Trauma Assessment and Management, Exams of Nursing

Download Trauma Assessment and Management and more Exams Nursing in PDF only on Docsity! 1 TNCC Test Bank 300 Questions and Answers 2024 An adult patient with a knife injury to the neck has an intact airway and ishemodynamically stable. They complain of difficulty swallowing and speaking. In theprimary survey, further assessment is indicated next for which of the followingconditi ns ?a. Damage to the cervical spineb. An expanding pneumothoraxc. Lacerati n of the carotid arteryd. Injury to the thyroid gland - ansa. Damage to the cervical spine A patient arrives at the emergency department by private vehicle after sustaining aninjury to the right lower extremity while using a saw. There is a large gaping wound tothe ri ht thigh area with significant bleeding. What is the priority intervention?a. Elevate the extremity to the level of the heartb. Initi te direct pressurec. Apply a tourniquetd. Cover the open wound with sterile saline dressings - ansb. Initiate direct pressure A patient fell two weeks ago, striking their head. Today, the patient presented with a persistent headach and nausea a d was diagnose with a small subdural hematoma.The pa ient has been in the ED for 24 hours awaiting an inpatient bed. The night shifturse reports the patient has been anxious, restless, shaky, and vomited twice duringhe night. The patient states they couldn't sleep because a young child kept coming intothe room. What is the most likely cause for these signs and symptoms?a. increa e intracranial pressureb. alcohol withdrawalc. rhabdomyolysisd. pulmonar embolus - ansb. alcohol withdrawal A patient involved in a MVC has sustained a fracture to the second rib of the anterior leftchest. Which concurrent injury is most commonly associated with this fracture?a. Bl nt cardiac injuryb. Brachial plexus injuryc. Pneumothoraxd. He t r - ansb. Brachial plexus injury A patient with a spinal cord injury at C5 is being cared for in the emergency departmentwhile awaiting transport to a trauma center. Which of the following represents thehigh t priority for ongoing assessment and management for this patient?a. maintain adequate respiratory status.b. administer balanced resuscitation fluidc. perform serial assessments of neurologic function 2 d. maintain core temperature - ansa. maintain adequate respiratory status A trauma nurse cared for a child with devastating burns two weeks ago. The nursecalled in sick for a couple of days and is now back working on the team. Which of thefollowing behaviors would indicate this nurse is coping well?a. They are talking about taking the emergency nursing certification examination.b. They keep requesting to be assigned to the walk-in/ambulatory areac. They re impatient and snap at their coworkers.d. They are thinking about transferring out of the emergency department. - ansa. Theyre talking about taking the emergency nursing certification examination. Following a bomb explosion, fragmentation injuries from the bomb or objects in theenvironment are examples of which phase of injury?a. primaryb. secondaryc. tertiaryd. quaternary - ansb. secondary In a patient with severe traumatic brain injury, hypocapnia causes which condition?a. Respiratory acidosisb. Metabolic acidosisc. Neurogenic shockd. Cerebral vasoconstriction - ansd. Cerebral vasoconstriction The general impression step in the initial assessment provides the opportunity to dowhich of the following?a. Assess for uncontrolled internal hemorrhageb. Accur tely triage the patientc. R prioritize circulation before airway or breathing.d. Activate the trauma team - ansc. Reprioritize circulation before airway or breathing. The nurse is obtaining a history for a patient who presents following sexual assault. Thishistory is completed using which of the following techniques?a. Bring the family in to the interview room.b. Use direct quotes to record information.c. Obtain i formation specific only to the assault.d. Provide food and drink to help create rapport. - ansb. Use direct quotes to recordinf rma io n. The vital signs of a pregnant trauma patient at 30 weeks include a blood pressure of94/62 mm Hg and a heart rate of 108 beats/minute. Fetal heart tones are 124 5 Airway Interventions: - ansSuctionRemove foreign body if notedJaw thrust maneuver (maintain cspine)Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)Consider definitive airway Alertness Assessment - ansA- AlertV-Verbal P- PainfulU- Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: spontaneous breathing,symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use,diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),ontus ons/abrasions/deformities (signs of underlying injury), open pneumothoraces(sucking chest wound), JVD, tracheal position, signs of inhalation injury Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space midclavicular line and bases at the fifth intercostal space anterior axillary line Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV pulsations at suprasternal notch or supraclavicular area Life-threatening pulmonary injuries requiring immediate intervention: open pneumothorax, tension pneumothorax, flail chest, hemothorax. Breathing and Ventilation Intervention - ansBreathing absent: jaw-thrust maneuver, oral airway adjunct, assist ventilation with bag-mask device, prepare for definitive airway Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% or higher. If ineffective: assist with bag-mask and determine need for definitive airway C (Primary Survey) - ansCirculation and Control of Hemorrhage Cardiogenic Shock - ansResults from pump failure in the presence of adequateintravascular volume. There is a lack of cardiac output and end-organ perfusions condary to a decrease in myocardial contractility and/or valvular insufficiency. 6 Acute causes - myocardial infarction, dysrhythmias or toxicologic pathologies. Heart failure is a chronic cause. Blunt cardiac injury may present similar to MI. Excess of volume administration or increased after load can result in pulmonary edema and increased myocardial ischemia. Inotropic support to improve contractility. Circulation and Control of Hemorrhage Assessment - ansInspect: Uncontrolled external bleeding, skin color Auscultate: Muffled heart sounds - may indicate pericardial tamponade Palpate: carotid and/or femoral pulses for rate, rhythm, strength Circulation and Control of Hemorrhage Interventions - ansControl and treat externalbl eding: apply direct pressure, elevate bleeding extremity, apply pressure over arterialsit s, consider use of a tourniquet. 2 large bore IVs, if unable consider IO, obtain labs and crossmatch. Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L. **Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosisand may c use hypothermia. Component therapy, including administering RBC, plasmaand platelets is a balanced approach so that O2 delivery is optimized, acidosiscorrect and c agulopathy prevented. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating blood volume Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume Distributive - maldistribution of an adequate circulating blood volume (septic, anaphylactic, neurogenic) 7 Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate with fluorescein. Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling, irritation Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain,ophth lmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours.(Do NOT patch - increases infection) Corneal Foreign Body - ansRoutinely metal, plastic or wood. Findings: photophobia, pain, injected conjunctiva (redness), lid swelling Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics, oral analgesia Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slit lamp. Findings: similar to abrasion, pain out of proportion to findings, decreased vision Treatment: treat small lacerations similar to an abrasion, larger lacerations need ophthalmology referral and possible surgery Cycloplegic agent - ansCycloplegia is paralysis of the ciliary muscle of the eye, resultingin a los of accommodation. Because of the paralysis of the ciliary muscle, thecurvature of the lens can no longer be adjusted to focus on nearby objects. D (Primary Survey) - ansDisability (Neurologic Status) Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result of CNS injury until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion, hypoventilation or acid-base imbalance. 1 0 Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects. Palpate: areas of tenderness, step-offs, crepitus BONY DEFORMITIES: Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominal pressure. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient. Observed with serial abdominal exams. Findings of contrast extravasation may be embolized by IR. For surgical patients - fluid resuscitation is essential. Risks of surgery include disruptionof the natural tamponade process due to the evacuation of large amounts of bloodresulting in hypovolemia. Hypovolemic Shock - ansCaused by a decrease in the amount of circulating blood volume. In trauma typically results from hemorrhage, but can result in a precipitous loss ofvolume, ie v miting or diarrhea. Burn trauma can result in hypovolemic shock from damage to the cell membranes leading to plasma and protein leakage. of body water, results in inadequate perfusion. 1 1 Hyperventilation can cause increased intrathoracic pressure resulting in compression of the heart and decreased cardiac output. Initial Assessment - ans1. Preparation and Triage 2. Primary Survey3. Reevaluation4. Secondary Survey5. Reevaluation Adjuncts6. Reevaluation and Post Resuscitation Care7. Definitive Care or Transport Intraocular Foreign Body - ans*TRUE EMERGENCY AND EARLY INTERVENTION IS ESSENTIAL. Findings: compromised visual acuity, misshapen pupils, pain Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTEDeye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmicABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ans Liver - ansLargest solid organ of the body. RUQ, 6th to 10th ribs. Encased by Glisson capsule with blood vessels, lymphatics and nerves. Filters 1.7L of blood per minute. The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose andbilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol andbile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary forclotting). Obstructive Shock - ansResults from hypo perfusion of the tissue due to an obstruction in either the vasculature or heart. 1 2 Tension pneumothorax - increased thoracic pressure leads to displacement of the vena cava, obstruction to atrial filling, decreased preload and decreased cardiac output. Cardiac tamponade - impedes diastolic expansion and filling leads to decreased preload, strokes volume and cardiac output and ultimately end organ perfusion. P (AVPU) - ansPainful. Responds only to painful stimuli. (Airway adjunct may be needed while determining need for intubation) Reevaluation - ansPortable radiograph - AP chest, pelvis. Can quickly identify potentially life-threatening injuries such as pneumothorax or pelvic fracture withun ontrolled internal hemorrhage. Can also confirm placement of ET tubes, ch st t besand gastric tubes. Consider need for transfer. shock - ansInadequate tissue perfusion. Spleen - ansEncapsulated organ LUQ level of 9th-11th ribs and curves around a portionof the stomach. Minimal elasticity and flexibility - most frequent injured organ in blunttraum a. Secondary lymph organ that filters and cleanses the blood. Removes old RBCs andhold reserve of blood. It recycles iron. It removes antibody-coated bacteria. Supplieslymphocytes to stimulate an immune response to blood borne microorganisms. Stores200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure. Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption,intraparenchymal hematoma or subcapsular hem toma. Contra t blush or extravasation- hyperdense area that represent traumatic disruption. Active extravasation impliesongoing bleeding. 1 5 Auscultate: Muffled heart sounds - may indicate pericardial tamponade Palpate: carotid and/or femoral pulses for rate, rhythm, strength Circulation and Control of Hemorrhage Interventions - ansControl and treat externalbl eding: apply direct pressure, elevate bleeding extremity, apply pressure over arterialsit s, consider use of a tourniquet. 2 large bore IVs, if unable consider IO, obtain labs and crossmatch. Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L. **Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosisand may c use hypothermia. Component therapy, including administering RBC, plasmaand platelets is a balanced approach so that O2 delivery is optimized, acidosiscorrect and c agulopathy prevented. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating bloodvolum e Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume Distributive - maldistribution of an adequate circulating blood volume (septic,anaphylactic, neurogenic) Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate withfluorescei n. Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling,irritati on Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain,ophth lmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours.(Do NOT patch - increases infection) Corneal Foreign Body - ansRoutinely metal, plastic or wood. Findings: photophobia, pain, injected conjunctiva (redness), lid swelling 1 6 Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics, oral analgesia Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slit lamp. Findings: similar to abrasion, pain out of proportion to findings, decreased vision Treatment: treat small lacerations similar to an abrasion, larger lacerations need ophthalmology referral and possible surgery Cycloplegic agent - ansCycloplegia is paralysis of the ciliary muscle of the eye, resultingin a los of accommodation. Because of the paralysis of the ciliary muscle, thecurvature of the lens can no longer be adjusted to focus on nearby objects. D (Primary Survey) - ansDisability (Neurologic Status) Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result of CNS injury until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion, hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulating volume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia orreduction of the mean systemic volume and venous return to the heart or drop inp eload, resulting in distributive shock. Anaphylactic: release of inflammatory mediators, such as histamine, which contracts bronchial smooth muscle and increases vascular permeability and vasodilation. 1 7 Septic Shock: systemic release of bacterial endotoxins, resulting in an increasedvascular permeability and vasodilation Neurogenic shock: loss of sympathetic nervous system control of vascular tone, whichproduces venous and arterial vasodilation. With the loss of sympathetic nervous systeminput in spinal cord injury, unopposed vagal activity may result in decreased cardiacoutput through bradycardia. TREATMENT: increase systemic resistance, controlled volume replacement. Vasoconstriction and in some cases (neurogenic) Atropine to counteract bradycardia. E (Primary Survey) - ansExposure and Environmental Control Exposure and Environmental Control - ansCarefully and completely undress the patient. Inspect for uncontrolled bleeding and note any obvious injuries. Prevent heat loss. Hypothermia combined with hypotension and acidosis is a potentiallylethal combination in the injured patient. Consider: warm blankets, keep ambientt m erature warm, warm IVF, forced air warmers, radiant warming lights. F (Primary Survey) - ansFull Set of VS & Family Presence G (Primary Survey) - ansGet Resuscitation Adjuncts:(LMNOP )L: LabsM: Monitor cardiac rate and rhythmN: Naso or orogastric tube considerationO: Oxygenation - SpO2 and/or etCO2 monitorP: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes2: Opens eyes in response to pain3: Opens eyes in response to voice4: Opens eyes spontaneously VERBAL 1. Makes no sounds2. Makes sounds 2 0 Intraocular Foreign Body - ans*TRUE EMERGENCY AND EARLY INTERVENTION IS ESSENTIAL. Findings: compromised visual acuity, misshapen pupils, pain Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTEDeye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmicABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ans Liver - ansLargest solid organ of the body. RUQ, 6th to 10th ribs. Encased by Glisson capsule with blood vessels, lymphatics and nerves. Filters 1.7L of blood per minute. The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose andbilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol andbile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary forclotting). Obstructive Shock - ansResults from hypo perfusion of the tissue due to an obstruction in either the vasculature or heart. Tension pneumothorax - increased thoracic pressure leads to displacement of the vena cava, obstruction to atrial filling, decreased preload and decreased cardiac output. Cardiac tamponade - impedes diastolic expansion and filling leads to decreased preload, strokes volume and cardiac output and ultimately end organ perfusion. P (AVPU) - ansPainful. Responds only to painful stimuli. (Airway adjunct may be needed while determining need for intubation) Reevaluation - ansPortable radiograph - AP chest, pelvis. Can quickly identify potentially life-threatening injuries such as pneumothorax or pelvic fracture with 2 1 uncontrolled internal hemorrhage. Can also confirm placement of ET tubes, chest tubesand gastric tubes. Consider need for transfer. shock - ansInadequate tissue perfusion. Spleen - ansEncapsulated organ LUQ level of 9th-11th ribs and curves around a portionof the stomach. Minimal elasticity and flexibility - most frequent injured organ in blunttraum a. Secondary lymph organ that filters and cleanses the blood. Removes old RBCs andhold reserve of blood. It recycles iron. It removes antibody-coated bacteria. Supplieslymphocytes to stimulate an immune response to blood borne microorganisms. Stores200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure. Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption,intraparenchymal hematoma or subcapsular hem toma. Contra t blush or extravasation- hyperdense area that represent traumatic disruption. Active extravasation impliesongoing bleeding. Nonoperative management is preferred if hemodynamically stable, stable H/H x 12-24hours, minimal transfusion requirements (<2units), grade I or II without blush, age <55,a ert able to assist in assessment of abdomen. Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal. Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumoni , Neisseria meningitides and Haemophil s influenza. At risk forpn umoco cal sepsis. Need annual flu shot and q5yr meningococcal andpneumococcal vaccines. 2 2 U (AVPU) - ansUnresponsive. Does not respond to any stimuli. V (AVPU) - ansVerbal. Needs verbal stimuli to respond.(Airway adjunct may be needed to prevent tongue obstruction) A (AVPU) - ansAlert. Will be able to maintain airway once clear. A (Primary Survey) - ansAirway and alertness with simultaneous cervical spinalstab lizatio n. Airway Assessment - ansInspect: tongue obstruction, loose/missing teeth, foreignobjects, blood, vomitus, secretions, edema, burns or evidence of inhalation injury Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor) Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneousemphyse ma Airway Interventions: - ansSuctionRemove foreign body if notedJaw thrust maneuver (maintain cspine)Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)Consider definitive airway Alertness Assessment - ansA- AlertV-Verbal P- PainfulU- Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: spontaneous breathing,symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use,diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),ontus ons/abrasions/deformities (signs of underlying injury), open pneumothoraces(sucking chest wound), JVD, tracheal position, signs of inhalation injury Auscultate: presence, absence and equality of breath sounds at 2nd intercostal spacemidclavicular line and bases at the fifth intercostal space anterior axillary line 2 5 Cycloplegic agent - ansCycloplegia is paralysis of the ciliary muscle of the eye, resultingin a los of accommodation. Because of the paralysis of the ciliary muscle, thecurvature of the lens can no longer be adjusted to focus on nearby objects. D (Primary Survey) - ansDisability (Neurologic Status) Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result of CNS injury until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion, hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulating volume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia orreduction of the mean systemic volume and venous return to the heart or drop inp eload, resulting in distributive shock. Anaphylactic: release of inflammatory mediators, such as histamine, which contracts bronchial smooth muscle and increases vascular permeability and vasodilation. Septic Shock: systemic release of bacterial endotoxins, resulting in an increased vascular permeability and vasodilation Neurogenic shock: loss of sympathetic nervous system control of vascular tone, which produc s venous and arterial vasodilation. With the loss f sympathetic nervous syst minput in spi al cord injury, unopposed vagal activity may result in decreased cardiacoutput through bradycardia. TREATMENT: increase systemic resistance, controlled volume replacement. Vasoconstriction and in some cases (neurogenic) Atropine to counteract bradycardia. E (Primary Survey) - ansExposure and Environmental Control 2 6 Exposure and Environmental Control - ansCarefully and completely undress the patient. Inspect for uncontrolled bleeding and note any obvious injuries. Prevent heat loss. Hypothermia combined with hypotension and acidosis is a potentiallylethal combination in the injured patient. Consider: warm blankets, keep ambientt m erature warm, warm IVF, forced air warmers, radiant warming lights. F (Primary Survey) - ansFull Set of VS & Family Presence G (Primary Survey) - ansGet Resuscitation Adjuncts:(LMNOP )L: LabsM: Monitor cardiac rate and rhythmN: Naso or orogastric tube considerationO: Oxygenation - SpO2 and/or etCO2 monitorP: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes2: Opens eyes in response to pain3: Opens eyes in response to voice4: Opens eyes spontaneously VERBAL1. Makes no sounds2. Makes sounds3. Words4. Confused, disoriented5. O , converses normally MOTOR1. Makes no movements2. Extension to painful stimuli (decerebrate)3. Abnormal flexion to painful stimuli (decorticate)4. Withdr wal to painful stimuli5. Localizes painful stimuli6. Obeys commands 2 7 H (Secondary Survey) - ansHistoryPreho pital Report (MIST)M: MOII: Injuries sustainedS: Sig s and symptoms in the fieldT: Treatment in field Patient History (SAMPLE):S: SymptomsA: Allergies and tetanus statusM: MedicationsP: Past medical historyL: Last oral intakeE: Ev nts and Environmental factors related to injury. H: Head and Face Head to Toe Assessment (secondary survey) - ansSOFT TISSUE: Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects. Palpate: areas of tenderness, step-offs, crepitus BONY DEFORMITIES: Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominal pressure. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma 3 0 lymphocytes to stimulate an immune response to blood borne microorganisms. Stores 200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure. Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption,intraparenchymal hematoma or subcapsular hem toma. Contra t blush or extravasation- hyperdense area that represent traumatic disruption. Active extravasation impliesongoing bleeding. Nonoperative management is preferred if hemodynamically stable, stable H/H x 12-24hours, minimal transfusion requirements (<2units), grade I or II without blush, age <55,a ert able to assist in assessment of abdomen. Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal. Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumoni , Neisseria meningitides and Haemophil s influenza. At risk forpn umoco cal sepsis. Need annual flu shot and q5yr meningococcal andpneumococcal vaccines. U (AVPU) - ansUnresponsive. Does not respond to any stimuli. V (AVPU) - ansVerbal. Needs verbal stimuli to respond. (Airway adjunct may be needed to prevent tongue obstruction) A (AVPU) - ansAlert. Will be able to maintain airway once clear. A (Primary Survey) - ansAirway and alertness with simultaneous cervical spinal stabilization. Airway Assessment - ansInspect: tongue obstruction, loose/missing teeth, foreignobjects, blood, vomitus, secretions, edema, burns or evidence of inhalation injury 3 1 Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor) Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneousemphyse ma Airway Interventions: - ansSuctionRemove foreign body if notedJaw thrust maneuver (maintain cspine)Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)Consider definitive airway Alertness Assessment - ansA- AlertV-Verbal P- PainfulU- Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: spontaneous breathing,symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use,diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),ontus ons/abrasions/deformities (signs of underlying injury), open pneumothoraces(sucking chest wound), JVD, tracheal position, signs of inhalation injury Auscultate: presence, absence and equality of breath sounds at 2nd intercostal spacemidclavicular line and bases at the fifth intercostal space anterior axillary line Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JVpulsations at suprasternal notch or supraclavicular area Life-threatening pulmonary injuries requiring immediate intervention: openpn umo horax, tension pneumothorax, flail chest, hemothorax. Breathing and Ventilation Intervention - ansBreathing absent: jaw-thrust maneuver, oralairway adjunct, assist ventilation with bag-mask device, prepare for definitive airway Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% orhigher. If ineffective: assist with bag-mask and determine need for definitive airway C (Primary Survey) - ansCirculation and Control of Hemorrhage 3 2 Cardiogenic Shock - ansResults from pump failure in the presence of adequateintravascular volume. There is a lack of cardiac output and end-organ perfusions condary to a decrease in myocardial contractility and/or valvular insufficiency. Acute causes - myocardial infarction, dysrhythmias or toxicologic pathologies. Heartfailure is a chronic cause. Blunt cardiac injury may present similar to MI. Excess of volume administration or increased after load can result in pulmonary edemaand increas yocardial ischemia. Inotropic support to improve contractility. Circulation and Control of Hemorrhage Assessment - ansInspect: Uncontrolled externalbleeding, skin color Auscultate: Muffled heart sounds - may indicate pericardial tamponade Palpate: carotid and/or femoral pulses for rate, rhythm, strength Circulation and Control of Hemorrhage Interventions - ansControl and treat externalbl eding: apply direct pressure, elevate bleeding extremity, apply pressure over arterialsit s, consider use of a tourniquet. 2 large bore IVs, if unable consider IO, obtain labs and crossmatch. Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L. **Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosisand may c use hypothermia. Component therapy, including administering RBC, plasmaand platelets is a balanced approach so that O2 delivery is optimized, acidosiscorrect and c agulopathy prevented. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating bloodvolum e Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume 3 5 N: Naso or orogastric tube considerationO: Oxygenation - SpO2 and/or etCO2 monitorP: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes2: Opens eyes in response to pain3: Opens eyes in response to voice4: Opens eyes spontaneously VERBAL1. Makes no sounds2. Makes sounds3. Words4. Confused, disoriented5. O , converses normally MOTOR1. Makes no movements2. Extension to painful stimuli (decerebrate)3. Abnormal flexion to painful stimuli (decorticate)4. Withdr wal to painful stimuli5. Localizes painful stimuli6. Obeys commands H (Secondary Survey) - ansHistoryPreho pital Report (MIST)M: MOII: Injuries sustainedS: Sig s and symptoms in the fieldT: Treatment in field Patient History (SAMPLE):S: SymptomsA: Allergies and tetanus statusM: MedicationsP: Past medical historyL: Last oral intakeE: Ev nts and Environmental factors related to injury. 3 6 H: Head and Face Head to Toe Assessment (secondary survey) - ansSOFT TISSUE: Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects. Palpate: areas of tenderness, step-offs, crepitus BONY DEFORMITIES: Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominal pressure. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient. Observed with serial abdominal exams. Findings of contrast extravasation may be embolized by IR. For surgical patients - fluid resuscitation is essential. Risks of surgery include disruptionof the natural tamponade process due to the evacuation of large amounts of bloodresulting in hypovolemia. Hypovolemic Shock - ansCaused by a decrease in the amount of circulating blood volume. In trauma typically results from hemorrhage, but can result in a precipitous loss ofvolume, ie v miting or diarrhea. 3 7 Burn trauma can result in hypovolemic shock from damage to the cell membranes leading to plasma and protein leakage. of body water, results in inadequate perfusion. Hyperventilation can cause increased intrathoracic pressure resulting in compression of the heart and decreased cardiac output. Initial Assessment - ans1. Preparation and Triage2. Primary Survey3. Reevaluation4. Secondary Survey5. Reevaluation Adjuncts6. Reevaluation and Post Resuscitation Care7. Definitive Care or Transport Intraocular Foreign Body - ans*TRUE EMERGENCY AND EARLY INTERVENTION IS ESSENTIAL. Findings: compromised visual acuity, misshapen pupils, pain Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTEDeye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmicABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ans Liver - ansLargest solid organ of the body. RUQ, 6th to 10th ribs. Encased by Glisson capsule with blood vessels, lymphatics and nerves. Filters 1.7L of blood per minute. The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose andbilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol andbile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary forclotting ). 4 0 P-Painful U- Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: spontaneous breathing,symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use,diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),ontus ons/abrasions/deformities (signs of underlying injury), open pneumothoraces(sucking chest wound), JVD, tracheal position, signs of inhalation injury Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space midclavicular line and bases at the fifth intercostal space anterior axillary line Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV pulsations at suprasternal notch or supraclavicular area Life-threatening pulmonary injuries requiring immediate intervention: open pneumothorax, tension pneumothorax, flail chest, hemothorax. Breathing and Ventilation Intervention - ansBreathing absent: jaw-thrust maneuver, oral airway adjunct, assist ventilation with bag-mask device, prepare for definitive airway Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% or higher. If ineffective: assist with bag-mask and determine need for definitive airway C (Primary Survey) - ansCirculation and Control of Hemorrhage Cardiogenic Shock - ansResults from pump failure in the presence of adequateintravascular volume. There is a lack of cardiac output and end-organ perfusions condary to a decrease in myocardial contractility and/or valvular insufficiency. Acute causes - myocardial infarction, dysrhythmias or toxicologic pathologies. Heart failure is a chronic cause. Blunt cardiac injury may present similar to MI. Excess of volume administration or increased after load can result in pulmonary edema and increased myocardial ischemia. Inotropic support to improve contractility. 4 1 Circulation and Control of Hemorrhage Assessment - ansInspect: Uncontrolled external bleeding, skin color Auscultate: Muffled heart sounds - may indicate pericardial tamponade Palpate: carotid and/or femoral pulses for rate, rhythm, strength Circulation and Control of Hemorrhage Interventions - ansControl and treat externalbl eding: apply direct pressure, elevate bleeding extremity, apply pressure over arterialsit s, consider use of a tourniquet. 2 large bore IVs, if unable consider IO, obtain labs and crossmatch. Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L. **Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosisand may c use hypothermia. Component therapy, including administering RBC, plasmaand platelets is a balanced approach so that O2 delivery is optimized, acidosiscorrect and c agulopathy prevented. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating blood volume Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume Distributive - maldistribution of an adequate circulating blood volume (septic, anaphylactic, neurogenic) Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate with fluorescein. Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling, irritation Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain,ophth lmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours.(Do NOT patch - increases infection) 4 2 Corneal Foreign Body - ansRoutinely metal, plastic or wood. Findings: photophobia, pain, injected conjunctiva (redness), lid swelling Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics,ora analgesia Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slitlamp . Findings: similar to abrasion, pain out of proportion to findings, decreased vision Treatment: treat small lacerations similar to an abrasion, larger lacerations needophthalmology referral and possible surgery Cycloplegic agent - ansCycloplegia is paralysis of the ciliary muscle of the eye, resultingin a los of accommodation. Because of the paralysis of the ciliary muscle, thecurvature of the lens can no longer be adjusted to focus on nearby objects. D (Primary Survey) - ansDisability (Neurologic Status) Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result ofCNS inj ry until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion,hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulatingvolume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia orreduction of the mean systemic volume and venous return to the heart or drop inp eload, resulting in distributive shock. 4 5 Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominalpressur e. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guardingor rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient.Observed with serial abdominal exams. Findings of contrast extravasation may be embolized by IR. For surgical patients - fluid resuscitation is essential. Risks of surgery include disruptionof the natural tamponade process due to the evacuation of large amounts of bloodresulting in hypovolemia. Hypovolemic Shock - ansCaused by a decrease in the amount of circulating bloodvolum e. In trauma typically results from hemorrhage, but can result in a precipitous loss ofvolume, ie v miting or diarrhea. Burn trauma can result in hypovolemic shock from damage to the cell membranesleading to plasma and protein leakage. of body water, results in inadequate perfusion. Hyperventilation can cause increased intrathoracic pressure resulting in compression ofthe heart a d decreased cardiac output. Initial Assessment - ans1. Preparation and Triage2. Primary Survey3. Reevaluation4. Secondary Survey5. Reevaluation Adjuncts 4 6 6. Reevaluation and Post Resuscitation Care 7. Definitive Care or Transport Intraocular Foreign Body - ans*TRUE EMERGENCY AND EARLY INTERVENTION IS ESSENTIAL. Findings: compromised visual acuity, misshapen pupils, pain Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTEDeye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmicABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ans Liver - ansLargest solid organ of the body. RUQ, 6th to 10th ribs. Encased by Glisson capsule with blood vessels, lymphatics and nerves. Filters 1.7L of blood per minute. The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose andbilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol andbile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary forclotting). Obstructive Shock - ansResults from hypo perfusion of the tissue due to an obstruction in either the vasculature or heart. Tension pneumothorax - increased thoracic pressure leads to displacement of the vena cava, obstruction to atrial filling, decreased preload and decreased cardiac output. Cardiac tamponade - impedes diastolic expansion and filling leads to decreased preload, strokes volume and cardiac output and ultimately end organ perfusion. P (AVPU) - ansPainful. Responds only to painful stimuli. (Airway adjunct may be needed while determining need for intubation) 4 7 Reevaluation - ansPortable radiograph - AP chest, pelvis. Can quickly identifypotentially life-threatening injuries such as pneumothorax or pelvic fracture withun ontrolled internal hemorrhage. Can also confirm placement of ET tubes, chest tubesand gastric tubes. Consider need for transfer. shock - ansInadequate tissue perfusion. Spleen - ansEncapsulated organ LUQ level of 9th-11th ribs and curves around a portionof the stomach. Minimal elasticity and flexibility - most frequent injured organ in blunttraum a. Secondary lymph organ that filters and cleanses the blood. Removes old RBCs andhold reserve of blood. It recycles iron. It removes antibody-coated bacteria. Supplieslymphocytes to stimulate an immune response to blood borne microorganisms. Stores200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure. Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption,intraparenchymal hematoma or subcapsular hem toma. Contra t blush or extravasation- hyperdense area that represent traumatic disruption. Active extravasation impliesongoing bleeding. Nonoperative management is preferred if hemodynamically stable, stable H/H x 12-24hours, minimal transfusion requirements (<2units), grade I or II without blush, age <55,a ert able to assist in assessment of abdomen. Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal. Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumonia, Neisseria meningitides and Haemophilus influenza. At risk for 5 0 2 large bore IVs, if unable consider IO, obtain labs and crossmatch. Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L. **Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosisand may c use hypothermia. Component therapy, including administering RBC, plasmaand platelets is a balanced approach so that O2 delivery is optimized, acidosiscorrect and c agulopathy prevented. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating bloodvolum e Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume Distributive - maldistribution of an adequate circulating blood volume (septic,anaphylactic, neurogenic) Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate withfluorescei n. Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling,irritati on Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain,ophth lmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours.(Do NOT patch - increases infection) Corneal Foreign Body - ansRoutinely metal, plastic or wood. Findings: photophobia, pain, injected conjunctiva (redness), lid swelling Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics,ora analgesia Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slitlamp . Findings: similar to abrasion, pain out of proportion to findings, decreased vision 5 1 Treatment: treat small lacerations similar to an abrasion, larger lacerations need ophthalmology referral and possible surgery Cycloplegic agent - ansCycloplegia is paralysis of the ciliary muscle of the eye, resultingin a los of accommodation. Because of the paralysis of the ciliary muscle, thecurvature of the lens can no longer be adjusted to focus on nearby objects. D (Primary Survey) - ansDisability (Neurologic Status) Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result of CNS injury until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion, hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulating volume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia orreduction of the mean systemic volume and venous return to the heart or drop inp eload, resulting in distributive shock. Anaphylactic: release of inflammatory mediators, such as histamine, which contracts bronchial smooth muscle and increases vascular permeability and vasodilation. Septic Shock: systemic release of bacterial endotoxins, resulting in an increased vascular permeability and vasodilation Neurogenic shock: loss of sympathetic nervous system control of vascular tone, which produc s venous and arterial vasodilation. With the loss f sympathetic nervous syst minput in spi al cord injury, unopposed vagal activity may result in decreased cardiacoutput through bradycardia. 5 2 TREATMENT: increase systemic resistance, controlled volume replacement. Vasoconstriction and in some cases (neurogenic) Atropine to counteract bradycardia. E (Primary Survey) - ansExposure and Environmental Control Exposure and Environmental Control - ansCarefully and completely undress the patient. Inspect for uncontrolled bleeding and note any obvious injuries. Prevent heat loss. Hypothermia combined with hypotension and acidosis is a potentiallylethal combination in the injured patient. Consider: warm blankets, keep ambientt m erature warm, warm IVF, forced air warmers, radiant warming lights. F (Primary Survey) - ansFull Set of VS & Family Presence G (Primary Survey) - ansGet Resuscitation Adjuncts:(LMNOP )L: LabsM: Monitor cardiac rate and rhythmN: Naso or orogastric tube considerationO: Oxygenation - SpO2 and/or etCO2 monitorP: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes2: Opens eyes in response to pain3: Opens eyes in response to voice4: Opens eyes spontaneously VERBAL1. Makes no sounds2. Makes sounds3. Words4. Confused, disoriented5. O , converses normally MOTOR1. Makes no movements2. Extension to painful stimuli (decerebrate)3. Abnormal flexion to painful stimuli (decorticate) 5 5 Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTEDeye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmicABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ans Liver - ansLargest solid organ of the body. RUQ, 6th to 10th ribs. Encased by Glisson capsule with blood vessels, lymphatics and nerves. Filters 1.7L of blood per minute. The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose andbilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol andbile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary forclotting). Obstructive Shock - ansResults from hypo perfusion of the tissue due to an obstruction in either the vasculature or heart. Tension pneumothorax - increased thoracic pressure leads to displacement of the vena cava, obstruction to atrial filling, decreased preload and decreased cardiac output. Cardiac tamponade - impedes diastolic expansion and filling leads to decreased preload, strokes volume and cardiac output and ultimately end organ perfusion. P (AVPU) - ansPainful. Responds only to painful stimuli. (Airway adjunct may be needed while determining need for intubation) Reevaluation - ansPortable radiograph - AP chest, pelvis. Can quickly identify potentially life-threatening injuries such as pneumothorax or pelvic fracture withun ontrolled internal hemorrhage. Can also confirm placement of ET tubes, chest tubesand gastric tubes. Consider need for transfer. shock - ansInadequate tissue perfusion. 5 6 Spleen - ansEncapsulated organ LUQ level of 9th-11th ribs and curves around a portionof the stomach. Minimal elasticity and flexibility - most frequent injured organ in blunttraum a. Secondary lymph organ that filters and cleanses the blood. Removes old RBCs andhold reserve of blood. It recycles iron. It removes antibody-coated bacteria. Supplieslymphocytes to stimulate an immune response to blood borne microorganisms. Stores200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure. Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption,intraparenchymal hematoma or subcapsular hem toma. Contra t blush or extravasation- hyperdense area that represent traumatic disruption. Active extravasation impliesongoing bleeding. Nonoperative management is preferred if hemodynamically stable, stable H/H x 12-24hours, minimal transfusion requirements (<2units), grade I or II without blush, age <55,a ert able to assist in assessment of abdomen. Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal. Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumoni , Neisseria meningitides and Haemophil s influenza. At risk forpn umoco cal sepsis. Need annual flu shot and q5yr meningococcal andpneumococcal vaccines. U (AVPU) - ansUnresponsive. Does not respond to any stimuli. V (AVPU) - ansVerbal. Needs verbal stimuli to respond.(Airway adjunct may be needed to prevent tongue obstruction) A (AVPU) - ansAlert. Willbe able to maintain airway once clear. 5 7 A (Primary Survey) - ansAirway and alertness with simultaneous cervical spinal stabilization. Airway Assessment - ansInspect: tongue obstruction, loose/missing teeth, foreignobjects, blood, vomitus, secretions, edema, burns or evidence of inhalation injury Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor) Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneous emphysema Airway Interventions: - ansSuction Remove foreign body if notedJaw thrust maneuver (maintain cspine)Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)Consider definitive airway Alertness Assessment - ansA- AlertV-Verbal P- PainfulU- Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: spontaneous breathing,symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use,diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),ontus ons/abrasions/deformities (signs of underlying injury), open pneumothoraces(sucking chest wound), JVD, tracheal position, signs of inhalation injury Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space midclavicular line and bases at the fifth intercostal space anterior axillary line Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV pulsations at suprasternal notch or supraclavicular area Life-threatening pulmonary injuries requiring immediate intervention: open pneumothorax, tension pneumothorax, flail chest, hemothorax. 6 0 Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result ofCNS inj ry until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion,hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulatingvolume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia orreduction of the mean systemic volume and venous return to the heart or drop inp eload, resulting in distributive shock. Anaphylactic: release of inflammatory mediators, such as histamine, which contractsbronchial smooth muscle and increases vascular permeability and vasodilation. Septic Shock: systemic release of bacterial endotoxins, resulting in an increasedvascular permeability and vasodilation Neurogenic shock: loss of sympathetic nervous system control of vascular tone, whichproduces venous and arterial vasodilation. With the loss of sympathetic nervous systeminput in spinal cord injury, unopposed vagal activity may result in decreased cardiacoutput through bradycardia. TREATMENT: increase systemic resistance, controlled volume replacement.Vaso onstriction and in some cases (neurogenic) Atropine to counteract bradycardia. E (Primary Survey) - ansExposure and Environmental Control Exposure and Environmental Control - ansCarefully and completely undress the patient.Inspec for uncontrolled bleeding and note any obvious injuries. 6 1 Prevent heat loss. Hypothermia combined with hypotension and acidosis is a potentiallylethal combination in the injured patient. Consider: warm blankets, keep ambientt m erature warm, warm IVF, forced air warmers, radiant warming lights. F (Primary Survey) - ansFull Set of VS & Family Presence G (Primary Survey) - ansGet Resuscitation Adjuncts:(LMNOP )L: LabsM: Monitor cardiac rate and rhythmN: Naso or orogastric tube considerationO: Oxygenation - SpO2 and/or etCO2 monitorP: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes2: Opens eyes in response to pain3: Opens eyes in response to voice4: Opens eyes spontaneously VERBAL1. Makes no sounds2. Makes sounds3. Words4. Confused, disoriented5. O , converses normally MOTOR1. Makes no movements2. Extension to painful stimuli (decerebrate)3. Abnormal flexion to painful stimuli (decorticate)4. Withdr wal to painful stimuli5. Localizes painful stimuli6. Obeys commands H (Secondary Survey) - ansHistoryPreho pital Report (MIST)M: MOII: Injuries sustained 6 2 S: Signs and symptoms in the field T: Treatment in field Patient History (SAMPLE): S: SymptomsA: Allergies and tetanus statusM: MedicationsP: Past medical historyL: Last oral intakeE: Ev nts and Environmental factors related to injury. H: Head and Face Head to Toe Assessment (secondary survey) - ansSOFT TISSUE: Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects. Palpate: areas of tenderness, step-offs, crepitus BONY DEFORMITIES: Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominal pressure. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient. Observed with serial abdominal exams. Findings of contrast extravasation may be embolized by IR. 6 5 Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure. Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption,intraparenchymal hematoma or subcapsular hem toma. Contra t blush or extravasation- hyperdense area that represent traumatic disruption. Active extravasation impliesongoing bleeding. Nonoperative management is preferred if hemodynamically stable, stable H/H x 12-24hours, minimal transfusion requirements (<2units), grade I or II without blush, age <55,a ert able to assist in assessment of abdomen. Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal. Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumoni , Neisseria meningitides and Haemophil s influenza. At risk forpn umoco cal sepsis. Need annual flu shot and q5yr meningococcal andpneumococcal vaccines. U (AVPU) - ansUnresponsive. Does not respond to any stimuli. V (AVPU) - ansVerbal. Needs verbal stimuli to respond.(Airway adjunct may be needed to prevent tongue obstruction) A (AVPU) - ansAlert. Willbe able to maintain airway once clear. A (Primary Survey) - ansAirway and alertness with simultaneous cervical spinal stabilization. Airway Assessment - ansInspect: tongue obstruction, loose/missing teeth, foreignobjects, blood, vomitus, secretions, edema, burns or evidence of inhalation injury Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor) 6 6 Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneous emphysema Airway Interventions: - ansSuction Remove foreign body if notedJaw thrust maneuver (maintain cspine)Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)Consider definitive airway Alertness Assessment - ansA- AlertV-Verbal P- PainfulU- Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: spontaneous breathing,symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use,diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),ontus ons/abrasions/deformities (signs of underlying injury), open pneumothoraces(sucking chest wound), JVD, tracheal position, signs of inhalation injury Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space midclavicular line and bases at the fifth intercostal space anterior axillary line Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV pulsations at suprasternal notch or supraclavicular area Life-threatening pulmonary injuries requiring immediate intervention: open pneumothorax, tension pneumothorax, flail chest, hemothorax. Breathing and Ventilation Intervention - ansBreathing absent: jaw-thrust maneuver, oral airway adjunct, assist ventilation with bag-mask device, prepare for definitive airway Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% or higher. If ineffective: assist with bag-mask and determine need for definitive airway C (Primary Survey) - ansCirculation and Control of Hemorrhage 6 7 Cardiogenic Shock - ansResults from pump failure in the presence of adequateintravascular volume. There is a lack of cardiac output and end-organ perfusions condary to a decrease in myocardial contractility and/or valvular insufficiency. Acute causes - myocardial infarction, dysrhythmias or toxicologic pathologies. Heartfailure is a chronic cause. Blunt cardiac injury may present similar to MI. Excess of volume administration or increased after load can result in pulmonary edemaand increas yocardial ischemia. Inotropic support to improve contractility. Circulation and Control of Hemorrhage Assessment - ansInspect: Uncontrolled externalbleeding, skin color Auscultate: Muffled heart sounds - may indicate pericardial tamponade Palpate: carotid and/or femoral pulses for rate, rhythm, strength Circulation and Control of Hemorrhage Interventions - ansControl and treat externalbl eding: apply direct pressure, elevate bleeding extremity, apply pressure over arterialsit s, consider use of a tourniquet. 2 large bore IVs, if unable consider IO, obtain labs and crossmatch. Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L. **Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosisand may c use hypothermia. Component therapy, including administering RBC, plasmaand platelets is a balanced approach so that O2 delivery is optimized, acidosiscorrect and c agulopathy prevented. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating bloodvolum e Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume 7 0 N: Naso or orogastric tube considerationO: Oxygenation - SpO2 and/or etCO2 monitorP: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes2: Opens eyes in response to pain3: Opens eyes in response to voice4: Opens eyes spontaneously VERBAL1. Makes no sounds2. Makes sounds3. Words4. Confused, disoriented5. O , converses normally MOTOR1. Makes no movements2. Extension to painful stimuli (decerebrate)3. Abnormal flexion to painful stimuli (decorticate)4. Withdr wal to painful stimuli5. Localizes painful stimuli6. Obeys commands H (Secondary Survey) - ansHistoryPreho pital Report (MIST)M: MOII: Injuries sustainedS: Sig s and symptoms in the fieldT: Treatment in field Patient History (SAMPLE):S: SymptomsA: Allergies and tetanus statusM: MedicationsP: Past medical historyL: Last oral intakeE: Ev nts and Environmental factors related to injury. 7 1 H: Head and Face Head to Toe Assessment (secondary survey) - ansSOFT TISSUE: Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects. Palpate: areas of tenderness, step-offs, crepitus BONY DEFORMITIES: Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominal pressure. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient. Observed with serial abdominal exams. Findings of contrast extravasation may be embolized by IR. For surgical patients - fluid resuscitation is essential. Risks of surgery include disruptionof the natural tamponade process due to the evacuation of large amounts of bloodresulting in hypovolemia. Hypovolemic Shock - ansCaused by a decrease in the amount of circulating blood volume. In trauma typically results from hemorrhage, but can result in a precipitous loss ofvolume, ie v miting or diarrhea. 7 2 Burn trauma can result in hypovolemic shock from damage to the cell membranes leading to plasma and protein leakage. of body water, results in inadequate perfusion. Hyperventilation can cause increased intrathoracic pressure resulting in compression of the heart and decreased cardiac output. Initial Assessment - ans1. Preparation and Triage2. Primary Survey3. Reevaluation4. Secondary Survey5. Reevaluation Adjuncts6. Reevaluation and Post Resuscitation Care7. Definitive Care or Transport Intraocular Foreign Body - ans*TRUE EMERGENCY AND EARLY INTERVENTION IS ESSENTIAL. Findings: compromised visual acuity, misshapen pupils, pain Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTEDeye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmicABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ans Liver - ansLargest solid organ of the body. RUQ, 6th to 10th ribs. Encased by Glisson capsule with blood vessels, lymphatics and nerves. Filters 1.7L of blood per minute. The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose andbilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol andbile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary forclotting ). 7 5 P-Painful U- Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: spontaneous breathing,symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use,diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),ontus ons/abrasions/deformities (signs of underlying injury), open pneumothoraces(sucking chest wound), JVD, tracheal position, signs of inhalation injury Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space midclavicular line and bases at the fifth intercostal space anterior axillary line Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV pulsations at suprasternal notch or supraclavicular area Life-threatening pulmonary injuries requiring immediate intervention: open pneumothorax, tension pneumothorax, flail chest, hemothorax.Br athing and Ventilation Intervention - ansBreathing absent: jaw-thrust maneuver, oralairway adjunct, assist ventilation with bag-mask device, prepare for definitive airway Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% or higher. If ineffective: assist with bag-mask and determine need for definitive airway C (Primary Survey) - ansCirculation and Control of Hemorrhage Cardiogenic Shock - ansResults from pump failure in the presence of adequateintravascular volume. There is a lack of cardiac output and end-organ perfusions condary to a decrease in myocardial contractility and/or valvular insufficiency. Acute causes - myocardial infarction, dysrhythmias or toxicologic pathologies. Heartfailure is a chronic cause. Blunt cardiac injury may present similar to MI. Excess of volume administration or increased after load can result in pulmonary edema and increased myocardial ischemia. Inotropic support to improve contractility. 7 6 Circulation and Control of Hemorrhage Assessment - ansInspect: Uncontrolled external bleeding, skin color Auscultate: Muffled heart sounds - may indicate pericardial tamponade Palpate: carotid and/or femoral pulses for rate, rhythm, strength Circulation and Control of Hemorrhage Interventions - ansControl and treat externalbl eding: apply direct pressure, elevate bleeding extremity, apply pressure over arterialsit s, consider use of a tourniquet. 2 large bore IVs, if unable consider IO, obtain labs and crossmatch. Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L. **Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosisand may c use hypothermia. Component therapy, including administering RBC, plasmaand platelets is a balanced approach so that O2 delivery is optimized, acidosiscorrect and c agulopathy prevented. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating blood volume Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume Distributive - maldistribution of an adequate circulating blood volume (septic, anaphylactic, neurogenic) Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate with fluorescein. Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling, irritation Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain,ophth lmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours.(Do NOT patch - increases infection) 7 7 Corneal Foreign Body - ansRoutinely metal, plastic or wood. Findings: photophobia, pain, injected conjunctiva (redness), lid swelling Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics,ora analgesia Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slitlamp . Findings: similar to abrasion, pain out of proportion to findings, decreased vision Treatment: treat small lacerations similar to an abrasion, larger lacerations needophthalmology referral and possible surgery Cycloplegic agent - ansCycloplegia is paralysis of the ciliary muscle of the eye, resultingin a los of accommodation. Because of the paralysis of the ciliary muscle, thecurvature of the lens can no longer be adjusted to focus on nearby objects. D (Primary Survey) - ansDisability (Neurologic Status) Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result ofCNS inj ry until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion,hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulatingvolume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia orreduction of the mean systemic volume and venous return to the heart or drop inp eload, resulting in distributive shock. 8 0 Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominalpressur e. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guardingor rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient.Observed with serial abdominal exams. Findings of contrast extravasation may be embolized by IR. For surgical patients - fluid resuscitation is essential. Risks of surgery include disruptionof the natural tamponade process due to the evacuation of large amounts of bloodresulting in hypovolemia. Hypovolemic Shock - ansCaused by a decrease in the amount of circulating bloodvolum e. In trauma typically results from hemorrhage, but can result in a precipitous loss ofvolume, ie v miting or diarrhea. Burn trauma can result in hypovolemic shock from damage to the cell membranesleading to plasma and protein leakage. of body water, results in inadequate perfusion. Hyperventilation can cause increased intrathoracic pressure resulting in compression ofthe heart a d decreased cardiac output. Initial Assessment - ans1. Preparation and Triage2. Primary Survey3. Reevaluation4. Secondary Survey5. Reevaluation Adjuncts 8 1 6. Reevaluation and Post Resuscitation Care 7. Definitive Care or Transport Intraocular Foreign Body - ans*TRUE EMERGENCY AND EARLY INTERVENTION IS ESSENTIAL. Findings: compromised visual acuity, misshapen pupils, pain Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTEDeye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmicABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ans Liver - ansLargest solid organ of the body. RUQ, 6th to 10th ribs. Encased by Glisson capsule with blood vessels, lymphatics and nerves. Filters 1.7L of blood per minute. The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose andbilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol andbile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary forclotting). Obstructive Shock - ansResults from hypo perfusion of the tissue due to an obstruction in either the vasculature or heart. Tension pneumothorax - increased thoracic pressure leads to displacement of the vena cava, obstruction to atrial filling, decreased preload and decreased cardiac output. Cardiac tamponade - impedes diastolic expansion and filling leads to decreased preload, strokes volume and cardiac output and ultimately end organ perfusion. P (AVPU) - ansPainful. Responds only to painful stimuli. (Airway adjunct may be needed while determining need for intubation) 8 2 Reevaluation - ansPortable radiograph - AP chest, pelvis. Can quickly identifypotentially life-threatening injuries such as pneumothorax or pelvic fracture withun ontrolled internal hemorrhage. Can also confirm placement of ET tubes, chest tubesand gastric tubes. Consider need for transfer. shock - ansInadequate tissue perfusion. Spleen - ansEncapsulated organ LUQ level of 9th-11th ribs and curves around a portionof the stomach. Minimal elasticity and flexibility - most frequent injured organ in blunttraum a. Secondary lymph organ that filters and cleanses the blood. Removes old RBCs andhold reserve of blood. It recycles iron. It removes antibody-coated bacteria. Supplieslymphocytes to stimulate an immune response to blood borne microorganisms. Stores200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure. Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption,intraparenchymal hematoma or subcapsular hem toma. Contra t blush or extravasation- hyperdense area that represent traumatic disruption. Active extravasation impliesongoing bleeding. Nonoperative management is preferred if hemodynamically stable, stable H/H x 12-24hours, minimal transfusion requirements (<2units), grade I or II without blush, age <55,a ert able to assist in assessment of abdomen. Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal. Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumonia, Neisseria meningitides and Haemophilus influenza. At risk for 8 5 2 large bore IVs, if unable consider IO, obtain labs and crossmatch. Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L. **Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosisand may c use hypothermia. Component therapy, including administering RBC, plasmaand platelets is a balanced approach so that O2 delivery is optimized, acidosiscorrect and c agulopathy prevented. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating bloodvolum e Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume Distributive - maldistribution of an adequate circulating blood volume (septic,anaphylactic, neurogenic) Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate withfluorescei n. Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling,irritati on Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain,ophth lmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours.(Do NOT patch - increases infection) Corneal Foreign Body - ansRoutinely metal, plastic or wood. Findings: photophobia, pain, injected conjunctiva (redness), lid swelling Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics,ora analgesia Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slitlamp . Findings: similar to abrasion, pain out of proportion to findings, decreased vision 8 6 Treatment: treat small lacerations similar to an abrasion, larger lacerations need ophthalmology referral and possible surgery Cycloplegic agent - ansCycloplegia is paralysis of the ciliary muscle of the eye, resultingin a los of accommodation. Because of the paralysis of the ciliary muscle, thecurvature of the lens can no longer be adjusted to focus on nearby objects. D (Primary Survey) - ansDisability (Neurologic Status) Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result of CNS injury until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion, hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulating volume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia orreduction of the mean systemic volume and venous return to the heart or drop inp eload, resulting in distributive shock. Anaphylactic: release of inflammatory mediators, such as histamine, which contracts bronchial smooth muscle and increases vascular permeability and vasodilation. Septic Shock: systemic release of bacterial endotoxins, resulting in an increased vascular permeability and vasodilation Neurogenic shock: loss of sympathetic nervous system control of vascular tone, which produc s venous and arterial vasodilation. With the loss f sympathetic nervous syst minput in spi al cord injury, unopposed vagal activity may result in decreased cardiacoutput through bradycardia. 8 7 TREATMENT: increase systemic resistance, controlled volume replacement. Vasoconstriction and in some cases (neurogenic) Atropine to counteract bradycardia. E (Primary Survey) - ansExposure and Environmental Control Exposure and Environmental Control - ansCarefully and completely undress the patient. Inspect for uncontrolled bleeding and note any obvious injuries. Prevent heat loss. Hypothermia combined with hypotension and acidosis is a potentiallylethal combination in the injured patient. Consider: warm blankets, keep ambientt m erature warm, warm IVF, forced air warmers, radiant warming lights. F (Primary Survey) - ansFull Set of VS & Family Presence G (Primary Survey) - ansGet Resuscitation Adjuncts:(LMNOP )L: LabsM: Monitor cardiac rate and rhythmN: Naso or orogastric tube considerationO: Oxygenation - SpO2 and/or etCO2 monitorP: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes2: Opens eyes in response to pain3: Opens eyes in response to voice4: Opens eyes spontaneously VERBAL1. Makes no sounds2. Makes sounds3. Words4. Confused, disoriented5. O , converses normally MOTOR1. Makes no movements2. Extension to painful stimuli (decerebrate)3. Abnormal flexion to painful stimuli (decorticate) 9 0 Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTEDeye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmicABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ans Liver - ansLargest solid organ of the body. RUQ, 6th to 10th ribs. Encased by Glisson capsule with blood vessels, lymphatics and nerves. Filters 1.7L of blood per minute. The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose andbilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol andbile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary forclotting). Obstructive Shock - ansResults from hypo perfusion of the tissue due to an obstruction in either the vasculature or heart. Tension pneumothorax - increased thoracic pressure leads to displacement of the vena cava, obstruction to atrial filling, decreased preload and decreased cardiac output. Cardiac tamponade - impedes diastolic expansion and filling leads to decreased preload, strokes volume and cardiac output and ultimately end organ perfusion. P (AVPU) - ansPainful. Responds only to painful stimuli. (Airway adjunct may be needed while determining need for intubation) Reevaluation - ansPortable radiograph - AP chest, pelvis. Can quickly identify potentially life-threatening injuries such as pneumothorax or pelvic fracture withun ontrolled internal hemorrhage. Can also confirm placement of ET tubes, chest tubesand gastric tubes. Consider need for transfer. shock - ansInadequate tissue perfusion. 9 1 Spleen - ansEncapsulated organ LUQ level of 9th-11th ribs and curves around a portionof the stomach. Minimal elasticity and flexibility - most frequent injured organ in blunttraum a. Secondary lymph organ that filters and cleanses the blood. Removes old RBCs andhold reserve of blood. It recycles iron. It removes antibody-coated bacteria. Supplieslymphocytes to stimulate an immune response to blood borne microorganisms. Stores200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure. Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption,intraparenchymal hematoma or subcapsular hem toma. Contra t blush or extravasation- hyperdense area that represent traumatic disruption. Active extravasation impliesongoing bleeding. Nonoperative management is preferred if hemodynamically stable, stable H/H x 12-24hours, minimal transfusion requirements (<2units), grade I or II without blush, age <55,a ert able to assist in assessment of abdomen. Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal. Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumoni , Neisseria meningitides and Haemophil s influenza. At risk forpn umoco cal sepsis. Need annual flu shot and q5yr meningococcal andpneumococcal vaccines. U (AVPU) - ansUnresponsive. Does not respond to any stimuli. V (AVPU) - ansVerbal. Needs verbal stimuli to respond.(Airway adjunct may be needed to prevent tongue obstruction) A (AVPU) - ansAlert. Willbe able to maintain airway once clear. 9 2 A (Primary Survey) - ansAirway and alertness with simultaneous cervical spinal stabilization. Airway Assessment - ansInspect: tongue obstruction, loose/missing teeth, foreignobjects, blood, vomitus, secretions, edema, burns or evidence of inhalation injury Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor) Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneous emphysema Airway Interventions: - ansSuction Remove foreign body if notedJaw thrust maneuver (maintain cspine)Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)Consider definitive airway Alertness Assessment - ansA- AlertV-Verbal P- PainfulU- Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: spontaneous breathing,symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use,diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),ontus ons/abrasions/deformities (signs of underlying injury), open pneumothoraces(sucking chest wound), JVD, tracheal position, signs of inhalation injury Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space midclavicular line and bases at the fifth intercostal space anterior axillary line Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV pulsations at suprasternal notch or supraclavicular area Life-threatening pulmonary injuries requiring immediate intervention: open pneumothorax, tension pneumothorax, flail chest, hemothorax. 9 5 Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result ofCNS inj ry until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion,hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulatingvolume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia orreduction of the mean systemic volume and venous return to the heart or drop inp eload, resulting in distributive shock. Anaphylactic: release of inflammatory mediators, such as histamine, which contractsbronchial smooth muscle and increases vascular permeability and vasodilation. Septic Shock: systemic release of bacterial endotoxins, resulting in an increasedvascular permeability and vasodilation Neurogenic shock: loss of sympathetic nervous system control of vascular tone, whichproduces venous and arterial vasodilation. With the loss of sympathetic nervous systeminput in spinal cord injury, unopposed vagal activity may result in decreased cardiacoutput through bradycardia. TREATMENT: increase systemic resistance, controlled volume replacement.Vaso onstriction and in some cases (neurogenic) Atropine to counteract bradycardia. E (Primary Survey) - ansExposure and Environmental Control Exposure and Environmental Control - ansCarefully and completely undress the patient.Inspec for uncontrolled bleeding and note any obvious injuries. 9 6 Prevent heat loss. Hypothermia combined with hypotension and acidosis is a potentiallylethal combination in the injured patient. Consider: warm blankets, keep ambientt m erature warm, warm IVF, forced air warmers, radiant warming lights. F (Primary Survey) - ansFull Set of VS & Family Presence G (Primary Survey) - ansGet Resuscitation Adjuncts:(LMNOP )L: LabsM: Monitor cardiac rate and rhythmN: Naso or orogastric tube considerationO: Oxygenation - SpO2 and/or etCO2 monitorP: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes2: Opens eyes in response to pain3: Opens eyes in response to voice4: Opens eyes spontaneously VERBAL1. Makes no sounds2. Makes sounds3. Words4. Confused, disoriented5. O , converses normally MOTOR1. Makes no movements2. Extension to painful stimuli (decerebrate)3. Abnormal flexion to painful stimuli (decorticate)4. Withdr wal to painful stimuli5. Localizes painful stimuli6. Obeys commands H (Secondary Survey) - ansHistoryPreho pital Report (MIST)M: MOII: Injuries sustained 9 7 S: Signs and symptoms in the field T: Treatment in field Patient History (SAMPLE): S: SymptomsA: Allergies and tetanus statusM: MedicationsP: Past medical historyL: Last oral intakeE: Ev nts and Environmental factors related to injury. H: Head and Face Head to Toe Assessment (secondary survey) - ansSOFT TISSUE: Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects. Palpate: areas of tenderness, step-offs, crepitus BONY DEFORMITIES: Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominal pressure. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient. Observed with serial abdominal exams. Findings of contrast extravasation may be embolized by IR.