Week 10: Trauma & Burns

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True or False:
Injury is the 5th leading cause of death over all ages.
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Terms in this set (105)
What is an acceleration, blunt trauma force?Increased rate/velocity/speed of moving object Something at rest suddenly accelerates Where is the injury? Neck/face Whiplash Bleed in front and back of brainWhat is a deceleration, blunt trauma force?Sudden stop Injury is worse than in acceleration Bleed in front and back of brainWhat are the other two types of blunt trauma forces? (aside from acceleration/deceleration)-shearing -compressionWhat are the steps in the management of a trauma patient?1) Across the Room Survey -look for obvious signs of bleeding as you first see the patient 2) Primary Assessment -A: airway/alertness with c-spine stabilization -B: breathing -C: circulation -D: disability (neuro status) -E: expose (take clothes off) 3) Secondary Assessment -F: full set of vitals/focused adjuncts -G: give comfort measures -H: history and head-to-toe assessment -I: inspect posterior surfacesTrue or False: Blood loss is #1 thing that kills trauma patientsTrueWhat is important when managing the airway and c-spine in a trauma?-always maintain c-spine alignment and stabilization -ensure the airway is patent (is the patient talking? gurgling?) -if the airway is not patent, what is the cause? (blood-tube? vomit-suction?) -if airway is compromised, secure a definitive airway?What is important when managing breathing in a trauma?-assess chest wall excursion -ascultate lungs/percuss -assess RR and pattern -assess skin color -intubate if indicated -necessary procedures to correct cause of distressWhat is important when managing circulation in a trauma?-Circulation effective? LOC, skin color, pulse -Place 2 large bore IVs -Control external hemorrhage -Administer blood products -ACLS measures if arresting -Necessary procedures to correct cause of circulatory compromise -Vital signs: hypotensive? tachy?What is class I hemorrhagic shock: -blood loss (mL) (%)? -pulse rate? -BP? -pulse pressure? -RR? -UOP? -CNS/Mental Status? -Fluid replacement?-blood loss (mL) (%)? 750 mL; 15% -pulse rate? <100 -BP? normal -pulse pressure? normal or increased -RR? 14-20 -UOP? >30 -CNS/Mental Status? slightly anxious -Fluid replacement? crystalloidWhat is class II hemorrhagic shock: -blood loss (mL) (%)? -pulse rate? -BP? -pulse pressure? -RR? -UOP? -CNS/Mental Status? -Fluid replacement?-blood loss (mL) (%)? 750-1000 mL; 15-30% -pulse rate? >100 -BP? normal -pulse pressure? decreased -RR? 20-30 -UOP? 20-30 -CNS/Mental Status? mildly anxious -Fluid replacement? crystalloidWhat is class III hemorrhagic shock: -blood loss (mL) (%)? -pulse rate? -BP? -pulse pressure? -RR? -UOP? -CNS/Mental Status? -Fluid replacement?-blood loss (mL) (%)? 1500-2000 mL; 30-40% -pulse rate? >120 -BP? decreased -pulse pressure? decreased -RR? 30-40 -UOP? 5-15 -CNS/Mental Status? anxious; confused -Fluid replacement? crystalloid and bloodWhat is class IV hemorrhagic shock: -blood loss (mL) (%)? -pulse rate? -BP? -pulse pressure? -RR? -UOP? -CNS/Mental Status? -Fluid replacement?-blood loss (mL) (%)? >2000 mL; >40% -pulse rate? >140 -BP? decreased -pulse pressure? decreased -RR? >35 -UOP? negligible -CNS/Mental Status? confused; lethargic -Fluid replacement? crystalloid and bloodWhat is important when managing disability (neuro) in a trauma?-rapid neuro evaluation to establish LOC, pupillary size and reaction, lateralizing signs, and spinal cord injury level -glasgow coma scaleWhat is important when managing exposure (removing the patient's clothes) in a trauma?-remove clothing for full body assessment of injuries (proper decontamination if exposure to hazardous substance) -warm blankets to prevent hypothermia -trauma room should be hot (to prevent hypothermia)What are adjunct procedures and diagnostic tests done during the primary survey of a trauma patient?-ECG monitoring -urinary catheters -NGT (is suspected stomach bleed) -Thoracostomy tube -ET or OT intubation -Big 3 X-Rays (chest, abdomen, pelvis) -Labs -FAST exam (check heart, abdomen, spleen, liver for bleeding) -Needle decompression (mid-clavicular line, 2nd intercostal space) -Pericardiocentesis (draw off fluid from pericardium)What is done in a secondary assessment of a trauma patient?Complete head-to-toe evaluation -full history (mechanism of injury; injuries; medications; allergies) -complete physical exam including repeat vital signsWhat are secondary survey adjunct diagnostic tests and labs?-radiographic studies to assess for non life-threatening injuries -CT scans -extremity x-rays -contrast x-ray studies -endoscopy -ultrasonography -lab studiesWhat is the epidemiology of thoracic trauma?-1 of 4 deaths in US -MVCs account for 2/3 of deaths from thoracic injury -overall mortality is 10% -frequently associated with other injuries -significant association with morbidityWhat are examples of thoracic injuries?-chest wall: flail chest -pulmonary contusions -hemothorax (HTX) -pneumothorax (PTX) -heart -diaphragm -aorta or great vessels -esophagusWhat are clinical manifestations of thoracic trauma?-tachypnea; apnea -tracheal deviation (tension PTX) -JVD or jugular collapse -hypoxia or hypercarbia -metabolic acidosis -hypotenison -tachycardia -cardiac arrhythmias -cardiac arrestWhat are immediate life threatening injuries that can result from thoracic trauma?-airway obstruction -tension PTX -open PTX (sucking chest wound; penetrating lung injury) -flail chest -massive HTX -cardiac tamponadeWhat is a tension pneumothorax? leads to? clinical manifestations? treatment?-injury creates a one-way valve where air enters the pleural space but cannot escape -leads to: collapse of ipsilateral lung; mediastinal shifting; profound shock; compression of contralateral lung; cardiac tamponade and death -clinical manifestations: tachypnea, tachycardia, hypotension, absent breath sounds, tympany upon percussion, tracheal deviation toward unaffected side, JVD -treatment: immediate decompressionWhat is an open pneumothorax? treatment?-opening in the chest wall 2/3 the size of the trachea -air moves through hole in chest wall with respiratory efforts and becomes trapped -pressure builds in chest -treatment: dressing over wound occluded on 3 sides (to let the air get out, but not be sucked back in)What is flail chest? treatment?-Couple of broken ribs; ribs into pieces (floating pieces of rib) -two or more ribs fractured at two or more places -paradoxical chest movement with respiration; hypoxia; frequent need for intubation -when you breathe out, flail piece pops out; when you inhale, flial piece sucks down -treatment: supportive careWhat is a massive hemothorax? clinical features? treatment?-accumulation of >1500 mL of blood in the chest -clinical features: hypotension, tachycardia, tachypnea, absent breath sounds, dull on percussion, tracheal deviation toward unaffected side, jugular vein collapse -treatment: chest tube decompression, fluid resuscitation, auto transfusion, emergent thoracotomyWhat is cardiac tamponade? clinical manifestations? diagnosis? treatment?-penetrating injury to the heart -clinical manifestations: exaggerated pulsus paradoxus (>10 mmHg); beck's triad (hypotension, JVD, muffled heart tones); kussmaul's sign (paradoxical rise in JVD with inspiration) -diagnosis: clinical; ultrasound; subxiphoid pericardial window -treatment: pericardiocentesis (Get fluid out); emergent thoracotomy (done in ER if patient in PEA after penetrating chest wound)What are potentially life threatening injuries that can be sustained from a thoracic injury?-PTX -HTX -pulmonary contusions -blunt cardiac injury -traumatic rupture of the aorta -traumatic diaphragmatic hernia -esophageal injuryWhat is a massive HTX?Defined by immediate return of 1500 mL or greater of blood with CT placement (must go to OR immediately for a thoracotomy) -Also indicated if >200 mL of blood per hour for 2-4 hours or if persistent blood transfusion is neededWhat are indications for CT placement?-PTX -HTX -difficulty breathing/shortness of breath -tachypnea -decreased breath sounds -crepituse -hypoxia -hemodynamic instabilityWhat is a blunt cardiac injury?-cardiac contusion (can result in conduction abnormalities and should be monitored for 24 hours; risk of sudden dysrhythmia decreases after this time period) -chamber rupture/injury to additional parts : R>L ventricular injury; valve injury; coronary artery occlusion or dissection; chordae tendinae rupture; septal or free wall rupture -cardiac dysrhythmias -commotio cordisWhat is an aortic disruption?-common cause of sudden death after MVC or fall resulting from shearing forces -salvageable injuries often occur as incomplete laceration near the ligamentum arteriosum -aortography is gold standard; TEE is less invasive -CT has 100% sensitivity and specificity, but only stable patients should undergo this method of diganosticsWhat is a traumatic diaphragmatic hernia?-occurs in 1-7% of patients after blunt injury -diagnosis missed on initial presentation of 66% of patients -plain film findings of rupture include displacement of stomach, colon, or small bowel into the thorax (can be obscured by pleural effusion, basilar opacity, irregular diaphragm contour and rib fractures) -gut in your chest; hernia cuts off circulation to stuff in the gut; no bowel sounds -if diaphragm rupture is not promptly diagnosed, the patient may remain asymptomatic or develop incarceration of herniated abdominal viscera, which can occur at a time remote from the incidence of traumaWhat is esophageal rupture? clinical manifestations?-caused by forceful expulsion of gastric contents into the esophagus from a severe upper abdominal blow -ejection of contents causes a linear tear in the lower esophagus -leakage (of stomach contents) into the mediastinum occurs resulting in mediastinitis and eventual rupture into the pleural space causing an empyema -clinical manifestations: left PTX/HTX without rib fracture; trauma to sternum or epigastrum; particulate matter in the chest tube; presence of mediastinal airWhat are other potential thoracic trauma injuries?-rib fracture -sternal fracture -scapular fracture -clavical fracture -extra-thoracic vascular injury -traumatic asphyxia -air embolism -missile embolizationWhat are nursing considerations when caring for a patient with a thoracic trauma injury?-constant reassessment of primary assessment -assistance with set-up for procedures or OR transport -record of complete and strict I&Os -monitoring of tubes and assessment for appropriate function -transportation of patient to various radiographic studies -assess for signs of infection -tetanus update shot -wound care and dressing changes -early mobility if not contraindicated -pulmonary toilet (percussion therapy and suctioning) -DVT preventionWhat are blunt abdominal injuries?-injury as a result of rapid change in speed -visceral disruption caused by: direct blows; shear forcesWhat are common blunt abdominal injuries?-diaphragmatic rupture -duodenal rupture/hematoma -pancreas -kidneys -urethra -bladder -small bowel -pelvic fracturesWhat is a FAST exam?-focused assessment sonography in trauma -detects the presence of hemoperitoneum and pericardial fluid -4 views: hepatorenal, splenorenal, pelvic, cardiacWhat are the 2 types of penetrating abdominal injuries?-impalement or stab wounds: injury pattern follows trajectory of the offending object; surgical intervention depends upon patient presentation -gunshot wounds: trajectory may not be a straight line; may have further injury from blast and cavitation; mandatory surgical explorationWhat are areas penetrating abdominal injuries can affect?Diaphragm Liver Spleen Cardiac Stomach/Omentum Transverse colon Small bowel Sigmoid colon Mesentery Aorta Inferior vena cava Kidneys Urethra/Ureters Pancreas Ascending/Descending colon Adrenal glands Spine Bladder Rectum Vessels Reproductive organsWhat is abdominal compartment syndrome?-acute change in intra-abdominal pressure >20 mmHg -cardiac, pulmonary, renal, and splanchnic compromise -requires immediate surgical decompressionWhat is a bladder pressure? how is the procedure performed?-Used to measure abdominal compartment pressures -Inject 50-500 mL of saline into the bladder; place a needle thru the specimen port; place the transducer at the level of the symphysis pubis; record pressure with transducerWhat are immediate complications from the treatment of abdominal compartment syndrome? delayed complications?Immediate: -hypotension -cardiac arrest -unmeasured volume loss -hypothermia -loss of tamponade -bowel coverage -ventilation issues Delayed: -infection**** -serosal tear -GI fistual -loss of abdominal domain -large incisional hernia -definitive coverage -nutritionWhat are nursing considerations with abdominal traumatic injuries?-constant reassessment of primary assessment -Assistance with set-up for procedures or OR transport -Record of complete and strict I&Os -Monitoring of tubes and assessment for appropriate function -Transportation of pt to various radiographic studies -Assess for signs of infection -Wound care and dressing changes -Early mobility if not contraindicated -Pulmonary toilet -DVT preventionTrue or False: Estimated 1 Million burn injuries annuallytrue *2nd only to MVA deaths for ages 5-9True or False: 71% of burn victims are mentruetrue or false: 17% of burn victims are under age 5 12% age 60+true *scald injury most commonTrue or False 70% of burn injuries are due to fire/flame and scaldstrueTrue or False Burns are the 5th leading cause of non-fatal ED visit for children under age 1 in 2008trueWhat are the causes of burns?Injury or damage to body tissue caused by: -radiation -electricity -chemicals -heat (thermal): scalding, flames, steam, friction -cold: frostbiteThere are 3 zones of burns. What are the zones from inner most to outer most?Inner: zone of coagulation Middle: zone of stasis Outer: zone of hyperemiaWhat is the zone of coagulation?-innermost zone -area of irreversible tissue damageWhat is the zone of stasis?-middle zone -surrounds the zone of coagulation -area of ischemic tissueWhat is the zone of hyperemia?-outermost zone -area of increased tissue perfusionWhat is the goal when dealing with a patient's burn? (in terms of zone)Goal is to prevent zone of stasis from becoming zone of coagulationWhat is a superficial (1st degree) burn?-limited to epidermis -pink or red in appearance -dry on surface -painful sensation -days of healing timeWhat is a partial thickness superficial (2nd degree) burn?-extends into dermis -pink, clear blisters -moist on surface -painful sensation -14-21 days of healingWhat is a partial thickness deep (2nd degree) burn?-extends into deep (reticular dermis) -pink, hemorrhagic blisters, red -moist on surface -painful sensation -healing time: weeks to months; may progress to 3rd degree; may require grafting to reduce scarringWhat is a full thickness (3rd degree) burn?-extends thru dermis into SQ tissue -white, brown, eschar formation in appearance -dry, leathery appearance -insensate (due to nerve destruction) -requires excisionWhat is a full thickness (4th degree) burn?-complete destruction into SQ fat, muscle, and bone -brown; charred -dry -insensate (due to nerve destruction) -requires excisionWhat are the 3 phases of a burn?1) emergent phase (resuscitative) 2) acute phase (wound healing) 3) rehabilitative phase (long-term; restorative)What occurs in the emergent (resucitative) phase of a burn?-time of burn = 3 days -ends when fluid mobilization and diuresis begin -primary nursing concerns = airway; hypovolemic shock (fluid seeping out; need fluid rescucitation); edema (due to inflammation); organ function; fluid/electrolyte imbalance (high K+) -wound care: delayed until a patent airway, adequate circulation, and adequate fluid replacement have been established; debridement -stabilize ABCs -stop the burning process -begin fluid resuscitation -treat associated injuries -consider referral criteriaWhat occurs in the acute (wound healing) phase of a burn?-majority of wound care -ends when the burn wounds are covered with viable grafts or healing naturally -lasts weeks to months -primary nursing concerns: infection, preservation of function, scarringWhat occurs in the rehabilitative (long/restorative) phase of a burn?-begins when burns have healed; patient can resume self-care -duration depends on the severity of burn injury; can be life long -primary nursing concerns: adaptation, function, quality of lifeHow is total burn surface area calculated?-lund and browder chart -rule of 9sWhat is the rule of 9s?What is inhalation burn injury?-pulmonary injury due to hot air, toxic gases, or particulate matter -affects normal respiratory function through 3 mechanisms: 1) thermal damage to airways (impaired ventilation) 2) carbon monoxide or cyanide poisoning (tissue hypoxia) 3) chemical damage from noxious gases (impaired gas exchange)What are clinical manifestations of inhalation burns?-dyspnea with adventitious and/or decreased breath sounds -wheezing, stridor, etc. -upper airway edema -asphyxiationWhat do inhalation burns involving carbon monoxide present with?-cherry red coloring of the skin and mucous membranes -HA; dizziness -nausea -confusion, hallucinations, irritability -seizures -coma development -permanent neurological damageWhat are radiation burns caused by?-exposure to ionizing radiation or radio frequency energy (causes cellular DNA damage; may be associated with cancer development) -generally superficial burnsWhat are the most common causes of radiation burns? other causes?Sunburn Other: radiation treatment, microwave burns, x-ray burns, high power radio transmission, nuclear warfare, nuclear accidentsWhat are electrical burns caused by?burns resulting from intense heat generated from electrical currentWhat is an alternating current? what injury is caused by it?-current flows in a cyclical manner -tetanic muscle contractions occur -household electrical wires: low voltage, temperatures up to 1370 C; children under 5 most common victims -utility wires: high voltageWhat is an direct current? what injury is caused by it?-victim is thrown from current source -types: lightning, defibrillator, utility wires (high voltage) -temperatures up to 5000 CTrue or False Low voltage AC exposure is more harmful than a low voltage DC exposuretrueWhat are important considerations when assessing electrical burns?-voltage -type of current -location fo electrical source -duration of contact with the electrical source -check pulse to check for presence of arrhythmia -Be aware of tissue destruction (myoglobin, creatinine kinase, potassium levels) -entrance wound (high voltage entrance wound: charred, centrally depressed, leathery in appearance) -exit wound (high voltage exit: exploded outward appearance, may be small) -potential path of travel (hand to hand is 60% mortality; hand to foot 0% mortality) -presence of thermal burns -peripheral circulation -neruological status -cardiac dysrhythmias -fractures or dislocations from the force of current -head or neck injury if fall occurred (c-spine protection) -pain (may be minimal or absent due to destruction of nerve tissue)What 3 categories are chemical burns divided into?-alkali burns -acid burns -irritants *chemical burns occur at work and home from cleaning products or other regular household products; follow standard burn classificationsWhat are alkali chemical burns?-may appear trivial, but are the most dangerous -high pH -allows deep penetration thru the surface of the eye -severe injury to external (cornea) and internal structures (lens) -causes saponification- "soupy" wound -common alkali substances: fertilizers, cleaning products (ammonia), drain cleaners (lye), oven cleaners, and plaster or cement (lime)What are acidic chemical burns?-low pH; usually less severe than alkali burns (damage is localized due to rapid neutralization by natural buffer systems) -do not penetrate into the eye as readily as alkaline substances -common acids: sulfuric, sulfurous, hydrochloric, nitric, acetic, chromic, hydrofluoric, glass polish, vinegarWhat are chemical irritants?-neutral pH -cause more discomfort than actual damage -examples: most household detergents (common exposure that presents to ER)How do you manage a burn patient's airway?-Ensure patency of airway (if airway involvement suspected, be prepared for intubation or cricothyrotomy) -supplemental O2 Therapy (humidified air; titrate to maintain O2 sat >92%) -NG tube (avoid impairment of ventilation due to gastric distention)What is done in the acute management of a patient with a burn: irrigation?-irrigate wound with room temperature, cool water (no ice water) -chemical burns may need larger amounts of water (brush off dry chemical prior to irrigating to avoid reactivitng chemical) -preserve zone of stasis (associated with decreased scarring and skin grafting) -decreases pain -monitor for hypothermiaWhat is done in the acute management of a patient with a burn: fluid resuscitation?-small area or minor burns can use oral rehydration (<15-20% TBSA in adults; <10-15% TBSA in children) -parkland model (LR 4 mL/kg/TBSA over 24 hours) (1/2 of total volume given in first 8 hours) (rest of volume titrated over the next 16 hours)What is an escharotomy?-patients with circumferential burns are at highest risk -respiratory compromise (increased respiratory effort; increase in peak airway pressure in ventilated patients, decreased O2 saturation) *Constriction from burn eschar compromises *Respiratory effort *CirculationWhat is a faschiotomy?-procedure where the faschia is cut into to relieve increased compartment pressure from edema and circulatory compromise -5Ps: pain, paresthesia, poikilothermia, pulselessness, pallorWhat types of burns are at his risk for compartment syndrome?electrical burnsWhat are nursing considerations when caring for someone post-burn?-monitor cardiac rate and rhythm (HR <110 adequate volume; HR >120 inadequate volume) -monitor UOPA (0.5 cc/kg/hr adult; 20-50 cc/hr; 2 cc/kg/hour for kids) -observe for signs of rhabdomylosis (urine is dark, pink, red, with myoglobin) (increase fluid to double urine output) -monitor pH, PaO2, PaCO2, SpO2, serum bicarbonate, lactic acidWhat is done in the management of the acute phase of a burn?-prevent infection -preserve functioning -prevent scarringWhat type of dressing is done for a superficial (1st degree) burn?topical reliefWhat type of dressing is done for a partial thickness (2nd degree) burn?-open or exposed method (contaminated, high exudate burns; topical antimicrobial covered by non-adherent dressing) -closed or occlusive method (low exudate, superficial burns; occlusive dressing)What type of dressing is done for a full thickness (3rd or 4th degree) burn?-cover wounds with occlusive/petroleum dressing to protect for transport to burn center -topical such as silver sulfadiazine may interfere with burn center evaluation of burnWhat is done in the pain management of a patient with a burn wound?-Burn debridement considered one of the most painful injuries to endure -Inadequate pain management linked to increased stress & inflammatory response, poorer patient outcomes -Opioids: morphine, fentanyl (short half life; useful for painful procedures) -Anxiolytics: benzodiazepines (monitor closely for respiratory depression when used concomitantly with opioids) -Cooling -Covering (exposed nerve endings are very sensitive; moist/occlusive dressing)What does the grafting of burns involve?-splint in position of anatomical function -autograft, allograft, xenograft -several types: sheet (more cosmetic effect, used in conspicuous areas); mesh (used to cover large areas); full thickness flap (only appropriate for small areas); integra artificial skin -donor sites (unburned area; thighs, back, buttocks; covered with a synthetic occlusive dressing like opsite and tegaderm)What is done in the management/rehabilitative phase of a burn?-adaptation -function -quality of life -Pressure garments to minimize scarring & hypertrophy (Often begin use in acute phase) -Keep skin well moisturized -Encourage continued ROM and physical activity -Consider psychosocial aspect of healing (PTSD; Altered body image)What patient education should be done for burn prevention?-Smoke detectors -Lower hot water heater temperature to 49-54 degrees Celsius (Check bath water before placing children in tub) -Monitor children around open flames/ use screens and guards -Use proper safety equipment when working with chemicals (Know where your company's Material Safety Data Sheets (MSDS) are located) -Poison Control Center (800) 222-1222 -Proper use of Sunscreen