Must be interrupted or cellular dysfunction results in cellular swelling, rupture and death.
Massive Fluid Resuscitation
Greater than 10 units of PRBC’s over 24 hours or the replacement of the patient’s total blood volume in less than 24 hours.
It is associated with VERY poor outcomes.
Purpose is to restore oxygen transport to the tissues, stop the progression of shock, prevent complications.
Potential Complications of Massive Fluid Resuscitation
Acid base imbalances
SIRS (systemic inflammatory response syndrome)
ARDS (acute respiratory distress syndrome)
MODS (multi-organ dysfunction syndrome)
Result of metabolic acidosis—shift from aerobic to anaerobic metabolism resulting in accumulation of lactic acid…hence…lactic acidosis.
MUST REVERSE to prevent cellular death
May lead to changes in myocardial function, laryngeal spasm, neuromuscular and central nervous system hyperirritability
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.
Reduced factor V, FactorVIII and other clotting components
High levels of citrate in blood products reduce calcium…leading to an ineffective clotting cascade (calcium is a necessary co-factor for this process).
Platelet dysfunction can occur secondary to hypothermia or metabolic acidosis
Treatment of Dilutional Coagulopathy
Improve tissue perfusion
Administer clotting factors (FFP, cryoprecipitate, platelets)
Monitor labs (H&H, PLT count, fibrinogen, PT, PTT
Changes in the Coagulation Cascade
Initially helpful…release of inflammatory mediators…over time (can be a fairly short time) can result in SIRS, ARDS, MODS
Assessment and Management of specific Organ Injuries
Spinal Cord 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.
Tension Pneumo cont..
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.
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 2 nd 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.
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.
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 dressing…fourth 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
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: BECK’s Triad: muffled or distant heart sounds, hypotension, elevated venous pressure…and may not present until the patient is hypovolemic and hypotensive.
Pulsus paradoxus= a decrease in systolic blood pressure during spontaneous respiration.
Causes: penetrating trauma to chest, blunt trauma to chest.
Diagnosed with FAST ( focused abdominal sonography or pericardiocentesis—don’t 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.
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.
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.
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
Pulmonary Contusion cont..
The bruised lung becomes edematous, resulting in hypoxia and respiratory distress
Treatment is ventilatory support, careful fluid administration, pain management.
Most common injury after chest trauma
Rib fractures usually dx’d by xray, but can be clinically dx’d
HIGH IMPACT force is needed to fracture the 1 st and 2 nd ribs. Clinically look for major vessel injury..
Injury to the liver spleen and kidneys should be considered with fracture of ribs 10-12
Rib Fractures cont…
Treatment: Depends on ribs Fx’d 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.
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.
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.
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
Spinal Cord Injury
Mechanism of injury can be: hyperflexion, hyperextension, axial loading, rotation, penetrating trauma
Initially: ABC’s, immobilization
Triage to appropriate facility
Complete sensory &motor neuro exam
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
Spinal Cord Injury
Spinal Shock= loss of sympathetic output=Neurogenic shock results are bradycardia, hypotension.
Need vasopressors to compensate for loss of sympathetic innervation and resultant vasodilatation.
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!!!!
Can be caused by blunt or penetrating trauma.
Lacerations to the scalp produce profuse bleeding.
Fractures of the skull may have underlying brain injury
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)
Heady Injury cont..
Basilar Skull Fracture cont…
Ecchymosis over the mastoid (Battle’s sign)
Hemotympanium (blood in the middle ear)
Raccoon eyes or periorbital eccymoses =cribiform plate fracture
Head Injury cont.
Potential complications of Basilar Skull Fractures: Infection and cranial nerve injury.
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.
Secondary Head Injury
Prehospital MOST important
Supplemental oxygen, often intubation
Aggressive and careful volume replacement
ICP monitoring/ Goal is 20mm Hg
Cerebral Perfusion Pressure=MAP(mean arterial pressure) Minus Mean ICP and keep at 70mm Hg to decrease neurological disability.
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.
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
See Types of Fractures Table 18-7 on page 658
Extremity Assessment= the 5 P’s
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
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 .
Unstable Pelvis fractures can be life threatening secondary to potential for severe hemorrhage, exsanguination, damage to genitourinary system and sepsis.
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.
Complications of Musculoskeletal Injuries
Rhabdomolysis-a complication of crush injuries—marked vasoconstriction and hypotension followed by ARF
Results from muscle destruction.
Myogolobin and potassium are released from the damage muscles
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.
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.
An increase in pressure within that compartment produces the syndrome.
Internal sources= hemorrhages, edema, open or closed fractures, crush injuries
External sources=PASG’s, 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.
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 ABG’s, thrombocytopenia and petechiae.
Development of lipuria (fat in the urine) indicates severe fat embolism syndrome.
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!!!
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
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 (Kerr’s sign)
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
Usually attributed to blunt trauma
Presentation may include CVA tenderness, microscopic or gross hematuria, bruising, ecchymosis over the 11 th and 12 th ribs, hemorrhage or shock.