Trauma Pathophysiology and Assessment, Exams of Nursing

Download Trauma Pathophysiology and Assessment and more Exams Nursing in PDF only on Docsity! TNCC Trauma Nursing Core Course 7th Edition ENA Components of SBAR and its purpose - ANS S: Situation B: Background A: Assessment R: Recommendation Purpose- to provide framework for communication amount members of the healthcare team p. 7 Components of DESC and its purpose - ANS D: Describe the specific situation or behavior E: Express your concerns or how the situation makes you feel S: Suggest alternatives and seek agreement C: State consequences in terms of impact on performance goals Purpose- used in conflict management; paraphrasing the other person's comments is an important technique that should be done throughout the DESC script. Following discussion of consequences, team members should work towards consensus. p. 7 Components of CUS and its purpose - ANS C: I am Concerned U: I am Uncomfortable S: This is a Safety issue/ I am Stressed Purpose- used to "stop the line" if a team member senses or discovers an essential safety breach p. 7 Define trauma - ANS - Trauma is injury to living tissue caused by extrinsic agent - Regardless of MOI, trauma creates stressors that exceed the tissue's or organ's ability to compensate p. 9 Leading cause of death for ages 1. over 65 2. 5 to 24 3. 25 to 64 - ANS 1. Falls 2. MVCs 3. poisoning p. 9 Explain 3 phases of injury prevention - ANS Primary: prevention of the occurrence of the injury Secondary: Reduction in the severity of the injury that has occurred Tertiary: Improvement of outcomes related to the traumatic injury p. 10 Describe the three E's of injury control - ANS Engineering: technological interventions such as side impact airbags, automated blind spot alarms, ignition lock devices for those with DUIs. In playgrounds and sports, this involves surface material under playground equipment and athletic safety gear. Another intervention is improved use of smoke alarms in fire prevention p. 26 External energy forces can be exerted on the body by the following forces - ANS - Deceleration forces: include those applied in falls and collisions where injuries are caused by sudden stop of the body's motion - Acceleration forces: not as common as deceleration forces and result from a sudden and rapid onset of motion (parked car being hit by a vehicle traveling at a high rate of speed) - Compression force is an external force applied at times of impact, explains include: + Stationary objects such as dashboards or steering wheels, that collide with or push up into a person + Objects in motion such as bullets and stabbing instruments, bats and balls, fists and feet, or heavy falling objects + Blast forces p. 27 The degree to which tissues resist destruction under circumstances of energy transfer depends on... - ANS Their proximity to the impact and their structural characteristics p. 27 Structural strengths of tissue are described in what three ways? - ANS -Compression -Tensile -Shear p. 27 Compression strength refers to the tissue's ability to: - ANS Resist crush force - Compression injuries to organs occur when the organs are crushed from surrounding internal organs or structures such as a seatbelt worn up across the abdomen causing compression of the small bowel or a fracture to the lumbar spine p. 27 Tensile strength describes the tissue's ability to: - ANS Resist pulling apart when stretched - Tendons, ligaments, and muscles can tear when they are overstretched (Achilles tendon) p. 27 Shear strength describes the tissue's ability to: - ANS Resist a force applied parallel to the tissue - Coup/contrecoup injury, such as a boxer being hit in the head, is an example of this p. 27 Types of injuries include - ANS - Blunt trauma - Penetrating trauma - Thermal trauma - Blast trauma p. 28 Lateral impacts (T-bone) are associated with - ANS Shear injuries to aorta and other organs, fracture of the side clavicle, lateral pelvic and abdominal injuries, and lateral head and neck injury p. 30 Depending on the motorcycle design and rider positioning, the lower extremities can collide with the handlebars, resulting in... - ANS Femur and pelvis fractures and hip dislocations p. 31 Cavitation refers to the... - ANS Separation of surrounding tissue resulting from a sound and/or hydraulic wave force. This rapid motion can lead to crushing, tearing, and shearing forces on tissue. The impact of cavitation is dependent on the characterists of the affected tissue. Additional considerations include: - Air-filled organs such as lungs or stomach, are elastic, so this tissue tolerates high-velocity cavitation relatively well compared to other tissues - Solid organs such as the liver, have a greater propensity to shear or tear under the same forces - If those same forces are instead released inside the cranium, bone will resist expansion, augmenting soft tissue crushing, until the tensile strength of the bone is exceeded and an explosive release of pressure results ch. 4, p. 32 The U.S. Department of Defense classifies blast injuries in five levels: - ANS - Primary blast injuries: found in those closest to the detonation, with enclosed space detonation resulting in the most lethal impacts. Air-filled organs (tympanic membranes, lungs, stomach, and bowel) are most susceptible to rupture with primary blast injuries. - Secondary injuries: include fragment injuries and generally cause the greatest volume of casualties. They include injuries such as puncture wounds, lacerations, and impaled objects. - Tertiary injuries: include impacts with larger objects propelled by the blast wind resulting in blunt trauma. These cause high energy transfer and can result in pelvic or femur fractures or major thoracic injuries such as aortic and great vessel rupture. - Quaternary injuries: result of heat, flame, gas, and smoke. These injuries include external burns and internal burns from inhaled hot gases. ch. 5, p. 39 When does the approach to trauma care typically begin? - ANS With notification that a trauma patient is arriving to ED ch. 5, p. 39 What does 'safe practice' mean? - ANS Means taking into consideration the protection of the team, including: - observing universal precautions - donning PPE (gown, gloves, mask) prior to patient's arrival ch. 5, p. 39 What does 'safe care' mean? - ANS Means assuring the patient is getting to the right hospital in the right amount of time for the right care. American College of Surgeons Committee on Trauma (ACS-COT) developed trauma triage criteria that serves at the international standard to identify the trauma patient who would benefit from resuscitation and care at the right trauma facility with the appropriate resources. ch. 5, p. 40 During primary survey... - ANS Life-threatening conditions are identified and immediately corrected, beginning immediately upon the patient's arrival to the trauma room. ch. 5, p. 40 What is the most major cause of preventable death after injury? - ANS Uncontrolled hemorrhage ch. 5, p. 40 Explain the MARCH mnemonic - ANS M: MASSIVE HEMORRHAGE A: AIRWAY R: RESPIRATION - decompress suspected pneumo, seal open chest wounds, support ventilation and oxygenation as required C: CIRCULATION - vascular access and admin fluids H: HEAD INJURY/HYPOTHERMIA - prevent or treat hypotension and hypoxia to prevent worsening of traumatic brain injury and prevent or treat hypothermia ch. 5, p. 41-42 While in ED, alignment and protection of the cervical spine can be accomplished by which 2 ways? - ANS - Manual stabilization - Immobilization ch. 5, p. 42 Explain the AVPU mnemonic - ANS Used to quickly assess patient's level of alertness A- ALERT (If any of the responses below are elicited at this point, the airway may be compromised) V- responds to VERBAL stimuli, airway adjunct may be needed to keep tongue from obstructing airway P - responds to PAIN. U- UNRESPONSIVE. If patient is unresponsive, announce loudly to the team and direct someone to check if the patient has a pulse while assessing if the cause of the problem is the airway. Consider reprioritizing the assessment priority to <C>ABC ch. 5, p. 42 Use the jaw-thrust maneuver to open airway and assess for obstruction when the patient is... - ANS Unable to open the mouth, responds only to pain, or is unresponsive. ch. 5, p. 42 Once patient has airway in place, assess for proper placement by... - ANS - Presence of adequate rise and fall of the chest with assisted ventilation - Absence of gurgling on auscultation over epigastrium - Bilateral breath sounds present on auscultation - CO2 detector device color change ch. 5, p. 43 If patient's airway is NOT patent: - ANS 1. Suction airway - Avoid stimulating gag reflex - Use rigid suction device if obstructed by blood, vomitus, or secretions - Remove any foreign bodies carefully with forceps 2. If suctioning does not relieve airway obstruction, tongue may be cause. Insert airway adjunct. - Use jaw-thrust maneuver to open airway while maintaining manual stabilization - A nasopharyngeal airway can be used in patients who are conscious or unconscious - An oropharyngeal airway can be used in patients without gag reflex b. CARDIAC DYSFUNCTION ch. 5, p. 45 The standard approach to treating hypotension in trauma patients has been to infuse large volumes of IV fluids. Recent studies now recommend a different approach and note that an elevated BP may dislodge the body's formation of clots and promote further bleeding. In addition, large volumes of fluid lead to... - ANS Dilutional coagulopathy which worsens metabolic acidosis and may cause hypothermia ch. 5, p. 45 _________ therapy is now suggested for fluid resuscitation to replace patient losses, including administering PRBCs, plasma, and platelets. - ANS COMPONENT THERAPY ch. 5, p. 45 Assess pupils for... - ANS Equality, shape, and reactivity (PERRL) ch. 5, p. 45 Consider ABGs. A decreased level of consciousness may be an indicator of... - ANS Decreased cerebral perfusion, hypoventilation, or acid-base imbalance. ch. 5, p. 46 Hypothermia combined with ______ and ______ is a potentially lethal combination. - ANS HYPOTENSION and ACIDOSIS ch. 5, p. 46 Explain the LMNOP mnemonic - ANS Used to remember resuscitation adjuncts L - Lab studies (ABGs, blood type and crossmatch) - Lactic acid is an excellent reflection of tissue perfusion M - Monitor cardiac rate and rhythm: compare patient's pulse to the monitor's rhythm - Dysrhythmias (PVCs, a fib, or ST segment changes) may indicate blunt cardiac trauma - PEA may point to cardiac tamponade, tension pneumothorax, or profound hypovolemia N - Naso- or orogastric tube consideration: insertion provides stomach content evacuation and relief of gastric distention O - Oxygenation and ventilation assessment - Pulse ox may only be accurate if there is adequate peripheral perfusion - ETCO2 monitoring (capnography) provides instantaneous information about the ventilation, perfusion, and metabolism of carbon dioxide (35-45 is normal) ch. 5, p. 47 ABGs provide values of oxygen, CO2 and base excess, which are... - ANS Reflective endpoint measurements of the effectiveness of cellular perfusion, adequacy of ventilation, and the success of the resuscitation. An abnormal base deficit may indicate poor perfusion and tissue hypoxia, which results in the generation of hydrogen ions and metabolic acidosis. ch. 5, p. 46 When does the secondary survey (HI) begin? - ANS After the completion of the primary survey (ABCDE), after the initiation of resuscitation efforts, once vital functions have been stabilized and after consideration for resuscitation adjuncts (FG). ch. 5, p. 47 Additional history includes the following (MIST mnemonic) prehospital report: - ANS - MOI - Injuries sustained - Signs and Symptoms (in the field) - Treatment (in the field) ch. 5, p. 47 SAMPLE mnemonic regarding patient's history - ANS S - Symptoms associated with injury A - Allergies and tetanus status M - Medications currently used, including anticoagulant therapy P - Past medical history (hospitalizations/surgeries) L - Last oral intake E - Events and Environmental factors related to injury ch. 5, p. 48 E - Equipment failure, such as patient becoming detached from equipment or loss of capnography waveform ch. 6, p. 66 Maintain PaO2 between - ANS 100-200 mm Hg for ABGs ch. 6, p. 66 RSI pretreatment medications Cough reflex can be blocked using IV... - ANS LIDOCAINE 1.5 mg/kg ch. 6, p. 67 What are two examples of obstructive shock that may result from trauma? - ANS TENSION PNEUMOTHORAX and CARDIAC TAMPONADE ch. 7, p. 73 __________, which can occur in resuscitation, is a common IATROGENIC cause of INCREASED intrathoracic pressure resulting in COMPRESSION of the heart and DECREASED cardiac output. - ANS HYPERVENTILATION ch. 7, p. 74 Describe DISTRIBUTIVE SHOCK - ANS Occurs as result of maldistribution of an adequate circulating blood volume with loss of vascular tone or increased permeability. ch. 7, p. 75 Describe ANAPHYLACTIC SHOCK - ANS Results from release of inflammatory mediators (e.g. histamine) which contracts bronchial smooth muscles and increases vascular permeability and vasodilation. ch. 7, p. 75 Describe SEPTIC SHOCK - ANS Caused by systemic release of bacterial endotoxins, resulting in an increased vascular permeability and vasodilation. ch. 7, p. 75 Describe NEUROGENIC SHOCK - ANS Occurs with SCI results in the loss of SNS control of vascular tone, which produces venous and arterial vasodilation. ch. 7, p. 75 Early treatment for septic shock includes... - ANS Early administration of antibiotics and potential need for norepinephrine to vasoconstrict the peripheral vasculature, increase blood volume return to heart, and improve cardiac output. ch. 7, p. 75 The increase of the diastolic blood pressure with a narrowing pulse pressure... - ANS May be one of the first CONCRETE measurements signaling that the patient's circulatory status is compromised. ch. 7, p. 76 Activation of the SYMPATHETIC NERVOUS SYSTEM causes the ADRENAL glands to release TWO catecholamines - EPINEPHRINE and NOREPINEPHRINE. These cause... - ANS - HIGH levels of EPINEPHRINE cause smooth muscle relaxation in the airways and causes arteriole smooth muscle contractility (potentiating inotrophic effect). EPI also INCREASES heart rate (positive chronotrophic effect), peripheral vasocontriction, and glycogenolysis (breakdown of glycogen stores in liver into glucose for cellular use) - NOREPINEPHRINE increases heart rate, vascular tone through alpha-adrenergic receptor activation, and blood flow to skeletal muscle and triggers the release of glucose from energy stores. ch. 7, p. 77 One of the earliest responses to inadequately pefused tissue is... - ANS TACHYPNEA ch. 7, p. 78 As shock progresses, primary goal of the body is to maintain perfusion to vital organs. Sympathetic stimulation has little effect on the cerebral and coronary vessels since they are capable of autoregulation. Cerebral autoregulation maintains a constant... - ANS cerebral vascular blood flow as long as the MAP is maintained between 50-150... when autoregulation in the brain fails, perfusion becomes dependent solely on pressure. ch. 7, p. 78 Resuscitation-associated coagulopathy is associated with the trauma triad of death. It includes... - ANS HYPOTHERMIA impairs thrombin production and platelet function Disadvantages of auto-transfusion include: - ANS - Risk of contamination - RBCs might become hemolyzed during hemorrhage - Coagulation factors, including platelets and cryoprecipitate may be destroyed, increasing d-dimer in collected blood ch. 7, p. 81 Explain what Tranexamic acid (TXA) is - ANS A synthetic version of the amino acid lysine. It is an antifibrinolytic that inhibits activation of plasminogen, a substance responsible for dissolving clots. ch. 7, p. 81 Increased or bounding central pulses may indicate increased cardiac output. Peripheral pulses do not demonstrate a similar effect in the presence of hypovolemia due to vasocontriction. Thus, strong central pulses combined with weak peripheral pulses may be... - ANS Indicative of Shock ch. 7, p. 82 What lab studies are used to guide resuscitative efforts in shock? - ANS - Platelet count, clotting studies - Serum lactate, anion gap, base deficit, and ABGs to assess acidosis - Toxicology screen to help assess mental status and differentiate from head injury - Calcium level when rapidly infusing large volumes of blood products ch. 7, p. 83 Following the primary survey, FAST examination may be used to rapidly assess for bleeding from damage to the... - ANS Heart, liver, kidneys, and spleen. FAST also increasingly used to detect pneumothorax, especially tension pneumothorax. ch. 7, p. 84 Output less than 0.5 mL/kg per hour for two consecutive hours indicates... - ANS OLIGURIA ch. 7, p. 84 Pain Theories include... - ANS GATE CONTROL THEORY- proposes pain may be modulated by interneurons within spinal cord. Stimulation of the large A-beta cutaneous fibers was thought to close gate pain impulses from A-delta or C fibers. A-beta fibers carry impulses from touch, vibration, rubbing a painful area. Supports non-pharmacologic therapies for pain control such as ice, heat, massage. NEUROMATRIX THEORY- proposes that each person's brain produces a unique pattern of nerve impulses from a complex neural network with multidimensional inputs. This theory explains phantom limb pain and why people with similar injuries report differing levels and responses to pain. NEUROPLASTIC THEORY- suggests that neurons can be permanently affected and reshaped by the experience of pain. This theory attempts to explain chronic pain, pain syndromes, and phantom pain. ch. 8. p. 93 Classifications of acute pain are based on the source and origin and include... - ANS SOMATIC pain originates from skin and muscloskeletal structures VISCERAL PAIN originates from organs and may lead to referred pain ch. 8, p. 93 Explain oligoanalgesia - ANS the concept of undertreatment of pain ch. 8, p. 94 Physiologic effects of pain by system: Cardiovascular - ANS HYPERCOAGULATION INCREASED CARDIAC WORKLOAD INCREASED OXYGEN DEMAND ch. 8, p. 97 Physiologic effects of pain by system: Respiratory - ANS SPLINTING HYPOVENTILATION HYPERCARBIA RESPIRATORY ACIDOSIS INCREASED RISK OF ATELECTASIS & PNEUMONIA ch. 8, p. 97 Physiologic effects of pain by system: Musculoskeletal - ANS IMPAIRED MUSCLE FUNCTION IMMOBILITY FATIGUE MUSCLE SPASM If injury causes the CPP to fall outside the range between ___________ mm Hg, the brain loses its ability to autoregulate and CBF becomes directly dependent on MAP for perfusion. - ANS 50 and 160 mm Hg Ch. 9, p. 108 If autoregulation fails and MAP is elevated, _______ can result. - ANS EDEMA Ch. 9, p. 109 As ICP rises, CPP ________, resulting in cerebral ischemia, hypoxemia, and lethal secondary insult. - ANS DECREASES Ch. 9, p. 109 Early assessment findings of increased ICP include: - ANS - HEADACHE - NAUSEA/VOMITING - AMNESIA - BEHAVIOR CHANGES (IMPAIRED JUDGEMENT, RESTLESSNESS, DROWSINESS) - ALTERED LEVEL OF CONSCIOUSNESS ( HYPO/HYPERAROUSABILITY) Ch. 9, p. 109 Late assessment findings of increased ICP include: - ANS - DILATED, NON-REACTIVE PUPILS - UNRESPONSIVENESS to verbal/painful stimuli - ABNORMAL POSTURING - CUSHING RESPONSE Widening pulse pressure Reflex bradycardia Decreased respiratory effort Ch. 9, p. 109 Mastoid process ecchymooses - ANS Battles sign, indicates middle fossa fracture Ch. 9, p. 113 What can you assess to ensure the brainstem is intact? - ANS EXTRAOCULAR EYE MOVEMENTS (EOMs) - tests functions of CNs III, IV, and VI In presence of facial fractures, the inability to perform EOMs may indicate a trapped nerve Ch. 9, p. 113 Describe FOCAL BRAIN INJURIES - ANS Occur in localized area with grossly observable and identifiable brain lesions. They include... - CEREBRAL CONTUSION - INTRACEREBRAL HEMATOMA - EPIDURAL HEMATOMA - SUBDURAL HEMATOMA - HERNIATION SYNDROMES Ch. 9, p. 113 Assessment findings of a INTRACEREBRAL HEMATOMA - ANS - PROGRESSIVE, RAPID DECLINE IN LOC - HEADACHE - SIGNS OF INCREASING ICP - PUPIL ABNORMALITIES - CONTRALATERAL HEMIPARESIS - HEMIPLEGIA - ABNORMAL POSTURING Ch. 9, p. 114 Assessment findings of a EPIDURAL HEMATOMA - ANS - TRANSIENT LOC followed by lucid period lasting minutes to hours - HEADACHE, DIZZINESS - NAUSEA, VOMITING - CONTRALATERAL HEMIPARESIS - HEMIPLEGIA - ABNORMAL MOTOR POSTURING (FLEXION/EXTENSION) Extension is associated with brainstem HERNIATION and poor outcomes - IPSILATERAL UNILATERAL FIXED, DILATED PUPIL - RAPID DETERIORATION IN NEURO STATUS Ch. 9, p. 114 Assessment findings of an ACUTE SUBDURAL HEMATOMA - ANS - SEVERE HEADACHE - CHANGES IN LOC - Significant alterations in consciousness - ABNORMAL PUPILLARY RESPONSE - ABNORMAL POSTURING Ch. 9, p. 115 Explain what second impact syndrome is - ANS Refers to a condition that occurs when patient suffers a mild second TBI before recovery from the first. Rare but usually fatal. The second impact causes LOSS OF AUTO REGULATION LEADING TO CEREBRAL EDEMA Ch. 9, p. 115 POSTCONCUSSIVE SYNDROME assessment findings include: - ANS - NAUSEA - DIZZINESS, PERSISTENT HEADACHE - MEMORY and JUDGEMENT IMPAIRMENT as well as ATTENTION DEFICITS - INSOMNIA and SLEEP DISTURBANCES - LOSS OF LIBIDO - ANXIETY, IRRITABILITY, DEPRESSION, EMOTIONAL LIABILITY - Noise and light over sensitivity - ATTENTION or CONCENTRATION PROBLEMS Ch. 9, p. 115-116 Assessment findings of DIFFUSE AXONAL INJURY - ANS - UNCONSCIOUSNESS Mild DAI lasts 6-24 hrs Severe DAI lasts weeks to months - INCREASED ICP - ABNORMAL POSTURING - HTN (systolic BP between 140-160) - HYPERTHERMIA (104-105 F) - EXCESSIVE SWEATING - MILD TO SEVERE MEMORY LOSS; COGNITIVE, BEHAVIORAL, and INTELLECTUAL DEFICITS Ch. 9, p. 116 Explain why antipyretics are not effective in treating hyperthermia in acute brain injury. - ANS Fever is result of a change in thermoregulatory set point. A cooling blanket or ice packs may be used. Avoid causing shivering, it increases cerebral metabolic rate and may cause ICP to rise Ch. 9, p. 118 Why is CONTINUOUS ICP MONITORING important? - ANS Important for assessing brain injury and response of patient to treatment. It can provide early detection of secondary brain injury such as cerebral hypoxia, ischemia. The device reflects oxygen delivery to cerebral tissues and monitors temperature Ch. 9, p. 119 What are the two priorities in treating patients with TBI? - ANS Facilitating OXYGENATION and VENTILATION Ch. 9, p. 120 What is the difference between penetrating and perforating in regards to ocular injuries? - ANS Penetrating - having ENTRANCE WOUND, an INTRAOCULAR FOREIGN BODY when they are present Perforating - having ENTRANCE and EXIT WOUND Ch. 10, p. 125 True or false: ALL eye injuries, even the most minor, require a visual acuity examination. - ANS TRUE Ch. 10, p. 125 Up to 25% of the general population have UNEQUAL PUPILS, called ANISOCORIA; this is benign and caused by... - ANS - TRAUMA - INCAL HERNIATION - OCULOMOTOR NERVE (CN III) PALSY - MEDICATIONS - SOME NEBULIZERS (IPRATROPIUM) Ch. 10, p. 126 What can you do to easily see eyes that have abrasions? - ANS Stain them with fluorescein Ch. 10, 129 Treatment for CORNEAL ABRASIONS include: - ANS - TOPICAL OPHTHALMIC ANTIBIOTICS - protecting eye with METAL SHIELD - TOPICAL OPHTHALMIC CYCLOPLEGICS and OPHTHALMIC STEROIDS, OPHTHALMIC BETA-BLOCKERS if IOP is ELEVATED - Avoid aspirin and NSAIDs as they increase risk of re-bleeding - Risk of re-bleeding greatest 3-5 days after injury Ch. 10, p. 131 Explain RETROBULBAR HEMATOMA - ANS TRUE OPHTHALMOLOGIC EMERGENCY Hemorrhage into space behind globe; bleeding causes increased pressure behind globe causing elevation in IOP that compresses optic nerve and blood vessels. Early recognition is imperative to save vision. Assessment findings include: - SEVERE PAIN - DECREASED VISION - REDUCED EYE MOVEMENT - IOP > 40 mm Hg Treatment include: - Emergency decompression via LATERAL CANTHOTOMY indicated with IOP > 40 mm Hg Ch. 10, p. 131 Explain GLOBE RUPTURE - ANS - Considered a genuine EMERGENCY - Occurs when full thickness injury occurs to cornea or sclera or both -Once Dx is confirmed, it is important to protect eye from further injury Assessment findings include: - ANTERIOR CHAMBER APPEARING FLAT/SHALLOW - IRREGULAR or TEARDROP-SHAPED PUPILS or PRESENCE of what looks like a secondary pupil due to a tear in the ciliary body (traumatic iridodialysis) - PERIORBIAL ECCHYMOSIS - DECREASED VISUAL ACUITY and EOM - SEVERE SUBCONJUNCTIVAL HEMORRHAGE - NAUSEA - PAIN Treatment includes: - AVOID ANY TYPE OF PRESSURE TO GLOBE - DO NOT PERFORM TONOMETRY - APPLICATION OF RIGID SHIELD to protect affected eye - Administration of antiemetics - AVOID USE OF OPHTHALMIC DROPS or MEDICATIONS - CONSULTS * Pain not always present in globe penetration Ch. 10, p. 131 Ch. Ch. 10, p. 131-132 What symptoms usually indicate an INTRAOCULAR foreign body is present? - ANS - IRREGULAR PUPIL - SHALLOW ANTERIOR CHAMBER - POSITIVE SEIDEL TEST Ch. 10, p. 132 Explain eye irrigation when used for the removal of chemicals, foreign bodies, and debris from eye - ANS CONTRAINDICATED in patients who may have RUPTURED GLOBE - Prior to procedure, check eye pH then instill anesthetic drops unless contraindicated. - Use warmed NS or LR, warmed to body temp 37 C to limit risk of thermal injury - Morgan lens or intravenous tubing may be used to direct flow, remember the shorter the tubing, the greater the flow and pressure - Direct stream across eye from inner to outer eye - Irrigation continued until eye pH reaches neutral (7.0-7.3) Ch. 10, p. 133 What are the rules concerning standard imaging in relation to eye injury - ANS - If wood or a vegetative foreign body is suspected, MRI most appropriate imaging method to use, however, it is minimally useful in acute setting - CT scans not helpful if vegetative foreign bodies are suspected - the GOLD STANDARD for evaluation of mid-face and orbit trauma is a CT scan - Plain films are used to assess foreign bodies and fractures of facial structures, excluding orbits Ch. 10, p. 133-134 What is the most common cause of thoracic trauma? - ANS MVC's Palate for: - CENTRAL PULSES compare quality between left and right and lower and upper extremities - EXTERNAL JUGULAR VEIN DISTENTION - EXTREMITIES FOR MOTOR and SENSORY function Lower extremity paresis or paralysis may indicate an aortic injury Ch. 11, p. 142 Explain emergency thoracotomy - ANS Done when patient arrives with unstable vital signs or impending arrest... Indications for performing this include: - PERICARDIAL TAMPONADE needed to be evacuated - IMMEDIATE CONTROL OF MASSIVE INTRATHROATIC BLEEDING - PENETRATING TRAUMA with witnessed CARDIAC ARREST permitting open cardiac massage, or with massive hemorrhage in peritoneal cavity needing cross-clamping of aorta - It is rarely successful in patients with blunt chest trauma Ch. 11, p. 142-143 During the secondary survey in patient with thoracic or neck trauma, what questions do you want to ask? - ANS If patient is complaining of: - DYSPNEA - DYSPHAGIA - DYSPHONIA Was there a cardiac event prior to injury? If CPR is being performed, when was it started? - Important information in determining the indications for performing an emergency thoracotomy or when to consider withdrawal of support Ch. 11, p. 143 Explain TRACHEOBRONCHIAL INJURY and what are the assessment findings and interventions - ANS Usually caused by penetrating mechanisms, occurring in proximal trachea. Direct blows to neck or clothesline-type injuries common mechanisms for blunt trauma. Dx based on assessment findings and confirmed with BRONCHOSCOPY or CT. Assessment findings include: - DYSPNEA, TACHYPNEA - HOARSENESS - SUBCUTANEOUS EMPHYSEMA in neck, face, upper thorax - PNEUMOTHORAX, tension pneumothorax - HEMOPTYSIS - DECREASED OR ABSENT BREATH SOUNDS - SIGNS and SYMPTOMS of AIRWAY OBSTRUCTION Interventions include: - Attempts at ET placement may cause further damage, anesthesiology if available may reduce risk of intubation injury - Other approaches include flexible endoscopy, or smaller ET tube Ch. 11, p. 143 BLUNT ESOPHAGEAL INJURY - ANS Injury to esophagus, rare, results form blunt trauma Assessment findings include - AIR in MEDIASTINUM with possible widening - CONCURRENT LEFT PNEUMOTHORAX or HEMOTHORAX - ESOPHAGEAL MATTER IN CHEST TUBE - SUBCUTANEOUS EMPHYSEMA Interventions - Prepare for surgery Ch. 11, p. 143 FLAIL CHEST - ANS Classified as 2 or more fractures of 3 or more adjacent ribs and/or sternal fractures, creating free-floating segment Assessment findings include - PARADOXICAL CHEST MOVEMENT drawing in with chest expansion and pushing out with exhalation - DYSPNEA - CHEST WALL PAIN, CONTUSIONS Interventions - prepare for intubation - INEFFECTIVE COUGH - INCREASED WORK OF BREATHING - HYPOXIA - CHEST PAIN - CHEST WALL CONTUSIONS or ABRASIONS Interventions - Maintain SpO2 between 94-98% - Minimize or use IV fluids judiciously - Prepare for possible intubation ch. 11, p. 146 CARDIAC TAMPONADE - ANS Assessment findings Beck's Triad- HYPOTENSION, MUFFLED HEART SOUNDS, DISTENDED NECK VEINS - CHEST PAIN - TACHYCARDIA - DYSPNEA - CYANOSIS - Pulsus paradoxus greater than 10 mm Hg Interventions - Prepare for pericardial decompression - 3 to 4 cm incision made just left of xiphoid process - Needle percardiocentesis may also be used to relieve symptoms of cardiac tamponade but its only temporary solution ch. 11, p. 146 AORTIC DISRUPTION - ANS Assessment findings - Fractures of sternum, first or second rib or scapula - CARDIAC MURMURS - BACK, CHEST PAIN - UNEQUAL EXTREMITY PULSE STRENGTH or BLOOD PRESSURE (Significantly greater in upper extremities) - HYPOTENSION - TACHYCARDIA - SKIN CHANGES: diaphoresis, pallor, cyanosis - PHARAPLEGIA (due to disruption of spinal perfusion from aortic injury) - Radiograph findings include- left hemothorax, right-sided tracheal deviation, widened mediastinum Interventions - Prepare for surgery or angiography - Consider massive transfusion protocol ch. 11, p. 146 RUPTURED DIAPHRAGM - ANS Assessment findings - DYSPNEA or ORTHOPNEA - DYSPHAGIA - ABDOMINAL PAIN - SHARP EPIGASTRIC or CHEST PAIN RADIATING to left shoulder (Kehr sign) - Bowel sounds auscultated in the lungs on injured side Interventions - Prepare for surgery ch. 11, p. 146 When someone suffers a GSW, below what part of the body is considered an abdominal injury that requires an exploratory laparotomy? - ANS Below the nipple line ch. 12, p. 155 What are causes of peritoneal membrane irritation? - ANS - presence of blood - chemical peritonitis as result of gastric content leakage - possible enzyme spillage from pancreas into bowel and/or peritoneal cavity - bacterial contamination from bowel contents ch. 12, p. 158 Examples of referred pain include... - ANS - radiating to left shoulder (Kehr sign) - referred to testicle may be indicative of duodenal injury - always begin palpation away from inital site of pain by assessing the painful area last ch. 12, p. 158 Explain definitive care on pancreatic trauma - ANS - Non-op management including complete bowel rest, nutritional support, serial CT scanning with observation - Pseudocyst formations may be managed with percutaneous drainage - Pancreatic ductal injuries may need distal pancreatectomy - complications from pancreatic injury include, secondary hemorrhage, pancreatic fistula, abdominal abscess - s/s of infection occur often 7-10 days after injury and usually include fever, elevated WBC, nausea, vomiting ch. 12, p. 164 Are the lumen contents of the small bowel considered sterile? What is the pH? - ANS neutral pH, and sterile ch. 12, p. 164 Pertaining to abdominal trauma, What does non-operative management include? When does operative management occur? - ANS Non- serial abdominal exams Op- occurs in patients who exhibit signs of peritonitis or hemodynamic instability ch. 12, p. 164 What diagnostic exam is helpful to inspect abdominal spaces for spillage and to examine loops of bowel? - ANS Laparoscopy ch. 12, p. 164 What is used to diagnosis renal injuries? What are the cons? How are rectal injuries often managed? - ANS Sigmoidoscopy Cons- unprepared bowel may not detect injury Often managed with colostomy and distal rectal washout ch. 12, p. 165 Explain stable and unstable pelvic fractures - ANS Stable- does not involve pelvic ring or there is minial displacement of pelvic ring Unstable fractures- 2 or more fractures of pelvic ring that have outward rotational displacement ch. 12, p. 166 Assessment findings for renal injuries include - ANS - Turner sign (bruising by 11th and 12th ribs) - Hematuria - Frank tenderness, costovertebral angle tenderness, palpable flank mass - Structural damage or leakage of contrast on intravenous pyelogram (IVP) - If patient hemodyanmically unstable for CT, a single-infusion IVP can be performed at bedside followed by complete study once patient is stable - Positive urine dipstick for microscopic blood or leukocyte esterase - Abnormal or elevated BUN and creatinine 90% of injuries are minor. Anticipate nephrology consultation in more severe injures; surgical repair is required within 12 hours to salvage an ischemic kidney ch. 12, p. 167 Imaging studies for bladder and urethral injuries include - ANS - CT cystogram used to dx intraperitoneal or extraperitoneal bladder rupture - Urethrogram usually performed prior to insertion of urinary catheter when injury is suspected; contrast instilled at meatus. Detection of contrast media within bladder indicates adequate instillation, leakage demonstrates urethral disruption ch. 12, p. 168 Prophylactic administration of what can reduce the risk of contrast-induced nephropathy when patients serum creatinine is above 1.2mg? - ANS N-acetylcysteine along with hydration ch. 12, p. 170 55% of spinal injuries occur to which part of spine? - ANS cervical ch. 13, p. 179 hyperEXTENSION - ANS etiology/cause- backward thrust beyond anatomic capacity of vertebral column rest of injury- stretching or ligament tears, bony dislocations example- rear-end whiplash ch. 13, p. 179 hyperFLEXION - ANS etiology/cause- forceful forward flexion with head striking an immovable object Spinal cord neurons DO NOT regenerate; therefore, severe injury with cellular death may result in... - ANS - temporary or permanent loss of function - flaccidity - loss of reflexes ch. 13, p. 181 Central cord syndrome - ANS loss of motor function in upper extremities that is greater than that of lower extremities. often sacral sparing. bladder function may be affected ch. 13, p. 182 Anterior cord syndrome - ANS loss of pain and temperature sensation with weakness, paresthesia, and urinary retention ch. 13, p. 182 Brown-squared syndrome - ANS Contralateral loss of pain and temperature sensation and ipsilateral paralysis with reduced touch sensation ch. 13, p. 182 What are signs of worsening hypoxia with nerve injuries? - ANS Increased pain even when pulses remain present, often the first sign of increased compartment pressures ch. 14, p. 196 All open fractures are considered contaminated due to exposure to the environment and are at risk for infection. These sites of injury have poor wound healing with a risk of.... - ANS OSTEOMYELITIS and SEPSIS ch. 14, p. 197 Why do partial amputations have more severe bleeding than complete amputations? - ANS The severed arteries retract with complete amputations ch. 14, p. 197 What are complications related to crush injuries? - ANS Compartment syndrome, hyperkalemia, rhabdomyolysis K levels peak 12 hours after injury ch. 14, p. 198 RHABDOMYOLYSIS - ANS Signficant muscle damage and cellular destruction releases MYOGLOBIN, a muscle protein, into bloodstream. Since myoglobin is excreted in the kidneys, risk of acute renal failure is high in patients with crush injury. Classic triad of assessment findings include: - MUSCLE PAIN, NUMBNESS, CHANGES in SENSATION - MUSCLE WEAKNESS or PARLYSIS - DARK RED OR BROWN URINE other assessment findings include: - extensive soft tissue EDEMA and BRUISING - general WEAKNESS or MALAISE - evidence of hypovolemic shock - elevated creatinine kinase levels Treatment - aggressive fluid resuscitation to flush out myoglobin to prevent renal failure (>100 mL/hr until resolved is goal) ch. 14, p. 198 Sudden vision changes may indicate________ in the cerebral vascular - ANS A POSSIBLE FAT EMBOLISM ch. 14, p. 199 How high should you elevate limb in compartment syndrome? - ANS At level of heart, any higher can reduce circulation and tissue perfusion. Also ice is strongly contraindicated ch. 14, p. 200-201 What do you do with open wounds? - ANS Cover in saline-soaked dressings ch. 14, p. 201 How should you wrap an amputated part? - ANS Wrap it in slightly saline-moistened sterile gauze, placed in sealed plastic bag THEN place in a second bag containing ice water