Download Trauma Assessment and Management and more Exams Nursing in PDF only on Docsity! TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Expedite transfer to the closest trauma center - ANS A 56 y/o M pt involved in a motor vehicle crash is brought to the ED of a rural critical access facility. He complains of neck pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority intervention for this patient? a pertinent medical hx is crucial - ANS Which of the following considerations is the most important when caring for a geriatric trauma pt? Mitigation - ANS Following a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster . Which phase of the disaster life cycle does this describe? Multiple requests for water - ANS EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeobs screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance? hemoglobin does not readily release O2 for use by the tissues - ANS What is the effect of hypothermia on the oxyhemoglobin dissociation curve? acidosis - ANS Which of the following is a component of the trauma triad of death? Complete - ANS EMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury? flucuation in the water seal chamber - ANS Which of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system? insert an oropharyngeal airway if there is no gag reflex - ANS During the primary survey of an unconscious pt with multi-system trauma, the nurse notes snoring respirations. What priority nursing interventions should be preformed next? globe rupture - ANS A 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected? compensated - ANS A trauma pt is restless and repeatedly asking "where am i?" VS upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP 104/84, HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock? ventilate with a bag mask device - ANS An unresponsive trauma pt has an oropharygeal airway in place, shallow and labored respirations, and dusky skin. The trauma team has administered medications for drug-assisted intubation and attempted intubation but was unsuccessful. What is the most appropriate immediate next step? within 24 hrs of trauma - ANS When is the tertiary survey completed fora trauma pt? pressure - ANS An intubated and sedated pt in the ED has multiple extremity injuries with the potential for causing compartment syndrome. What is the most reliable indication of compartment syndrome in a patient who is unconscious? worsening pneumothorax - ANS Which of the following is possible complication of positive-pressure ventilation? pelvic stability - ANS the most reassuring finding for a male pt with hip pain after a fall is which of the following? subdural hematoma - ANS An elderly patient with a history of anticoagulant use presents after a fall at home today. She denies any loss of consciousness. She has a hematoma to her forehead and complains of headache, dizziness, and nausea. What is the most likely cause of her symptoms? fat embolism - ANS a pt has been in the ED for several hrs waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and complaining of leg pain. His wife reported that he suddenly became anxious and confused. Upon reassessment, the pt is restless with respiratory distress and petechiae to his neck. The pt is exhibiting s/sx most commonly associated with which of the following conditions? nausea and vomiting - ANS Which of the following is a late sign of increased intracranial pressure? serial FAST exams - ANS a 49 y/o restrained driver involved in a MVC presents to the trauma center complaining of abd, pelvic, and bilateral lower extremity pain. VS are stable. The nurse can anticipate all of these after a negative FAST exam EXCEPT which of the following? pericardiocentesis - ANS Which of the following is NOT considered goal-directed therapy for cardiogenic shock? endotracheal tube - ANS The trauma nurse knows that placing a bariatric patient in a ramped position providers better visualization during the insertion of which device? increased work of breathing? - ANS which of the following assessment findings differentiates a tension pneumothorax from a simple pneumothorax? calcium - ANS if a pt has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? identifying individuals who made mistakes during the traumatic event - ANS Which of the following is NOT considered a benefit of debriefings? 500 mL/hr - ANS You are treating a 27 y/o M in respiratory distress who was involved in a house fire. Calculating TBSA burned is deferred due to the need for emergent intubation. At what rate should you begin fluid resuscitation? advanced age - ANS Which of the following is most likely to contribute to inadequate oxygenation and ventilation? a 52 y/o diabetic male with a partial thickness burn to the left lower leg - ANS Which of the following patients warrants referral to a burn center? dressing removal - ANS A patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three sides. he is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis and decreasing blood pressure. Which of the following is the MOST appropriate immediate intervention? after a physical examination if the pt has no radiologic abnormalities on CT - ANS EMS arrives with the intoxicated driver of a car involved in a MVC. EMS reports significant damage to the drivers side of the car. The pt is asking to have the cervical collar removed. When it is appropriate to remove the cervical collar? MARCH - ANS Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? What is kinematics? - ANS A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. What is Newton's First Law? - ANS A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. What is the Law of Conservation of Energy? - ANS Energy can neither be created nor destroyed. It is only changed from one form to another. What is Newton's Second Law? - ANS Force equals mass multiplied by acceleration of deceleration. What is kinetic energy (KE)? - ANS KE equals 1/2 the mass (M) multiplied by the velocity squared. What is the Mnemonic for the Initial Assessment? - ANS A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) What is the Mnemonic for the Secondary Assessment? - ANS F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces Where do you listen to auscultate breath sounds? - ANS Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line. What are the late signs of breathing compromise? - ANS - Tracheal deviation - JVD What are signs of ineffective breathing? - ANS - AMS - Cyanosis, especially around the mouth - If pt is not alert or verbal, continue to monitor for any compromise to ABC's - If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. What is assessed and intervened for Expose/Environmental Controls? - ANS - Remove clothing - Ensure appropriate decontamination if exposed to hazardous material - Keep pt warm - Keep clothing for evidence What is the first thing assessed under the Secondary Assessment? - ANS FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence What is the second thing assessed under the Secondary Assessment? - ANS GIVE COMFORT MEASURES - Talking to pt - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain What is assessed under the Mnemonic "H"? - ANS HISTORY / HEAD-TO-TOE ASSESSMENT - MIVT - M = Mechanism of injury - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment What is assessed under the Mnemonic "I"? - ANS INSPECT POSTERIOR SURFACES - While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs. - Palpate vertebral column for deformity and areas of tenderness - Assess rectum for presence/absence of tone, presence of blood What she be done after the Secondary Assessment? - ANS Reassess: - Primary survey, - VS - Pain - Any injuries What are factors that contribute to ineffective ventilation? - ANS - AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age What medications are used during intubation? - ANS LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - ANS PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Splinting or shallow BS may be a result of pain What are you looking for when percussing the chest? - ANS Dullness: - hemothorax Hyperresonance - Pneumothorax What are you looking for when palpating the chest wall, clavicles and neck? - ANS - Tenderness - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. What is the DOPE mnemonic? - ANS D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing Explain Hypovolemic Shock. - ANS Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes: - Blood loss - Burns, etc. Explain Cardiogenic Shock. - ANS Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: - MI - Blunt cardiac injury - Mitral valve insufficiency - dysrhythmias - Cardiac Failure Explain Obstructive Shock. - ANS Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Distributive Shock. - ANS Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. What is vascular response? - ANS As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is renal response? - ANS Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes: - Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. Explain adrenal gland response. - ANS When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery? ICP is a reflection of what three volumes? What happens when one increases? - ANS 1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? - ANS - Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? - ANS - Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia What is Cushing's phenomenon or Cushing's Reflex? - ANS Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? - ANS 1. Uncal herniation 2. Central or transtentorial herniation Why does herniation occur? What are the symptoms? - ANS Because of uncontrolled increases in ICP. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration Define uncal herniation. - ANS The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. Define central or transtentorial herniation. - ANS A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? - ANS Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess Define Minor Head Trauma. - ANS GCS 13-15 Define Moderate Head Trauma - ANS Postresuscitative state with GCS 9-13. Define Severe Head Trauma. - ANS Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? - ANS A temporary change in neurologic function that may occur as a result of minor head trauma. S/S: - Transient LOC - Lucid period lasting a few minutes to several hours - Rapid deterioration in neurologic status - Severe H/A - Sleepiness - Dizziness - N/V - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma What is a subdural hematoma and its S/S? - ANS A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's What are intracerebral hematoma's and its S/S? - ANS Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia What are the S/S of a linear skull fx? - ANS - H/A - Possible decreased LOC What are the S/S of a depressed skull fx? - ANS - H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site What are the S/S of a basilar skull fx? - ANS - H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea How would you assess a pt with a cranial injury? - ANS (Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Orbital bony deformity What is LeFort I fracture and its S/S? - ANS Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion What is LeFort II fracture and its S/S? - ANS Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea What is LeFort III fracture and its S/S? - ANS Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion - CSF rhinorrhea What are the mandibular fracture S/S? - ANS - Malocclusion - Inability to open the mouth (trismus) - Pain, especially on movement - Facial asymmetry and a palpable step-off deformity - Edema or hematoma formation at the fracture site - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip What are neck injury S/S? - ANS - Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing) How would you assess a patient with ocular, maxillofacial and neck trauma? - ANS (Initial assessment) HISTORY - MOI? - Acceleration/Deceleration? - What was it caused by? - Pt restrained? Airbags deployed? Etc. - What are the pt's complaints? - Pt normally wear glasses or contacts? - Pt have hx of eye problems? - Pt ever have eye surgery? - Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION: - Inspect eye, orbits, face and neck - Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas - Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents - Determine whether lid lac's - Assess pupil's (PERRL) - Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome - Bilateral fixed and pinpoint pupils = pontine lesion or drugs - Mildly dilated pupil w/sluggish response may early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds With any eye injury, what should the evaluation and ongoing assessments be? - ANS - Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's What are the most common type of injury associated with chest trauma? - ANS blunt; MVC's. Penetrating; firarm injuries or stabbings What are S/S of a rib fracture? - ANS - Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What is a flail chest? - ANS A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases. What could a flail chest be associated with? - ANS - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma What are the S/S of flail chest? - ANS - Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. Define Pneumothorax. - ANS Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. What are the S/S of a pneumothorax? - ANS - Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) Define tension pneumothorax. - ANS Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. Immediate decompression should be performed. Treatment should not be delayed. What are the S/S of a tension pneumothorax? - ANS - Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign) Define Hemothorax. - ANS Accumulation of blood in the pleural space. What are the S/S of Hemothorax? - ANS - Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side What is a pulmonary contusion? - ANS They occur as a result of direct impact, deceleration or high- velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. What are the S/S of pulmonary contusion? - ANS - Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain Obtain Hx. PHYSICAL: Inspection: - Observe chest wall - Assess breathing effort and RR - Symmetry - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) Palpation: - Palpate chest wall, clavicles and neck for: - Tenderness - Swelling or hematoma - Subcutaneous emphysema - Note presence of bony crepitus - Palpate central and peripheral pulses and compare quality between: - Right and left extremities - Upper and lower extremities - Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax) - Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury). Auscultation: - Auscultate compare BP in both UE's and LE's - Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain). - Auscultate chest for presence of BS (diaphragmatic rupture) - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP What is the planning and implementation for thoracic injury? - ANS p. 142 What is kinematics? - ANS A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. What is Newton's First Law? - ANS A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. What is the Law of Conservation of Energy? - ANS Energy can neither be created nor destroyed. It is only changed from one form to another. What is Newton's Second Law? - ANS Force equals mass multiplied by acceleration of deceleration. What is kinetic energy (KE)? - ANS KE equals 1/2 the mass (M) multiplied by the velocity squared. What is the Mnemonic for the Initial Assessment? - ANS A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) What is the Mnemonic for the Secondary Assessment? - ANS F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces Where do you listen to auscultate breath sounds? - ANS Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line. What are the late signs of breathing compromise? - ANS - Tracheal deviation - JVD What are signs of ineffective breathing? - ANS - AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing What is assessed and intervened for Expose/Environmental Controls? - ANS - Remove clothing - Ensure appropriate decontamination if exposed to hazardous material - Keep pt warm - Keep clothing for evidence What is the first thing assessed under the Secondary Assessment? - ANS FULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence What is the second thing assessed under the Secondary Assessment? - ANS GIVE COMFORT MEASURES - Talking to pt - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain What is assessed under the Mnemonic "H"? - ANS HISTORY / HEAD-TO-TOE ASSESSMENT - MIVT - M = Mechanism of injury - I = Injuries sustained - V = Vital Signs - T = Treatment - Pt generated information - PMH - Head-to-toe assessment What is assessed under the Mnemonic "I"? - ANS INSPECT POSTERIOR SURFACES - While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs. - Palpate vertebral column for deformity and areas of tenderness - Assess rectum for presence/absence of tone, presence of blood What she be done after the Secondary Assessment? - ANS Reassess: - Primary survey, - VS - Pain - Any injuries What are factors that contribute to ineffective ventilation? - ANS - AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age What medications are used during intubation? - ANS LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - ANS PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry What are you looking for when percussing the chest? - ANS Dullness: - hemothorax Hyperresonance - Pneumothorax What are you looking for when palpating the chest wall, clavicles and neck? - ANS - Tenderness - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. What is the DOPE mnemonic? - ANS D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing Explain Hypovolemic Shock. - ANS Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes: - Blood loss - Burns, etc. Explain Cardiogenic Shock. - ANS Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: - MI - Blunt cardiac injury - Mitral valve insufficiency - dysrhythmias - Cardiac Failure Explain Obstructive Shock. - ANS Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Distributive Shock. - ANS Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. What is vascular response? - ANS As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is renal response? - ANS Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes: - Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. Explain adrenal gland response. - ANS When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery? ICP is a reflection of what three volumes? What happens when one increases? - ANS 1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? - ANS - Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? - ANS - Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia What is Cushing's phenomenon or Cushing's Reflex? - ANS Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? - ANS 1. Uncal herniation 2. Central or transtentorial herniation Why does herniation occur? What are the symptoms? - ANS Because of uncontrolled increases in ICP. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration Define uncal herniation. - ANS The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. Define central or transtentorial herniation. - ANS A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? - ANS Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess Define Minor Head Trauma. - ANS GCS 13-15 Define Moderate Head Trauma - ANS Postresuscitative state with GCS 9-13. Define Severe Head Trauma. - ANS Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? - ANS A temporary change in neurologic function that may occur as a result of minor head trauma. S/S: - Transient LOC - H/A - Confusion and disorientation - Severe H/A - Sleepiness - Dizziness - N/V - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma What is a subdural hematoma and its S/S? - ANS A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's What are intracerebral hematoma's and its S/S? - ANS Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia What are the S/S of a linear skull fx? - ANS - H/A - Possible decreased LOC What are the S/S of a depressed skull fx? - ANS - H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site What are the S/S of a basilar skull fx? - ANS - H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea How would you assess a pt with a cranial injury? - ANS (Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness - Depressions or deformities What is LeFort I fracture and its S/S? - ANS Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion What is LeFort II fracture and its S/S? - ANS Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea What is LeFort III fracture and its S/S? - ANS Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion - CSF rhinorrhea What are the mandibular fracture S/S? - ANS - Malocclusion - Inability to open the mouth (trismus) - Pain, especially on movement - Facial asymmetry and a palpable step-off deformity - Edema or hematoma formation at the fracture site - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip What are neck injury S/S? - ANS - Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing) How would you assess a patient with ocular, maxillofacial and neck trauma? - ANS (Initial assessment) HISTORY - MOI? - Acceleration/Deceleration? - What was it caused by? - Pt restrained? Airbags deployed? Etc. - What are the pt's complaints? - Pt normally wear glasses or contacts? - Pt have hx of eye problems? - Pt ever have eye surgery? - Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION: - Inspect eye, orbits, face and neck - Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas - Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents - Determine whether lid lac's - Assess pupil's (PERRL) - Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome - Bilateral fixed and pinpoint pupils = pontine lesion or drugs - Mildly dilated pupil w/sluggish response may early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Assess for consensual response - Assess redness, eye watering, blepharospasm - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds With any eye injury, what should the evaluation and ongoing assessments be? - ANS - Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's What are the most common type of injury associated with chest trauma? - ANS blunt; MVC's. Penetrating; firarm injuries or stabbings What are S/S of a rib fracture? - ANS - Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What is a flail chest? - ANS A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases. What could a flail chest be associated with? - ANS - Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma What are the S/S of flail chest? - ANS - Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. Define Pneumothorax. - ANS Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. What are the S/S of a pneumothorax? - ANS - Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) Define tension pneumothorax. - ANS Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. Immediate decompression should be performed. Treatment should not be delayed. What are the S/S of a tension pneumothorax? - ANS - Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign) Define Hemothorax. - ANS Accumulation of blood in the pleural space. What are the S/S of Hemothorax? - ANS - Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side What is a pulmonary contusion? - ANS They occur as a result of direct impact, deceleration or high- velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. What are the S/S of pulmonary contusion? - ANS - Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions - Observe chest wall - Assess breathing effort and RR - Symmetry - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) Palpation: - Palpate chest wall, clavicles and neck for: - Tenderness - Swelling or hematoma - Subcutaneous emphysema - Note presence of bony crepitus - Palpate central and peripheral pulses and compare quality between: - Right and left extremities - Upper and lower extremities - Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax) - Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury). Auscultation: - Auscultate compare BP in both UE's and LE's - Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain). - Auscultate chest for presence of BS (diaphragmatic rupture) - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP What is the planning and implementation for thoracic injury? - ANS p. 142 Kinematics - ANS Is the study of energy transfer as it applies to identifying actual or potential injuries. Biomechanics - ANS Is the general study of forces and their effects. Mechanism of Injury - ANS Is how external forces are transferred to the body, resulting in injury Newton's First Law of Motion - ANS an object in motion will remain in motion unless acted upon by another force Newton's Second Law of Motion - ANS The acceleration of an object depends on the mass of the object and the amount of force applied. Newton's Third Law of Motion - ANS For every action there is an equal and opposite reaction Law of Conservation of Energy - ANS Matter is neither created nor destroyed (but may change form) What are the five forms in which energy exist? - ANS 1. Mechanical 2. Thermal 3. Chemical 4. Electrical 5. Radiant Describe the 3 types of Internal forces of energy transfer in the context of trauma. - ANS Compression: The ability of the tissue to resist crush injury or force Tension: The ability to resist being pulled apart when stretched Shear: The ability to resist a force applied parallel to the tissue Describe the 3 types of external forces of energy transfer in the context of trauma. - ANS Deceleration: Force from a sudden stop in the body's motion Acceleration: Force from a sudden onset in the body's motion Compression: Force from being crushed between objects List the four main types of traumatic injury and give an example of each - ANS Blunt: The result of a broad energy impact across a large surface area. Penetrating: The What 4 environmental and pathophysiologic factors are considered when the mechanism of injury is a fall? - ANS List the populations at higher risk for interpersonal violence. - ANS Describe the types of abuse and the associated signs of each. - ANS What cues to abuse may be obtained during the history portion of the initial assessment? - ANS Describe specific injuries associated with interpersonal violence and abuse. - ANS List the basic components of evidence collection. - ANS Describe steps to maintain the forensic chain of custody. - ANS 1. Preparation and Triage 2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of transfer) 4. Secondary Survey (HI) with reevaluation adjuncts 5. Reevaluation and post resuscitation care 6. Definitive care of transfer to an appropriate trauma nurse - ANS Initial Assessment 1. A- airway and Alertness with simultaneous cervical spinal stabilization 2. B- breathing and Ventilation 3. circulation and control of hemorrhage 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces - ANS ABCDEFGHI Before the arrival of the pt - ANS When should PPE be placed: Pt is at hospital in the right amount of time, right care, right trauma facility, right resources - ANS Safe Care: Uncontrolled Hemorrhage - ANS Major cause of preventable death: reorganize care to C-ABC - ANS If uncontrolled hemorrhage .. Used at the beginning of the initial assessment 1. A Alert. If the pt is alert he or she will be able to maintain his or her airway once it is clear. 2. V responds to verbal stimuli responds to pain. If the patient needs verbal stimulation to respond, an airway adjunct may be needed to keep the tongue from obstructing the airway. 3. P responds to pain. If the pt. responds only to pain, he or she may not be able to maintain his or her airway adjunct may need to be placed while further assessment is made to determine the need for intubation. 4. U Unresponsive. If the pt. is unresponsive, announce it loudly to the team and direct someone to chk in the pt is pulseless while assessing if the cause of the problem is the airway. - ANS Airway and AVPU: ask pt to pen his or her mouth - ANS While assessing airway the patient is alert and responds to verbal stimuli you should.. jaw thrust maneuver to open airway and assess for obstruction. If pt has a suspected csi, the jaw thrust procedure should be done by two providers. One provider can maintain c-spine and the other can perform the jaw thrust maneuver. - ANS While assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should.. 1. The tongue obstructing the airway 2. loose or missing teeth 3. foreign objects 4. blood, vomit, or secretions' 5. edema 6. burns or evidence of inhalation injury Auscultiate or listen for: 1. Obstructive airway sounds such as snoring or gurgling 2. Possible occlusive maxillofacial bony deformity 3. Subcutaneous emphysema - ANS Inspect the mouth for: 1. Check the presence of adequate rise and fall of the chest with assisted ventilation 2. Absence of gurgling on auscultation over the epigastrium 3. Bilateral breath sounds present on auscultation 4. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor - ANS If the pt has a definitive airway in what should you do? apply direct pressure to bleeding elevate extremity apply pressure over arterial sites Consider a pelvic binder for pelvic fractures consider a tourniquet cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation d. use rapid infusion device - ANS C Interventions: Disability - Neurologic Status 1. Assess pupils for equality, shape, and reactivity (PERRL) 2. Assess GCS (eye opening, verbal response, and motor response) - ANS D 1. Get a CT 2. Consider ABG 's if decreased LOC 3. Consider glucose check - ANS D Interventions Exposure and Environmental Control Remove all clothes and assess for any obvious injuries and uncontrolled bleeding - ANS E IF clothing is needed for evidence preserve in paper bag. Maintain body temp - cover the pt, turn up heat in room, administer warm fluids - ANS E Interventions: Full set of vitals and family presence - ANS F Get Resuscitation Adjuncts L - Labs (maybe a lactic acid), a b g 's, blood type M - monitors N - naso or oro gastric tubes O Oxygen and ETC02 monitors P - pain assessment and management - ANS G Reevaluation and Consider the need to Transfer - ANS Final step in primary survey H,I - ANS Secondary Survery History and Head to toe MIST - prehospital report MOI Injuries sustained S s/s in the field T treatment in the field if patients family present get a better hx on them - ANS H Sample is part of history S symptoms associated with injury A allergies and tetanus status M meds currently on including anticoagulant therapy P past medical hx L last oral intake E Events and environment factors related to the injury - ANS SAMPLE inspect for lacs, abrasions, asymmetry of facial expressions palate for depressions and tenderness look at ears for drainage - ANS Head to toe assessment: Head and face immobilize cervical spine, tenderness, tracheal deviation - ANS Head to toe assessment: Neck and cervical spine inspect, auscultate, palpate any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles lacs, contusions, 3. Pretreatment 4. Paralysis and Induction 5. Protecting and positioning - v 6. Placement of proof - secure the tube 7. Post intubation - secure ETT Tube, get X-ray for placement - ANS Steps of Rapid Sequence Intubation from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume. - ANS Hypovolemic Shock results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion. Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma. - ANS Obstructive Shock Results from pump failure in the presence of adequate intravascular volume. There is a lack of cardiac output and end organ perfusion secondary to a decrease in myocardial contractility and/or valvular insufficiency. Ex: MI's or dysrhythmia are common causes - ANS Cariogenic Shock occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone. Goal: Volume replacement and vasoconstriction - ANS Distributive Shock A breath every 5 to 6 seconds: 10-12 ventilations per minute - ANS Bag mask ventilation Stroke Volume X HR - ANS Cardiac Output = .. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ANS Baroreceptors: activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP - ANS Chemoreceptors: 50 to 150 - ANS MAP Range the decrease coagulopathy .. you will you bleed more - ANS The colder you are the more acidic you are.. in massive transfusion protocol... responsible for dissolving clots - ANS TXA stabilized vital signs, improved mental status, improved urine output - ANS What are indicators of increased perfusion? - ANS Prehospital shock index pg. 85 Flail chest - ANS Paradoxical chest wall movement can be caused by blunt trauma. air escapes from injured lung to pleural space and negative intrapleural pressure is lost causing partial or collapsed lung - ANS Simple Pneumothorax 1. Dyspnea 2. Tachycardia 3. Decreased or absent breath sounds on the injured side 4. CP - ANS Simple Pneumo assessment: Tx is based on size, presence of sx, and stability. For those are aysmpomatic and stable. Observation with or without oxygen. Larger pneumo who are unstable or likely to deteriorate a chest tube is placed. - ANS Simple pneumo interventions: can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking" Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair. - ANS Open Pneumo: Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD. - ANS Tension pneumo A 14 gauge needle that is inserted into the 2nd intercostal space in the midclavicular line on the affected side over the top of the rib to avoid neuromuscular bundle that runs under the rib. Prepare for chest tube placement. - ANS Tension pneumo intervention Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm. What are contributing factors to injuries related to blunt traumas? - ANS The point of impact on the patient's body, the type of surface that is hit, the tissues ability to resist (bone versus soft tissue, air- filled versus solid organs), and the trajectory of force. What are the seven patterns of pathway injuries related to motor vehicle accidents? - ANS Up and over, down and under, lateral, rotational, rear, roll over, and ejection. Differentiate between the three impacts of motor vehicle impact sequence. - ANS The first impact occurs when the vehicle collided with another object. The second impact occurs after the initial impact when the occupant continues to move in the original direction of travel until they collide with the interior of the vehicle or meet resistance. The third impact occurs when internal structures collide within the body cavity. What are the three factors that contribute to the damage caused by penetrating trauma's? - ANS The point of impact, the velocity and speed of impact, and the proximity to the object. What causes the primary effects of blast traumas? - ANS The direct blast effects. Types of injuries include last long, tympanic membrane rupture and middle ear damage, abdominal hemorrhage and perforation, global rupture, mild Trumatic brain injury. What causes the secondary effects of blast traumas? - ANS Projectiles propelled by the explosion. Injuries include penetrating or blunt injuries or I penetration. What causes the tertiary effects of blast traumas? - ANS Results from individuals being thrown by the blast wind. Injuries include hole or partial body translocation from being thrown against a hard service: blunt or penetrating trauma's, fractures, traumatic amputations. What causes quarternary effects of blast traumas? - ANS All explosion related injuries, illnesses, or diseases not due to the first three mechanisms. Injuries include external and internal burns, crush injuries, closed and open brain injuries, asthmatic or breathing problems from dust smoke or toxic fumes, angina, or hyper glycemia and hypertension. What causes quinary effects of blasts traumas? - ANS Those associated with exposure to hazardous materials from radioactive, biologic, or chemical components of a blast. Injuries include a variety of health effects depending on agent. What are the three processes that transfer oxygen from the air to the lungs and blood stream - ANS Ventilation: the active mechanical movement of air into and out of the lungs; diffusion: the passive movement of gases from an area of higher concentration to an area of lower concentration; and perfusion: the movement of blood to and from the lungs as a delivery medium of oxygen to the entire body. When would you use a nasopharyngeal airway versus an oral pharyngeal airway? - ANS Nasopharyngeal airways is contraindicated in patients with facial trauma or a suspected basilar skull fracture. Oral pharyngeal airways is used in unresponsive patients unable to maintain their airway, without a gag reflex as a temporary measure to facilitate ventilation with a bag mask device or spontaneous ventilation until the patient can be intubated. Describe the measurement of an NPA - ANS Measure from the tip of the patient's nose to the tip of the patients earlobe. Measurement of an OPA - ANS Place the proximal end or flange of the airway adjunct at the corner of the mouth to the tip of the mandibular angle. True or false: NPAs and OPAs are definitive airways. - ANS False. When placing one of these? One should consider the potential need for a definitive airway. Name the three ways to confirm ETT placement - ANS Placement of a CO2 monitoring device, Assessing for equal chest rise and fall, and listening at the epigastrium and four lung fields for equal breath sounds. When capnography measurement reads greater than 45MMHG, the nurse should consider increasing or decreasing the ventilation rate? - ANS Increasing the ventilation rate. Doing so would allow the patient to blow off retained CO2. When capnography measurement reads less than 35MMHG, the nurse should consider increasing or decreasing the ventilation rate? - ANS Decreasing the ventilation rate. By doing so, the nurse allows the patient to retain CO2. What are the three stages of shock - ANS Compensated, decompensated or progressive, and irreversible. What are the signs of compensated shock? - ANS Anxiety, confusion, restlessness, increased respiratory rate, narrowing pulse pressure were diastolic increases yet systolic remains unchanged, tachycardia with bounding pulses, and decreased urinary output What are the signs and symptoms of decompensated shock? - ANS Decreased level of consciousness, hypertension, narrow pulse pressure, tachycardia with weak pulses, tachypnea, skin that is cool clammy and cyanotic, base access outside the normal range, and serum lactate levels greater than two to 4MMOL/L. What are the signs and symptoms of irreversible shock? - ANS Obtunded stuporous or comatose state, marked hypertension and heart failure, bradycardia with possible dysrhythmias, decreased and shallow respiratory rate, pale cool and clammy skin, kidney liver and other organ failure, severe acidosis, elevated lactic acid levels, worsening base access on ABGs, coagulopathies with petechiae purpura or bleeding. What are the four types of shock? - ANS Hypovolemic, Cardiogenic, Obstructive, & Distributive What is the trauma triad of death? - ANS hypothermia, acidosis, coagulopathy