Comprehensive Guide to Abdominal and Thoracic Trauma Management, Exams of Nursing

Download Comprehensive Guide to Abdominal and Thoracic Trauma Management and more Exams Nursing in PDF only on Docsity! TCRN Exam questions and answers | updated 2024 Kehr's sign - Referred left shoulder pain, usually indicates a splenic injury Base deficit - Base deficit more than -6 indicates the need for agressive resuscitation and determination of the etiology CXR - Most important tool providing useful information in the early minutes. Can identify major sources of blood loss from injuries in the chest or elevated diaphragm with displacement of abdominal organs Tracheobronchial injury - Should be suspected if after chest tube placement a significant air leak is present Diagnostic Peritoneal Lavage - Alternative to FAST scan to detect abd bleeding. A urinary catheter and gastric tube should be in place prior to procedure. FAST - Focused Assessment with Sonography in Trauma. Used to detect free fluid in peritoneum or hemoperitoneum. Free fluid appears "black" on the screen. Has replaced DPL when available. Positive FAST scan - Hemodynamically unstable trauma patient with a positive fast are taken directly to the OR for laparotomy Ultrasound abd exam - Not useful to detect injuries to the diaphragm, intestine and pancreas. In patients with obesity, ascites and/or subQ emphysema the accuracy is reduced. CT scan - Hemodynamically stable patients may be taken to CT Angiography - Embolization is useful in treating patient with unstable pelvic fractures, liver and splenic hemorrhage. Use of hybrid OR suites to allow for surgical and interventional radiology methods of treatment simultaneously. Diagnostic laparoscopy - Can be used to detect or exclude finding so f hemoperitoneum, organ injury, intestinal spillage or peritoneal penetration. Most useful in evaluating possible diaphragmatic injuries, espectially in penetrating thoracoabdominal injuries on the left site Diaphragmatic injuries - Usually resultant of penetrating throacoabdominal injuries on the left side, including 11-12 rib fractures on the left. Small intestine injuries - Result from shearing forces in MVC or direct blows that crush intestine between force and the vertebrae. Most commonly intra-abd injury in penetrating trauma. Occurs often with spinal injury. Pancreatic/solid organ injury are predictive of increased risk for hollow viscus injury. Signs of peritonitis develop. Any blow to the abd/penetrating injury to the lower chest/abd should increase suspicion of injury Treatment of small intestine injury - Control bleeding prior to exploration. Debridement and closure and ligation of bleeders. Resection for multiple defects. Observe for wound infection/abscess development Cause of duodenum injuries - Penetrating trauma most frequent cause. Usually conconcurrent mult-organ injuries. Usually found intraoperatively, commonly missed during exlap. Blunt force injury cause by vetebral compression. Pancreas - uncommon injury. If ductal tears, digestive enzymes invade. Major therapeutic challenge for clinical team. Most are associated with intra-abdominal injury and are found intraoperatively. GSW/Stab wounds are frequently the cause. Retroperitoneal injury - Associated with blunt trauma involving pelvic fractures Abdominal vascular injury - Usually occur with pelvic, thoracic or visceral injury. Retroperitoneal hematoma in conjunction with pelvic or spine trauma can contain up to 4 L of blood. Pitfalls of abdominal trauma - failure to suspect intra-abdominal injury from mechanism of injury, failure to fully evaluate complaints of abdominal pain following blunt abdominal injury, failure to perform timely operative intervention, failure to recognize hemodynamic compromise and delay surgery for further diagnostic tests Blood loss hypovolemia: class I - < 750 ml/15% of blood volume, HR < 100, normal B/P, normal PP, RR 14-20, CNS slightly anxious Blood loss hypovolemia: class II - 750-1500/15-30%, >100, normal BP, decreased PP, RR 20-30, Mildly anxious Blood loss hypovolemia: class III - 1500-2000/30-40%, HR >129, decreased b/p, decreased PP, RR 30-40, anxious/confused Blood loss hypovolemia: class IV - >2000/>40%, HR > 140, decreased b/p, PP decreased, RR >35, confused and lethargic Compartment syndrome - Common areas for compartment syndrome include: lower leg, forearm, foot, hand, gluteal region and thigh Burn formula - Adult and Chemical burns > 20% TBSA resuscitate at 2 ml LR x kg x TBSA in the first 24 hrs. High voltage electrical injuries - 4 ml LR x kg x % TBSA in the first 24 hours Peds Burn formula (14 and under and < 40 kgs) - 3 ml LR x kg x % TBSA in the first 24 hours Inhalation injury - Do not wait to intubate, swelling will increase then increase the difficulty of placing an ETT. Stridor or horseness is a late sign. Compartment syndrome signs and symptoms - Pain out of proportion for the injury, weak or absent distal pulses, delayed cap refil, firmness on palpation of muscle/soft tissue in surrounding area, distal skin cool to touch, distal skin pale or cyanotic, decrase in patient sensation Hypovolemia in childresn - children can be hemodynamically stable up to a 40% blood loss but only have a blood volume of 7-8% of their body weight Hypovolemic shock - chaning mentation, tachycardia, >120 HR greatest concern, cool, clammy skin, prolonged cap refill, narrowed pulse pressure (normal 40-50), decrased urine output, hypotension Hypotension in shock -Systolic blood pressure does not fall until 30% blood loss in adults SIRS - Systemic Inflammatory Response Syndrome. Severe physiologic reaction to injury characterized by systemic release of inflammatory cytokines and chemokines. Two or more of the following: temp > 38 or < 36, HR > 90, RR > 20 or PaCO < 32, WBC >12 or <4 or > 10% bands MODS - After SIRS becomes stage 3 and severe hypotension refractory to fluid and ionotropic support ischemic insult progresses. Dysfunction of at least two organ systems from inflammatory insult, trauma or sepsis. Causes of secondary brain injury - hypoxia, hypotension, hypocapnea or hypercapnea Secondary brain injury - Leads to cerebral edema, mass effect, ischemia, cellular death Optimizing oxygenation, ventilation and hemodynamics - Intubate with RSI, maintain O2 sat > 90%, optimally 98%, ETCO2 monitoring to keep around 35 - provides information about adequacy of circulatory flow, hyperventilation causes vasoconstriction and reduces PaCO2 and causes ischemia, PaCo2 < 30 Monroe-Kellie doctrine - Pressure volume relationships within the intracranial cavity, the craium is a non-expandable vault, increasing iCP is a warning that contents under pressure will try to relieve pressure by finding an exit in the area of least resistant - brain herniation Normal ICP - 0-15, > 20 requires intervention 8 Cranium bones -ethmoid, parietal, sphenoid, temporal, occipital Dura - Outermost layer-firmly adhered to the inner skull with fixed attachments of the cranial sutures Arachnoid - Loosely adhered to the pia mater, which makes the potential arachnoid space Pia - closely associated with grey matter of the brain, is the innermost layer CSF circulates - Between the pia and the arachnoid in the subarachnoid space, cushions and protects the brain and spinal cord Middle meningeal artery - Key cause of epidural bleeds cerebrum - right and left hemispheres of the brain ventricular system - approx 500 ml of CSF is produced in the choroid plexus of the lateral ventricles each day third cranial nerve - brainstem is the origin for the CNIII - CNX and CNXII GCS 10 - Eye opening to voice, confused verbal response, withdraws to pain GCS < 8 - intubate, accepted definition of coma - categorized as severe brain injury GCS 9-12 - moderate brain injury GCS >12 - minor brain injury CPP - cerebral perfusion pressure, maintain 60-70 mmHg Avoid hypotension in ICH - Solitary and multiple episodes of hypotension have been shown to increase the morbidity and mortality associated with brain injury Cushings Triad - hypertension, bradycardia and irregular respirations - ominous signs of herniation and require immediate attention and possible surgical intervention ICP monitoring - Placed in all salvageable head injury patients with GCS < 8 after resuscitation with an abnormal CT scan, GCS < 8 after resuscitation with a normal CT scan and at least two of the following findings: over 40 yo, systolic <90, bi or unilateral posturing CPP/brain tissue oxygenation - assessed through the use of devices such as the brain tissue oxygen monitoring catheter to monitor cerebral perfusion, oxygenation and oxygen carrying capacity Cerebral contusion - capillaries within the brain tissue are damaged imaging negative Autonomic dysreflexia - uncontrolled, massive sympathetic reflex to noxious stimuli, below level of lesion Hyphema - blood in anterior chamber of eye, prevent rebleeding, bedrest, limited activity, HOB elevated, cycloplegic agents - atropine gtts, may need patch Open Globe - minimize additional damage, shield w/o pressure, eye patches contraindicated, anticipate need for OR Orbital blowout fracture - Diplopia, can cause eye to look upward secondary to muscle/nerve impigement, emergency surgical repair indicated, delays increase risk of vision loss LeFort I - transverse fx between maxillary and orbital floor, may include maxillary sinuses. Lower maxilla and teeth are mobile or floating but nose and midface stable. May have trismus, malocclusion. Check for mandible fx. Lefort II - includs central maxilla, nasal area, ethmoid bones, tripod shape, grasping front teeth and palate causes movement to nose and upper lip w/o movement to orbital complex, caved in appearance, edema, subconjunctival hemorrhage and epistaxis, early intubation for airway protection. CSF presence - rhinorrhea suggests open skull fx LeFort III - complete craniofacial dysfunction, associated with massive soft tissue, ocular injuries, TBI, skull injuries, cribiform plate and dural tears, rocking mxillar moves the entire face Tripod fx - separation of all three major attachments of the zygoma to the rest of the face Orbigozygomatic fracture - complex fractures of zygoma and orbital floor, pain, trismus, diplopia, numbness to upper lip, lower lid and bilateral nasal area, surgical repair indicated Neck trauma - internal jugular vein and internal carotid artery most commonly injured Zone I neck trauma - highest mortality, angle of mandible to base of skull, difficult to assess, and exploration can increase mortality Zone II neck trauma - mid portion of neck, injuries apparent on exam, most carotid injuries occur here, manage by observation. Zone III Neck trauma - clavicles and sternal notch to cricoid cartilage. hard to assess surgically as so high at skull base. Diagnosis essential as infection can occur and impact mortality after 24 hours. Embolization very valuable, exploration can damage cranial nerves. Angiography to delineate site of injury S/S of emergency intervention in neck trauma - airway obstruction, pulsatile bleeding, expanding hematoma, unresponsive, extensive subcutaneous emphysema s/s of neck trauma needing more diagnostics - voice change, wide mediatstinum, hemoptysis, hematemesis, dysphonia/dysphagia, drooling, bloody sputum, horner's syndrome, pain with turning neck Horner's syndrome - a contracted pupil, drooping upper eyelid, and local inability to sweat on one side of the face, caused by damage to sympathetic nerves on that side of the neck Neck trauma treatment - stabiltize airway, pressure control for bleeding, subclavial injury needs IV on opposite site, consider permissive hypotension, repair vs ligation, shunting, embolization, ligation, antithrombotic Neck trauma diagnostic testing - CXR mandated for zone I, CT most accepted, CT angiogram - excellent for laryngeal and tracheal injuries, as reliable as arteriography.