Trauma Nursing - Faculty Sites - Metropolitan Community College
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Transcript Trauma Nursing - Faculty Sites - Metropolitan Community College
Trauma
Nursing
By: Diana Blum RN MSN
Metropolitan
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 Trauma
Heat
Bites
Cold
Electrical
Altitude
Near
drowning
Spinal
Head
Musculoskeletal
Stab/gunshot wounds
rape
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
Assessment
Mental status…Seizure may
Monitor vitals frequently
Renal status
occur
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 Exhaustion
Caused
Stems
by dehydration
from heavy perspiration
Poor electrolyte consumption
Signs/Symptoms
Normal
Flu
mental status
like
Headache
Weakness
N/V
Orthostatic hypotension
Tachycardia
Heat Exhaustion
Treatment
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 Injuries
Most
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
3
insulation is the culprit
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
2
Peak in July and August
main types in North America are
pit vipers (look for warm blooded prey)
Water moccasins, copperheads, rattlesnakes
Most of bites
From North Carolina to Florida and in the Gulf states, Arizona,
and Texas
Coral snakes
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
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
S/S
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 Stings
Spiders:
Almost
carnivorous
all are venomous
Most not harmful to humans
Brown recluse, black widow, and
tarantula are dangerous for example
Scorpions:
England
not in Midwest or New
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 states
http://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
Rare:
grafting
Malaise, Joint pain, Petechaie,
N/V Fever, Chills
Pruritis
Erythema
Extreme: 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 do
S/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
Scorpions
Found
in many states
Not usual in midwest or new england
unless pet, or transported in baggage
Venom in stinger located on the tail
s/s
Localized
pain
Inflammation
Mild symptoms
Treatment:
pain meds, wound care,
supportive management
Bark scorpion
Deadly
Has a fatal sting
Found in tress, wood
piles, and around
debris
Humans stung when it gets in clothing,
shoes, blankets, and items left on
ground
Solid yellow, brown, or tan in color
Have thin pinchers, thin tail, and a
tubercle
Found 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
Monitor
Assess
ABCs
VS, LOC, ECG, and UO
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 with
Ingested 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 of
Carbon Monoxide Poisoning
Inhaled carbon monoxide binds to hemoglobin as
carboxyhemoglobin, which does not transport oxygen
Manifestations: CNS symptoms predominate
Treatment
Skin color is not a reliable sign
pulse oximetry is not valid
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/HAPE
Throbbing headache, anorexia, N/V
Chilled, irritable
Similar symptoms to alcohol hangover
VS variable
DOE or at rest
High altitude cerebral edema (HACE)
Unable to perform ADLs
Ataxia w/o focal signs (decreased motor coordination)
Confusion, impaired judgment , seizures
Stupor, Coma, Death from brain swelling
Increased
ICP over 1-3 days
High altitude pulmonary edema (HAPE)
Most frequent cause of death
Poor exercise intolerance and recovery
Fatigue and weakness
Tachycardia and tachypnea, rales, pneumonia
Increased pulmonary artery pressure
Altitude Illness
Site
Descent to lower
altitude
Monitor for symptom
progression
Rest
O2 if available
Hospital
Acetazolamide
Acts as bicarb diuretic
Sulfa drug
Take 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
down
(quadriplegia): paralysis from neck
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
fx
Proper body alignment
Traction
Monitor
is possible
vs q4 hours or more
Neuro checks q4 hours or more
Monitor for neurogenic shock
(hypotension and bradycardia)
Prepare for possible surgery
Teach 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
contacting head
Deceleration-
by external force
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 injuryhemorrhage
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
CHARACTERISTICS
Acute compartment syndrome
Hyperkalemia
Rhabdomyolosis – myoglobin released into blood
S/S
Wringer type injuries
Natural disasters
Work related injuries
Drug or alcohol overdose
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
Levels
Surgical-example digit
Traumatic- example digit
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 Wound
Stab Wound w/ single
edge blade
4
Gun shot wounds
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 twopiece 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
Feeling numb and detached
Memory problems
Avoidance of things
anxiety
PTSD
emotions
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