Transcript Thelan`s Critical Care Nursing

CHAPTER 25
Trauma
Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.
OBJECTIVES



Compare and contrast injuries associated with
blunt and penetrating trauma.
Discuss mechanism of injury, pathophysiology,
assessment findings, medical management,
and nursing management of traumatic injuries
to the head, spinal cord, heart, lungs, and
abdomen.
Use assessment findings to identify potential
complications and sequelae of traumatic
injuries.
PREVENTION OF TRAUMA

Unintentional injury
 Motor
vehicle accident vs. motor vehicle
crash
Prevention, recognition, and treatment of
intimate partner violence
 Alcohol

 AUDIT
alcohol screening questionnaire
 CAGE alcohol screening questionnaire
MECHANISMS OF INJURY

Blunt trauma
 Motor
vehicle collisions
 Contact sports
 Blunt force injuries
 Falls

Penetrating trauma
 Stabbings
 Firearm
injuries
 Impalement
PHASES OF TRAUMA CARE
PREHOSPITAL RESUSCITATION

Immediate stabilization and
transportation
 Airway
maintenance
 Control of external bleeding and shock
 Immobilization
 Immediate transport (ground or air)
PHASES OF TRAUMA CARE
ED RESUSCITATION

Primary survey (A, B, C, D, E)
 Airway
maintenance
 Breathing and ventilation
 Circulation and hemorrhage control
 Disability and neurological status
 Exposure/environmental control
PHASES OF TRAUMA CARE
RESUSCITATION PHASE

Hypovolemic shock
 Blood

Two large-bore peripheral intravenous
lines
 Fluid

loss
resuscitation
Placement of urinary and gastric
catheters
PHASES OF TRAUMA CARE
SECONDARY SURVEY

AMPLE
 Allergies
 Medications
currently used
 Past medical history
 Last meal
 Events/environment related to injury
QUESTION
Which of the following pieces of information
would be important when taking a history
from a patient with a blunt chest injury?
A.
B.
C.
D.
Caliber of weapon
Restraint status
Gender of assailant
Weapon used
ANSWER
B.
Restraint status
Restraint status (lap belt, shoulder harness, or
combination) is important information for the patient
with blunt chest trauma. Caliber of weapon, gender of
assailant, and weapon used are information that should
be elicited in the case of a patient with penetrating
trauma.
PHASES OF TRAUMA CARE

Definitive care/operative phase
 Trauma

is a “surgical disease”
Critical care phase
 Advanced
trauma life-support guidelines
 Trauma complications
 Acute
respiratory distress syndrome
 Sepsis
 Shock states
 Multiple organ dysfunction syndrome
TRAUMATIC BRAIN INJURIES (TBI)

Mechanism of Injury


Penetrating


Leading causes – falls, motor vehicle crashes,
struck by or against events, and assaults
Penetrating object – bullet
Blunt trauma
Deceleration
 Acceleration
 Rotational forces

(continued)
TRAUMATIC BRAIN INJURIES (TBI)
(CONTINUED)

Pathophysiology

Primary injury
 Direct
injury to the parenchyma
 Hemorrhage and compression of nearby structures

Secondary injury
 Biochemical
and cellular response to initial trauma
 Can exacerbate primary injury
 Consequences of increased intracranial pressure


Risks of cerebral hypoperfusion
Cerebral edema
(continued)
TRAUMATIC BRAIN INJURIES (TBI)
(CONTINUED)
Skull fracture
 Concussion
 Contusion

 Acceleration-deceleration
injuries
 Coup-contrecoup mechanism of injury
(continued)
COUP-CONTRECOUP
MECHANISM OF INJURY
FIGURE 25-1 Coup and contrecoup head injury after blunt trauma. A, Coup injury: impact against object, showing the site of
impact and direct trauma to brain (a), shearing of subdural veins (b), and trauma to the base of the brain (c). B, Contrecoup
injury: impact within skull, showing the site of impact from brain hitting opposite side of skull (a) and shearing forces throughout
brain (b). These injuries occur in one continuous motion; the head strikes the wall (coup) and then rebounds (contrecoup).
TRAUMATIC BRAIN INJURIES (TBI)
(CONTINUED)

Cerebral Hematomas
 Epidural
hematoma
 Subdural hematoma
 Intracerebral hematoma
(continued)
TYPES OF CEREBRAL HEMATOMAS
FIGURE 25-2 Types of hematomas. A, Subdural hematoma. B, Epidural hematoma. C, Intracerebral hematoma.
TRAUMATIC BRAIN INJURIES (TBI)
(CONTINUED)

Missile injuries
 Depressed,

penetrating, or perforating
Diffuse axonal injury (DAI)
 Prolonged
posttraumatic coma
 Stretching and tearing of axons at time of
injury
 Microscopic lesions throughout the brain
(continued)
MISSILE INJURIES
FIGURE 25-3 Bullet wounds of the head. A bullet wound or other penetrating missile wounds cause an open (compound)
skull fracture and damage to brain tissue. Shock wave effects are transmitted throughout the brain. A, Perforating injury.
B, Penetrating injury.
TRAUMATIC BRAIN INJURIES (TBI)
(CONTINUED)

Assessment in TBI


Glasgow Coma Scale
Degree of injury




Mild injury
Moderate injury
Severe injury
Nursing assessment





Level of consciousness
Motor movements
Pupillary response
Respiratory function
Vital signs
DIAGNOSTIC PROCEDURES IN TBI
CT scan
 Electrophysiology studies in ongoing
assessment
 MRI

MEDICAL MANAGEMENT OF TBI
Surgical management
 Nonsurgical management

NURSING DIAGNOSIS PRIORITIES
Ineffective breathing pattern related to
neuromuscular impairment, perceptual or
cognitive impairment
 Risk for aspiration
 Impaired gas exchange related to
ventilation/perfusion mismatching
 Imbalanced nutrition: less than body
requirements related to lack of exogenous
nutrients and increased metabolic demand

(continued)
NURSING DIAGNOSIS PRIORITIES
(CONTINUED)
Powerlessness related to lack of control
over current situation
 Decreased intracranial adaptive capacity
related to failure of normal compensatory
mechanisms
 Impaired physical mobility related to
perceptual or cognitive impairment
 Ineffective cerebral tissue perfusion
related to hemorrhage

NURSING MANAGEMENT OF TBI

Nursing priorities focus on:
Stabilizing vital signs
 Preventing further injury
 Reducing increases in ICP and maintaining
adequate cerebral perfusion pressure

 Hemodynamic
management
 Fluid management
 Cerebral perfusion pressure more than 70 mm Hg
Aggressive pulmonary care
 Reduce environmental stimuli

SPINAL CORD INJURIES
MECHANISM OF INJURY

Hyperflexion
 Sudden

deceleration
Hyperextension
 Backward
and downward motion
Rotation
 Axial loading

 Vertical

compression
Penetrating injuries
AXIAL LOADING
FIGURE 25-4 Spinal cord compression burst fracture. Compression injuries cause burst fractures of the vertebral body
that often send bony fragments into the spinal canal or directly into the spinal cord.
PATHOPHYSIOLOGY OF
SPINAL CORD INJURIES

Primary injury


Neurological damage occurs at moment of
impact
Secondary injury
Complex biochemical processes affecting cellular
functions
 Occur within minutes of injury and can last days
to weeks

(continued)
PATHOPHYSIOLOGY OF
SPINAL CORD INJURIES (CONTINUED)

Functional injury of spinal cord
 Complete
injury
 Quadriplegia
 Paraplegia
 Incomplete
injury
(continued)
PATHOPHYSIOLOGY OF
SPINAL CORD INJURIES (CONTINUED)

Spinal shock



Neurogenic shock


Occurs shortly after traumatic injury to the spinal cord
Complete loss of all muscle tone and normal reflex activity
below the level of the injury
Injury to the descending sympathetic pathways
Autonomic dysreflexia

Life-threatening complications

Bradycardia, hypertension, facial flushing, and headache
ASSESSMENT AFTER
SPINAL CORD INJURY
Airway
 Breathing
 Circulation
 Neurological assessment
 Diagnostic procedures
 Screening for spinal cord injury

15% of trauma patients with injury will have a
cervical spine injury
 Eastern Association of Surgeons in Trauma
guidelines

(continued)
ASSESSMENT AFTER
SPINAL CORD INJURY (CONTINUED)

Diagnostic procedures
 Diagnostic
 CT
x-rays
scan
 Tomograms
 Myelography
 MRI
MEDICAL MANAGEMENT AFTER
SPINAL CORD INJURY

Pharmacological management
 Methylprednisolone

Surgical management
 Provides

spinal column stability
Nonsurgical management
 Cervical
 Halo
injury
vest
 Thoracolumbar
injury
HALO VEST
FIGURE 25-6 Halo vest. The halo traction brace immobilizes the cervical spine, which allows the patient to
ambulate and participate in self-care.
NURSING DIAGNOSIS PRIORITIES
SPINAL CORD INJURY
Decreased cardiac output related to lack of
sympathetic innervation
 Risk for autonomic dysreflexia related to spinal
cord injury above T6
 Impaired gas exchange related to alveolar
hypoventilation
 Ineffective breathing pattern related to
impairment of innervation of diaphragm (lesion
above C5), complete or mixed loss of intercostal
muscle function

(continued)
NURSING DIAGNOSIS PRIORITIES SPINAL
CORD INJURY (CONTINUED)
Impaired physical mobility related to
neuromuscular impairment, immobilization
by traction, and paralysis
 Risk for impaired skin integrity related to
immobility, traction, tissue pressure, altered
peripheral circulation, and sensation
 Bowel incontinence related to disruption of
innervation to bowel and rectum, perceptual
impairment, and altered fluid and food
intake

(continued)
NURSING DIAGNOSIS PRIORITIES
SPINAL CORD INJURY (CONTINUED)
Constipation related to disruption of
innervation to bowel and rectum,
perceptual impairment, and altered fluid
and food intake
 Impaired urinary elimination related to
disruption in bladder innervation, bladder
atony

(continued)
NURSING DIAGNOSIS PRIORITIES
SPINAL CORD INJURY (CONTINUED)
Disturbed body image related to actual
change in body structure, function, or
appearance
 Ineffective coping related to situational
crisis and personal vulnerability

NURSING MANAGEMENT AFTER
SPINAL CORD INJURY

Nursing priorities are aimed at:
 Preventing
secondary damage to the spinal
cord
 Managing cardiovascular and pulmonary
complications
 Coaching the patient to overcome the
psychosocial challenges associated with
severe neurological deficit
THORACIC INJURIES

Mechanism of injury
 Blunt
thoracic trauma
 Penetrating thoracic injuries
CHEST WALL INJURIES
Rib fractures
 Flail chest
 Ruptured diaphragm

FLAIL CHEST
FIGURE 25-7 Flail chest. A, Normal inspiration. B, Normal expiration. C, The area of lung underlying the unstable
chest wall sucks in on inspiration. D, The same area balloons out on expiration. Notice the movement of
mediastinum toward opposite lung on inspiration.
PULMONARY INJURIES
Pulmonary contusion
 Tension pneumothorax
 Open pneumothorax
 Hemothorax

QUESTION
Which of the following positions should be
used with a patient who has a left-sided
pulmonary contusion with severe
hypoxemia?
A.
B.
C.
D.
Patient should be placed on the left side
Patient should be positioned prone
Patient should be placed in semi-Fowler’s
position
Patient should be placed on the right side
ANSWER
D.
Patient should be placed on the right side
Patients with unilateral contusions and significant
hypoxia are placed with the injured side up and
uninjured side down (“down with the good lung”). This
positioning maximizes the match between pulmonary
ventilation and perfusion.
TENSION PNEUMOTHORAX
FIGURE 25-8 A tension pneumothorax usually is caused by an injury that perforates the chest wall or pleural space.
Air flows into the pleural space with inspiration and becomes trapped. As pressure in the pleural space increases, the
lung on the injured side collapses and causes the mediastinum to shift to the opposite side. (From Marx J, et al:
Rosen’s Emergency medicine: concepts and clinical practice, ed 5, St Louis, 2002, Mosby.)
HEMOTHORAX
FIGURE 25-9 Blunt or penetrating thoracic trauma can cause bleeding into the pleural space to form a hemothorax.
CARDIAC AND VASCULAR INJURIES
Penetrating cardiac injuries
 Cardiac tamponade

 Beck’s
triad
 Pulsus paradoxus

Blunt cardiac injuries (BCI)
 EAST
guidelines
CARDIAC TAMPONADE
FIGURE 25-10 Cardiac tamponade is the progressive accumulation of blood in the pericardial sac.
BLUNT CARDIAC INJURY
FIGURE 25-11 Blunt cardiac trauma. Sudden acceleration (as from contact with the steering wheel) can cause the
heart to be thrown against the sternum.
NURSING DIAGNOSIS PRIORITIES
THORACIC INJURIES
Impaired gas exchange related to alveolar
hypoventilation from lung contusion
 Ineffective breathing pattern related to
pain from rib fractures
 Decreased cardiac output related to low
preload from tension pneumothorax,
hemothorax, or cardiac tamponade

NURSING MANAGEMENT

Nursing priorities emphasize delivery of
adequate:
 Oxygen
 Ventilation
 Pain
management
 Prevention of complications
ABDOMINAL INJURIES

Mechanism of injury
 Blunt
trauma
 Penetrating trauma
ASSESSMENT OF
ABDOMINAL INJURIES

Physical assessment
Location of entry and exit sites associated with
penetrating trauma assessed and documented
 Cullen’s sign
 Grey Turner’s sign
 Distended abdomen
 Rebound tenderness
 Kehr’s sign

(continued)
ASSESSMENT OF
ABDOMINAL INJURIES (CONTINUED)

Diagnostic assessment
 Diagnostic
 Bedside
 Chest
 CT
peritoneal lavage (DPL)
ultrasound
x-ray
scan of abdomen
DIAGNOSTIC PERITONEAL LAVAGE
FIGURE 25-12 Diagnostic peritoneal lavage (DPL) can exclude or confirm the presence of intraabdominal injury
with a high accuracy rate.
COMBINED ABDOMINAL
ORGAN INJURIES
Multivisceral injuries
 Damage control surgery

 Initial
operation
 Intensive care unit resuscitation
 Definitive reoperation

Abdominal compartment syndrome
 End-organ
dysfunction caused by
intraabdominal hypertension
SPECIFIC ORGAN INJURIES

Liver injuries
 Life-threatening
hemorrhaging
 Hemodynamic instability
 Coagulopathies, acidosis, and hyperthermia

Spleen injuries
 Life-threatening
hemorrhaging
 Sepsis

Intestinal injuries
 Sepsis
and abscess or fistula formation
GENITOURINARY INJURIES

Mechanism of injury
 Blunt
trauma
 Penetrating trauma

Assessment
 Flank
pain or colic pain
 Bluish discoloration of the flanks
 Perineal discoloration
 Urine/hematuria
SPECIFIC GENITOURINARY INJURIES

Renal trauma
Flank ecchymosis
 Fracture of inferior ribs or spinous processes
 Gross hematuria
 CT scan


Bladder trauma
Caused by pelvic fractures
 Lower abdominal bruising, distention, and pain
 Difficulty in voiding
 Retrograde urethrogram

COMPLICATIONS OF TRAUMA

Hypermetabolism
 Initiate
enteral feedings within 72 hours for
patients with blunt and penetrating
abdominal injuries and those with head
injuries
Infection
 Sepsis

(continued)
COMPLICATIONS OF TRAUMA
(CONTINUED)

Pulmonary
 Respiratory
failure
 Fat embolism syndrome
Pain
 Renal complications

 Renal
failure
 Myoglobinuria
(continued)
COMPLICATIONS OF TRAUMA
(CONTINUED)

Vascular complications
 Compartment
syndrome
 Venous thromboembolism
 Missed injury
 Commonly
discovered in first 24 to 48 hours after
presentation
 MODS
SPECIAL CONSIDERATIONS IN
TRAUMA CARE

Meeting needs of family members and
significant others
 Crisis

situation for family and friends
Trauma in older patients
 Risk
of falls
 Risk of motor vehicle collisions
 Limited physiological reserve
 Age-related organ changes