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traumatic injury

Terms in this set (53)

describe mechanism of injury
-think about not just what you hit but what is loose in the vehicle
-blunt trauma
-penetrating trauma
def blunt trauma
injury resulting from external forces without disrupting skin integrity; transfer energy from one form to another
types of blunt trauma
motor vehicle crash
pedestrian hit car
falls
contact sports
crush injuries
physical assault
blunt injury mechanisms of injury
-acceleration/decerleration: (coup-contre-coup) they're going fast, they stop fast, the brain hits the front of the skull then the back.
-shearing (tearing injuries) often with rotation; boxers that get hit in the side of face and neck/head spins
-compression (squeezing): being crushed under something
common blunt traumatic injuries
-head injuries: acceleration/deceleration/ shearing
-spinal cord injuries: shearing; A/D
-fractures: shearing; compression
-abdominal/thorax: shearing; compression
blunt chest trauma
thinking about the organs and structures in the chest
-heart, lungs, great vessels
-associated with A/D forces
-incidences: MCV/ assault
describe rib fractures
-- if a rib is displaced there can be a vascular injury--
-usually from blunt trauma
-very painful
-patients often under versatile and restrict mobility due to pain
-if not managed aggressively can lead to atelectasis and pneumonia
treatment goals for rib fractures
-manage pain
-early mobility
-aggressive pulmonary toilet
describe flail chest
when several ribs in a row are broken
when patient breaths instead of expand on inspiration it sucks in
describe pulmonary contusion
high pressure waves from rapid compression/decompression
-results in diffuse vascular and tissue damage with ARDS-like consequences
-presentation often delayed: 24-72 post injury
-bruising leads to alveolar hemorrhage, edema and inflammation within the lung
CM and Dx of pulmonary contusion
may see infiltrates on CXR and auscultatable crackles
looks alot with ARDS with worsening hypoxia
-mild: incr RR and HR; blood tinged sputum
-mod: more significant increased in RR, HR; inability to cough effectively, lung crackles, C/O chest pain; ABG- decr PaO2, incr Pa CO2
-severe: mod sx, plus ARDS-like manifestations
other causes of pulmonary contusions
-aspiration of gastric contents or creek water
-toxic inhalation or inhalation burns
-inflammatory cytokine release due to-- sepsis, massive transfusion, pancreatic injury, DIC and shock
management of pulmonary contusion
think of ARDS management!!
-oxygen, early mobility, pulm toilet, intubate with mech. vent for acute resp failure, PEEP, sedation, pain control
describe tension pneumothorax
one-way valve problem
-air-leak, tear does not seal; air sucked in during inhalation and is not released during expiration
CM of tension pneumothorax
-SOA
-restless/anxious
-pallor
-dyspnea
-sternal retractions
-panicky
-neck vein distention
-deviated trachea
-damaged side will have no breath sounds
tx of tension pneumo
an immediate needle thoracostomy and then a chest tube placed
subcutaneous emphysema
-how to recognize it
-what to anticipate
-how to recognize: edematous appearance; palpation- feels and sounds like "rice crispies"
-anticipate: STAT CXR-- watch their airway and wait for it to go away
cardiac tamponade
-CM
-treatment
an acute pericardial effusion where the fluid builds up more rapidly than the sac can accommodate for; life threatening
-CM: becks triad- elevated RAP w/ JVD, hypotension, muffled heart sounds
-treatment: pericardiocentesis- can hit a lung, the heart or a vessel (watch EKG, RR and O2 sat)
describe blunt cardiac injury
-CM
-Dx
-cardiac contusion
-bruising of myocardium
-CM: CP, sinus tach, hypotension are indicative when coupled with a chest injury pattern; ST changes, dysrhythmia or heart blocks may be apparent
-may do an echo to evaluate cardiac injury
blunt abdominal traumatic injury
-what is it?
-possible complications
-what is it?: injuries occurring from the nipple line to mid-thigh
-possible complications: massive hemorrhage --> shock, intraabdominal hypertension (IAH)
describe IAH
you have bled so much and the belly is so tight
its like a tension pneumo and it will cause the CV system to collapse because it can't maintain CO. there is so much pressure pushing up
-can be very hidden
-compression or shearing: seatbelt injuries!!
solid organ lacerations
-describe
-diagnose
-treatment
these patients can be really sick; we try not to operate- if we can let them bleed and control it then great. We don't want to open them up and bleed more
-splenic and liver lacs:
--lower mortality if can let tamponade off and avoid OR; monitor in ICU for signs of bleeding
-dx: serial labs to trend hct and coag markers; serial abdominal exam and symptom observation
-tx: hemodynamic assessment; volume and targeted blood product admin; bedrest; embolization in angiography for bleeding
abdominal trauma signs
ranges from subtle to severe
what are you looking for?
-increased ABD girth, distention; w/ palpation- guarding, rigidity
-cullen's sign
-grey turners sign
-wounds: entrance and exit
-presence of abdominal: abrasions, hematomas, bruising, burns; tire tracks or seat belt marks
Cullen's sign vs Grey Turner's sign
cullens: periumbilical ecchymosis
grey turners: flank ecchymosis
abdominal compartment syndrome (ACS)
-most common causes
looks like they're dying; extremely tachycardic, hard to ventilate, very high pressure
causes:
-post injury primary ACS in shocked, coagulopathic patient with severe abdominal injuries
-post injury secondary ACS in patients with trauma and severe extra abdominal bleeding needing large volume transfusions
-uncontrolled bleeding coupled with large volumes of crystalloid resuscitation leads to increased intra-abdominal pressure
abdominal compartment syndrome (ACS)
-systemic effects
-CV: incr SVR, CVP, PAWP, tachycardia, decreased CO, hypotension (late)
-pulm: decr lung compliance, hypercapnia, hypoxemia; incr PIP
-renal: oliguria, azotemia, prerenal failure
-neurological: incr ICP, altered LOC
-GI: small bowel ischemia, sepsis, translocation of bacteria from gut, really incr intraabdominal pressure, multiple organ dysfunction
ACS treatment
open them up at bedside, sometimes will stay open
-decompressive laparatomy --> open abdominal management bringing its own morbidity and potential mortality
-prevention: not always avoidable, timely hemorrhage control in order to avoid high crystalloid volumes
complications of ACS
all of the ischemia byproducts build up and then start going back to the heart; pt becomes acidotic, start seeing EKG changes; can have PE, bc blood wasnt circulating for a bit, so can through microemboli
-reperfusion asystole: byproducts of ischemia circulate to the heart causing acidosis related impairment of electrical activity. patient must be resuscitated with sodium bicarb
-pulm embolism: associated with reperfusion; monitor for dyspnea, pleuritic chest pain, signs of shock. oxygen and thrombolytics must be available
nursing implications of complications of ACS
-maintain and monitor o2
-wound care
-mechanical ventilation
-volume resuscitation
-vasopressors--- must be adequately fluid resuscitated!!
pelvic injuries
-what to look for
-how is it confirmed?
what to look for
-perianal ecchymosis
-pain on palpation
-"rocking" of iliac crests
-hematuria
-lower extremity rotation on paresis

how is it confirmed?
-hands, then x-ray
pelvic injuries
-management
monitor for shock!!
management: never turn this patient until they go to the OR; immobilize and monitor for hemorrhage
-emergent: prevent/treat hemorrhage
--embolization of bleeding vessels, packing pelvis
-stabilization:
--temporary; interventional/unstable fx (external fixation device); definitive (internal fixation surgery)
long bone fractures
ORTHOPEDIC EMERGENCY
-should go to the OR immediately for repair
-if too unstable for OR, traction or external fixation at the bedside
-fracture complication= acute compartment syndrome
compartment syndrome
-sx
-tx
fracture continues to bleed, closed space and lots of volume; it gets tighter and tighter until it compresses on vasculature, pt can lose a limb or die!!
-sx: extremely painful, gets cool and pale, extreme pain with dorsiflexion; loss of pulse with a doppler
-tx: open her up-- faciotomy! keep going until get a pulse
describe fat emboli syndrome
this is why they immediately go to OR or put in traction; like a PE but its just fat
-associated with long bone and pelvic fractures
-fat globules from bone enter bloodstream after being displaced by trauma to bone
fat emboli syndrome
-CM
-diagnosis and treatment
CM- classic triad= hypoxemia, neurologic abnormalities, and sometimes a petechial rash; decreased breath sounds, crackles; may need vent

dx and tx: based on sx
-CXR fairly normal
-CT of chest show focal areas of ground glass opacification
-sx tx and supportive care
-vent with peep and high flow o2
-select pulm vasodilator inhaled nitric oxide
-chest tubes
-sedation/paralytics
-prone positioning
describe rhabdomyolysis
with crush injuries; muscle damage occurs and the byproducts get into circulation and damage kidneys
-big sign: brown, bloody looking urine; urinalysis will say there is blood with minimal RBC, and myoglobin, myoglobin is present in urine
-really high creatinine kinase indicates muscle breakdown
causes and sequelae of rhabdomyolysis
causes:
-muscle damage from untreated compartment syndrome
-crush injuries
-muscle breakdown from long periods of laying in the same position (pinned or lying unconscious on a hard surface)
-extreme exercise
sequelae:
-acute renal failure
-permanent renal failure
treatment of rhabdomyolysis
-aggressive hydration, serial kinase and urine myoglobins: LITERS OF FLUID
-may use diuretics
-may alkalinize urine with bicarb drip
-electrolyte replacement: bc peeing alot
-monitor urine myoglobin levels
-dialysis if renal failure occurs
describe penetrating traumatic injury
-def: injury results from a missile; anything can become a missile at the right velocity!!
-types: low/medium energy-- low= knives, arrows; medium= hand guns, some rifles; high energy= hunting rifles, shotguns
-GSW: often associated with multiple internal injuries in chest/abdomen
-stab wounds and impalement- tend to be more localized

*LEAVE IMPALED OBJECTS IN PLACE*
special consideration: the elderly trauma victim
-ages 65+
-physiologic changes predispose to injury (don't feel pain as acutely, more prone to hypothermia, less subQ fat, more chronic diseases)
-delayed reaction times
-disturbances of gait and balance
-diminished visual acuity
-hearing and other sensory loss
hypothermia in elderly patient
low metabolic rate; keep room warm
-common for elderly trauma victims to be hypothermic and at risk for accidental iatrogenic hypothermia
-older patients have a lower basal metabolic rate and are very susceptible to ambient temps
-some medical conditions predispose the patient to hypothermia
-must be treated aggressively
the pregnant trauma victim
-injuries are difficult to predict; blunt abd trauma is associated with different injuries than in a non-preg patient
--CO incr up to 50%, RBC vol only incr by 30%; high output, low resistance state (naturally vasodilate); maternal HR incr and slight incr in SV; BP decr 5-15 mmHg
(more circulating volume but hct is lower, will lose 30-40% before show sx of hypovolemia more blood loss may occur and can compensate but then she'll drop like a rock)
management of pregnant trauma victim
-maternal health is paramount
-resuscitation meds are dosed for the mother
-place mother in lateral supine position (to prevent vena cava syndrome)
-proceed with initial primary survey just for mother
-secondary survey can address fetal monitoring and assessment
-if more than 24 wks, and cardio-pulm arrrest occurs, an emergency c-section should be performed immediately in ED and mom should be resuscitated during and after
primary survey
CABC-- look for bleeding first!
-timing
-three purposes: 1) ID and treat life-threatening conditions 2) don't miss anything! 3) stabilize patient
-rule of primary survey: when discover life-threatening problem- STOP AND FIX IT, then go back to the survey
what is the primary survey composed of?
CABCDE-- see if they're bleeding first!
-A: airway- obstruction, simple or advanced airway
-B: breathing- effort and effectiveness
-C: circulation- pulses, temp, color and cap refill
-D: disability- quick neuro assessment
-E: exposure- maintain body temps

-priority patient history: comorbidities? pregnant? substance abuse?
what is the secondary survey?
head to toe approach
thorough exam of each body system
trauma patient requires repeated re-evaluation
continuous monitoring of vital signs critical
-rule of secondary is same as primary!!
secondary survey: AMPLE
-allergies, medication, PMH, last meal, events
trauma resuscitation
-hemorrhage: hypovolemic shock resulting from acute blood loss; early recognition and treatment is key in survival
-potential blood loss from select injuries
-recognition of source is crucial!!
-2 large bore 14-16 G IV; AC
-warmed NS
-PRBC (type specific if can)
-O+ for males, O- for females of childbearing age
-platelets if platelets <50
-FFP for INR greater than 2 or PTT >1-1.5
-cryoprecipitate for fibrinogen
-use rapid infuser with warmer
-issues with large scale transfusion (can trigger ARDS)
goal parameters
SBP >90
MAP >70 (60?)
HR <100
UOP >30 ML
SVO2: 65-80%
Skin: warm, dry
serum lactate: <2.0
base deficit +/- 3.0
trauma triad
1. coagulopathy
2. metabolic acidosis
3. hypothermia

all of these things potentiate each other!!!
-direct blood transfusion for whatever is going on; fluid resuscitate to get lactic acid out
hypothermia in trauma
-distinctly different from hypothermia in cardiac arrest, brain injury, organ transplantation and other conditions
-*cold is always bad in trauma*
metabolic acidosis
the more acidotic you are, the less the tissues are able to use the o2; will not respond to vasopressors without bicarb
-indicator of shock
indicator of tissue utilization of o2
-it is more reflective of true volume deficit than any other physiologic variable
roadblocks to trauma resuscitation
-decreased preload
-increased hypothermia
-decreased coagulation
-increased metabolic acidosis
-not treating before or as patient is transferred/transported
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