Trauma Care and Management in ICU, Exams of Nursing

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Trauma (ICU)

Deceleration - Not all organs decelerate at once Will die from a tear in these 2 things -

1. Descending thoracic aorta (ligamentum arteriosum)
2. Duodenum (ligament of trites) Difference between pellets and bullets - Pellets expand on impact and cause multiple injuries to internal structures Bullets damage whatever is in the direct path and can ricochet off bones Trimodal distribution of trauma death -
3. Minutes- at scene, "the golden hour"
4. Minutes-hours: ER, OR
5. Days-weeks: ICU from complications 6 phases of trauma care -
6. Prehospital resuscitation
7. Hospital resuscitation
8. Definitive care and operative phase
9. Critical care.
10. Intermediate care
11. Rehabilitation
12. Prehospital Resuscitation - GOAL: immediate stabilization and transport
13. ER Resuscitation -
14. Rapid primary survey
15. Resuscitation of vital functions
16. Secondary survey
17. Initiation of definitive care 9home or admit) a) Primary survey - ABCDE Airway Breathing Circulation Disability Exposure/environmental control Airway - -Assess airway patency

-Position patient -Open airway -Stabilize c-spine -Interventions Breathing - OPEN AIRWAY DOES NOT ASSURE ADEQUATE VENTILATION AND GAS EXCHANGE -Supplemental O2 for ALL trauma pts Circulation - Look for hemorrhage Disability - -Rapid neuro assessment AVPU Alert Responds to Verbal Responds to Pain Unresponsive -Glasgow Coma scale Exposure/environmental control - -Cut away clothing -Prevent heat loss -Keep trauma patients WARM b) Resuscitation phase - -2 large bore IVs (18G or bigger) -Blood samples drawn -Warm LR/blood -Urinary catheter -NG tube (prevents aspiration, decompression, etc) c) Secondary survey - -Begins when primary survey ends -Cont monitoring of ABCs -Completion of diagnostic tests -Head-to-toe -H/o of incident (MIVT: mechanism, injuries, vital signs, treatment) -Past medical history (AMPLE: allergies, medications, past medical ho/pregnancy, last meal, events/environment r/t injury)

3. Definitive care - -After secondary survey is complete -After injuries are identified -Surgery
4. Critical care phase -

-Admit to ICU -Good report from ER or OR (or SBAR) -Ongoing assessment -look for subtle complications -Third peak of trimodal distribution of trauma death 3 things that will kill a trauma patient -

1. Hypothermia
2. Acidosis
3. Coagulopathies Hypothermia - -The lower the temp is allowed to drop, the higher mortality climbs with 100% mortality at 32 C (89.6 F) Treatments for hypothermia - -Passive: Remove blood or saline soaked dressings, clothes, blankets, increase room temp to 78 F, decrease air flow over pt -Active external: warming blankets, overhead radiant warmers, head coverings -Active internal: humidified and warm vent circuits, heated IV fluids Acidosis - -Below 7.2: CV and coagulation system -Below 7.1: Poor long term outcomes -Above 7.29: Best survival outcomes Tx for acidosis - Avoid: Hypoventilation, excessive saline use, aortic clamping, vasopressors, massive transfusions -Bicarb if below 7. -Treat underlying cause Coagulopathy - 4 main causes: -dilutional -DIC -Acidosis -Hypothermia Tests and tx for coagulopathy - Platelets PT/INR-FFP PTT-FFP LeFort Facial fractures - -Prone to ineffective airway clearance -At risk for fluid volume deficit-bleeding -Often assoc with cervical SCI -DON'T LET INJURIES DISTRACT YOU (ABCs)

-CT best dx procedure -Med management: Stabilization with plates and screws La Fort 1 - -Horizontal fracture -Maxilla separate from rest of face La Fort II - -Horizontal fracture -Involves middle face -Orbit, ethmoid, and nasal bone -Can be associated with CSF leak La Fort III - -Complete craniofacial separation -Associated with CSF leak LeFort Nursing Management - -Protect airway -Manage OG tube -Antiemetics -HOB 30 degrees -Wire cutters at bedside?? Thoracic Injuries - -From violent crime or MVCs -Trauma to chest wall, lungs, heart, great vessels, esophagus -Can be blunt or penetrating Rib fractures - -1st or 2nd rib fractures: intrathoracic vascular injuries -Right sided fractures 8th rib: liver -Left sided fractures 8th rib: spleen Primary goal of rib fractures - PAIN MANAGEMENT Complications of rib fractures - Atelectasis, pneumonia Flail chest - -Caused by blunt trauma -2 or more ribs are fractured in 2 or more places and no longer attached to the thoracic cage -Paradoxical chest wall movement -Impaired chest wall motion---decreased TV---imppaired cough----hypoventilation and atelectasis Interventions for flail chest - -Oxygenation -Pain meds

-Intubation and mechanical ventilation Pulmonary contusion -