Pasg Anti Shock Garment

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Pasg Anti Shock Garment

  1. 1. Introduction to Emergency Nursing Concepts Sandra H. Lewis, ARNP-BC-ADM
  2. 2. Prehospital Care and Transport <ul><li>The time from injury to definitive care is a determinant of survival, particularly those with major internal hemorrhage. </li></ul><ul><li>Careful attention must be given to the airway with cervical spine immobilization, breathing and circulation. (ABC’s) </li></ul>
  3. 3. Continued… <ul><li>Full spinal mobilization is being challenged and reexamined: </li></ul><ul><li>Asking: Is full spinal mobilization necessary in all trauma patients? </li></ul><ul><li>How appropriate is the assessment of prehospital assessment? </li></ul><ul><li>Concerns over the high false positive rate that occurs with prolonged spinal immobilization. </li></ul>
  4. 4. Current Guidelines
  5. 5. Objectives <ul><li>1. Explain emergency care as a collaborative, holistic approach that includes patient, family and significant others. </li></ul><ul><li>Discuss priority emergency measures for any patient with an emergency situation. </li></ul><ul><li>3. Discuss pre-hospital, emergency care and resuscitation of the trauma patient. </li></ul>
  6. 6. Objectives <ul><li>Discuss disaster triage concepts and contrast with traditional triage concepts. </li></ul>
  7. 7. Trauma <ul><li>The fourth leading cause of death for ALL ages. </li></ul><ul><li>Nearly ½ of all traumatic incidents involve the use of alcohol, drugs or other substance abuse. </li></ul><ul><li>Is predominantly a disease of the young and carries potential for permanent disability. </li></ul>
  8. 8. Systems Approach to Trauma <ul><li>An organized approach to trauma care that includes: </li></ul><ul><li>Prevention, access, acute hospital care, rehabilitation, and research. </li></ul>
  9. 9. Trimodal Distribution of Death <ul><li>First peak- seconds to minutes from time of injury to death—severe injuries: lacerations of the brain, brainstem, high spinal cord, heart aorta, large blood vessels. </li></ul><ul><li>Second peak- minutes to several hours: subdural, epidurdal hematomas, hemopneumothorax, ruptured spleen, lacerated liver, pelvic fractures, other injuries associated with major blood loss. </li></ul>
  10. 10. <ul><li>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. </li></ul>
  11. 11. Levels of Trauma Care <ul><li>American college of Surgeons Committee on Trauma </li></ul><ul><li>Level’s I-IV, Level ones are the most sophisticated and care for all aspects from prevention to rehabilitation. </li></ul>
  12. 12. Trauma Triage <ul><li>Minor trauma: single system injury that does not pose threat to life or limb and can be appropriately treated at a basic emergency facility. </li></ul><ul><li>Major trauma: serious multi system injuries that require immediate intervention to prevent disability. </li></ul>
  13. 13. Mechanism of Injury <ul><li>Is vital to the initial assessment and may raise suspicions about the patients injury pattern. </li></ul><ul><li>Blunt vs. penetrating injury </li></ul>
  14. 14. Blunt Trauma <ul><li>Most often results from vehicular accidents, but may occur in assaults, falls from heights, and sports related injuries. </li></ul><ul><li>May be caused by accelerating, decelerating, shearing, crushing, and compressing forces. </li></ul>
  15. 15. Blunt Trauma, cont. <ul><li>Coup-contra coup injury </li></ul><ul><li>Body tissues respond differently to kinetic energy…low density porous tissues and structures, such as lungs, often experience little damage because of their elasticity. </li></ul>
  16. 16. Blunt Trauma cont. <ul><li>The heart , spleen and liver are less resilient often rupturing or fragmenting. </li></ul><ul><li>Often, overt external signs are not apparent…making the mechanism of injury most important to the practitioner performing the physical examination. </li></ul>
  17. 17. Penetrating Trauma <ul><li>Results from the impalement of foreign objects into the body. </li></ul><ul><li>More easily diagnosed because of obvious injury signs. </li></ul><ul><li>Stab wounds are usually low velocity…the direct path, the depth and width determine injury. </li></ul><ul><li>Women tend to have trajectories in a downward motion, men in an upward force. </li></ul>
  18. 18. Penetrating Trauma cont. <ul><li>Ballistic trauma may be either low or high velocity injuries. </li></ul><ul><li>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. </li></ul>
  19. 19. Penetrating Trauma, cont. <ul><li>Injuries sustained from penetrating objects must be assessed for the potential for infection from the debris carried by the penetrating object. </li></ul>
  20. 20. Disaster / Mass Casualty Triage Concepts <ul><li>Most severe injuries in mass trauma events are fractures, burns, lacerations, and crush injuries. </li></ul><ul><li>Most common injuries are eye injuries, sprains, strains, minor wounds and ear damage. (CDC Website) </li></ul>
  21. 21. Mass Casualty: Who is at risk? <ul><li>Anyone in surrounding area. </li></ul><ul><li>Rescue workers and volunteers. </li></ul>
  22. 22. Bioterrorism Agents/Diseases, Threats <ul><li>CDC Website ( see handout) </li></ul>
  23. 23. Disaster Triage <ul><li>www.bt.cdc.gov/masstrauma/index.asp </li></ul><ul><li>www.nyerrn.com/simulators </li></ul>
  24. 24. Pre-Hospital Care and Transport <ul><li>The time from injury to definitive care is a determinant of survival. </li></ul><ul><li>Careful attention is given to C-spine immobilization, breathing and circulation…(ABC’s) </li></ul>
  25. 25. Current Guidelines on C-Spine Immobilization <ul><li>Although it has been challenged, C-spine immobilization is still the protocol for trauma patients until diagnostically cleared (X-Ray) </li></ul>
  26. 26. Additional Pre-Hospital Measures <ul><li>Occlusive dressings to open chest wounds </li></ul><ul><li>Needle thoracotomy to relieve tension pneumothorax </li></ul><ul><li>Endotracheal intubation </li></ul><ul><li>Cricothyrtomy </li></ul>
  27. 27. Caveat!!! <ul><li>Research has indicated INCREASED mortality with IV fluids BEFORE hemorrhage control. </li></ul><ul><li>Transport is not delayed to start IV access! </li></ul>
  28. 28. Transport How is it decided? <ul><li>Travel time </li></ul><ul><li>Terrain </li></ul><ul><li>Availability of air or ground transport </li></ul><ul><li>Capability of personnel </li></ul><ul><li>Weather </li></ul>
  29. 29. Emergency Care Phase Preparation <ul><li>Trauma team at receiving hospital responds before arrival of patient </li></ul><ul><li>Report has been transmitted </li></ul><ul><li>Preparations are initiated based on report. </li></ul>
  30. 30. Initial Patient Assessment <ul><li>Clinical presentation </li></ul><ul><li>Physical assessment </li></ul><ul><li>History of traumatic event </li></ul><ul><li>Pre-existing illness </li></ul>
  31. 31. Primary Survey <ul><li>Most crucial assessment tool in trauma care </li></ul><ul><li>1-2 minutes MAX! </li></ul><ul><li>Designed to identify life threatening injuries ACCURATELY </li></ul><ul><li>Establish priorities </li></ul><ul><li>Provide simultaneous therapeutic interventions. </li></ul>
  32. 32. Resuscitation Phase <ul><li>Secondary Survey: </li></ul><ul><li>Table18:2 page 647/648 </li></ul><ul><li></li></ul>
  33. 33. EFGHI = <ul><li>E- Expose the patient </li></ul><ul><li>F- *Full set of vital signs, *five interventions (cardiac monitor, pulse oximetry, urinary catheter, NG if not contraindicated, lab studies) </li></ul><ul><li>G- giving comfort measures…pain control, reassurance to patient and family </li></ul><ul><li>H- history/ head to toe assessment </li></ul><ul><li>I- inspect for hidden injuries-log roll patient to inspect posterior aspect. </li></ul>
  34. 34. Sequence of Diagnostic Procedures <ul><li>Influenced by: </li></ul><ul><li>Level of consciousness </li></ul><ul><li>Stability of patient’s condition </li></ul><ul><li>Mechanism of injury </li></ul><ul><li>Identified injuries </li></ul>
  35. 35. Maintain Airway Patency <ul><li>Essential to trauma management </li></ul><ul><li>EVERY trauma patient has potential for airway obstruction </li></ul><ul><li>Most common obstruction: Tounge </li></ul><ul><li>Other common causes: blood or vomitus, secretions, structural impairment, depressed sensorium, absent gag reflex </li></ul>
  36. 36. How to open the airway? <ul><li>Jaw thrust or chin lift!!! </li></ul><ul><li>These maneuvers do not hyperextend the neck or compromise the integrity of the C-spine </li></ul>
  37. 37. Maintaining the airway <ul><li>Simple, simple!! </li></ul><ul><li>Nasopharyngeal airway </li></ul><ul><li>Oropharyngeal airways </li></ul>
  38. 38. Definitive Nonsurgical Airway <ul><li>Endotracheal intubation-Complete control of the airway </li></ul><ul><li>Nasotracheal intubation—INDICATED for the spontaneously breathing patient..CONTRAINDICATED in the patient with facial, frontal sinus, basilar skull or cribriform plate fractures. </li></ul>
  39. 39. Choice of Airway management <ul><li>Familiarity of procedure </li></ul><ul><li>Clinical condition of the patient </li></ul><ul><li>Degree of hemodynamic stability </li></ul><ul><li>A PATENT AIRWAY IS THE CORNERSTONE OF SUCCESSFUL TRAUMA RESUSCITATION </li></ul>
  40. 40. A LIFE THREATENING CONDITION EXISTS <ul><li>Altered mental status (agitation) </li></ul><ul><li>Cyanosis( nail beds and mucous membranes) </li></ul><ul><li>Asymmetrical chest expansion </li></ul><ul><li>Use of accessory muscles/abdominal muscles </li></ul><ul><li>Sucking chest wounds </li></ul><ul><li>Paradoxical movements of the chest wall </li></ul><ul><li>Tracheal shift </li></ul><ul><li>Distended neck veins </li></ul><ul><li>Diminished or absent breath sounds </li></ul>
  41. 41. Impaired Gas Exchange <ul><li>Follows airway obstruction as the nest most crucial problem for the trauma patient. </li></ul><ul><li>Reasons: decreased inspired air, retained secretions, lung collapse or compression, atelectasis, accumulation of blood in the thoracic space. </li></ul>
  42. 42. Decreased Cardiac Output/Hypovolemia <ul><li>Acute Blood loss—MOST common cause in acute trauma </li></ul><ul><li>May be external or internal </li></ul>
  43. 43. Treatment <ul><li>PASG- anti-shock garment (pneumatic anti-shock garment) </li></ul><ul><li>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. </li></ul><ul><li>Elevates systemic pressure by shunting a small amount of blood into central circulation. </li></ul><ul><li>CAN be a detriment, elevates BP, and in the event of hemorrhage without DEFINITIVE control can be fatal. </li></ul>
  44. 44. Additional Causes of Decreased Cardiac Output <ul><li>(impaired venous return to the heart) </li></ul><ul><li>Tension Pneumothorax </li></ul><ul><li>Pericardial Tamponade (from decreased filling and ventricular ejection fraction) </li></ul>
  45. 45. Table 18-4 <ul><li>Pay attention to Class I through IV *EBL (estimated blood loss) </li></ul><ul><li>*Changes in pulse, BP, RR, UOP, mental status. </li></ul><ul><li>Note the fluid/blood needed to replace: 3:1 rule </li></ul>
  46. 46. Priority Interventions <ul><li>Patent airway </li></ul><ul><li>Maintaining adequate ventilation </li></ul><ul><li>Adequate gas exchange </li></ul><ul><li>Then: </li></ul><ul><li>Control hemorrhage, replace circulating volume, restore tissue perfusion </li></ul>
  47. 47. Control of External Hemorrhage <ul><li>Direct Pressure </li></ul><ul><li>Elevation </li></ul><ul><li>Compression of pressure points (arteries, veins) </li></ul><ul><li>AVOID tourniquets…can compromise loss of circulation and loss of limb </li></ul>
  48. 48. Control of Internal Hemorrhage <ul><li>Identification and correction of underlying problem. </li></ul>
  49. 49. Fluid Resuscitation <ul><li>Venous Access and Volume infused are key. </li></ul><ul><li>Two large bore IV’s 14-16 gauge. (never less that 18, that is the smallest to give blood through rapidly and not have hemolysis) </li></ul><ul><li>Forearm and anti-cubital veins are preferred </li></ul><ul><li>Central lines are more beneficial as resuscitation MONITORING tools </li></ul>
  50. 50. Fluid Resuscitation Cont… <ul><li>A pulmonary artery catheter may be inserted in the critical care unit to monitor volume. </li></ul><ul><li>RULE: Venous access with largest bore catheter possible. </li></ul><ul><li>Isotonic fluids are used INITIALLY </li></ul><ul><li>Ringer’s Lactate is first choice followed by Normal Saline </li></ul>
  51. 51. Fluid Resuscitation Cont… <ul><li>Large bore catheters, short tubing, rapid infuser devise that warms fluids and blood. </li></ul><ul><li>An initial bolus of 2 liters of fluid is used unless there is contraindication… </li></ul><ul><li>3:1 rule= 3mls of crystalloid for each 1ml of blood loss. </li></ul><ul><li>INITIAL response to fluid challenge is urine output..should =50 ml in adult, LOC, heart rate, BP and capillary refill. </li></ul>
  52. 52. Three Response Patterns <ul><li>Rapid Response- respond quickly to fluid challenge and remains stable at completion of bolus. </li></ul><ul><li>Transient Response- responds quickly but declines when fluids are slowed </li></ul><ul><li>(indicates continued blood loss) </li></ul><ul><li>**Non Response- fail to hemodynamically respond to crystalloid and blood…require immediate surgical intervention. </li></ul><ul><li>See table 18-5 on page 652 </li></ul>
  53. 53. Decision to give Blood <ul><li>Based on patients response to initial fluid. </li></ul><ul><li>** if unresponsive to fluid, type specific blood is given, IF LIFE THREATENING…may give O positive. </li></ul><ul><li>***Crossmatched, type specific should be given as soon as possible. </li></ul>
  54. 54. Auto-transfusion <ul><li>Collection of blood from the patients intra-thoracic injuries is anti-coagulated and filtered and administered to the patient. </li></ul><ul><li>SAFE, carries no compatibility problems, no risk of transmitted disease. </li></ul>
  55. 55. During resuscitative phase <ul><li>Imperative to locate etiology of hemorrhage: </li></ul><ul><li>Chest and pelvis, extremity X-rays </li></ul><ul><li>Abdominal ultrasound </li></ul><ul><li>Abdominal CT can be used but in the case of hemodynamic instability Peritoneal lavage is the quick, invasive test of choice </li></ul>
  56. 56. Peritoneal Lavage <ul><li>Insertion of lavage catheter directly into the abdomen </li></ul><ul><li>Aspiration of greater than 10 mls blood and patient goes directly for surgery. </li></ul><ul><li>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. </li></ul>
  57. 57. Hypothermia <ul><li>Defined as a core temp of 35 degrees Centigrade </li></ul><ul><li>Can occur year round </li></ul><ul><li>More susceptible person: older, using alcohol or sedatives, severe injury, massive transfusions. </li></ul><ul><li>In presence of cooler atmospheric temps </li></ul><ul><li>Submersion in water </li></ul><ul><li>Rapid infusion of room temp. IV fluids </li></ul><ul><li>Effects the myocardium and the coagulation system. </li></ul><ul><li>Can result in bradycardia, atrial and ventricular fibrillation. </li></ul>
  58. 58. Treatment <ul><li>Warm fluids </li></ul><ul><li>Warming blankets </li></ul><ul><li>Overhead warmers </li></ul>
  59. 59. Ongoing Signs and Symptoms of Shock <ul><li>Decreased H&H </li></ul><ul><li>Deterioration of PaO2 and pH </li></ul><ul><li>Rising base deficits </li></ul><ul><li>Diminished UOP (less than >.5ml/kg/hr) </li></ul><ul><li>Increasing Lactate levels </li></ul>
  60. 60. Unreliability of H&H <ul><li>Can take up to 4 HOURS!! To re-equilibrate, therefore cannot gauge degree of shock. </li></ul>
  61. 61. On-going Metabolic acidosis <ul><li>Result of hypovolemia and hypoxia </li></ul><ul><li>Indicates inadequate tissue perfusion </li></ul><ul><li>Indicates anaerobic metabolism—very inefficient cellular metabolism. </li></ul><ul><li>Must be interrupted or cellular dysfunction results in cellular swelling, rupture and death. </li></ul>
  62. 62. Massive Fluid Resuscitation <ul><li>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. </li></ul><ul><li>It is associated with VERY poor outcomes. </li></ul>
  63. 63. Continued.. <ul><li>Purpose is to restore oxygen transport to the tissues, stop the progression of shock, prevent complications. </li></ul>
  64. 64. Potential Complications of Massive Fluid Resuscitation <ul><li>Acid base imbalances </li></ul><ul><li>Electrolyte imbalances </li></ul><ul><li>Hypothermia </li></ul><ul><li>Dilutional coagulopathies </li></ul><ul><li>Volume overload </li></ul><ul><li>SIRS (systemic inflammatory response syndrome) </li></ul><ul><li>ARDS (acute respiratory distress syndrome) </li></ul><ul><li>MODS (multi-organ dysfunction syndrome) </li></ul>
  65. 65. Oxygen Debt <ul><li>Result of metabolic acidosis—shift from aerobic to anaerobic metabolism resulting in accumulation of lactic acid…hence…lactic acidosis. </li></ul><ul><li>MUST REVERSE to prevent cellular death </li></ul>
  66. 66. Electrolyte Imbalances <ul><li>Hypocalcemia </li></ul><ul><li>Hypomagnesemia </li></ul><ul><li>Hyperkalemia </li></ul><ul><li>May lead to changes in myocardial function, laryngeal spasm, neuromuscular and central nervous system hyperirritability </li></ul>
  67. 67. Third Spacing <ul><li>Vessels become more permeable to fluids and molecules, leading a change in movement from the intravascular space to the interstitial space. </li></ul><ul><li>Patients become more hypovolemic requiring more fluid replacement. </li></ul>
  68. 68. Dilutional Coagulopathy <ul><li>Dilutional thrombocytopenia </li></ul><ul><li>Reduced fibrinogen </li></ul><ul><li>Reduced factor V, FactorVIII and other clotting components </li></ul><ul><li>High levels of citrate in blood products reduce calcium…leading to an ineffective clotting cascade (calcium is a necessary co-factor for this process). </li></ul><ul><li>Platelet dysfunction can occur secondary to hypothermia or metabolic acidosis </li></ul>
  69. 69. Treatment of Dilutional Coagulopathy <ul><li>Improve tissue perfusion </li></ul><ul><li>Resolve hypothermia </li></ul><ul><li>Administer clotting factors (FFP, cryoprecipitate, platelets) </li></ul><ul><li>Monitor labs (H&H, PLT count, fibrinogen, PT, PTT </li></ul>
  70. 70. Changes in the Coagulation Cascade <ul><li>Initially helpful…release of inflammatory mediators…over time (can be a fairly short time) can result in SIRS, ARDS, MODS </li></ul>
  71. 71. Assessment and Management of specific Organ Injuries <ul><li>Chest Injuries </li></ul><ul><li>Spinal Cord Injuries </li></ul><ul><li>Head Injuries </li></ul><ul><li>Musculoskeletal Injuries </li></ul><ul><li>Abdominal Injuries </li></ul>
  72. 72. Chest Injuries <ul><li>Tension Pneumothorax- is rapidly fatal </li></ul><ul><li>Easily resolved with early recognition and intervention </li></ul><ul><li>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. </li></ul><ul><li>The increased pressure causes pressure on the heart and great vessels compressing them TOWARD the unaffected side. </li></ul>
  73. 73. Tension Pneumo cont.. <ul><li>Physical evidence: </li></ul><ul><li>Mediastinal Shift & distended neck veins. </li></ul><ul><li>RESULTS in: decreased Cardiac Output and alterations in gas exchange </li></ul><ul><li>Manifested by: severe resp. distress, chest pain, hypotension, tachycardia, absence of breath sound son affected side, and tracheal deviation </li></ul><ul><li>Cyanosis is a LATE manifestation. </li></ul>
  74. 74. Tension Pneumo cont… <ul><li>Diagnosis based on CLINICAL presentation not Chest x-ray </li></ul><ul><li>Treatment is never delayed to confirm by X-ray </li></ul><ul><li>Immediate decompression with a 14 gauge needle (thoracostomy)..inserted at the 2 nd intercostal space at the midclavicular line on the INJURED side. </li></ul><ul><li>This converts a tension pneumo to a simple pneumo. </li></ul><ul><li>Definitive treatment then requires placement of a chest tube. </li></ul>
  75. 75. Hemothorax <ul><li>Collection of blood in the pleural space </li></ul><ul><li>From injuries to the heart, great vessels, or pulmonary parenchyma </li></ul><ul><li>Signs and symptoms: decreased breath sounds, dullness to percussion on affected side, hypotension, respiratory distress. </li></ul><ul><li>Treatment: Placement of chest tube. </li></ul>
  76. 76. Open Pneumothorax <ul><li>Results from penetrating trauma that allows air to pass IN AND OUT of the pleural space. </li></ul><ul><li>Patient presents with hypoxia and hemodynamic instability </li></ul><ul><li>Management: Three sided occlusive dressing…fourth side is LEFT OPEN to allow for exhalation of air from the pleural cavity. </li></ul><ul><li>IF the dressing is occluded on all four sides the patient may develop a tension pneumothorax. </li></ul><ul><li>Treatment: Chest tube placement </li></ul>
  77. 77. Cardiac Tamponade <ul><li>Life threatening condition caused by RAPID accumulation of fluid (usually blood) in the pericardial sac. </li></ul><ul><li>As intra-pericardial pressure increases, cardiac output is impaired because of decreased venous return. </li></ul><ul><li>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. </li></ul><ul><li>Pulsus paradoxus= a decrease in systolic blood pressure during spontaneous respiration. </li></ul>
  78. 78. Cardiac Tamponade <ul><li>Causes: penetrating trauma to chest, blunt trauma to chest. </li></ul><ul><li>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) </li></ul><ul><li>Aspirated pericardial blood usually will not clot unless the heart has been penetrated. </li></ul>
  79. 79. Cardiac Tamponade cont.. <ul><li>Arterial BP can dramatically improve with as little as 15-20 ml of blood removed. </li></ul><ul><li>Nurses should anticipate and prepare for pericardiocentesis in the event of cardiac arrest. </li></ul>
  80. 80. Pulmonary Contusion <ul><li>Results from blunt or penetrating trauma to the chest </li></ul><ul><li>One of the most common causes of death after trauma </li></ul><ul><li>Predisposes the patient to pneumonia and ARDS. </li></ul><ul><li>Can be difficult to detect. </li></ul>
  81. 81. Pulmonary Contusion cont.. <ul><li>May not be seen on initial X-ray </li></ul><ul><li>Infiltrates and hypoxemia may not occur for hours of days. </li></ul><ul><li>Clinical presentation includes: chest abrasions, ecchymosis, bloody secretions, PaO2 of 60mmHG or less on room air. </li></ul><ul><li>Often associated with flail chest and rib fractures </li></ul>
  82. 82. Pulmonary Contusion cont.. <ul><li>The bruised lung becomes edematous, resulting in hypoxia and respiratory distress </li></ul><ul><li>Treatment is ventilatory support, careful fluid administration, pain management. </li></ul>
  83. 83. Rib Fractures <ul><li>Most common injury after chest trauma </li></ul><ul><li>Rib fractures usually dx’d by xray, but can be clinically dx’d </li></ul><ul><li>HIGH IMPACT force is needed to fracture the 1 st and 2 nd ribs. Clinically look for major vessel injury.. </li></ul><ul><li>Injury to the liver spleen and kidneys should be considered with fracture of ribs 10-12 </li></ul>
  84. 84. Rib Fractures cont… <ul><li>Treatment: Depends on ribs Fx’d and age of patient. Elderly with multiple rib fx may require hospitalization. </li></ul><ul><li>Patient Teaching is very important: </li></ul><ul><li>DO NOT restrict chest movement, pain control, ambulation. </li></ul>
  85. 85. Flail Chest <ul><li>Usually caused by blunt force trauma, EX: Chest hits steering wheel. </li></ul><ul><li>Three or more adjacent ribs are fractured. </li></ul><ul><li>Flail section floats freely resulting in paradoxical chest movement. </li></ul><ul><li>Flail section contracts INWARD with inspiration and expands OUTWARD with expiration. </li></ul><ul><li>Treatment: Intubation/mechanical ventilation, frequent pulmonary care, aggressive pain management. </li></ul>
  86. 86. Aortic Disruption <ul><li>Produced by blunt trauma to the chest </li></ul><ul><li>Ex: rapid deceleration from head-on MVA, ejection, or falls. </li></ul><ul><li>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. </li></ul>
  87. 87. Aortic disruption cont.. <ul><li>Signs: weak femoral pulses, dysphagia, dyspnea,hoarsness, pain. </li></ul><ul><li>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. </li></ul><ul><li>CONFIRMATION is done with aortogram </li></ul><ul><li>Treatment is SURGICAL </li></ul>
  88. 88. Spinal Cord Injury <ul><li>Mechanism of injury can be: hyperflexion, hyperextension, axial loading, rotation, penetrating trauma </li></ul><ul><li>Initially: ABC’s, immobilization </li></ul><ul><li>Triage to appropriate facility </li></ul><ul><li>Complete sensory &motor neuro exam </li></ul>
  89. 89. Spinal Cord Injury <ul><li>Lateral C-Spine films, possible Spinal CT to rule out occult fracture. </li></ul><ul><li>Dislocations of the spine are reduced ASAP </li></ul><ul><li>Postural reduction with tongs, halo traction or surgical fusion. </li></ul><ul><li>IV methylprednisolone within 8 hours </li></ul>
  90. 90. Spinal Cord Injury <ul><li>Spinal Shock= loss of sympathetic output=Neurogenic shock results are bradycardia, hypotension. </li></ul><ul><li>Need vasopressors to compensate for loss of sympathetic innervation and resultant vasodilatation. </li></ul>
  91. 91. Spinal Cord Injury cont. <ul><li>Potential Complications: GI dysfunction, autonomic dysreflexia, DVT, orthostatic hypotension, loss of bowel and bladder function, immobility, spasticity, and contractures. </li></ul><ul><li>THINK EARLY PREVENTION AND INTERVENTION!!!! </li></ul>
  92. 92. Head Injury <ul><li>Can be caused by blunt or penetrating trauma. </li></ul><ul><li>Lacerations to the scalp produce profuse bleeding. </li></ul><ul><li>Fractures of the skull may have underlying brain injury </li></ul>
  93. 93. Heady Injury cont… <ul><li>Basilar skull fractures are located at the base of the cranium and potentially involve 5 bones that form the base of the skull. </li></ul><ul><li>Are diagnosed based on the presence of CSF in the nose (rhinorrhea) or ears (otorrhea) </li></ul>
  94. 94. Heady Injury cont.. <ul><li>Basilar Skull Fracture cont… </li></ul><ul><li>Ecchymosis over the mastoid (Battle’s sign) </li></ul><ul><li>Hemotympanium (blood in the middle ear) </li></ul><ul><li>Raccoon eyes or periorbital eccymoses =cribiform plate fracture </li></ul>
  95. 95. Head Injury cont. <ul><li>Potential complications of Basilar Skull Fractures: Infection and cranial nerve injury. </li></ul>
  96. 96. Secondary Head Injury <ul><li>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. </li></ul>
  97. 97. Secondary Head Injury <ul><li>Prehospital MOST important </li></ul><ul><li>Supplemental oxygen, often intubation </li></ul><ul><li>Aggressive and careful volume replacement </li></ul><ul><li>ICP monitoring/ Goal is 20mm Hg </li></ul><ul><li>Cerebral Perfusion Pressure=MAP(mean arterial pressure) Minus Mean ICP and keep at 70mm Hg to decrease neurological disability. </li></ul>
  98. 98. Secondary Head Injury cont.. <ul><li>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. </li></ul>
  99. 99. Nursing Care for Traumatic Head Injury <ul><li>Airway, adequate ventilation and gas exchange, clearance of pulmonary secretions, proper head alignment, close neurological function monitoring. </li></ul><ul><li>Pulmonary complications are common, aggressive pulmonary hygiene </li></ul><ul><li>HOB at 30 degrees </li></ul><ul><li>Assess for intracranial hemodynamics(ICP and perfusion pressure) and patient tolerance </li></ul>
  100. 100. Musculoskeletal Injuries <ul><li>See Types of Fractures Table 18-7 on page 658 </li></ul><ul><li>Extremity Assessment= the 5 P’s </li></ul><ul><li>Pallor pain, pulses, parethesia, paralysis (describes the neurovascular status of the injured extremity. </li></ul><ul><li>When possible the injured extremity if compared with the non-injured extremity </li></ul>
  101. 101. Musculoskeletal Injury cont.. <ul><li>Fracture wounds should be debrided and the fracture reduced within 18 hours to prevent infection and nonunion. </li></ul><ul><li>If hemodynamically unstable, skeletal traction to realign the extremity may be used . </li></ul>
  102. 102. MS Cont.. <ul><li>Unstable Pelvis fractures can be life threatening secondary to potential for severe hemorrhage, exsanguination, damage to genitourinary system and sepsis. </li></ul>
  103. 103. Traumatic Soft Tissue Injury <ul><li>Categorized as: contusions, abrasions, lacerations, punctures, hematomas, amputations, and avulsions. </li></ul><ul><li>All wounds are considered contaminated. </li></ul><ul><li>Tetanus Toxoid and antibiotics are always CONSIDERED. </li></ul>
  104. 104. Complications of Musculoskeletal Injuries <ul><li>Rhabdomolysis-a complication of crush injuries—marked vasoconstriction and hypotension followed by ARF </li></ul><ul><li>Results from muscle destruction. </li></ul><ul><li>Myogolobin and potassium are released from the damage muscles </li></ul>
  105. 105. Cont. <ul><li>Can result in life threatening hyperkaemia. </li></ul><ul><li>Myoglobin excreted through the urine, combined with hypovolemia, produces ARF and ATN if not aggressively treated. </li></ul><ul><li>Treatment= Aggressive saline replacement, alkalinization of urine, osmotic diuresis. </li></ul>
  106. 106. Compartment Syndrome <ul><li>Places the patient at risk for limb loss. </li></ul><ul><li>More common in the legs and forearms but can occur other places. </li></ul><ul><li>The closed muscle compartment contains neurovascular bundles tightly covered by fascia. </li></ul>
  107. 107. Cont… <ul><li>An increase in pressure within that compartment produces the syndrome. </li></ul><ul><li>Internal sources= hemorrhages, edema, open or closed fractures, crush injuries </li></ul><ul><li>External sources=PASG’s, casts, skeletal traction, air splints. </li></ul><ul><li>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. </li></ul><ul><li>Treatment s immediate surgical fasciotomy. </li></ul>
  108. 108. Fat Embolism <ul><li>Usually associated with long bone, pelvis, and multiple fractures. </li></ul><ul><li>Usually develops within 24 to 48 hours after injury. </li></ul><ul><li>Hallmark clinical signs: low grade fever, new onset tachycardia, dyspnea, increased resp rate and effort, abnormal ABG’s, thrombocytopenia and petechiae. </li></ul><ul><li>Development of lipuria (fat in the urine) indicates severe fat embolism syndrome. </li></ul>
  109. 109. Fat embolism cont.. <ul><li>Prevention is the best treatment. </li></ul><ul><li>Treatment is directed at preserving pulmonary function and maintenance of cardiovascular function. </li></ul><ul><li>Careful attention to EKG changes. </li></ul><ul><li>See Box 18-2 on page 660 IMPORTANT!!! </li></ul>
  110. 110. Abdominal Injuries <ul><li>The Classic sign is PAIN. </li></ul><ul><li>But may be obscured by AMS, drug or alcohol intoxication, Spinal cord Injury with impaired sensation </li></ul><ul><li>The liver is the most commonly injured organ from blunt or penetrating trauma </li></ul>
  111. 111. Cont… <ul><li>Liver injuries are graded I through VI. </li></ul><ul><li>Splenic injury most commonly occurs from blunt trauma but can be caused by penetrating trauma. </li></ul><ul><li>Presentation: LUQ tenderness, peritoneal irritation, referred pain to the left shoulder (Kerr’s sign) </li></ul>
  112. 112. Cont… <ul><li>Graded I to V. </li></ul><ul><li>Diagnosed with FAST, Abd. CT or peritoneal lavage. </li></ul><ul><li>Patients more at risk for pneumococcal disease and should have immunization with in first few post op days after splenectomy </li></ul>
  113. 113. Cont…Kidney Injury <ul><li>Usually attributed to blunt trauma </li></ul><ul><li>Presentation may include CVA tenderness, microscopic or gross hematuria, bruising, ecchymosis over the 11 th and 12 th ribs, hemorrhage or shock. </li></ul>
  114. 114. Cont… <ul><li>Diagnostic testing= IVP, CT scan, angiography, cystoscopy. </li></ul>
  115. 115. Critical Care Phase <ul><li>ABC’c </li></ul><ul><li>Post OP standard VS= q5min x3, q15minx3, q30min X2, q1 hour forward. </li></ul><ul><li>Shivering is to be avoided=increase in metabolic rate and increase in oxygen demands. </li></ul>
  116. 116. Cont.. <ul><li>Physical Assessment =FULL BODY </li></ul><ul><li>Level of Consciousness </li></ul><ul><li>Invasive Line assessment </li></ul><ul><li>Pain Assessment </li></ul><ul><li>Ongoing Assessments revolve around the patient’s diagnosis and/or surgical procedure. </li></ul><ul><li>Anticipation and prevention of untoward complications. </li></ul><ul><li>READ PAGES 661-668 CAREFULLY </li></ul>
  117. 117. Damage Control Surgery <ul><li>= Staged laporaotmy </li></ul><ul><li>Trying to avoid hypothermia, acidosis, coagulopathy </li></ul><ul><li>Shown to improve outcomes of critically ill patients with sever intra-abdominal injuries. </li></ul>
  118. 118. ARDS <ul><li>Chapter 13 fully covers </li></ul><ul><li>May occur 2 to 48 hours after traumatic injury, however sometimes up to 5 days or more before RECOGNIZABLE clinical signs. </li></ul><ul><li>There are direct and indirect causes. </li></ul>
  119. 119. Cont… <ul><li>Clinical Manifestations: hypoxemia, rising CO2 levels, tachypnea, dyspnea, pulmonary hypertension, decreased lung compliance, new diffuse bilateral lung infiltrates. </li></ul><ul><li>Treatment: correction of underlying cause---maximize O2 to the tissues, decrease pulmonary congestion, prevent further lung damage, support cardiovascular system. </li></ul>
  120. 120. DVT <ul><li>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. </li></ul>
  121. 121. Cont.. <ul><li>Clinical Manifestations= pain and tenderness, swelling fever, venous distention, palpable cord, discoloration, + Homan’s sign </li></ul><ul><li>Treatment= prevention, prophylaxis, early ambulation, sequential compression devices, filter placement in the inferior vena cava. </li></ul>
  122. 122. Cont. <ul><li>Pulmonary embolism is an often fatal complication of DVT </li></ul><ul><li>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) </li></ul>
  123. 123. Infection <ul><li>Pulmonary </li></ul><ul><li>Catheter Sepsis </li></ul><ul><li>Sinusitis </li></ul>
  124. 124. Acute Renal Failure <ul><li>From systemic effects of trauma </li></ul><ul><li>OR from actual injury to the renal system </li></ul><ul><li>There is a reduction in renal blood flow in the trauma patient associated with shock or low cardiac output. </li></ul>
  125. 125. Altered Nutrition <ul><li>Nutritional demands are increased in the trauma patient by alterations in metabolism </li></ul><ul><li>Metabolism is increased by activation of the sympathetic response. </li></ul><ul><li>Ebb (1 st 24-48 hours after injury) and Flow Phase (peaks 5-10 days after injury) </li></ul>
  126. 126. Cont. <ul><li>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 </li></ul>
  127. 127. Cont.. <ul><li>Anthropometric measurements </li></ul><ul><li>Nutrition replacement in 24 to 48 hours. </li></ul><ul><li>Route based on individual status of patient…can be enteral, or parenteral </li></ul>
  128. 128. Multiple Organ Dysfunction Syndrome <ul><li>Immune, inflammatory, and hormonal responses are underlying causes. </li></ul><ul><li>Defined as presence of altered organ function in the acutely ill. </li></ul><ul><li>There is incomplete understanding of its pathophysiology. </li></ul><ul><li>Management focuses on prevention, early identification, elimination of sources of infection, maint. Of tissue oxygenation and nutritional support. </li></ul>

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