://www.videojug.com/film/how-to-treat-an-insect-bite

Brown recluse spider Bites result in ulcerative lesions Cytotoxic effect to tissue Medium in size Light brown color with dark brown fiddle

shaped mark from eyes Shy in nature..hide in boxes, closets,

basements, sheds, garages, luggage, shoes, clothing, bedsheets, clothes

Over 1-3 days lesion becomes dark and necrotic…eschar even forms, and sloughs

Surgery is often needed Skin grafting

Rare: Malaise, Joint pain, Petechaie, N/V Fever, Chills

PruritisErythemaExtreme: hemolytic, renal failure,

death

Treatment At site

Cold compress initially and intermittently over 4 days (may limit necrosis)

Rest Elevation of extremity NEVER use heat

At hospital Topical antiseptic Sterile dressing

changes Antibx Dapsone:

polymorphonuclear leukocyte inhibitor: 50mg twice/day

Monitor lab work closely

Surgery consult Debridment and skin

grafting

Black Widow Found in every state but Alaska Prefers cool, damp, environment Black in color with red hourglass pattern on

abd Male are smaller and lighter color that

females Carry neurotoxic venom Bites to humans are defensive in nature Main prey other bugs, snakes, and lizards Bite is can be painful, local reactions Systemic reactions can happen in 1 hour and

involve the neuromuscular system

Causes lactrodectism Venom causes neurotransmitters to release from nerve

terminals s/s

Abd pain Peritonitis like symptoms

N/V Hypertension Muscle rigidity Muscle spasms Facial edema Pytosis Diaphoresis Weakness Increased salavation Priapism Respiratory difficulty Faciculations parathesias

At site Apply an ice pack Monitor for

systemic involvement

ABCs

At hospital Monitor vitals Pain meds Muscle relaxants Tentanus Monitor for seizures Antihypertensives Anti venom if

needed Call poison control

Tarantulas Largest spider Found mostly in tropical and subtropical

parts of USA Some are in dry arid states like New Mexico

and Arizona Can live 25 years Venom paralyzes prey and causes muscle

necrosis Most human bites have local effects Have urticating hairs in dorsal abd area that

can be launched for a defensive technique landing in skin and causing an inflammatory response

USA trantulas don’t produce systemic reactions

Worldly ones doS/S

Pain at site Swelling Redness Numbness Lymphangitis Intense pruritis Severe ophthalmic reactions if hairs come

in contact with eyes

Treatment Pain meds Immobolize extremity Elevate site Remove hairs with sticky tape followed by

irrigation For eyes: irrigation with saline Antihistamines and steroids for pruritis

ScorpionsFound in many states Not usual in midwest or new england

unless pet, or transported in baggageVenom in stinger located on the tails/s

Localized pain Inflammation Mild symptoms

Treatment: pain meds, wound care, supportive management

Bark scorpionDeadlyHas a fatal stingFound in tress, wood piles, and around

debrisHumans stung when it gets in clothing,

shoes, blankets, and items left on ground

Solid yellow, brown, or tan in colorHave thin pinchers, thin tail, and a

tubercleFound in Arizona, New Mexico, Texas,

Nevada, and California Has neurotoxic venom

s/s Involve cranial nerves May be symptom free Pain Respiratory failure Pancreatitis Musculoskeletal dysfunction

Gentle tap at possible sting site while client not looking greatly increases pain, and is confirmation of bite

Symptoms begin immediately and reach maximum intensity in 5 hours

Most symptoms resolve in 9- 30 hours Pain and parathesia can last 2 weeks

Treatment Monitor vitals May need intubation Supply O2 IV Fluids Ice pack to sting site Pain meds and sedatives with caution in

non intubated client Wound care Call poison control Atropine gtts to help with hypersalavation Antivenom if needed

Bees/Wasps Stings cause wide array of reactions S/S

Anaphylaxis most severe Respiratory failure Hypotension Decrease in LOC Dysrhythmias Cardiac arrest

Pain Local reaction Swelling N/V Diarrhea Pruritis Urticaria Lip swelling

treatment At site

Remove stinger Ice pack Epipen if allergy to

bees Call 911 if needed

In hospital ABCs Check history for

allergy Epinephrine Antihistamine O2 NS 0.9% corticosteroids

Patient Education Wear protective clothing when working in areas

with known venomous athropods (bees, scorpions, wasps)

Cover garbage cans Use screens in windows and doors Inspect clothing and, shoes and gear before

putting on Shake out clothing and gear that is on ground Exterminate the exterior house Do not place hands where eyes can not see Do not keep insects as pets Epi pen if allergy to bee/wasp

POP QUIZ If someone collapsed at the boston

marathon. Core temp reflects 106 degree. Urine is tea colored. What does this mean?

If antivenom is not available what do you do??

Poisoning

According to your book, Poison is any substance that when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relativity small amounts injures the body by its chemical action

Treatment goals: Remove or inactivate the poison before it is absorbed Provide supportive care in maintaining vital organ

systems Administer specific antidotes Implement treatment to hasten the elimination of the

poison

Assessment of Patients With Ingested Poisons

Remember ABCs Monitor VS, LOC, ECG, and UO Assess lab values Determine what, when, and how much substance

was ingested Assess signs and symptoms of poisoning and

tissue damage Assess health history Determine age and weight

Interventions for those withIngested Poisons

remove the toxin or decrease its absorption Use emetics Gastric lavage Activated charcoal Cathartic when appropriate Administration of specific antagonist as early as

possible Other measures may include diuresis, dialysis, or

hemoperfusion

Management ofCarbon Monoxide Poisoning

Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen

Manifestations: CNS symptoms predominate Skin color is not a reliable sign pulse oximetry is not valid

Treatment Get to fresh air immediately Perform CPR as necessary Administer oxygen: 100% or oxygen under hyperbaric

pressure Monitor patient continuously

Draw blood levels May need HBO

Management of Food Poisoning

A sudden illness due to the ingestion of contaminated food or drink Food poisoning has the ability to result in respiratory

paralysis and death depending on the cause ABCs and supportive measures are key Treatment

correct fluid and electrolyte imbalances Control nausea and vomiting Provide clear liquid diet and progression of diet after

nausea and vomiting subside

Patients With Substance Abuse

Acute alcohol intoxication Alcohol poisoning may result in death Maintain airway Observe for CNS depression and hypotension Rule out other potential causes of the behaviors

before it is assumed the patient is intoxicated Use a nonjudgmental, calm manner Patient may need sedation if noisy or belligerent Examine for withdrawal delirium, injuries, and

evidence of other disorders Commonly abused substances: ???

see Table 71-1

Lightning Year round problem

Most common in summer Caused by electrical charge in cloud

Large energy with small duration High voltage is 1000 volts Lighting is 1 million volts

Cloud to ground is most dangerous Flash over phenomenon: force powerful

enough to blow off or damage the victims clothing

Injury is by: Direct strike Spashing or side flash off of near by structure Through the ground

Lightning Best remedy: AVOIDANCE Education

Observe forecasts Seek shelter when your hear thunder

DO NOT stand under tree DO NOT stand in an open area Isolated sheds and caves are dangerous

Leave water immediately Avoid metal objects If camping stay away from metal tent poles and

wet walls Stay away from open doors, windows, fireplaces Turn off electrical equipment Stay off of telephone Move to valley area and huddle in ball if in open

area (this minimizes target area)

Interventions At site

Spinal immobilization Monitor ABCs CPR Sterile dressings for

burns

Hospital care ACLS Telemetry ABC support Ventilator prn Creatinine kinase

level to determine muscle damage

Monitor for kidney failure

Monitor for rhabdomyolosis (muscle destruction)

Burn precautions Tetanus Xfer to burn center

Altitude related Illness High altitude is elevations above 5000 feet

most ski resorts As altitude increasesbarametric pressure

decrease This means less o2 the higher you go

Oxygen is 21% of the barametric pressure Acclimatizationthe process of adapting to

high altitudes Increased RR

Decrease in CO2 Respiratory alkalosis Impaired REM

Excess bicarb excretion through the kidneys Cerebral blood flow increases

3 most common altitude illnesses Acute Mountain Sickness (AMS)

Precursor for HACE/HAPEThrobbing headache, anorexia, N/VChilled, irritableSimilar symptoms to alcohol hangoverVS variable DOE or at rest

High altitude cerebral edema (HACE)Unable to perform ADLsAtaxia w/o focal signs (decreased motor coordination)Confusion, impaired judgment , seizuresStupor, Coma, Death from brain swelling

Increased ICP over 1-3 days High altitude pulmonary edema (HAPE)

Most frequent cause of deathPoor exercise intolerance and recoveryFatigue and weaknessTachycardia and tachypnea, rales, pneumoniaIncreased pulmonary artery pressure

Altitude Illness Site

Descent to lower altitude

Monitor for symptom progression

Rest O2 if available

Hospital Acetazolamide

Acts as bicarb diureticSulfa drugTake 24 hours before

ascent and take for 1st 2 days of the trip

125mg-250mg po BID or 500mg SR cap daily

Dexamethazone: 4mg – 8mg po or IM initially then 4mg q6hours during descent

O2 Monitor airway Lasix Critical care

Altitude Education Plan a slow descent Avoid overexertion and over exposure to

cold Avoid alcohol and sleeping pills Stay hydrated and have adequate

nutrition If symptoms develop descend

immediately O2 if able Wear protective gear Wear sunscreen

Near Drowning

Rip currents are powerful currents of water moving away from shore.

More people die every year from rip currents than from shark attacks, tornadoes, lightning or hurricanes.

According to the United States Lifesaving Association, 80 percent of surf beach rescues are attributed to rip currents, and more than 100 people die annually from drowning when they are unable to escape a rip current.

Rip currents can attain speeds as high as 8 feet per second Some rip currents last for a few hours; others are permanent.

Rip currents range from 50 to 100 feet or more in width. They can extend up to 1000 feet offshore.

If caught in a rip current: •Remain calm to conserve energy and think

clearly. •Never fight against the current. •Think of it like a treadmill that cannot be turned

off, which you need to step to the side of. •Swim out of the current in a direction following

the shoreline. When out of the current, swim at an angle--away from the current--towards shore.

•If you are unable to swim out of the rip current, float or calmly tread water. When out of the current, swim towards shore.

•If you are still unable to reach shore, draw attention to yourself by waving your arm and yelling for help.

POP QUIZ What does salt do to the body?

Causes Leaving small

children unattended around bathtubs and pools

Drinking alcohol while boating or swimming

Inability to swim or panic while swimming

Falling through thin ice

Blows to the head or seizures while in the water

Attempted suicide

Symptoms Symptoms can vary, but

may include: Abdominal distention Bluish skin of the face,

especially around the lips Cold skin and pale

appearance Confusion Cough with pink, frothy

sputum Irritability Lethargy No breathing Restlessness Shallow or gasping

respirations Chest pain Unconsciousness Vomiting

Prevention Avoid drinking alcohol whenever swimming or boating. Observe water safety rules. Take a water safety course. Never allow children to swim alone or unsupervised

regardless of their ability to swim. Never leave children alone for any period of time, or

let them leave your line of sight around any pool or body of water. Drowning have occurred when parents left "for just a minute" to answer the phone or door.

Drowning can occur in any container of water. Do not leave any standing water (in empty basins, buckets, ice chests, kiddy pools, or bathtubs). Secure the toilet seat cover with a child safety device.

Fence all pools and spas. Secure all the doors to the outside, and install pool and door alarms.

If your child is missing, check the pool immediately.

Spinal Cord Injuries (SCI) tetraplegia (quadriplegia): paralysis from

neck down Loss of bowel and bladder control Loss of motor function Loss of reflex activity Loss of sensation Coping issues*Christopher Reeve is example of this injury*

Complete: spinal cord severed and no nerve impulses below level of injury

Incomplete: allow some function and movement below level of injury

Causes of SCI Primary

Hyperflexion (moved forward excessively) Hyperextension (MVA) Axial loading (blow at top of head causes

shattering) Excessive rotation (turning beyond normal range) Penetrating (knife, bullet)

Secondary Neurogenic shock Vascular insult Hemorrhage Ischemia Electrolyte imbalance

Cervical Injuries Anterior cord syndrome

Damage to anterior portion of gray and white matter as a result of decreased blood supply..pt will have a loss of motor function, pain, and temperature sensation but touch, vibration, and position remain intact

Posterior cord lesion Damage to posterior white and gray matter..pt has

intact motor function but loss of vibratory sense, crude touch, and position sensation

Brown Sequard syndrome Result of penetrating injury that causes hemisection

of spinal cord. Motor function , proprioseption, vibration, and deep

touch are lost on the same side as injury (ipsilateral) On the other side (contralateral) the sensation of

pain, temperature and light touch are affected Central cord syndrome

Loss of motor function in upper extremities and varying degrees of sensation remain

Assessment Of SCI 1st assess respiratory status

ET tube may be necessary if compromised 2nd assess for intra-abdominal hemorrhage

(hypotension, tachycardia, weak and thready pulse)

3rd assess motor function C4-5 apply downward pressure while the client

shrugs C5-6 apply resistance while client pulls up arms C7 apply resistance while pt straightens flexed

arms C8 check hand grasp L2-4 apply resistance while the client lifts legs from

bed L5 apply resistance while client dorsiflexes feet S1 apply resistance while client plantar flexes feet

Emergency Care of SCI Observe for signs of autonomic dysreflexia

Sever HTN, bradycardia, sever headache, nasal stuffiness, and flushing Caused by noxious stimuli like distended bladder or

constipation Immediate interventions

Place in sitting position Call doctor Loosen tight clothes Check foley tubing if present Check for impaction Check room temp Monitor BP q10-15 minutes Give nitrates or hydralazine per md order

Treatment of SCI Immobilize fxProper body alignment

Traction is possibleMonitor vs q4 hours or moreNeuro checks q4 hours or moreMonitor for neurogenic shock

(hypotension and bradycardia)Prepare for possible surgeryTeach skin care, ADLs, wound

prevention techniques, bowel and bladder training, medications, and sexuality

Brain Injuries (TBI) Open- skull fx or when skull is pierced by penetrating

object Linear fx- simple clean break Depressed fx- bone pressed in towards tissue Open fx-lacerated scalp that creates opening to brain

tissue Comminuted fx- bone fragments and depresses into

brain tissue Basilar- unique fx at base of skull with CSF leaking

though the ear or nose Closed- blunt trauma

Mild concussion-brief LOC Diffuse axonal injury- usually from MVA

May go into coma Contusion-bruising of brain

Site of impact (coupe) Opposite side of impact (contrecoupe)

Laceration-tearing of cortical surface vessels that leads to hemorrhage edema and inflammation

Motor Vehicle Collisions Frontal

Front of car stops and driver keeps going Injuries: Seatbelt, Steering wheel, TBI, cspine,

flail chest, myocardial contusion Side

Injuries: Cspine, flail chest, pneumothorax Rear

Hyperextension, cspine Rollover

Multiple injuries

POP QUIZ A front end collision with airbags and

seatbelts in place and working may break ribs. If this occurs what do we need to monitor for?

Figure 74.2 Unrestrained frontal impact.

Other types of multiple injuries Motorcyle

Tib/fib, chest, abd, TBI, cspine, femur

Pedestrian Femur, chest, lower extremities

Falls Calcaneous, compression, wrist, TBI

Blunt Trauma by Force Acceleration-caused by external force

contacting head

Deceleration- when head suddenly stops or hits a stationary object

Interventions for musculoskeletal trauma

Fractures Open Closed Spontaneous Stress Compression Greenstick Spiral Oblique Impacted

Displaced Non-displaced fragmented

Stages of healing 48-72 hours after injury hematoma forms at

break site Area of bone necrosis forms secondary to

diminished blood flow Fibroblasts and osteoblasts come to site Fibrocartilage forms =new foundation Callus forms 2-6 weeks after initial break 3 weeks to 6 months later new bone is

formed

Musculoskeletal assessment Assess for life threatening complications Skin color and temp Movement Sensation Pulses especially distal to the injury Cap refill Pain Listen for crepitation-grating sound Look for ecchymosis Assess for subcutaneous emphysema-bubbles under

skin (like bubble wrap when pushed) Assess clients feeling of situation Some fractures can causes internal injury-

hemorrhage

diagnostics No special lab tests except maybe D-Dimer

for clots H/H could be low due to bleeding CT Bone scan MRI X-rays

Affected extremity

interventions Inspect fx site Palpate area lightly Assess motor function Immobilize extremity Realignment Cast Traction Surgery

open reduction with internal fixation

education Provide education regarding medication Instruct the client on s/s of infection (foul

discharge, purulent drainage, fever, lethargy, etc)

Instruct on dressing changes and importance of them

Instruct about pressure ulcer prevention Instruct on use of crutches or walker if

needed Instruct about HHC and other available

resources

Specific fractures

Fx of clavicle usually from a fall Fx of scapula not common and caused by direct impact Fx of humerus common in older adult Fx of olecrenon usually from fall directly onto elbow Fx of radius and ulna usually Fx together Fx of wrist and hand most common site is the carpal

scaphoid bone in young adult men..one of the most misdiagnosed Fx b/c of poor visibility on x-ray

Fx of hip caused by falls Fx of femur caused from trauma Fx of patella result from direct impact Fx of tibia and fibula usually break together Fx of ankle and foot difficult to heal because of instability of

ankle bone

Fx of ribs and sternum caused by chest trauma and potentially can puncture lungs, heart and arteries

Fx of pelvis can also cause major internal damage because of the vascular structure present

Compression Fx of the spine usually caused by osteoporosis. This causes pain, deformity, neurologic compromise

Femur and Pelvic Fractures

High incidence of hemmorage Femur fx-cast, brace, splint, traction

Fat embolism: fat from bone released into blood and into heart, lungs, etc

Pelvic- girdle, assess for stability Large amount of force Rectal exam

Figure 56.10 Vascular anatomy of the pelvis.

Dislocations Painful Needs to be reduced ASAP Can cause nerve damage Avascular Necrosis

Dislocation occludes blood supply

complications

Acute compartment syndrome: increase pressure compromises circulation to are. Most common in lower leg and forearm.

Fat embolism: fat from bone released into blood and into heart, lungs, etc. Most common with long bone fx

DVT PE INFECTION: from break or from implanted hardware..bone

infection most common with open fx Fracture blisters: associated with twisting injury..fluid moves into

vacant spaces..leads to infection Ischemic necrosis: blood flow to bone is disrupted Delayed union: unhealed after 6 months Nonunion:never completely heal Malunion: heal incorrectly

CRUSH SYNDROME

CAUSES Wringer type injuries Natural disasters Work related injuries Drug or alcohol overdose

CHARACTERISTICS Acute compartment syndrome Hyperkalemia Rhabdomyolosis – myoglobin released into blood

S/S Hypovolemia, hyperkalemia, compartment syndrome

TX IVF, diuretics, low dose dopamine, sodium bicarb,

kayexelate, hemodialysis is possible.

Complex regional pain syndrome s/s: debilitating pain, atrophy, autonomic

dysfunction (excessive sweating, vascular changes), and motor impairment (muscle paresis)

Caused by hyperactive sympathetic nervous system

Results from trauma Common in feet and hands 3 stages:

1: lasts 1-3 months; local severe burning pain, edema, vasospasm, muscle spasms

2: 3-6 months; pain, edema, muscle atrophy, spotty osteoporosis

3: marked muscle atrophy, intractable pain, severely limited mobility, contractures, osteoporosis

Sports related injuries Tears Lock knee Torn ACL Tendon rupture Dislocation Subluxation Strains Sprains Torn rotator cuff

Interventions for musculoskeletal trauma

Casts Braces Splints Traction Surgery Reduction (realignment)

amputations

Removal of part of the body Types

Surgical-example digit Traumatic- example digit

Levels Lower extremity: digits, bka, aka, midfoot Upper extremity: hands, fingers, arms

Complications Hemorrhage Infection Phantom limb pain: perceive pain in the amputated limb Immobility Neuroma: sensitive tumor consisting of nerve cells found

at several nerve endings Contractures

assessments

Skin color Temp Sensation Pulses Cap refill Assess feelings r/t amputation

Young: bitter, hostile, uncooperative, loss of job, loss of hobbies, altered self concept, feeling a loss of independence

Assess families perceptions also Routine preop xrays done BP done in all extremities Angiography to look at layout of vessels

Stab wounds 4 types of wounds

Incised = Sharp cut like injuries (knives, glass)

Slash wounds= more longer than deep

Stab wound= depth longer than length

Defense wound= warding wounds (like on hand)

Defense WoundStab Wound w/ single edge blade

Gun shot wounds4 types

Close contact= illustrates a patternized abrasion around the wound

Contact= barrel has contacted the skin and the gases have passed into SQ tissues faint abrasion ring and sone grey/black discoloration

Intermediate wound= powder tatooing Exit wound= slit like exit wound…no

powder or soot

Wound Care Treatment (at Site) Bleeding can usually be stopped by applying direct

pressure to the wound. Very large foreign objects stuck in a wound should be

stabilized. Do not remove them. All wounds require immediate thorough cleansing with

fresh tap water. Gently scrub the wound with soap and water to remove

foreign material. If a syringe is available, it should be used to provide high-pressure irrigation.

Remove dead tissue from the wound with a sterile scissors or scalpel.

After cleaning the wound, a topical antibiotic ointment (bacitracin) should be applied 3 times per day.

Wounded extremities should be immobilized and elevated. Puncture wounds are usually not sutured (stitched) unless

they involve the face.

If the wound is clean, the edges can be drawn together with tape. (Do not cover wounds inflicted by animals or

that occurred in seawater with tape.) Oral antibiotics are usually recommended to prevent

infection. If infection develops, continue antibiotics for

at least 5 days after all signs of infection have cleared.

Inform the doctor of any drug allergy prior to starting any antibiotic. The doctor will prescribe the appropriate antibiotic. Some may cause sensitivity to the sun, so sunscreen (at least SPF 15) is mandatory while taking these antibiotics.

Pain may be relieved with 1-2 acetaminophen (Tylenol) every 4 hours, 1-2 ibuprofen (Motrin, Advil) every 6-8 hours, or both.

Call 911 or get to ER immediately if stab or gunshot wound.

Sexual Abuse Sexual abuse (also referred to as molestation) is defined as the

forcing of undesired sexual acts by one person to another. The term incest is defined as sexual abuse between family members, and the euphemism "bad touch" is sometimes used to describe such abuse. (Renvoizé 1982)

Different types of sexual abuse involve: Non-consensual, forced physical sexual behavior such as rape or

sexual assault Psychological forms of abuse, such as verbal sexual behavior or stalking. The use of a position of trust for sexual purposes.

Acquaintance rape - forced sexual intercourse between individuals who know each other - is a crime that is widespread on many college and university campuses. Usually, both parties involved in acquaintance rape have been drinking -

often to excess. Research has not yet explained how and why alcohol is related to

aggression in general or to acquaintance rape in particular http://www.youtube.com/watch?v=PvXxzZUuIn0

Sexual Abuse Signs of sexual abuse Unexplained injuries (especially to parts of

the female body that can be covered by a two-piece swimsuit)

Torn or stained clothing or underwear Pregnancy Sexually transmitted diseases (STDs) Unexplained behavioral problems Depression Self abuse and/or suicidal behavior Drug and/or alcohol abuse Sudden loss of interest in sexual activity Sudden increase of sexual behavior

The doctor in the emergency room will examine the victim for injuries and collect evidence. The attacker may have left behind pieces of evidence such as

clothing fibers, hairs, saliva or semen that may help identify him.

In most hospitals, a "rape kit" is used to help collect evidence. A rape kit is a standard kit with little boxes, microscope slides

and plastic bags for collecting and storing evidence. Samples of evidence may be used in court.

Next, the doctor will need to do a blood test. Women will be checked for pregnancy and all rape victims are tested for diseases that can be passed through sex. Cultures of the cervix may be sent to a lab to check for

disease, too. The results of these tests will come back in several days or a few weeks.

It's important for the client to see their own doctor in 1 or 2 weeks to review the results of these tests. If any of the tests are positive, the victim will need to talk with your doctor about treatment.

Rape Classified as assault Primary cause is an aggressive desire to

dominate according to experts Difficult to prosecute b/c of lack of evidence Statistics

Women by men: 90-91% most frequent Male by male: 9-10% less common Little to no research on women offenders

Definition Intercourse , is attempted or happens without

consent of one of the parties involved (penetration with penis or objects etc)

Effects of rape Unpredictable emotions

Feeling numb and detached Memory problems Avoidance of things anxiety

PTSD can occur Relive the rape over and over

Disturbed sleeping patterns Eating habits affected

More stats If reported to police 50% chance an arrest

will be made If arrest made, 80% chance of prosecution If prosecuted, 58% chance of felony

conviction If felony conviction, 69% chance of jail time

Mandatory reporting If abuse suspected

Child Domestic Any type