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Trauma Nursing

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Title: Trauma Nursing


1
Trauma Nursing
  • By Diana Blum RN MSN
  • Metropolitan Community College

2
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

3
  • 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

4
Common Trauma
  • Heat
  • Bites
  • Cold
  • Electrical
  • Altitude
  • Near drowning
  • Spinal
  • Head
  • Musculoskeletal
  • Stab/gunshot wounds
  • rape

5
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

6
Treatment
  • Lower temp as quickly as possible(102 and lower)
    How can this be done?
  • Mortality duration of hyperthermia
  • ABCs
  • Give 02, Start large bore IV
  • Insert foley
  • Labs
  • Lytes, CBC, myoglobin. Cardiac enzymes

7
Assessment
  • Mental statusSeizure may occur
  • Monitor vitals frequently
  • Renal status
  • 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

8
Heat
  • Exhaustion
  • Stroke

9
Heat Exhaustion
  • Caused by dehydration
  • Stems from heavy perspiration
  • Poor electrolyte consumption
  • Signs/Symptoms
  • Normal mental status
  • Flu like
  • Headache
  • Weakness
  • N/V
  • Orthostatic hypotension
  • Tachycardia

10
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

11
Heat Stroke
  • Leads to organ failure and death
  • Mortality rate up to 80
  • 2 types
  • Exertional
  • Sudden onset
  • Too heavy clothes
  • Classic
  • Occurs over period of time
  • Chronic exposure to heat
  • Example (no air conditioning)

12
Heat Stroke
  • 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
  • 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

13
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

14
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

15
HYPOTHERMIA
16
COLD
  • 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

17
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

18
Assessment
  • Apathy, drowsiness, pulmonary edema,
    coagulopathies
  • Weak HR and BP
  • Hypoxemia
  • Continuous temperature and EKG
  • Watch for dysrhythmias

19
Rewarming
  • Warm fluids, blankets
  • Cardiopulmonary bypass
  • Warm lavage

20
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23
Frost Bite
  • Inadequate insulation is the culprit
  • 3 stages
  • Superficial (frost nip)
  • Mild
  • Severe
  • Frostnip produces mild pain, numbness,pallor of
    affected skin
  • Graded like burns-partial thick or full thick
  • 1st degree- hyperemia, edema
  • 2nd degree- fluid blisters with partial thick
    necrosis
  • 3rd degree- dark fluid blisters, sub cutaneous
    necrosis
  • 4th degree- no blisters, no edema, necrosis to
    muscle and bone

24
Snake BITES
25
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
  • Peak in July and August
  • 2 main types in North America are
  • pit vipers (look for warm blooded prey)
  • Water moccasins, copperheads, rattlesnakes
  • Most of bites
  • Coral snakes
  • From North Carolina to Florida and in the Gulf
    states, Arizona, and Texas

26
Snake Bites
  • 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

27
Snake Bites
  • 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
  • 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

28
Snake Bites
  • 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

29
Snake Bites
  • Action of venom
  • Blocks binding of acetylcholine at post synaptic
    junction
  • S/S
  • 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

30
Snake Bites
  • 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

http//www.expotv.com/videos/reviews/19/169/Coghla
n27sSnakeBiteKit/156505
31
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 2060 minutes after death
    due to bite reflex
  • Use caution when transporting snake with victim
    to hospitalmake sure it is in a sealed container.

32
Arthropod Bites and Stings
  • Spiders carnivorous
  • Almost all are venomous
  • Most not harmful to humans
  • Brown recluse, black widow, and tarantula are
    dangerous for example
  • Scorpions not in Midwest or New England
  • 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-insec
t-bite
33
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

34
  • Over 1-3 days lesion becomes dark and
    necroticeschar even forms, and sloughs
  • Surgery is often needed
  • Skin grafting
  • Rare Malaise, Joint pain, Petechaie, N/V Fever,
    Chills
  • Pruritis
  • Erythema
  • Extreme hemolytic, renal failure, death

35
  • 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

36
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

37
  • 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

38
  • 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

39
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

40
  • USA trantulas dont 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

41
  • 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

42
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

43
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

44
  • 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

45
  • 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

46
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

47
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

48
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

49
Poisoningoverdose
50
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

51
Assessment of Patients With Ingested Poisons
  • Remember ABCs
  • Monitor VS, LOC, ECG, and UO
  • Assess 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

52
Interventions for those withIngested 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

53
  • Corrosive agents such as acids and alkalis cause
    destruction of tissues by contact
  • DO NOT induce vomiting with corrosive agents

54
Management ofCarbon Monoxide Poisoning
  • Inhaled carbon monoxide binds to hemoglobin as
    carboxyhemoglobin, which does not transport
    oxygen
  • Manifestations CNS symptoms predominate
  • Skin color is not a reliable sign
  • pulse oximetry is not valid
  • Treatment
  • 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

55
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

56
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

57
LIGHTNING
58
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

59
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)

60
Lightning
  • Most lethal effect is asystole or Vfib
  • Most victims suffer cardiac injury
  • S/S
  • Mottled skin
  • Cardiac arrest
  • Respiratory arrest
  • Decreased or absent peripheral pulses
  • Temporary paralysis
  • Loss of Consciousness
  • Amnesia, confusion, disorientation
  • Photophobia
  • Seizures
  • Fatigue and PTSD
  • Ruptured tympanic membranes
  • Blindness, cataracts, retinal detachment
  • Skin burns
  • Ferning marks branching on the skin

61
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

62
Altitude related Illness
  • High altitude is elevations above 5000 feet ?
    most ski resorts
  • As altitude increases?barametric pressure
    decrease
  • This means less o2 the higher you go
  • Oxygen is 21 of the barametric pressure
  • Acclimatization?the 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

63
  • 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

64
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

65
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

66
DROWNING
67
Near Drowning
68
  • 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.

69
  • 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.

70
  • 6,000 to 8,000 people drown in the U.S. each
    year. Most drownings occur within a short
    distance of safety. Immediate action and first
    aid can prevent death.
  • A person who is drowning usually can NOT shout
    for help. Be alert for signs of drowning.
  • Suspect an accident if you see someone in the
    water fully clothed. Watch for uneven swimming
    motions, which indicate a swimmer is getting
    tired. Often the body sinks, and only the head
    shows above the water.
  • Children can drown in only a few inches of water.
  • It may be possible to revive a drowning victim
    even after a prolonged period of submersion,
    especially if the person was in very cold water.

71
  • 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

72
  • First Aid
  • When someone is drowning
  • Extend a long pole or branch to the person, or
    use a throw rope attached to a buoyant object,
    such as a life ring or life jacket. Toss it to
    the person, then pull him or her to shore.
  • People who have fallen through ice may not be
    able to grasp objects within their reach or hold
    on while being pulled to safety.
  • Do not place yourself in danger. Do NOT get into
    the water or go out onto ice unless your are
    absolutely sure it is safe.
  • If you are trained in rescuing people, do so
    immediately if you are absolutely sure it will
    not cause you harm.
  • If the victim's breathing has stopped, begin
    rescue breaths as soon as you can. This often
    means starting the breathing process while still
    in the water.
  • Continue to breathe for the person every few
    seconds while moving them to dry land. Once on
    land, give CPR if needed.

73
  • Always use caution when moving a drowning victim.
  • Assume that the person may have a neck or spine
    injury, and avoid turning or bending the neck.
  • Keep the head and neck very still during CPR and
    while moving the person.
  • You can tape the head to a backboard or
    stretcher, or secure the neck by placing rolled
    towels or other objects around it.
  • Follow these additional steps
  • Keep the person calm and still. Seek medical help
    immediately.
  • Remove any cold, wet clothes from the person and
    cover with something warm to prevent hypothermia.
  • Give first aid for any other serious injuries.
  • The person may cough and have difficulty
    breathing once breathing re-starts. Keep
    Reassuring the person without providing false
    hope.

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  • DO NOT
  • DO NOT go out on the ice to rescue a drowning
    person that you can reach with your arm or an
    extended object.
  • DO NOT attempt a swimming rescue yourself unless
    you are trained in water rescue.
  • DO NOT go into rough or turbulent water that may
    endanger you.
  • Do not perform the Heimlich maneuver unless
    repeated attempts to position the airway to use
    rescue breathes failed and you suspect the
    persons airway is blocked. It increases the
    chances that an unconscious victim will vomit and
    subsequently choke
  • When to Contact a Medical Professional
  • If you cannot rescue the drowning person without
    endangering yourself, call for emergency medical
    assistance immediately. If you are trained and
    able to rescue the person, do so and then call
    for medical help.
  • All possible drownings should be checked by a
    doctor.

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  • 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 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.

76
Multisystem Trauma
77
Spinal Cord Injuries (SCI)
  • tetraplegia (quadriplegia) paralysis from neck
    down
  • 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

78
  • Complete spinal cord severed and no nerve
    impulses below level of injury
  • Incomplete allow some function and movement
    below level of injury

79
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

80
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

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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

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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

84
NRSG DX
  • Ineffective tissue perfusion r/t interruption of
    arterial flow
  • Ineffective airway clearance r/t SCI
  • Ineffective breathing pattern r/t SCI
  • Impaired gas exchange r/t SCI

85
Treatment of SCI
  • Immobilize fx
  • Proper body alignment
  • Traction is possible
  • Monitor 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

86
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

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  • Always assume c-spine injury
  • ABC highest priority
  • Control bleeding right away

89
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

90
Figure 74.2 Unrestrained frontal impact.
91
Other types of multiple injuries
  • Motorcyle
  • Tib/fib, chest, abd, TBI, cspine, femur
  • Pedestrian
  • Femur, chest, lower extremities
  • Falls
  • Calcaneous, compression, wrist, TBI

92
  • Battles sign
  • Raccoon eyes
  • Flail chest
  • Tension Pneumothorax
  • Hemothorax

93
Blunt Trauma by Force
  • Acceleration-caused by external force contacting
    head
  • Deceleration- when head suddenly stops or hits a
    stationary object

94
Increased ICP
  • Normal ICP is 10-15mmHg
  • Normal increases occur with coughing, sneezing,
    defecation
  • Leading cause of death for head trauma
  • As ICP increases cerebral perfusion decreases
    causing tissue hypoxia, decrease serum pH, and
    increase in CO2

95
ICP continued
  • 3 types of edema
  • Vasogenic increase in brain tissue volume
  • Cytotoxic result of hypoxia
  • Interstitial occurs with brain swelling

96
Hematoma
  • Epidural- bleed b/w dura and inner table
  • Subdural-bleed below dura and above arachoid
  • Intracerebral-accumulation of blood in brain
    tissue

97
Hydrocephalus
  • abnormal increase in CSF volume
  • Causes impaired reabsorption from subarachnoid
    hemorrhage or meningitis
  • may be congenital or acquired
  • Acquired hydrocephalus develops at the time of
    birth or at some point afterward. It can affect
    individuals of all ages and may be caused by
    injury or disease.
  • Symptoms vary with age, disease progression, and
    individual differences in tolerance to the
    condition

98
Brain Herniation
  • Increased ICP will shift and move brain tissue
    downward
  • Central Herniation
  • Downward shift to brainstem
  • S/S
  • Cheyne stokes , pinpoint pupils, hemodynamic
    instability
  • The most life threatening is Uncal because it
    causes pressure on the 3rd cranial nerve
  • S/S
  • Dilated, nonreactive pupils, ptosis, rapidly
    decreased LOC

99
Interventions for musculoskeletal trauma
  • Fractures
  • Open
  • Closed
  • Spontaneous
  • Stress
  • Compression
  • Greenstick
  • Spiral
  • Oblique
  • Impacted
  • Displaced
  • Non-displaced
  • fragmented

100
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

101
Factors that affect healing
  • Age
  • Severity of trauma
  • Bone injured
  • Inadequate immobilization
  • Infection
  • Avascular necrosis

102
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
    injury-hemorrhage

103
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

104
Nursing diagnosis
  • Acute pain
  • Risk for infection
  • Impaired physical mobility
  • Etc.

105
interventions
  • Inspect fx site
  • Palpate area lightly
  • Assess motor function
  • Immobilize extremity
  • Realignment
  • Cast
  • Traction
  • Surgery
  • open reduction with internal fixation

106
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

107
  • 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

108
  • 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

109
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

110
Figure 56.10 Vascular anatomy of the pelvis.
111
Dislocations
  • Painful
  • Needs to be reduced ASAP
  • Can cause nerve damage
  • Avascular Necrosis
  • Dislocation occludes blood supply

112
Other surgeries
  • Vertebroplasty
  • Kyphoplasty
  • Both are minimally invasive
  • Both use a bone cement to provide immediate
    relief of pain

113
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
  • Nonunionnever completely heal
  • Malunion heal incorrectly

114
CRUSH SYNDROME
  • CAUSES
  • Wringer type injuries
  • Natural disasters
  • Work related injuries
  • Drug or alcohol overdose
  • CHARACTERISTICS
  • Acute compartment syndrome
  • Hyperkalemia
  • Rhabdomyolosis myoglobin released into blood
  • S/S
  • Hypovolemia, hyperkalemia, compartment syndrome
  • TX
  • IVF, diuretics, low dose dopamine, sodium bicarb,
    kayexelate, hemodialysis is possible.

115
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

116
Tx
  • Pain control
  • PT
  • OT
  • ROM
  • Gentle skin care
  • Support groups, etc

117
Sports related injuries
  • Tears
  • Lock knee
  • Torn ACL
  • Tendon rupture
  • Dislocation
  • Subluxation
  • Strains
  • Sprains
  • Torn rotator cuff

118
Interventions for musculoskeletal trauma
  • Casts
  • Braces
  • Splints
  • Traction
  • Surgery
  • Reduction (realignment)

119
amputations
  • Removal of part of the body
  • Types
  • Surgical-example digit
  • Traumatic- example digit
  • Levels
  • 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

120
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

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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)

123
  • Defense Wound
  • Stab Wound w/ single edge blade

124
Gun shot wounds
  • 4 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 woundno powder or soot

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  • 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.

127
  • 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
  • Some may cause sensitivity to the sun, so
    sunscreen (at least SPF 15) is mandatory while
    taking these antibiotics.
  • Pain may be relieved with Tylenol or ibuprofen

128
In Hospital Treatment
  • Stay Safe. If you are not the victim, practice
    Universal precautions and wear PPE.
  • Try to control bleeding before anything else.
  • Putting pressure directly on the puncture wound
    while holding it above the level of the heart for
    15 minutes should be enough to stop bleeding.
  • Avoid Tourniquets unless medical care will be
    delayed for several hours.
  • Call 911 if any Deep puncture wounds (or those of
    unknown depth) to the abdomen, back, pelvis,
    thigh, chest, or if bleeding will not stop
  • Holes in the chest can collapse the lungs
  • Deep puncture wounds to the chest should be
    immediately sealed by hand or with a dressing
    that does not allow air to flow ( 3 sided).
  • IF complaints of SOB occur or victim gets worse
    after sealing the chest puncture wound then
    unseal it.
  • Once bleeding has been controlled, wash the
    puncture wound with warm water and mild soap

129
SEXUAL ABUSE
130
Sexual Abuse
  • Sexual abuse (also referred to as molestation) is
    defined as the forcing of undesired sexual acts
    by one person to another.
  • Incest is defined as sexual abuse between family
    members
  • Different types of sexual abuse involve
  • Non-consensual, forced physical sexual behavior
  • 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.
  • Usually related to drinking
  • http//www.youtube.com/watch?vPvXxzZUuIn0

131
Sexual Abuse
  • Signs of sexual abuse
  • Unexplained injuries (especially to parts of the
    female body that can be covered by a two-piece
    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

132
  • 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.
  • Samples of evidence may be used in court.
  • blood tests are done to check for pregnancy and
    diseases that can be passed through sex.
  • Cultures of the cervix may be sent to a lab to
    check for disease, too. The results will come
    back in several days or a few weeks.
  • Follow up with PCP is important. If any of the
    tests are positive, treatment options will be
    discussed.

133
  • If a birth control pill or intrauterine device
    (IUD) the chance of pregnancy is small.
  • If no birth control is taken the victim may
    consider pregnancy prevention treatment.
  • Pregnancy prevention consists of taking 2
    estrogen pills when you first get to the hospital
    and 2 more pills 12 hours later. This treatment
    reduces the risk of pregnancy by 60 to 90. (The
    treatment may make you feel sick to your
    stomach.)
  • If not already vaccinated for hepatitis B, the
    victim should get that vaccination followed by
    one after 1 month and a third in 6 months.
  • The doctor will also discuss (HIV) infection. you
    can take 2 medicines Retrovir and Epivir -- for
    4 weeks to aid in prevention

134
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)

135
Types of rape
  • Gang
  • Multiple offenders, one victim
  • Date
  • Custodial
  • Serial
  • Marital
  • Prison
  • Acquaintance
  • Wartime
  • Statuatory

136
Effects of rape
  • Unpredictable emotions
  • Feeling numb and detached
  • Memory problems
  • Avoidance of things
  • anxiety
  • PTSD can occur
  • Relive the rape over and over
  • Disturbed sleeping patterns
  • Eating habits affected

137
More stats
  • If reported to police 50 chance an arrest will
    be made
  • If arrest made, 80 chance of prosecution
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