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Nursing Management of Patients with Trauma Cheat Sheet by

Adult Health 2

Trauma Centers

Level 1: compr­ehe­nsive care for any need r/t injury; prevention & research
Level 2: can provide care for all injured pts, many of same types of care but often on-call; preven­tion, no research
Level 3: prompt assessment , resusc­ita­tion, surgery if needed, stabilize pt; contract w/ another hospital
Level 4: (ED) staff have ACLS, stabilize & transfer; can do mild trauma
Level 5: evaluate, stabilize, transfer

Mechanisms of Injury

Radiation
Electrical
Thermal
Chemical
Mechanical
Motion
Motion: car damage helps w/ body damage
Rapid fwd decel - organs on body on tree
Head-on collision - front impact, windsh­ield, steering wheel, dashboard
Dashb­oard - knee, long-bone, C-spine, pelvis
T-bone - side of body, rib fx from console
Rollover - depends, thrown if no seat belt
Airbags - put seat back as far as possible

Diagnostic Studies

Radiol­ogical tests
Diagnostic perineal lavage (now - US)
Labs - ABGs, CBC, coagul­ation studies (r/t DIC), serum electr­olytes
Glucose (r/t stress response)
UA on all trauma pts (tox & pregnancy)
Blood type & screen (trans­fusion)

Initial Assessment & Management

MAIN GOAL: minimize time from initial insult to definitive care, optimize pre-ho­spital care
Want them to be there within 1 hr of injury
Primary Survey - often in ER, find injuries
- A irway
- B reathing (pain, pattern)
- C irculation (hypo­volemic shock common)
- D isability (LOC, >length w/o consci­ousness = >di­sab­ility - Glasgow Coma Scale)
- E xposure (anything we're missing?)
Resu­sci­tation Phase
Crys­tal­loids (isot­onic) Coll­oids (large molecu­les) Blood (O-, T&C, type)
Seco­ndary Survey - History, AMPLE
- A llergies
- M edications
- P MH
- L ast meal - (dec. aspiration risk)
- E vents preceeding
Also: examine body, indwelling cath (I&O), NGT (decom­press stomach), special prodecures (WKG, XR, CT)
Oper­ative Phase
- Must be as stable as possible
Critical Care Phase - ICU
- Close intensive care, frequent assess­ments
- IV lines & fluids
- Ventilator
Carotid + = SBP >60 / Femoral + = SBP >70
Radial + = SBP >80

Chest Trauma

Penetr­ating or blunt
Children have more pliable chests (carti­lage)
Types:
- Myocardial or pulm. contusion
- Rib fx
- Flail chest
- Cardiac tamponade
- Pneumo­thorax
- Hemothorax

Myocar­dia­l/P­ulm­onary Contusion

Myoc­ardial contus­ion: bruising to heart; R side most common
- Dec. contra­ctility dec. CO
Asse­ssm­ent - c/o CP, SOB
Pulm­onary contus­ion: bruising to lungs
- Most common chest injury
Asse­ssm­ent - erythema, bruising on outside, pain w/ breathing
Mana­gem­ent - ABC(DE)
Pain on breathing risk for - pneumonia, hyperc­apnic, hypoxic
May also see rib fx

Rib Fractures

Common injury usually due to blunt trauma
- Ribs 4-9 most common, 1-3 take sig. force
Risk for - ARDS
Asse­ssm­ent - hypove­nti­lating hypoxia hyperc­apnia
Mana­gem­ent - treat pain to prevent ARDS, can get up, move, breathe

Flail Chest

Multiple rib fx, part discon­nected (3+) {nl}} - Often unilat­eral, r/t blunt chest trauma
Para­doxical breath­ing: flail part floats w/ breathing
Risk for - ARDS
Asse­ssm­ent - hypove­nti­lating = hypoxia, hyperc­apnia
Mana­gem­ent - ventil­lator, PEEP

Cardiac Tamponade

Fluid accumu­lation in perica­rdium dec. CO
Asse­ssm­ent - Beck's Triad (muffled heart sounds, JVD, hypote­nsion
Mana­gem­ent - suppor­tive, O2,
perica­rdi­oce­ntesis
Heart won't move if 200-300 mL!

Pneumo­thorax

Injury in which air enters pleural space, usually r/t blunt trauma
Open (openning in chest cavity) vs. closed
Asse­ssm­ent
Mana­gem­ent - chest tube, pain control, O2
GOAL: dec. + pressure & restore - pressure
Patho - trauma to lung injury air enters lung collapses alveoli collapse atelec­tasis V/Q mismatch hypoxia

Tension Pneumo­thorax

Life-­thr­eat­ening compli­cation usually r/t blunt chest trauma (pneum­oth­orax)
- Can quickly be fatal if not detected, treated
Asse­ssm­ent - deviation of everything to unaffected side (trachea); diminished lung sounds, cyanosis, JVD, hypote­nsive
Mana­gem­ent - Release air!

Hemothorax

Usually due to blunt chest trauama or penetr­ating injury
Simple (~1500 mL) or mass­ive (~3000 mL)
Asse­ssm­ent - dec. breath sounds, hypoxia; percuss = dull on affected side (may have total of 3 L buildup per side)
Mana­gem­ent - chest tube or surgery
 

Diagnostic Findings

CXR
fracture, hemo- or pneumo­thorax
ABG's
hypoxemic, acid-base imbalance
EKG
hypoxemia arrythmias
CBC
serial CBC's q6h to determine bleeding, something else

Chest Trauama Management

GOAL: prevent respir­atory compromise & compli­cations
Airway
Hemo - replace blood
Chest tube insertion
Check dressing around CT for erythema
IVF & blood replac­ement
OR depending on severity
No vent cough, deep breathe (ARDS!), ICS
Splint if rib fx
Pain - nerve block

Abdominal Trauma

Injury blunt or penetr­ating
Massive blood loss/shock & not know until severe retrop­eri­toneal
Asse­ssm­ent - s/s may vary greatly, REASSESS!
Pain
Wounds & abrasions
Bruising
Bowel sounds
Balance signs
Kehr's sign: acute shoulder pain r/t
blood/­other irritants in peritoneum when pt is lying & legs elevated
= ruptured spleen
Cullen's sign: bruising below umbilicus
Turner's sign: flank bruising
Diaphr­agmatic rupture (hear bowel sounds w/ breath sounds)
Hypovo­lemia w/ large blood loss
Spleen most commonly damaged!
- Abd. aorta, liver, & hepatic vessels
Bladder rupture from blunt trauma
Knife wound w/ evisce­ration sterile saline on organs
Impalement injury STABILIZE & remove in OR

Diagnostic Studies

X-ray
CT scan - GOLD STANDARD FOR INJURIES
CBC (serial H&H)
WBC - inflam­mation; abd wounds often dirty = prophy­lactic antibi­otics
Serum glucose
Serum amylase
Liver enzymes
US - bleeding?
Peri­toneal lavage

Abdominal Trauma Management

GOAL: correct volume deficit, prevent shock & infection
Prophy­lactic antibi­otics
IVF - crysta­lloids, colloids, blood
NGT, Foley
All invasive procedures
Try non-na­rcotic analgesics no ilieus

Limb Trauma

Types:
- Stra­ins: stress injury to muscle at tendon
- Spra­ins: ligament injury
- Frac­tur­es: break in the bone
Asse­ssm­ent:
Strains & sprains - pain, swelling, tender­ness, muscle spasms
Fract­ures - same + loss of movement, may actually see bone/d­efo­rmity
Diag­nos­tics - XR (broken bones, visualize struct­ures)
Mana­gem­ent - immobi­lize, RICE
- Compre­ssion bandage
- Ice first 24-48 hr, heat to inc. circul­ation

6 P's of Limb Trauma

CARD­IOV­ASC­ULAR
NEUR­OVA­SCU­LAR
Pulseless
Parest­hesia
Pallor
Paralysis
Polar
Pain
 

Crush Injuries

Blood not circul­ating
Hypovo­lemic shock
Paralysis
Erythema - r/t broken blood vessels (= edema) & hard
Damaged body part
Renal dysfun­ction - rhabdo­molysis

Compli­cations of Trauma

Hype­rme­tab­olism - NEED 3,000 cal + regular BMR in first 24-48 hr
- Lose diaphr­agmatic integrity = won't get off vent, bacteria migrate = VAP
- Promotes healing: inc. permea­bility of bowel = easier for bacteria to enter blood (infec­tion, sepsis)
Infe­ction - antobi­otics prophy­lac­tic­ally; seen in first 3 days, may be septic
Sepsis - debride often
Rhab­dom­yol­ysis - tissue breakdown myoglobin released AKI renal failure
- Dark, tea-co­lored urine
- Genera­lized weakness, muscle stiffness
- Treatment: IVF to clean out kidneys & lg molecules to dec. kidney damage
Multiple organ system dysfun­ction (MODS)
PULMONARY
Resp­iratory failure - risk of ARDS
Pulm­onary embolism - r/t damages, DIC
Fat embolism syndrome - long bone break = high risk
- Affects clotting system, thromb­ocy­topenia
Pain - always an issue

More Compli­cations of Trauma

GASTRO­INT­ESTINAL
Hemo­rrh­age
Acal­culous cholec­yst­itis
RENAL
Renal failure
Myog­lob­inu­ria
VASCULAR
Comp­artment syndrome - inc. pressure in confined space = restricts blood flow = area tense, swollen, no pulse fasciotomy
- Exper­ienced pain out of proportion with what you would expect
Venous thromb­oem­bol­ism
Hypo­ten­sion
Elderly - other comorb­idities make recovery difficult
               

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