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Introduction to Emergency Nursing Concepts

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Title: Introduction to Emergency Nursing Concepts


1
Introduction to Emergency Nursing Concepts
  • Sandra H. Lewis, ARNP-BC-ADM

2
Prehospital Care and Transport
  • The time from injury to definitive care is a
    determinant of survival, particularly those with
    major internal hemorrhage.
  • Careful attention must be given to the airway
    with cervical spine immobilization, breathing and
    circulation. (ABCs)

3
Continued
  • Full spinal mobilization is being challenged and
    reexamined
  • Asking Is full spinal mobilization necessary in
    all trauma patients?
  • How appropriate is the assessment of prehospital
    assessment?
  • Concerns over the high false positive rate that
    occurs with prolonged spinal immobilization.

4
Current Guidelines
5
Objectives
  • 1. Explain emergency care as a collaborative,
    holistic approach that includes patient, family
    and significant others.
  • Discuss priority emergency measures for any
    patient with an emergency situation.
  • 3. Discuss pre-hospital, emergency care and
    resuscitation of the trauma patient.

6
Objectives
  • Discuss disaster triage concepts and contrast
    with traditional triage concepts.

7
Trauma
  • The fourth leading cause of death for ALL ages.
  • Nearly ½ of all traumatic incidents involve the
    use of alcohol, drugs or other substance abuse.
  • Is predominantly a disease of the young and
    carries potential for permanent disability.

8
Systems Approach to Trauma
  • An organized approach to trauma care that
    includes
  • Prevention, access, acute hospital care,
    rehabilitation, and research.

9
Trimodal Distribution of Death
  • First peak- seconds to minutes from time of
    injury to deathsevere injuries lacerations of
    the brain, brainstem, high spinal cord, heart
    aorta, large blood vessels.
  • Second peak- minutes to several hours
    subdural, epidurdal hematomas, hemopneumothorax,
    ruptured spleen, lacerated liver, pelvic
    fractures, other injuries associated with major
    blood loss.

10
  • Third peak-occurs several days to weeks after the
    initial injury most often the result of sepsis
    and multiple organ failure. At this stage,
    outcomes are affected by care previously provided.

11
Levels of Trauma Care
  • American college of Surgeons Committee on Trauma
  • Levels I-IV, Level ones are the most
    sophisticated and care for all aspects from
    prevention to rehabilitation.

12
Trauma Triage
  • Minor trauma single system injury that does not
    pose threat to life or limb and can be
    appropriately treated at a basic emergency
    facility.
  • Major trauma serious multi system injuries that
    require immediate intervention to prevent
    disability.

13
Mechanism of Injury
  • Is vital to the initial assessment and may raise
    suspicions about the patients injury pattern.
  • Blunt vs. penetrating injury

14
Blunt Trauma
  • Most often results from vehicular accidents, but
    may occur in assaults, falls from heights, and
    sports related injuries.
  • May be caused by accelerating, decelerating,
    shearing, crushing, and compressing forces.

15
Blunt Trauma, cont.
  • Coup-contra coup injury
  • Body tissues respond differently to kinetic
    energylow density porous tissues and structures,
    such as lungs, often experience little damage
    because of their elasticity.

16
Blunt Trauma cont.
  • The heart , spleen and liver are less resilient
    often rupturing or fragmenting.
  • Often, overt external signs are not
    apparentmaking the mechanism of injury most
    important to the practitioner performing the
    physical examination.

17
Penetrating Trauma
  • Results from the impalement of foreign objects
    into the body.
  • More easily diagnosed because of obvious injury
    signs.
  • Stab wounds are usually low velocitythe direct
    path, the depth and width determine injury.
  • Women tend to have trajectories in a downward
    motion, men in an upward force.

18
Penetrating Trauma cont.
  • Ballistic trauma may be either low or high
    velocity injuries.
  • Missiles or bullets that come into contact with
    internal structures that produce a change in in
    pathway release more energy and result in more
    injury than a direct pathway.

19
Penetrating Trauma, cont.
  • Injuries sustained from penetrating objects must
    be assessed for the potential for infection from
    the debris carried by the penetrating object.

20
Disaster / Mass Casualty Triage Concepts
  • Most severe injuries in mass trauma events are
    fractures, burns, lacerations, and crush
    injuries.
  • Most common injuries are eye injuries, sprains,
    strains, minor wounds and ear damage. (CDC
    Website)

21
Mass Casualty Who is at risk?
  • Anyone in surrounding area.
  • Rescue workers and volunteers.

22
Bioterrorism Agents/Diseases, Threats
  • CDC Website ( see handout)

23
Disaster Triage
  • www.bt.cdc.gov/masstrauma/index.asp
  • www.nyerrn.com/simulators

24
Pre-Hospital Care and Transport
  • The time from injury to definitive care is a
    determinant of survival.
  • Careful attention is given to C-spine
    immobilization, breathing and circulation(ABCs)

25
Current Guidelines on C-Spine Immobilization
  • Although it has been challenged, C-spine
    immobilization is still the protocol for trauma
    patients until diagnostically cleared (X-Ray)

26
Additional Pre-Hospital Measures
  • Occlusive dressings to open chest wounds
  • Needle thoracotomy to relieve tension
    pneumothorax
  • Endotracheal intubation
  • Cricothyrtomy

27
Caveat!!!
  • Research has indicated INCREASED mortality with
    IV fluids BEFORE hemorrhage control.
  • Transport is not delayed to start IV access!

28
TransportHow is it decided?
  • Travel time
  • Terrain
  • Availability of air or ground transport
  • Capability of personnel
  • Weather

29
Emergency Care PhasePreparation
  • Trauma team at receiving hospital responds before
    arrival of patient
  • Report has been transmitted
  • Preparations are initiated based on report.

30
Initial Patient Assessment
  • Clinical presentation
  • Physical assessment
  • History of traumatic event
  • Pre-existing illness

31
Primary Survey
  • Most crucial assessment tool in trauma care
  • 1-2 minutes MAX!
  • Designed to identify life threatening injuries
    ACCURATELY
  • Establish priorities
  • Provide simultaneous therapeutic interventions.

32
Resuscitation Phase
  • Secondary Survey
  • Table182 page 647/648
  • 32

33
EFGHI
  • E- Expose the patient
  • F- Full set of vital signs, five interventions
    (cardiac monitor, pulse oximetry, urinary
    catheter, NG if not contraindicated, lab studies)
  • G- giving comfort measurespain control,
    reassurance to patient and family
  • H- history/ head to toe assessment
  • I- inspect for hidden injuries-log roll patient
    to inspect posterior aspect.

34
Sequence of Diagnostic Procedures
  • Influenced by
  • Level of consciousness
  • Stability of patients condition
  • Mechanism of injury
  • Identified injuries

35
Maintain Airway Patency
  • Essential to trauma management
  • EVERY trauma patient has potential for airway
    obstruction
  • Most common obstruction Tounge
  • Other common causes blood or vomitus,
    secretions, structural impairment, depressed
    sensorium, absent gag reflex

36
How to open the airway?
  • Jaw thrust or chin lift!!!
  • These maneuvers do not hyperextend the neck or
    compromise the integrity of the C-spine

37
Maintaining the airway
  • Simple, simple!!
  • Nasopharyngeal airway
  • Oropharyngeal airways

38
Definitive Nonsurgical Airway
  • Endotracheal intubation-Complete control of the
    airway
  • Nasotracheal intubationINDICATED for the
    spontaneously breathing patient..CONTRAINDICATED
    in the patient with facial, frontal sinus,
    basilar skull or cribriform plate fractures.

39
Choice of Airway management
  • Familiarity of procedure
  • Clinical condition of the patient
  • Degree of hemodynamic stability
  • A PATENT AIRWAY IS THE CORNERSTONE OF SUCCESSFUL
    TRAUMA RESUSCITATION

40
A LIFE THREATENING CONDITION EXISTS
  • Altered mental status (agitation)
  • Cyanosis( nail beds and mucous membranes)
  • Asymmetrical chest expansion
  • Use of accessory muscles/abdominal muscles
  • Sucking chest wounds
  • Paradoxical movements of the chest wall
  • Tracheal shift
  • Distended neck veins
  • Diminished or absent breath sounds

41
Impaired Gas Exchange
  • Follows airway obstruction as the nest most
    crucial problem for the trauma patient.
  • Reasons decreased inspired air, retained
    secretions, lung collapse or compression,
    atelectasis, accumulation of blood in the
    thoracic space.

42
Decreased Cardiac Output/Hypovolemia
  • Acute Blood lossMOST common cause in acute
    trauma
  • May be external or internal

43
Treatment
  • PASG- anti-shock garment (pneumatic anti-shock
    garment)
  • When inflated, PASG compresses the legs and
    abdomen, resulting in increased venous return and
    SVR(systemic vascular resistance) preventing
    further blood loss into the abdomen and legs.
  • Elevates systemic pressure by shunting a small
    amount of blood into central circulation.
  • CAN be a detriment, elevates BP, and in the event
    of hemorrhage without DEFINITIVE control can be
    fatal.

44
Additional Causes of Decreased Cardiac Output
  • (impaired venous return to the heart)
  • Tension Pneumothorax
  • Pericardial Tamponade (from decreased filling and
    ventricular ejection fraction)

45
Table 18-4
  • Pay attention to Class I through IV EBL
    (estimated blood loss)
  • Changes in pulse, BP, RR, UOP, mental status.
  • Note the fluid/blood needed to replace 31 rule

46
Priority Interventions
  • Patent airway
  • Maintaining adequate ventilation
  • Adequate gas exchange
  • Then
  • Control hemorrhage, replace circulating volume,
    restore tissue perfusion

47
Control of External Hemorrhage
  • Direct Pressure
  • Elevation
  • Compression of pressure points (arteries, veins)
  • AVOID tourniquetscan compromise loss of
    circulation and loss of limb

48
Control of Internal Hemorrhage
  • Identification and correction of underlying
    problem.

49
Fluid Resuscitation
  • Venous Access and Volume infused are key.
  • Two large bore IVs 14-16 gauge. (never less that
    18, that is the smallest to give blood through
    rapidly and not have hemolysis)
  • Forearm and anti-cubital veins are preferred
  • Central lines are more beneficial as
    resuscitation MONITORING tools

50
Fluid Resuscitation Cont
  • A pulmonary artery catheter may be inserted in
    the critical care unit to monitor volume.
  • RULE Venous access with largest bore catheter
    possible.
  • Isotonic fluids are used INITIALLY
  • Ringers Lactate is first choice followed by
    Normal Saline

51
Fluid Resuscitation Cont
  • Large bore catheters, short tubing, rapid infuser
    devise that warms fluids and blood.
  • An initial bolus of 2 liters of fluid is used
    unless there is contraindication
  • 31 rule 3mls of crystalloid for each 1ml of
    blood loss.
  • INITIAL response to fluid challenge is urine
    output..should 50 ml in adult, LOC, heart rate,
    BP and capillary refill.

52
Three Response Patterns
  • Rapid Response- respond quickly to fluid
    challenge and remains stable at completion of
    bolus.
  • Transient Response- responds quickly but declines
    when fluids are slowed
  • (indicates continued blood loss)
  • Non Response- fail to hemodynamically respond
    to crystalloid and bloodrequire immediate
    surgical intervention.
  • See table 18-5 on page 652

53
Decision to give Blood
  • Based on patients response to initial fluid.
  • if unresponsive to fluid, type specific blood
    is given, IF LIFE THREATENINGmay give O
    positive.
  • Crossmatched, type specific should be given as
    soon as possible.

54
Auto-transfusion
  • Collection of blood from the patients
    intra-thoracic injuries is anti-coagulated and
    filtered and administered to the patient.
  • SAFE, carries no compatibility problems, no risk
    of transmitted disease.

55
During resuscitative phase
  • Imperative to locate etiology of hemorrhage
  • Chest and pelvis, extremity X-rays
  • Abdominal ultrasound
  • Abdominal CT can be used but in the case of
    hemodynamic instability Peritoneal lavage is the
    quick, invasive test of choice

56
Peritoneal Lavage
  • Insertion of lavage catheter directly into the
    abdomen
  • Aspiration of greater than 10 mls blood and
    patient goes directly for surgery.
  • If less than 10 mls of blood, 1 liter of warmed
    NS is infused into peritoneal cavity, then
    drained and sent for cell counts, amylase, bile,
    food particles, bacteria, fecal matter.

57
Hypothermia
  • Defined as a core temp of 35 degrees Centigrade
  • Can occur year round
  • More susceptible person older, using alcohol or
    sedatives, severe injury, massive transfusions.
  • In presence of cooler atmospheric temps
  • Submersion in water
  • Rapid infusion of room temp. IV fluids
  • Effects the myocardium and the coagulation
    system.
  • Can result in bradycardia, atrial and ventricular
    fibrillation.

58
Treatment
  • Warm fluids
  • Warming blankets
  • Overhead warmers

59
Ongoing Signs and Symptoms of Shock
  • Decreased HH
  • Deterioration of PaO2 and pH
  • Rising base deficits
  • Diminished UOP (less than gt.5ml/kg/hr)
  • Increasing Lactate levels

60
Unreliability of HH
  • Can take up to 4 HOURS!! To re-equilibrate,
    therefore cannot gauge degree of shock.

61
On-going Metabolic acidosis
  • Result of hypovolemia and hypoxia
  • Indicates inadequate tissue perfusion
  • Indicates anaerobic metabolismvery inefficient
    cellular metabolism.
  • Must be interrupted or cellular dysfunction
    results in cellular swelling, rupture and death.

62
Massive Fluid Resuscitation
  • Greater than 10 units of PRBCs over 24 hours or
    the replacement of the patients total blood
    volume in less than 24 hours.
  • It is associated with VERY poor outcomes.

63
Continued..
  • Purpose is to restore oxygen transport to the
    tissues, stop the progression of shock, prevent
    complications.

64
Potential Complications of Massive Fluid
Resuscitation
  • Acid base imbalances
  • Electrolyte imbalances
  • Hypothermia
  • Dilutional coagulopathies
  • Volume overload
  • SIRS (systemic inflammatory response syndrome)
  • ARDS (acute respiratory distress syndrome)
  • MODS (multi-organ dysfunction syndrome)

65
Oxygen Debt
  • Result of metabolic acidosisshift from aerobic
    to anaerobic metabolism resulting in accumulation
    of lactic acidhencelactic acidosis.
  • MUST REVERSE to prevent cellular death

66
Electrolyte Imbalances
  • Hypocalcemia
  • Hypomagnesemia
  • Hyperkalemia
  • May lead to changes in myocardial function,
    laryngeal spasm, neuromuscular and central
    nervous system hyperirritability

67
Third Spacing
  • Vessels become more permeable to fluids and
    molecules, leading a change in movement from the
    intravascular space to the interstitial space.
  • Patients become more hypovolemic requiring more
    fluid replacement.

68
Dilutional Coagulopathy
  • Dilutional thrombocytopenia
  • Reduced fibrinogen
  • Reduced factor V, FactorVIII and other clotting
    components
  • High levels of citrate in blood products reduce
    calciumleading to an ineffective clotting
    cascade (calcium is a necessary co-factor for
    this process).
  • Platelet dysfunction can occur secondary to
    hypothermia or metabolic acidosis

69
Treatment of Dilutional Coagulopathy
  • Improve tissue perfusion
  • Resolve hypothermia
  • Administer clotting factors (FFP,
    cryoprecipitate, platelets)
  • Monitor labs (HH, PLT count, fibrinogen, PT, PTT

70
Changes in the Coagulation Cascade
  • Initially helpfulrelease of inflammatory
    mediatorsover time (can be a fairly short time)
    can result in SIRS, ARDS, MODS

71
Assessment and Management of specific Organ
Injuries
  • Chest Injuries
  • Spinal Cord Injuries
  • Head Injuries
  • Musculoskeletal Injuries
  • Abdominal Injuries

72
Chest Injuries
  • Tension Pneumothorax- is rapidly fatal
  • Easily resolved with early recognition and
    intervention
  • Air enters the pleural cavity without a route of
    escape, with each inspiration, additional air
    enters the pleural space, INCREASING
    intrathoracic pressure causing collapse of the
    lung.
  • The increased pressure causes pressure on the
    heart and great vessels compressing them TOWARD
    the unaffected side.

73
Tension Pneumo cont..
  • Physical evidence
  • Mediastinal Shift distended neck veins.
  • RESULTS in decreased Cardiac Output and
    alterations in gas exchange
  • Manifested by severe resp. distress, chest pain,
    hypotension, tachycardia, absence of breath sound
    son affected side, and tracheal deviation
  • Cyanosis is a LATE manifestation.

74
Tension Pneumo cont
  • Diagnosis based on CLINICAL presentation not
    Chest x-ray
  • Treatment is never delayed to confirm by X-ray
  • Immediate decompression with a 14 gauge needle
    (thoracostomy)..inserted at the 2nd intercostal
    space at the midclavicular line on the INJURED
    side.
  • This converts a tension pneumo to a simple
    pneumo.
  • Definitive treatment then requires placement of a
    chest tube.

75
Hemothorax
  • Collection of blood in the pleural space
  • From injuries to the heart, great vessels, or
    pulmonary parenchyma
  • Signs and symptoms decreased breath sounds,
    dullness to percussion on affected side,
    hypotension, respiratory distress.
  • Treatment Placement of chest tube.

76
Open Pneumothorax
  • Results from penetrating trauma that allows air
    to pass IN AND OUT of the pleural space.
  • Patient presents with hypoxia and hemodynamic
    instability
  • Management Three sided occlusive dressingfourth
    side is LEFT OPEN to allow for exhalation of air
    from the pleural cavity.
  • IF the dressing is occluded on all four sides the
    patient may develop a tension pneumothorax.
  • Treatment Chest tube placement

77
Cardiac Tamponade
  • Life threatening condition caused by RAPID
    accumulation of fluid (usually blood) in the
    pericardial sac.
  • As intra-pericardial pressure increases, cardiac
    output is impaired because of decreased venous
    return.
  • Classic signs are BECKs Triad muffled or
    distant heart sounds, hypotension, elevated
    venous pressureand may not present until the
    patient is hypovolemic and hypotensive.
  • Pulsus paradoxus a decrease in systolic blood
    pressure during spontaneous respiration.

78
Cardiac Tamponade
  • Causes penetrating trauma to chest, blunt trauma
    to chest.
  • Diagnosed with FAST ( focused abdominal
    sonography or pericardiocentesisdont with 16 or
    18 gauge cath over needle and 35 ml syringe and 3
    way stopcock)
  • Aspirated pericardial blood usually will not clot
    unless the heart has been penetrated.

79
Cardiac Tamponade cont..
  • Arterial BP can dramatically improve with as
    little as 15-20 ml of blood removed.
  • Nurses should anticipate and prepare for
    pericardiocentesis in the event of cardiac arrest.

80
Pulmonary Contusion
  • Results from blunt or penetrating trauma to the
    chest
  • One of the most common causes of death after
    trauma
  • Predisposes the patient to pneumonia and ARDS.
  • Can be difficult to detect.

81
Pulmonary Contusion cont..
  • May not be seen on initial X-ray
  • Infiltrates and hypoxemia may not occur for hours
    of days.
  • Clinical presentation includes chest abrasions,
    ecchymosis, bloody secretions, PaO2 of 60mmHG or
    less on room air.
  • Often associated with flail chest and rib
    fractures

82
Pulmonary Contusion cont..
  • The bruised lung becomes edematous, resulting in
    hypoxia and respiratory distress
  • Treatment is ventilatory support, careful fluid
    administration, pain management.

83
Rib Fractures
  • Most common injury after chest trauma
  • Rib fractures usually dxd by xray, but can be
    clinically dxd
  • HIGH IMPACT force is needed to fracture the 1st
    and 2nd ribs. Clinically look for major vessel
    injury..
  • Injury to the liver spleen and kidneys should be
    considered with fracture of ribs 10-12

84
Rib Fractures cont
  • Treatment Depends on ribs Fxd and age of
    patient. Elderly with multiple rib fx may
    require hospitalization.
  • Patient Teaching is very important
  • DO NOT restrict chest movement, pain control,
    ambulation.

85
Flail Chest
  • Usually caused by blunt force trauma, EX Chest
    hits steering wheel.
  • Three or more adjacent ribs are fractured.
  • Flail section floats freely resulting in
    paradoxical chest movement.
  • Flail section contracts INWARD with inspiration
    and expands OUTWARD with expiration.
  • Treatment Intubation/mechanical ventilation,
    frequent pulmonary care, aggressive pain
    management.

86
Aortic Disruption
  • Produced by blunt trauma to the chest
  • Ex rapid deceleration from head-on MVA,
    ejection, or falls.
  • Four common sites of dissection the left
    subclavian artery at the level of the ligamentum
    arteriosum, the ascending aorta, the lower
    thoracic aorta above the diaphragm, and avulsion
    of the innominate artery at the aortic arch.

87
Aortic disruption cont..
  • Signs weak femoral pulses, dysphagia,
    dyspnea,hoarsness, pain.
  • Chest x-ray shows wide mediastinum(greater or
    equal to 8mm), tracheal deviation to the right,
    depressed mainstem bronchus, first and second rib
    fractures, left hemothorax.
  • CONFIRMATION is done with aortogram
  • Treatment is SURGICAL

88
Spinal Cord Injury
  • Mechanism of injury can be hyperflexion,
    hyperextension, axial loading, rotation,
    penetrating trauma
  • Initially ABCs, immobilization
  • Triage to appropriate facility
  • Complete sensory motor neuro exam

89
Spinal Cord Injury
  • Lateral C-Spine films, possible Spinal CT to rule
    out occult fracture.
  • Dislocations of the spine are reduced ASAP
  • Postural reduction with tongs, halo traction or
    surgical fusion.
  • IV methylprednisolone within 8 hours

90
Spinal Cord Injury
  • Spinal Shock loss of sympathetic
    outputNeurogenic shock results are bradycardia,
    hypotension.
  • Need vasopressors to compensate for loss of
    sympathetic innervation and resultant
    vasodilatation.

91
Spinal Cord Injury cont.
  • Potential Complications GI dysfunction,
    autonomic dysreflexia, DVT, orthostatic
    hypotension, loss of bowel and bladder function,
    immobility, spasticity, and contractures.
  • THINK EARLY PREVENTION AND INTERVENTION!!!!

92
Head Injury
  • Can be caused by blunt or penetrating trauma.
  • Lacerations to the scalp produce profuse
    bleeding.
  • Fractures of the skull may have underlying brain
    injury

93
Heady Injury cont
  • Basilar skull fractures are located at the base
    of the cranium and potentially involve 5 bones
    that form the base of the skull.
  • Are diagnosed based on the presence of CSF in the
    nose (rhinorrhea) or ears (otorrhea)

94
Heady Injury cont..
  • Basilar Skull Fracture cont
  • Ecchymosis over the mastoid (Battles sign)
  • Hemotympanium (blood in the middle ear)
  • Raccoon eyes or periorbital eccymoses cribiform
    plate fracture

95
Head Injury cont.
  • Potential complications of Basilar Skull
    Fractures Infection and cranial nerve injury.

96
Secondary Head Injury
  • Refers to the systemic (hypotension, hypoxia,
    anemia, hypocapnia, hyperthermia) or intracranial
    ( edema, intracranial hypertension, seizures,
    vasospasm) changes that result in alteration in
    the nervous system..page 657..read this!!! Very
    important.

97
Secondary Head Injury
  • Prehospital MOST important
  • Supplemental oxygen, often intubation
  • Aggressive and careful volume replacement
  • ICP monitoring/ Goal is 20mm Hg
  • Cerebral Perfusion PressureMAP(mean arterial
    pressure) Minus Mean ICP and keep at 70mm Hg to
    decrease neurological disability.

98
Secondary Head Injury cont..
  • Osmotic and loop diuretics, CSF drainage,
    hyperventilation (results in vasoconstriction of
    cerebral vessels allowing more space for swelling
    brain tissue), paralysis WITH sedation,
    pentobarbital induced coma is final intervention
    when all else fails.

99
Nursing Care for Traumatic Head Injury
  • Airway, adequate ventilation and gas exchange,
    clearance of pulmonary secretions, proper head
    alignment, close neurological function
    monitoring.
  • Pulmonary complications are common, aggressive
    pulmonary hygiene
  • HOB at 30 degrees
  • Assess for intracranial hemodynamics(ICP and
    perfusion pressure) and patient tolerance

100
Musculoskeletal Injuries
  • See Types of Fractures Table 18-7 on page 658
  • Extremity Assessment the 5 Ps
  • Pallor pain, pulses, parethesia, paralysis
    (describes the neurovascular status of the
    injured extremity.
  • When possible the injured extremity if compared
    with the non-injured extremity

101
Musculoskeletal Injury cont..
  • Fracture wounds should be debrided and the
    fracture reduced within 18 hours to prevent
    infection and nonunion.
  • If hemodynamically unstable, skeletal traction to
    realign the extremity may be used .

102
MS Cont..
  • Unstable Pelvis fractures can be life threatening
    secondary to potential for severe hemorrhage,
    exsanguination, damage to genitourinary system
    and sepsis.

103
Traumatic Soft Tissue Injury
  • Categorized as contusions, abrasions,
    lacerations, punctures, hematomas, amputations,
    and avulsions.
  • All wounds are considered contaminated.
  • Tetanus Toxoid and antibiotics are always
    CONSIDERED.

104
Complications of Musculoskeletal Injuries
  • Rhabdomolysis-a complication of crush
    injuriesmarked vasoconstriction and hypotension
    followed by ARF
  • Results from muscle destruction.
  • Myogolobin and potassium are released from the
    damage muscles

105
Cont.
  • Can result in life threatening hyperkaemia.
  • Myoglobin excreted through the urine, combined
    with hypovolemia, produces ARF and ATN if not
    aggressively treated.
  • Treatment Aggressive saline replacement,
    alkalinization of urine, osmotic diuresis.

106
Compartment Syndrome
  • Places the patient at risk for limb loss.
  • More common in the legs and forearms but can
    occur other places.
  • The closed muscle compartment contains
    neurovascular bundles tightly covered by fascia.

107
Cont
  • An increase in pressure within that compartment
    produces the syndrome.
  • Internal sources hemorrhages, edema, open or
    closed fractures, crush injuries
  • External sourcesPASGs, casts, skeletal
    traction, air splints.
  • The pain is described as throbbing appearing
    DISPROPORTIONATE TO THE INJURY. Increases with
    muscle stretching. The affected area is firm to
    touch. Paresthesia distal to the compartment,
    pulselessness, and paralysis are LATE signs.
  • Treatment s immediate surgical fasciotomy.

108
Fat Embolism
  • Usually associated with long bone, pelvis, and
    multiple fractures.
  • Usually develops within 24 to 48 hours after
    injury.
  • Hallmark clinical signs low grade fever, new
    onset tachycardia, dyspnea, increased resp rate
    and effort, abnormal ABGs, thrombocytopenia and
    petechiae.
  • Development of lipuria (fat in the urine)
    indicates severe fat embolism syndrome.

109
Fat embolism cont..
  • Prevention is the best treatment.
  • Treatment is directed at preserving pulmonary
    function and maintenance of cardiovascular
    function.
  • Careful attention to EKG changes.
  • See Box 18-2 on page 660 IMPORTANT!!!

110
Abdominal Injuries
  • The Classic sign is PAIN.
  • But may be obscured by AMS, drug or alcohol
    intoxication, Spinal cord Injury with impaired
    sensation
  • The liver is the most commonly injured organ from
    blunt or penetrating trauma

111
Cont
  • Liver injuries are graded I through VI.
  • Splenic injury most commonly occurs from blunt
    trauma but can be caused by penetrating trauma.
  • Presentation LUQ tenderness, peritoneal
    irritation, referred pain to the left shoulder
    (Kerrs sign)

112
Cont
  • Graded I to V.
  • Diagnosed with FAST, Abd. CT or peritoneal
    lavage.
  • Patients more at risk for pneumococcal disease
    and should have immunization with in first few
    post op days after splenectomy

113
ContKidney Injury
  • Usually attributed to blunt trauma
  • Presentation may include CVA tenderness,
    microscopic or gross hematuria, bruising,
    ecchymosis over the 11th and 12th ribs,
    hemorrhage or shock.

114
Cont
  • Diagnostic testing IVP, CT scan, angiography,
    cystoscopy.

115
Critical Care Phase
  • ABCc
  • Post OP standard VS q5min x3, q15minx3, q30min
    X2, q1 hour forward.
  • Shivering is to be avoidedincrease in metabolic
    rate and increase in oxygen demands.

116
Cont..
  • Physical Assessment FULL BODY
  • Level of Consciousness
  • Invasive Line assessment
  • Pain Assessment
  • Ongoing Assessments revolve around the patients
    diagnosis and/or surgical procedure.
  • Anticipation and prevention of untoward
    complications.
  • READ PAGES 661-668 CAREFULLY

117
Damage Control Surgery
  • Staged laporaotmy
  • Trying to avoid hypothermia, acidosis,
    coagulopathy
  • Shown to improve outcomes of critically ill
    patients with sever intra-abdominal injuries.

118
ARDS
  • Chapter 13 fully covers
  • May occur 2 to 48 hours after traumatic injury,
    however sometimes up to 5 days or more before
    RECOGNIZABLE clinical signs.
  • There are direct and indirect causes.

119
Cont
  • Clinical Manifestations hypoxemia, rising CO2
    levels, tachypnea, dyspnea, pulmonary
    hypertension, decreased lung compliance, new
    diffuse bilateral lung infiltrates.
  • Treatment correction of underlying
    cause---maximize O2 to the tissues, decrease
    pulmonary congestion, prevent further lung
    damage, support cardiovascular system.

120
DVT
  • Increased incidence of DVT patients with
    obesity, age, malignancy, pregnancy, heart
    failure, SCI, recent surgery, extremity
    fractures, pelvic fractures, history of DVT,
    prolonged immobilization, resp. failure, of
    transfusions,central venous catheterization,
    vascular injury.

121
Cont..
  • Clinical Manifestations pain and tenderness,
    swelling fever, venous distention, palpable cord,
    discoloration, Homans sign
  • Treatment prevention, prophylaxis, early
    ambulation, sequential compression devices,
    filter placement in the inferior vena cava.

122
Cont.
  • Pulmonary embolism is an often fatal complication
    of DVT
  • Clinical manifestations of PE sudden onset
    dyspnea, sudden onset chest pain, rapid shallow
    resps, SOB, Auscultation of bronchial breath
    sounds, pale, dusky or cyanotic skin, Anxiety,
    decreased LOC, signs of hypovolemic shock
    (decreased BP, narrowing pulse pressure,
    tachycardia)

123
Infection
  • Pulmonary
  • Catheter Sepsis
  • Sinusitis

124
Acute Renal Failure
  • From systemic effects of trauma
  • OR from actual injury to the renal system
  • There is a reduction in renal blood flow in the
    trauma patient associated with shock or low
    cardiac output.

125
Altered Nutrition
  • Nutritional demands are increased in the trauma
    patient by alterations in metabolism
  • Metabolism is increased by activation of the
    sympathetic response.
  • Ebb (1st 24-48 hours after injury) and Flow Phase
    (peaks 5-10 days after injury)

126
Cont.
  • Because of this increased need the patient may
    demonstrated decreased body mass, increased O2
    consumption, increased CO2 production, delayed
    wound healing, and a weakened immune system

127
Cont..
  • Anthropometric measurements
  • Nutrition replacement in 24 to 48 hours.
  • Route based on individual status of patientcan
    be enteral, or parenteral

128
Multiple Organ Dysfunction Syndrome
  • Immune, inflammatory, and hormonal responses are
    underlying causes.
  • Defined as presence of altered organ function in
    the acutely ill.
  • There is incomplete understanding of its
    pathophysiology.
  • Management focuses on prevention, early
    identification, elimination of sources of
    infection, maint. Of tissue oxygenation and
    nutritional support.
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