TNCC Trauma Nursing Core Course 7th Edition ENA, Exams of Nursing

Download TNCC Trauma Nursing Core Course 7th Edition ENA and more Exams Nursing in PDF only on Docsity! TNCC Trauma Nursing Core Course 7th Edition ENA Components of SBAR and its purpose - ANSWER S: Situation B: Background A: Assessment R: Recommendation Purpose- to provide framework for communication amount members of the healthcare team p. 7 Components of DESC and its purpose - ANSWER D: Describe the specific situation or behavior E: Express your concerns or how the situation makes you feel S: Suggest alternatives and seek agreement C: State consequences in terms of impact on performance goals Purpose- used in conflict management; paraphrasing the other person's comments is an important technique that should be done throughout the DESC script. Following discussion of consequences, team members should work towards consensus. p. 7 Components of CUS and its purpose - ANSWER C: I am Concerned U: I am Uncomfortable S: This is a Safety issue/ I am Stressed Purpose- used to "stop the line" if a team member senses or discovers an essential safety breach p. 7 Define trauma - ANSWER - Trauma is injury to living tissue caused by extrinsic agent - Regardless of MOI, trauma creates stressors that exceed the tissue's or organ's ability to compensate p. 9 Leading cause of death for ages 1. over 65 2. 5 to 24 3. 25 to 64 - ANSWER 1. Falls 2. MVCs 3. poisoning p. 9 Explain 3 phases of injury prevention - ANSWER Primary: prevention of the occurrence of the injury Secondary: Reduction in the severity of the injury that has occurred Tertiary: Improvement of outcomes related to the traumatic injury p. 10 Describe the three E's of injury control - ANSWER Engineering: technological interventions such as side impact airbags, automated blind spot alarms, ignition lock devices for those with DUIs. In playgrounds and sports, this involves surface material under playground equipment and athletic safety gear. Another intervention is improved use of smoke alarms in fire prevention Enforcement and legislation: include laws at all jurisdictional levels regarding driving while intoxicated, booster seats, primary seatbelt use, and distracted driving. For sports this includes rules regarding illegal hits, examination after impact, and return-to-play requirements after a head injury Education: these can be community-based initiatives such as public service announcements for improved seatbelt use, education regarding risks of distracted driving, programs to commit to no texting while driving, and promotions for bicycle helmet giveaways with instructions for proper use p. 11 How can the trauma nurse have an impact when it comes to the legislative process? - ANSWER By advocating for stronger laws and more consistent enforcement p. 11 Define kinematics - ANSWER The study of energy transfer as it applies to identifying actual or intentional injuries p. 25 Define biomechanics - ANSWER The general study of forces and their effects p. 25 Define mechanism of injury (MOI) - ANSWER How external energy forces in the environment are transferred to the body p. 25 Depending on the motorcycle design and rider positioning, the lower extremities can collide with the handlebars, resulting in... - ANSWER Femur and pelvis fractures and hip dislocations p. 31 Cavitation refers to the... - ANSWER Separation of surrounding tissue resulting from a sound and/or hydraulic wave force. This rapid motion can lead to crushing, tearing, and shearing forces on tissue. The impact of cavitation is dependent on the characterists of the affected tissue. Additional considerations include: - Air-filled organs such as lungs or stomach, are elastic, so this tissue tolerates high- velocity cavitation relatively well compared to other tissues - Solid organs such as the liver, have a greater propensity to shear or tear under the same forces - If those same forces are instead released inside the cranium, bone will resist expansion, augmenting soft tissue crushing, until the tensile strength of the bone is exceeded and an explosive release of pressure results ch. 4, p. 32 The U.S. Department of Defense classifies blast injuries in five levels: - ANSWER - Primary blast injuries: found in those closest to the detonation, with enclosed space detonation resulting in the most lethal impacts. Air-filled organs (tympanic membranes, lungs, stomach, and bowel) are most susceptible to rupture with primary blast injuries. - Secondary injuries: include fragment injuries and generally cause the greatest volume of casualties. They include injuries such as puncture wounds, lacerations, and impaled objects. - Tertiary injuries: include impacts with larger objects propelled by the blast wind resulting in blunt trauma. These cause high energy transfer and can result in pelvic or femur fractures or major thoracic injuries such as aortic and great vessel rupture. - Quaternary injuries: result of heat, flame, gas, and smoke. These injuries include external burns and internal burns from inhaled hot gases. - Quinary injuries are those associated with exposure to hazardous materials from radioactive, biologic, or chemical components of a blast. ch. 4, p. 33 Compression may occur from the effects of chemical substances and can cause.. - ANSWER Edema, restricting or obstructing the airways, oxygenation, and ventilation. This can result from aspiration of liquids or inhalation of powder or noxious gas. ch. 4, p. 33-34 The Haddon Matrix broadened the approach and placed emphasis on countermeasures, such were more effective than changing human behavior. Haddon describes three phases of the injury event: - ANSWER Pre-event, Event, Post-event For each phase of the event, countermeasures for prevention can be applied. They include: The host (human) The agent (motor vehicle) The physical environment (socioeconomic environment) ch. 4, p. 34 Initial assessment - approach to trauma patient care that requires a process to identify and treat or stabilize life-threatening injuries in an efficient and timely manner. It is divided into the following process points: - ANSWER - Preparation and triage - Primary survey (ABCDE) with resuscitation adjuncts (FG) - Reevaluation (consideration of transfer) - Secondary survey (HI) with reevaluation adjuncts - Reevaluation and post resuscitation care - Definitive care of transfer to an appropriate trauma center ch. 5, p. 39 The A-I mnemonic helps the trauma nurse rapidly assess for and intervene in life- threatening injuries and identify all injuries in a systematic manner. - ANSWER A: airway and alertness with simultaneous cervical spinal stabilization B: breathing and ventilation C: circulation and control of hemorrhage D: disability (neurological status) E: exposure and environmental control F: full set of vital signs and family presence G: get resuscitation adjuncts: L - lab studies (ABGs) and obtain specimen for blood type and cross match M - monitor for continuous cardiac rhythm and rate assessment N - naso or orogastric tube consideration O - oxygenation and ventilation analysis: pulse oximetry and end-tidal carbon dioxide (ETCO2) monitoring and capnography P - pain assessment and management H: history and head-to-toe assessment I: inspect posterior surfaces ch. 5, p. 39 When does the approach to trauma care typically begin? - ANSWER With notification that a trauma patient is arriving to ED ch. 5, p. 39 What does 'safe practice' mean? - ANSWER Means taking into consideration the protection of the team, including: - observing universal precautions - donning PPE (gown, gloves, mask) prior to patient's arrival ch. 5, p. 39 What does 'safe care' mean? - ANSWER Means assuring the patient is getting to the right hospital in the right amount of time for the right care. American College of Surgeons Committee on Trauma (ACS-COT) developed trauma triage criteria that serves at the international standard to identify the trauma patient who would benefit from resuscitation and care at the right trauma facility with the appropriate resources. ch. 5, p. 40 During primary survey... - ANSWER Life-threatening conditions are identified and immediately corrected, beginning immediately upon the patient's arrival to the trauma room. ch. 5, p. 40 What is the most major cause of preventable death after injury? - ANSWER Uncontrolled hemorrhage ch. 5, p. 40 Explain the MARCH mnemonic - ANSWER M: MASSIVE HEMORRHAGE A: AIRWAY R: RESPIRATION - decompress suspected pneumo, seal open chest wounds, support ventilation and oxygenation as required C: CIRCULATION - vascular access and admin fluids H: HEAD INJURY/HYPOTHERMIA - prevent or treat hypotension and hypoxia to prevent worsening of traumatic brain injury and prevent or treat hypothermia ch. 5, p. 41-42 While in ED, alignment and protection of the cervical spine can be accomplished by which 2 ways? - ANSWER - Manual stabilization - Immobilization ch. 5, p. 42 A rapid, thready pulse may indicate (a. _______), and an irregular pulse may warn of potential (b. _______). - ANSWER a. HYPOVOLEMIA b. CARDIAC DYSFUNCTION ch. 5, p. 45 The standard approach to treating hypotension in trauma patients has been to infuse large volumes of IV fluids. Recent studies now recommend a different approach and note that an elevated BP may dislodge the body's formation of clots and promote further bleeding. In addition, large volumes of fluid lead to... - ANSWER Dilutional coagulopathy which worsens metabolic acidosis and may cause hypothermia ch. 5, p. 45 _________ therapy is now suggested for fluid resuscitation to replace patient losses, including administering PRBCs, plasma, and platelets. - ANSWER COMPONENT THERAPY ch. 5, p. 45 Assess pupils for... - ANSWER Equality, shape, and reactivity (PERRL) ch. 5, p. 45 Consider ABGs. A decreased level of consciousness may be an indicator of... - ANSWER Decreased cerebral perfusion, hypoventilation, or acid-base imbalance. ch. 5, p. 46 Hypothermia combined with ______ and ______ is a potentially lethal combination. - ANSWER HYPOTENSION and ACIDOSIS ch. 5, p. 46 Explain the LMNOP mnemonic - ANSWER Used to remember resuscitation adjuncts L - Lab studies (ABGs, blood type and crossmatch) - Lactic acid is an excellent reflection of tissue perfusion M - Monitor cardiac rate and rhythm: compare patient's pulse to the monitor's rhythm - Dysrhythmias (PVCs, a fib, or ST segment changes) may indicate blunt cardiac trauma - PEA may point to cardiac tamponade, tension pneumothorax, or profound hypovolemia N - Naso- or orogastric tube consideration: insertion provides stomach content evacuation and relief of gastric distention O - Oxygenation and ventilation assessment - Pulse ox may only be accurate if there is adequate peripheral perfusion - ETCO2 monitoring (capnography) provides instantaneous information about the ventilation, perfusion, and metabolism of carbon dioxide (35-45 is normal) ch. 5, p. 47 ABGs provide values of oxygen, CO2 and base excess, which are... - ANSWER Reflective endpoint measurements of the effectiveness of cellular perfusion, adequacy of ventilation, and the success of the resuscitation. An abnormal base deficit may indicate poor perfusion and tissue hypoxia, which results in the generation of hydrogen ions and metabolic acidosis. ch. 5, p. 46 When does the secondary survey (HI) begin? - ANSWER After the completion of the primary survey (ABCDE), after the initiation of resuscitation efforts, once vital functions have been stabilized and after consideration for resuscitation adjuncts (FG). ch. 5, p. 47 Additional history includes the following (MIST mnemonic) prehospital report: - ANSWER - MOI - Injuries sustained - Signs and Symptoms (in the field) - Treatment (in the field) ch. 5, p. 47 SAMPLE mnemonic regarding patient's history - ANSWER S - Symptoms associated with injury A - Allergies and tetanus status M - Medications currently used, including anticoagulant therapy P - Past medical history (hospitalizations/surgeries) L - Last oral intake E - Events and Environmental factors related to injury ch. 5, p. 48 What are odors you want to be sure to document? - ANSWER Alcohol, gasoline, other chemicals ch. 5, p. 48 Explain the B2-Transferrin test - ANSWER Gold standard for identifying CSF otorrhea or rhinorrhea ch. 5, p. 48 What are some circumstances that may lead to unreliable pulse ox readings? - ANSWER - Poor peripheral perfusion - BP cuff inflated above sensor - CO poisoning (carboxyhemoglobin) - Methemoglobinemia - Severe dehydration Pulse ox provides evidence of SaO2 but not PaO2. The non-liner relationship between the two measurements is reflected in the oxyhemoglobin-dissociation curve. ch. 6, p. 65 Oxyhemoglobin-dissociation curve indicates the correlation of tissue oxygneation (PaO2) as it saturates the hemoglobin molecule (SO2). P50 describes the oxygen pressure when the hemoglobin molecule is 50% saturated. Normal P50 is 26.7 mm Hg. A shift in the curve notes changes in the relationship: - ANSWER Shift to the RIGHT occurs in an environment of HIGH metabolic demand. Hemoglobin's affinity for oxygen decreases, making it easier to release the bound oxygen to the tissues. A shift to the right occurs in response to: - Increased carbon dioxide (hypercapnia) - Increased temp (hyperthermia) - Increased 2,3-diphosphoglycerate levels (a substance in blood that helps O2 move from hemoglobin to the tissues) - Decreased pH (acidemia) Shift to the LEFT occurs in an environment of LOW metabolic demand. Hemoglobin's affinity for oxygen increases, making it harder to release bound oxygen to the tissues. A shift to the right occurs in response to: - Decreased carbon dioxide (hypocapnia) - Decreased temp (hypothermia) - Decreased 2,3-diphosphoglycerate levels - Elevated pH (alkalosis) - Carbon monoxide and methemoglobinemia ch. 6, p. 65 Trauma nurse should be attempting to maintain NORMOTHERMIA and NORMOCARBIA, which... - ANSWER Decreases risk of.. HYPOTHERMIA ACIDOSIS 150... when autoregulation in the brain fails, perfusion becomes dependent solely on pressure. ch. 7, p. 78 Resuscitation-associated coagulopathy is associated with the trauma triad of death. It includes... - ANSWER HYPOTHERMIA impairs thrombin production and platelet function ACIDOSIS impairs thrombin production COAGULOPATHY results in depletion of clotting factors through hemodilution and impaired ability to produce clotting factors ch. 7, p. 78 Stage I: Compensated Shock - ANSWER - Anxiety, lethargy, confusion, restlessness from oxygen being shunted to brainstem - Systolic BP usually within normal range - Rising diastolic BP, results in narrowed pulse pressure, which is a reflection of peripheral constriction - A bounding and/or slightly tachycardic pulse - Increased RR - Decreased urine output ch. 7, p. 79 Stage II: Decompenstated or Progressive Shock - ANSWER - LOC deteriorates patient becomes obtunded or unconscious as cell switch to anaerobic metabolism with increasing levels of lactic and pyruvic acids - Normal or slightly decreased systolic BP - Narrowing pulse pressure that continues until peripheral vascular vasoconstriction fails to provide cardiovascular support - HR > 100 beats/min - Weak, thready pulses - Rapid, shallow respirations - Cool, clammy, cyanotic skin - Base excess not within normal range of -2 to +2 - Serum lactate levsl > 2 to 4 ch. 7, p. 79 Stage III: Irreversible Shock - ANSWER - Obtunded, stuporous, comatose - Marked hypotension and HF - Bradycardia with possible dysrhythmias - Decreased and shallow RR - Pale, cool, clammy skin - Kidney, liver, and other organ failure - Severe acidosis, elevated lactic acid levels, and worsening base excess on ABGs - Coagulopathies with petechiae, purpura, or bleeding ch. 7, p. 79 Replacement with packed cells and saline without also transfusing with _______ and _______ further dilutes the patient's ability to clot blood. - ANSWER PLATELETS and PLASMA ch. 7, p. 79 Because calcium is a vital part of the clotting casade, hypocalcemia, as a result of a massive transfusion, can actually worsen hypovolemic shock by... - ANSWER Permitting continued bleeding Signs of hypocalemia include- dysrhythmias, muscle tremors, and seizures ch. 7, p. 81 Disadvantages of auto-transfusion include: - ANSWER - Risk of contamination - RBCs might become hemolyzed during hemorrhage - Coagulation factors, including platelets and cryoprecipitate may be destroyed, increasing d-dimer in collected blood ch. 7, p. 81 Explain what Tranexamic acid (TXA) is - ANSWER A synthetic version of the amino acid lysine. It is an antifibrinolytic that inhibits activation of plasminogen, a substance responsible for dissolving clots. ch. 7, p. 81 Increased or bounding central pulses may indicate increased cardiac output. Peripheral pulses do not demonstrate a similar effect in the presence of hypovolemia due to vasocontriction. Thus, strong central pulses combined with weak peripheral pulses may be... - ANSWER Indicative of Shock ch. 7, p. 82 What lab studies are used to guide resuscitative efforts in shock? - ANSWER - Platelet count, clotting studies - Serum lactate, anion gap, base deficit, and ABGs to assess acidosis - Toxicology screen to help assess mental status and differentiate from head injury - Calcium level when rapidly infusing large volumes of blood products ch. 7, p. 83 Following the primary survey, FAST examination may be used to rapidly assess for bleeding from damage to the... - ANSWER Heart, liver, kidneys, and spleen. FAST also increasingly used to detect pneumothorax, especially tension pneumothorax. ch. 7, p. 84 Output less than 0.5 mL/kg per hour for two consecutive hours indicates... - ANSWER OLIGURIA ch. 7, p. 84 Pain Theories include... - ANSWER GATE CONTROL THEORY- proposes pain may be modulated by interneurons within spinal cord. Stimulation of the large A-beta cutaneous fibers was thought to close gate pain impulses from A-delta or C fibers. A-beta fibers carry impulses from touch, vibration, rubbing a painful area. Supports non- pharmacologic therapies for pain control such as ice, heat, massage. NEUROMATRIX THEORY- proposes that each person's brain produces a unique pattern of nerve impulses from a complex neural network with multidimensional inputs. This theory explains phantom limb pain and why people with similar injuries report differing levels and responses to pain. NEUROPLASTIC THEORY- suggests that neurons can be permanently affected and reshaped by the experience of pain. This theory attempts to explain chronic pain, pain syndromes, and phantom pain. ch. 8. p. 93 Classifications of acute pain are based on the source and origin and include... - ANSWER SOMATIC pain originates from skin and muscloskeletal structures VISCERAL PAIN originates from organs and may lead to referred pain ch. 8, p. 93 Explain oligoanalgesia - ANSWER the concept of undertreatment of pain ch. 8, p. 94 Physiologic effects of pain by system: Cardiovascular - ANSWER HYPERCOAGULATION INCREASED CARDIAC WORKLOAD INCREASED OXYGEN DEMAND - BEHAVIOR CHANGES (IMPAIRED JUDGEMENT, RESTLESSNESS, DROWSINESS) - ALTERED LEVEL OF CONSCIOUSNESS ( HYPO/HYPERAROUSABILITY) Ch. 9, p. 109 Late assessment findings of increased ICP include: - ANSWER - DILATED, NON- REACTIVE PUPILS - UNRESPONSIVENESS to verbal/painful stimuli - ABNORMAL POSTURING - CUSHING RESPONSE Widening pulse pressure Reflex bradycardia Decreased respiratory effort Ch. 9, p. 109 Mastoid process ecchymooses - ANSWER Battles sign, indicates middle fossa fracture Ch. 9, p. 113 What can you assess to ensure the brainstem is intact? - ANSWER EXTRAOCULAR EYE MOVEMENTS (EOMs) - tests functions of CNs III, IV, and VI In presence of facial fractures, the inability to perform EOMs may indicate a trapped nerve Ch. 9, p. 113 Describe FOCAL BRAIN INJURIES - ANSWER Occur in localized area with grossly observable and identifiable brain lesions. They include... - CEREBRAL CONTUSION - INTRACEREBRAL HEMATOMA - EPIDURAL HEMATOMA - SUBDURAL HEMATOMA - HERNIATION SYNDROMES Ch. 9, p. 113 Assessment findings of a INTRACEREBRAL HEMATOMA - ANSWER - PROGRESSIVE, RAPID DECLINE IN LOC - HEADACHE - SIGNS OF INCREASING ICP - PUPIL ABNORMALITIES - CONTRALATERAL HEMIPARESIS - HEMIPLEGIA - ABNORMAL POSTURING Ch. 9, p. 114 Assessment findings of a EPIDURAL HEMATOMA - ANSWER - TRANSIENT LOC followed by lucid period lasting minutes to hours - HEADACHE, DIZZINESS - NAUSEA, VOMITING - CONTRALATERAL HEMIPARESIS - HEMIPLEGIA - ABNORMAL MOTOR POSTURING (FLEXION/EXTENSION) Extension is associated with brainstem HERNIATION and poor outcomes - IPSILATERAL UNILATERAL FIXED, DILATED PUPIL - RAPID DETERIORATION IN NEURO STATUS Ch. 9, p. 114 Assessment findings of an ACUTE SUBDURAL HEMATOMA - ANSWER - SEVERE HEADACHE - CHANGES IN LOC - IPSILATERAL DILATED or NONREACTIVE PUPIL - CONTRALATERAL HEMIPARESIS Ch. 9, p. 114 Assessment findings of a CHRONIC SUBDURAL HEMATOMA - ANSWER - ALTERED or STEADY DECLINE IN LOC - HEADACHE - LOSS OF MEMORY or ALTERED REASONING - MOTOR DEFICIT: CONTRALATERAL HEMIPARESIS, HEMIPLEGIA, OR ABNORMAL MOTOR POSTURING OR ATAXIA - APHASIA - IPSILATERAL UNILATERAL FIXED and DILATED PUPIL - INCONTINENCE - SEIZURES Ch. 9, p. 114 Assessment findings of a HERNIATION SYNDROME - ANSWER - ASYMMETRIC PUPILLARY REACTIVITY - UNILATERAL or BILATERAL PUPILLARY DILATION - ABNORMAL MOTOR POSTURING - other evidence of neurologic deterioration (loss of normal, reflexes, paralysis, or change in LOC) Ch. 9, p. 115 Assessment findings of a DIFFUSE INJURY - ANSWER Injuries that occur over a wide spread area, not always identifiable on CT because damage involves contusions or hearing and stretching of micro vascular, not a localized hematoma. These injuries commonly follow a direct blow to the head and are often sports-related. Patients can have varying degrees of symptoms that last minutes to hours. Assessment findings include: - TRANSIENT LOC - HEADACHE, DIZZINESS - NAUSEA, VOMITING - CONFUSION, DISORIENTATION - MEMORY LOSS and CONCENTRATION DIFFICULTY - IRRITABILITY and FATIGUE Ch. 9, p. 115 Assessment findings for MILD, MODERATE, and SEVERE TRAUMATIC BRAIN INJURY INCLUDE: - ANSWER MILD - GCS 13-15 - Brief (<30 min) LOC - POST-TRAUMATIC AMNESIA < 24 hours - No change on neuron aging studies MODERATE - GCS score 9-12 - Wide variety of symptoms, including ALTERATIONS IN CONSCIOUSNESS, CONFUSION, AMNESIA, and FOCAL NEUROLOGICAL DEFICITS - May deteriorate to severe head injury over time SEVERE - GCS score <8 - Significant alterations in consciousness - ABNORMAL PUPILLARY RESPONSE - ABNORMAL POSTURING Ch. 9, p. 115 Explain what second impact syndrome is - ANSWER Refers to a condition that occurs when patient suffers a mild second TBI before recovery from the first. Rare but usually fatal. The second impact causes LOSS OF AUTO REGULATION LEADING TO CEREBRAL EDEMA Ch. 9, p. 115 POSTCONCUSSIVE SYNDROME assessment findings include: - ANSWER - NAUSEA Ch. 10, p. 130 Explain OBITAL FRACTURE - ANSWER - NOT CONSIDERED OPHTHALMOLOGIC EMERGENCY unless there is IMPAIRED VISION or GLOBE RUPTURE - Usually result from DIRECT BLOW TO EYE - Complication of this type of fracture is ENTRAPMENT OF THE INFERIOR RECTUS or INFERIOR OBLIQUE MUSCLE Assessment findings include: - PERIORBIAL ECCHYMOSIS - DIPLOPIA WITH UPWARD GAZE - ENOPHTHALMOS - INFRAORBITAL NUMBNESS - DECREASED EOM Treatment includes: - ORAL ANTIBIOTICS - COOL COMPRESSES - CONSULT with possible surgical repair if pt continues to have DIPLOPIA or ENOPHTHALMOS 1-2 weeks after swelling has decreased - Discharge instructions include: advise pt to AVOID BLOWING NOSE, SNEEZING, and/or PERFORMING A VASALVA MANEUVER BEARING DOWN Ch. 10, p. 130-131 Explain HYPHEMA - ANSWER Collection of blood in anterior chamber of eye - classified as spontaneous or traumatic Assessment findings include: - PAIN, PHOTOPHOBIA - NOTICEABLE COLLECTION OF BLOOD IN EYE CHAMBER - BLURRY VISION due to blood in chamber - INCREASED IOP, NAUSEA, and SEVERE PAIN with grade 4 Treatment includes: - ELEVATING HOB 30 degrees - protecting eye with METAL SHIELD - TOPICAL OPHTHALMIC CYCLOPLEGICS and OPHTHALMIC STEROIDS, OPHTHALMIC BETA-BLOCKERS if IOP is ELEVATED - Avoid aspirin and NSAIDs as they increase risk of re-bleeding - Risk of re-bleeding greatest 3-5 days after injury Ch. 10, p. 131 Explain RETROBULBAR HEMATOMA - ANSWER TRUE OPHTHALMOLOGIC EMERGENCY Hemorrhage into space behind globe; bleeding causes increased pressure behind globe causing elevation in IOP that compresses optic nerve and blood vessels. Early recognition is imperative to save vision. Assessment findings include: - SEVERE PAIN - DECREASED VISION - REDUCED EYE MOVEMENT - IOP > 40 mm Hg Treatment include: - Emergency decompression via LATERAL CANTHOTOMY indicated with IOP > 40 mm Hg Ch. 10, p. 131 Explain GLOBE RUPTURE - ANSWER - Considered a genuine EMERGENCY - Occurs when full thickness injury occurs to cornea or sclera or both -Once Dx is confirmed, it is important to protect eye from further injury Assessment findings include: - ANTERIOR CHAMBER APPEARING FLAT/SHALLOW - IRREGULAR or TEARDROP-SHAPED PUPILS or PRESENCE of what looks like a secondary pupil due to a tear in the ciliary body (traumatic iridodialysis) - PERIORBIAL ECCHYMOSIS - DECREASED VISUAL ACUITY and EOM - SEVERE SUBCONJUNCTIVAL HEMORRHAGE - NAUSEA - PAIN Treatment includes: - AVOID ANY TYPE OF PRESSURE TO GLOBE - DO NOT PERFORM TONOMETRY - APPLICATION OF RIGID SHIELD to protect affected eye - Administration of antiemetics - AVOID USE OF OPHTHALMIC DROPS or MEDICATIONS - CONSULTS * Pain not always present in globe penetration Ch. 10, p. 131 Ch. Ch. 10, p. 131-132 What symptoms usually indicate an INTRAOCULAR foreign body is present? - ANSWER - IRREGULAR PUPIL - SHALLOW ANTERIOR CHAMBER - POSITIVE SEIDEL TEST Ch. 10, p. 132 Explain eye irrigation when used for the removal of chemicals, foreign bodies, and debris from eye - ANSWER CONTRAINDICATED in patients who may have RUPTURED GLOBE - Prior to procedure, check eye pH then instill anesthetic drops unless contraindicated. - Use warmed NS or LR, warmed to body temp 37 C to limit risk of thermal injury - Morgan lens or intravenous tubing may be used to direct flow, remember the shorter the tubing, the greater the flow and pressure - Direct stream across eye from inner to outer eye - Irrigation continued until eye pH reaches neutral (7.0-7.3) Ch. 10, p. 133 What are the rules concerning standard imaging in relation to eye injury - ANSWER - If wood or a vegetative foreign body is suspected, MRI most appropriate imaging method to use, however, it is minimally useful in acute setting - CT scans not helpful if vegetative foreign bodies are suspected - the GOLD STANDARD for evaluation of mid-face and orbit trauma is a CT scan - Plain films are used to assess foreign bodies and fractures of facial structures, excluding orbits Ch. 10, p. 133-134 What is the most common cause of thoracic trauma? - ANSWER MVC's Others include: Falls, crush injury, assaults, gunshot and stabbing wounds, ped vs. vehicle collisions Ch. 11, p. 140 If a penetrating wound is found below the 4th intercostal space, penetration into the _________ is suspected until proven otherwise. - ANSWER ABDOMINAL CAVITY Ch. 11, p. 140 Penetrating injury to the chest wall and lacerated lung tissue can cause the loss of ________________. Thus, the collection of air or blood in the pleural space causes ______________. - ANSWER A. NORMAL NEGATIVE INTRAPLEURAL PRESSURE B. LUNG COLLAPSE Interventions include: - Attempts at ET placement may cause further damage, anesthesiology if available may reduce risk of intubation injury - Other approaches include flexible endoscopy, or smaller ET tube Ch. 11, p. 143 BLUNT ESOPHAGEAL INJURY - ANSWER Injury to esophagus, rare, results form blunt trauma Assessment findings include - AIR in MEDIASTINUM with possible widening - CONCURRENT LEFT PNEUMOTHORAX or HEMOTHORAX - ESOPHAGEAL MATTER IN CHEST TUBE - SUBCUTANEOUS EMPHYSEMA Interventions - Prepare for surgery Ch. 11, p. 143 FLAIL CHEST - ANSWER Classified as 2 or more fractures of 3 or more adjacent ribs and/or sternal fractures, creating free-floating segment Assessment findings include - PARADOXICAL CHEST MOVEMENT drawing in with chest expansion and pushing out with exhalation - DYSPNEA - CHEST WALL PAIN, CONTUSIONS Interventions - prepare for intubation Ch. 11, p. 144 TENSION PNEUMOTHORAX - ANSWER Occurs when air enters INTRAPLEURAL space but cannot escape on expiration, increasing pressure causes lung on injuries side to collapse. If pressure not relieved, mediastinum can shift toward the uninjured side compressing heart, great vessels, and ultimately the opposite lung. As pressure rises, venous return is hampered, cardiac output decreases, and hypotension occurs. Assessment findings include: - ANXIETY, SEVERE RESTLESSNESS - SEVERE RESPIRATORY DISTRESS - SIGNIFICANTLY DIMINISHED OR ABSENT BREATH SOUNDS on injured side - HYPOTENSION - DISTENDED NECK, HEAD, UPPER EXTREMITY VEINS (may not be evident if patient has experienced significant blood loss) - TRACHEAL DEVIATION or shift toward injured side - CYANOSIS (late sign) Interventions - Immediate chest X-RAY if pt somewhat stable - prepare for immediate needle thoracentesis 14 g needle inserted into 2nd intercostal space in mid clavicular line on affected side over the top of the rib to avoid neurovascular bundle that runs under rib - prepare for chest tube placement, which is the definitive treatment ch. 11, p. 145 HEMOTHORAX - ANSWER caused by blood accumulating in the intrapleural space. Results from injury to lung, costal blood vessels, great vessels and from laceration to liver or spleen combined with diaphragm injury. Assessment findings include - ANXIETY or RESTLESSNESS - DYSPNEA, TACHYPNEA - CHEST PAIN - SIGNS OF SHOCK- tachycardia, cyanosis, diaphoresis, hypotension - DECREASED BREATH SOUNDS ON INJURED SIDE Interventions - Prepare for needle thoracentesis and chest tube insertion - Ensure 2 large IV catheters and blood is available before thoracentesis to treat large volume blood loss if needed ch. 11, p. 146 PULMONARY CONTUSION - ANSWER commonly occur from rapid deceleration or direct blunt impact such as MVCs or falls - it develops when capillary blood leaks into lung parenchyma with edema and inflammation, it may be localized or diffuse The subtle assessment findings associated with pulmonary contusions usually develop over time rather than immediately after injury. Assessment findings - DYSPNEA - INEFFECTIVE COUGH - INCREASED WORK OF BREATHING - HYPOXIA - CHEST PAIN - CHEST WALL CONTUSIONS or ABRASIONS Interventions - Maintain SpO2 between 94-98% - Minimize or use IV fluids judiciously - Prepare for possible intubation ch. 11, p. 146 CARDIAC TAMPONADE - ANSWER Assessment findings Beck's Triad- HYPOTENSION, MUFFLED HEART SOUNDS, DISTENDED NECK VEINS - CHEST PAIN - TACHYCARDIA - DYSPNEA - CYANOSIS - Pulsus paradoxus greater than 10 mm Hg Interventions - Prepare for pericardial decompression - 3 to 4 cm incision made just left of xiphoid process - Needle percardiocentesis may also be used to relieve symptoms of cardiac tamponade but its only temporary solution ch. 11, p. 146 AORTIC DISRUPTION - ANSWER Assessment findings - Fractures of sternum, first or second rib or scapula - CARDIAC MURMURS - BACK, CHEST PAIN - UNEQUAL EXTREMITY PULSE STRENGTH or BLOOD PRESSURE (Significantly greater in upper extremities) - HYPOTENSION - TACHYCARDIA - SKIN CHANGES: diaphoresis, pallor, cyanosis - PHARAPLEGIA (due to disruption of spinal perfusion from aortic injury) - Radiograph findings include- left hemothorax, right-sided tracheal deviation, widened mediastinum Interventions - Prepare for surgery or angiography - Consider massive transfusion protocol ch. 11, p. 146 - Pancreatic ductal injuries may need distal pancreatectomy - complications from pancreatic injury include, secondary hemorrhage, pancreatic fistula, abdominal abscess - s/s of infection occur often 7-10 days after injury and usually include fever, elevated WBC, nausea, vomiting ch. 12, p. 164 Are the lumen contents of the small bowel considered sterile? What is the pH? - ANSWER neutral pH, and sterile ch. 12, p. 164 Pertaining to abdominal trauma, What does non-operative management include? When does operative management occur? - ANSWER Non- serial abdominal exams Op- occurs in patients who exhibit signs of peritonitis or hemodynamic instability ch. 12, p. 164 What diagnostic exam is helpful to inspect abdominal spaces for spillage and to examine loops of bowel? - ANSWER Laparoscopy ch. 12, p. 164 What is used to diagnosis renal injuries? What are the cons? How are rectal injuries often managed? - ANSWER Sigmoidoscopy Cons- unprepared bowel may not detect injury Often managed with colostomy and distal rectal washout ch. 12, p. 165 Explain stable and unstable pelvic fractures - ANSWER Stable- does not involve pelvic ring or there is minial displacement of pelvic ring Unstable fractures- 2 or more fractures of pelvic ring that have outward rotational displacement ch. 12, p. 166 Assessment findings for renal injuries include - ANSWER - Turner sign (bruising by 11th and 12th ribs) - Hematuria - Frank tenderness, costovertebral angle tenderness, palpable flank mass - Structural damage or leakage of contrast on intravenous pyelogram (IVP) - If patient hemodyanmically unstable for CT, a single-infusion IVP can be performed at bedside followed by complete study once patient is stable - Positive urine dipstick for microscopic blood or leukocyte esterase - Abnormal or elevated BUN and creatinine 90% of injuries are minor. Anticipate nephrology consultation in more severe injures; surgical repair is required within 12 hours to salvage an ischemic kidney ch. 12, p. 167 Imaging studies for bladder and urethral injuries include - ANSWER - CT cystogram used to dx intraperitoneal or extraperitoneal bladder rupture - Urethrogram usually performed prior to insertion of urinary catheter when injury is suspected; contrast instilled at meatus. Detection of contrast media within bladder indicates adequate instillation, leakage demonstrates urethral disruption ch. 12, p. 168 Prophylactic administration of what can reduce the risk of contrast-induced nephropathy when patients serum creatinine is above 1.2mg? - ANSWER N-acetylcysteine along with hydration ch. 12, p. 170 55% of spinal injuries occur to which part of spine? - ANSWER cervical ch. 13, p. 179 hyperEXTENSION - ANSWER etiology/cause- backward thrust beyond anatomic capacity of vertebral column rest of injury- stretching or ligament tears, bony dislocations example- rear-end whiplash ch. 13, p. 179 hyperFLEXION - ANSWER etiology/cause- forceful forward flexion with head striking an immovable object rest of injury- wedge fractures, facet dislocations, subluxation (due to ligament rupture), teardrop, odontoid or transverse process fractures example- head-on MVC with head hitting windshield, creating starburst effect ch. 13, p. 179 ROTATIONAL - ANSWER etiology/cause- combination of forceful forward flexion with lateral displacement of cervical spine rest of injury- posterior ligament rupture and/or anterior fracture, dislocation of vertebral body example- MVC to front or near lateral area of vehicle results in conversion of forward motion to a spinning-type motion ch. 13, p. 179 AXIAL LOADING - ANSWER etiology/cause- direct force transmitted along the length of vertebral column rest of injury- deformity of vertebral column, secondary edema of spinal cord resulting in neurologic effects example- diver striking head on bottom of pool ch. 13, p. 179 Explain NEUROGENIC SHOCK and what are the assessment findings - ANSWER Occurs with SC damage at T6 or higher, resulting in sympathetic regulation disruption of vagal tone leading to loss of vascular resistance and generalized vasodilation Assessment findings - BRADYCARDIA - HYPOTENSION - WARM, NORMAL COLOR SKIN - CORE TEMPERATURE INSTABILITY ch. 13, p. 181 SPINAL SHOCK - ANSWER When spinal cord is injured, cascade of events takes place - Blood supply to cord can be disrupted - Axons are severed or damaged - Conduction of electrical activity of neurons and axons is compromised - All of the above result in loss of function which can last from several hours to several days - A transient hypotensive period and poor venous circulation may be seen - Disruption of thermal control centers results in sweating and lack of ability to regulation body temp - Transient loss of muscle tone (flaccidity) and complete or incomplete paralysis with reflex losses - Bowel and bladder dysfunction