used to design public policy, legislation and injury prevention programs gathers data such as ›...
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TRAUMAMary Corcoran RN, BSN, MICN
Trauma Overview
Epidemiology
Used to design public policy, legislation and injury prevention programs
Gathers Data such as› Incidence› Prevalence› Age› Sex› Race/Ethnicity› Geographic distribution› Morbidity and Mortality
Epidemiology
Trauma is a disease that remains the leading cause of death for all Americans Regardless of gender, race or economic status
Leading Cause of death for ages 1-45yrs› (see chart pg 234)
Facto
rs C
on
tribu
ting
to
Trau
ma
Age
1-3 yrs= MVA› Due to unrestrained/ or improperly restrained
15-24= Accidents related to Drugs and Alcohol› Due to poor judgment and risk-taking behavior
16-19= MVA› Due to inexperience, lack of seatbelt usage,
etoh with driving 75+= “injuries”
› Due to frailer health, pre-existing conditions, Falls (most common cause in 65+ age group)
› Drivers 65+ have the highest death rate, per mile driven (except for teenagers)
› More likely to sustain a C-Spine injury
Facto
rs C
on
tribu
ting
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Trau
ma
Gen
der
Race
Males are 2.5 times more likely to be injured than females› Related to their participation in hazardous
activities, and greater risk taking The Auto vs Ped, and MVA death rate is
2x higher across the life span compared to women
African American- Homicide, MV (65+), and auto/ped
White/Native American- Suicide Hispanic- Pedestrian, Homicide
Factors Contributing to Death by Trauma
Fire Arms Alcohol Geography –Urban vs Rural Chronology- Weekends and Holidays
Patient Assessment
Beware of Adrenaline- pt may at first appear uninjured
MOI- What is the Mechanism Of Injury, and does the injury match?
Trauma Team Criteria?
Patient Assessment
A-Airway B-Breathing C-Circulation D-Disability E-Exposure/Environment F-Full Vitals, Family G-Give comfort measures H- Head to Toe/ History I-Inspect Posterior Surfaces
http://www.youtube.com/watch?v=LcdLqfdIkFc
Trauma Assessment
When to notify Trauma Team
Alert (minor)› Ejection› Death in same pass space› Extrication <20min› Falls <20ft› Rollover w/ injury› Auto Ped/Bike <5mph› Ped thrown or run over› MCA <20mph› Age >59 with blunt injury
to chest/abd› Children <5yrs› 2 long bone Fx› Pregnancy 23wks +
Activation (major)› GCS <13› Airway Compromise
Intubated PTA
› BP <90s Age specific in kids
› Penetrating injuries to head, neck, torso, and extremities prox to elbow and knee
› Traumatic Full Arrest› Paralysis› Amputation prox to wrist and
ankle› Bone Injury:
Pelvic FX, open skull
› Transferred receiving blood› MD discretion
Summary
Treatment of trauma patients depends on identifying all injuries and rapidly intervening to correct those that are “life threating”
Consideration of mechanisms of injury is essential to identifying patients with possible underlying injuries who require further evaluation and treatment
Head Trauma
Layers of the Brain
Traumatic Brain Injury (TBI) Leading Cause of Death and permanent
disability- considered a MAJOR public health problem
2 million people every year› 8x more than cancer, 34x more than HIV
50,000 deaths, 200,000 hospitalizations, 1million ER visits
$60 billion in costs in 2000› Average lifetime cost per survivor $111,578› Average cost per fatality $454,717
Head Trauma
Injuries can occur to the skull, brain, soft tissues, vascular structures, and cranial injuries
Mechanism are varied› Car crashes, sports, falls, penetrating
wounds› High risk behaviors include ETOH abuse,
drugs
Specific Injuries Classified by: Mechanism
› Blunt or Penetrating Severity
› Mild, Moderate or Severe Type
› Fracture, focal brain injury, diffuse brain injury
Minor Injuries
GCS is 14-15› Usually discharged after short observation
Normal pupils, may be asymptomatic, intact orientation/memory
Eg: Scalp Lacerations
Moderate Injury GCS 9-13
› High potential for increased ICP
Associated with Structural injury/damage
May require more frequent monitoring
Eg: Contusion
Severe Injury
GCS- 8 or less› Associated with Severe structural damage
High mortality rate Usually have long term or permanent
cognitive and physical disabilities› Aggressive initial management to ensure
adequate oxygenation and preventing HTN is essential
Increased Intracranial Pressure
A reaction to a change in any one of the 3 fixed brain volumes› Brain, CSF, or blood
If not immediately corrected will compromise cerebral blood flow
Normal ICP is 0-15, greater than 20=intracranial hypertension
Increased ICP Early S/S ~ HA, N/V, ALOC, pupils
sluggish Late S/S ~ Pupils fixed/dilated,
arousable only to deep stimuli (gcs <8), posturing, temperature changes› Cushings Triad (High blood pressure,
bradycardia, irregular resp rate)
Increased Intracranial Pressure
Treatment› Monitor ABC’s › Prepare for intubation (propofol)› Medicate with benzo’s › Mannitol?› Decrease stimulus› Consider insertion of ICP monitor› Decrease metabolic demands of the brain
Maintain normal temperature Maintain normal glucose Prevent seizures (Dilantin)
Skull Fractures
Linnear skull fracture
Non-displaced, most common type, usually benign
Skull Fractures
Depressed skull fracture› Damages underlying
brain tissue and vessels by compression or laceration. May precipitate seizures
Skull Fractures
Basilar skull fracture› May occur in anterior, posterior or middle
fossa. Leads to infection, hematoma, CSF leakage, SZ
› S/S ~ ALOC, pupil change, CSF leak, Battle sign, Raccoon eyes, change in mentation Change in mentation or combative
behavior, is hallmark› Avoid nasal intubation or NGT
BasilarSkull Fracture
Contusion
Bruise on the surface of the brain Occurs from movement of the brain
within the skull Coup and Contrcoup S/S are ALOC, N/V, vision changes,
weakness, and speech deficit
Epidural Hematoma Collection of blood between skull and dura Usually r/t laceration of the middle
meningeal artery assosciated with a temporal or parietal skull fracture
Mortality is 50% S/S ~ Initial period of unconsciousness,
lucid interval (5 min-6 hrs), rapid unconsciousness, unilateral fixed or dilated pupils, Cushing’s Triad
TX: prepare for evacuation/OR
Subdural Hematoma
Collection of blood between dura mater and subarachnoid layer
Usually caused by trauma Usually venous, therefore a slower
bleed S/S ~ HA, drowsiness, confusion,
steady decline in LOC, unilateral fixed and/or dilated pupils
TX: ABC’s, prep for OR (most successful if done within 4hrs of injury)
Subarachnoid Hemorrhage
Collection of blood between arachnoid mater and the pia mater
Caused by aneurysm rupture, AV malformation. › Aneurysm can be caused by valsalva,
sexual activity, heavy lifting, or excitement Usually 40-60 y/o. 12% die before
reaching hospital, 30% that survive have severe neurologic deficits
Subarachnoid Hemorrhage S/S ~
› “Worst headache of my life”› Accompanied by N/V or sudden seizure› Meningeal signs (fever, nuchal rigidity)
Subarachnoid Hemorrhage
Concussion
Traumatic, reversible neurological event when there is a temporary loss of consciousness and retrograde amnesia
S/S ~ dizziness, N/V, loss of memory of event
CT to r/o bleed Education to return if s/s
Diffuse Axonal Injury (DAI) Widespread disruption of neurologic
function without any focal lesions noted S/S
› immediate LOC lasting days-months› May see posturing› Loss of brain stem reflexes (no gag/cough)› HTN, hyperthermia, excessive sweating
TX: ABC’s prepare for intubation, mannitol
Spinal Trauma
Spinal Trauma
Damage of spinal cord tissue r/t penetrating trauma, fracture, or dislocation
Most often in males 15-35 y/o Costs: $218-741,000 for first year with
lifetime cost just under $3,000,000yr!
Sensory Dermatomes
AS
SES
SM
EN
T
Inspectio
n
Observe for obvious signs of Spinal injury, including deformity of the vertebral column, cervical edema, and wounds
Ventilatory pattern may indicate spinal injury
Can they feel pain, or move arms and legs?
Priapism Spinal fluid leakage
AS
SES
SM
EN
T
Palpation
Diaphoretic above level of injury› Indicates sympathetic injury
(above T4) Poikilothermic- assumes
temperature of surroundings› Hypothermia
Sensory status- sharp or dull Sacral and Perineal sensations Entire column should be
palpated for pain, tenderness and step-off deformity
*use log-roll technique*
Radiologic Intervention 3view XR- must see C7-T1 junction Swimmers View- Open Mouth view
› Used for C1,C2 views CT-“Recons”
› Done at same time as Chest/Abd CT MRI- used for suspected Cord injury
› Not good at bony injuries› SCIWORA (Spinal Cord Injury without
Radiologic Abnormality)
Management Methylprednisolone- reduces
biochemical responses when given within 8hrs of injury› Suspected to cause infection, PNA, decub
etc. Foley- for incont, or to monitor output NG/OG with intubation Warming blanket/fluids- pt can’t
thermoregulation Hypothermia???
Cervical Fixation
Halo/cervical tongs- provides c/s traction
Spinal Shock
When complete spinal cord injury occurs, all motor and sensory function below the level of injury is lost› Immediate onset
S/S: Flaccid paralysis, a-reflexia, bowel/bladder dysfunction, disruption in thermoregulation› Neurogenic shock (above T6) s/s include
sypathetic NS causes Bradycardia and Hpotension
Central cord syndrome
• Results from hyperextension• Bowel and
bladder fx intact
Anterior cord syndrome
• Results from disruption of the anterior spinal artery
• Can feel vibration, touch, and pressure• Posterior cord
syndrome light touch impaired by not lost
Brown-Sequard Syndrome Results from
Hemisection of the cord Most common from
penetrating injury Ipsilateral (same side)
paresis or hemiplegia and total loss of function
Contralateral (opposite side) has decreased sensation to pain and temperature changes
Autonomic Dysreflexia
Complication of injury at or above T6 Life Threating injury- occurs when
sympathetic stimulation leads to massive uncontrolled cardiovascular response
Common Causes: Full bowel or bladder at the time of injury
Autonomic Dysreflexia
S/S › sudden severe HA› HTN› sweating› flushing above level of injury› coolness below level of injury› Anxiety› Blurred vision
TX-ABC’s, raise HOB, identify cause, foley
Thoracic/Abdominal Trauma
Thoracic Trauma
Some of the most life threatening injuries
Have a lot of concurrent injuries
Anatomy
Pulmonary System Cardiovascular System
Patient Assessment
ABC’s Auscultation of lung sounds Inspect chest wall integrity Ultrasound (FAST Scan) of heart and
lungs
Chest Wall Injuries
Rib Fractures
Most common type of blunt chest injury S/S – SOB, localized pain with
movement, chest wall ecchymosis or contusion
Bony crepitus Usually does not require treatment
other than pain meds Elderly may need admission
Flail Chest
Defined as fractures in 2 or more adjacent ribs in 2 or more places, or bilateral detachment of the sternum from costal cartilage.
Usually associated with Massive crush injury, high speed MVC.
Will see paradoxical movement to affected area
Sternal Fracture Decreased incidence with increased
use of seatbelts, shoulder restraints and air bags› Usually caused by steering wheel impact,
sporting injury or falls Increased potential for cardiac or
pulmonary injury
Traumatic Asphyxia
Result of severe crush injury to the thorax › Long period of time, such as being pinned
Pathology:› Direct increase in thoracic and superior vena
cava pressure from the injury› Combined with closure of the glottis
S/S› Severe cyanosis of face and neck› Subconjunctival and retinal hemorrhages› Transient LOC, SZ, or blindness
Pulmonary Injuries
Laryngeal Injury
Rare and Life threating Caused by “clothesline” type injuries Females with long narrow necks are
predisposed s/s:
› Hoarseness, stridor, hematoma, ecchymosis, tenderness, sq emphysema, crepitus, or loss of landmarks
Tx:› NPO, HOB 30-45degrees, O2, ETT, Tracheostomy
Pneumothorax
Accumulation of air in the pleural space S/S – SOB, tachycardia, tachypnea,
decreased or absent breath sounds on the injured side, chest pain
Chest tube is indicated for PTX of usually greater than 10%
Needle decompression or chest tube insertion
Open Pneumotorax
“sucking chest wound”› May see bubbles or hear a “hissing” sound
Usually result of penetrating chest wound
Apply 3 sided dressing, allowing air out but not in
If penetrating object still in place *DO NOT REMOVE*
Tension PTX
Life threating Accumulation of air in one pleural
space forces thoracic contents to the opposite side of the chest› Air can get in but not out
Immediate needle decompression is required
Hemothorax An accumulation of
blood in the pleural space
S/S – SOB, Tachypnea, chest pain, decreased breath sounds
TX – chest tube with suction. May need to consider auto-transfusion or O.R.
Chest Tube insertion
YouTube - Chest Tube Insertion..!
Pulmonary Contusion
Potentially leathal 75% of pts with chest injury
› 40% mortality Contusions occur when underlying lung
parenchyma is damaged, causing edema and hamorrhage
Tx: › Semi-fowlers, suction, ETT (for severe
hypoxia)› Usually improve in 3-5 days
Ruptured Diaphragm
Potentially life threatening injury
S/S – SOB, difficulty swallowing, abd pain, bowel sounds heard in the lower to middle chest, decreased lung sounds on injured side
Cardiac and Great Vessel
Injury
Pericardial Tamponade Collection of blood
in pericardial sac S/S- Hypotension,
tachycardia or PEA, SOB, cyanosis› Beck’s Triad ~
Hypotension, JVD, muffled heart tones
Pericardiocentsis
http://www.youtube.com/watch?v=T1LbBxxwjak
Aortic Injury
Immediately fatal in most cases, usually die at the scene
Dx done by CXR
Aortic Injuries
Caused by penetrating or blunt trauma
S/S ~ hypotension, decreased LOC, chest pain, decreased quality of femoral pulses
Abdominal Trauma
Abdominal Trauma
Significant source of morbidity and mortality
Patients usually have a lot of pain and high risk for bleeding
Anatomy Peritoneum Solid Organs
› Liver, spleen, gallbladder Hollow organs
› Stomach, Bowels, Bladder
Reproductive Organs› Uterus, ovaries, penis,
testes Vascular Structures
› Abdominal Aorta
Assessment History Mechanism
› Blunt, Penetrating, MVA Auscultation
› Abdominal quadrants Palpation
› Start away from area of pain
Interventions
Foley› Check for bleeding first and do rectal for
prostate placement NG/OGT
› When to use NG vs OG tubes Wound Care Medications
› Pain, ABX Diagnostics
› XR, CT, FAST, MRI, ANGIO, DPL, Labs
Splenic Injuries
Associated with fractures to 11th and 12th ribs
S/S ~ LUQ abd pain, left shoulder pain, abd wall rigidity.
Severe injuries require surgery
Hepatic Injuries
Scaled 1-5 (p308)
RUQ abd pain, abd wall rigidity, rebound tenderness
Can have diffuse right shoulder pain
Large and small bowel injuries
Occur in less than 1% of trauma injuries
Assess for Seatbelt Sign S/S ~ peritoneal irritation manifested
by abd wall muscle rigidity, pain, hypovolemic shock, gross blood from rectum
Triple contrast CT
DPL
http://www.youtube.com/watch?v=FXtoTrLuFj8
Renal Injuries
Most common is blunt contusion S/S Gross or microscopic hematuria Flank or abd tenderness Ecchymosis over flank area 1-5 Levels (pg310)
› 1=Minor, 5=Major
Renal Injuries
Orthopedic and NeurovascularTrauma
Anatomy
Bones› Cancellous (spongy)
Skull, vertebrae, pelvis, ends of long bones› Cortical (dense)
Long Bones Ligaments & Tendons- connect bones
together Joints
› Nonsynovial (non-movable)› Synovial (freely movable)
Assessment
ABCs Stabilize and control bleeding Assess for edema, deformity, abrasion,
laceration, puncture Focused neurovascular
› Pain, pulses, paralysis, parasthesia, pallor (5p’s)
Immobilization
ASAP Soft splints (pillows), hard splints
(fiberglass), Traction splint (reduce angulation)
Neurovascular checks pre and post Elevate and Ice after splint
Orthopedic Trauma
Immediate treatment required for following-› Open Fracture› Pulseless extremity› Compartment syndrome› Hemorrhaging
Back Pain Affects 60-80% of population beginning
at ages 30-40 May be chronic or acute Concern is to R/O serious injury/disease Red Flags
› Trauma, age >50, fever, cancer, muscle weakness or inability to move, loss of sensation, weight loss
TX ~ Rest, Ice, NSAIDS, usually resolves
Dislocations Loss of anatomical position of
2 bone surfaces Medical emergency due to risk
for nerve and blood vessel damage
Usually requires conscious sedation
Affects shoulder, ankle, patellar, elbow
Shoulder dislocations
High incidence of recurrence Specific mechanisms or historical facts may
be suggestive of certain types of dislocations, such as lightning injuries, electrical injuries, and seizure with posterior dislocations
throwing a ball or a punch or forceful pulling of the arm with an anterior dislocation
axial loading of an extremely abducted arm with inferior dislocation.
Fractures
Fracture assessment
General trauma assessment must be completed to r/o other injury (distracting)
Extremity exam (PMSC)› Pulse, Motor, Sensation, Cap refill
S/S ~ pain, deformity, edema, spasm, numbness, tingling, crepitus
TX: Immobilze, splint, pain meds, ice, elevate
Open Fractures
Considered contaminated because of possibility of foreign materials
Graded from 1-3 Patient will require pain meds,
antibiotics, and tetanus prophylaxis Usually are in surgery for copious
irrigation within 24 hours
Amputations
Need to know history of injury Straight or guillotine cut has best
replantation potential Contraindications include: de-gloved,
mangled, crushed body part, or mishandling of body part
Consider transfer to re-implantation center
Amputations
For body part› Gently lift of contaminates (no soap, no
betadine, no peroxide)› Wrap in saline soaked gauze and place in
dry plastic bag and seal› Place bag on top of ice› Avoid submersion in ice water and avoid
dry ice
Crush Injuries
Caused by prolonged entrapment or crushing blow
Cellular destruction and damage to vessels and nerves make crush injuries difficult to treat
Compartment Syndrome 6 P’s
› Pain› Pallor› Paresthesias› Pulses› Pressure› Paralysis
Treatment Steinman Pin
› Provides temporary reduction of long bone fx’s, until open reeducation or internal fixation can be done
Treatment
Casts› Place splint if severe swelling expected
Clean skin well prior to placement Education pt to look for compartment
syndrome and not to scratch inside cast
Ambulation
Crutches› Proper fit is key
Cane› Minimal assistance
Walker Wheelchair
› May be used temporarily until ambulation therapy or training complete
Maxillofacial Trauma
Anatomy
Principle facial bones include frontal, nasal, maxilla, zygoma, and mandible
Assessment
ABCs› Mandibular fx may cause tongue to be
displaced blocking the airway› Remove dentures or other foreign bodies
Suction secretions Palpate facial structures Check vision and perception Obvious deformity or inury
Soft Tissue Trauma
Repair Lacerations within 8-12hrs› Unless combative- wait until more
cooperative Road Rash
› Debridement done asap Hematomas
› Should be drained and dressed to prevent scaring
Avulsions› May require plastic surgery followup
Mandibular fractures
Mainly R/T MVA, altercations S/S
› Pain, tenderness (often referred to ear)› Inability to open mouth (trismus)› Malocclusion› Ruptured TM or blood behind TM› Numbness to lower lip
Mandible Fracture
Mandible Fracture
TX: › Assure airway clearance› Prep for OR› Possibly wiring of the jaw in the ED
Orbital Fractures
“Blowout” fracture Usually caused by ball, baseball bat, or
other blunt blow High risk for nerve and tissue
damage/entrapment S/S
› Double vision, facial anesthesia, pain, limited vertical eye movement, enopthalmos
Orbital Fracture
Orbital Fracture
TX› Ice to area› ABC’s/CSP› Instruct not to blow nose› Pain meds, antibiotics› Prep for OR ~ usually a few days after
once swelling has gone down
Zygomatic Fracture
Mainly R/T MVA, altercations Sometimes presented with orbital fx S/S ~ pain, assymmetry of the face,
flattened cheek, epistaxis, double vision, numbness to cheek
TX: ABC’s, ice, eventual OR
Zygomatic Fracture
Maxillary Fractures
R/T MVA, assaults Classified into “LeFort” 1, 2, or 3
› LeFort 1 ~ transverse detachment of entire maxilla above teeth at level of nasal floor
› LeFort 2 ~ fracture of midface that involves a triangular segment of the mid face and nasal bones
› LeFort3 ~ complete separation of the cranial attachments from the facial bones
Maxillary Fracture
S/S› Facial edema› Nasal swelling› Malocclusion› Nasal swelling› CSF rhinorrhea (II, III)
LUNCH