TNCC Trauma Nursing Core Course 7th Edition ENA – Flashcards
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Components of SBAR and its purpose
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S: Situation B: Background A: Assessment R: Recommendation Purpose- to provide framework for communication amount members of the healthcare team p. 7
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Components of DESC and its purpose
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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
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Components of CUS and its purpose
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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
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Define trauma
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- 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
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Leading cause of death for ages 1. over 65 2. 5 to 24 3. 25 to 64
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1. Falls 2. MVCs 3. poisoning p. 9
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Explain 3 phases of injury prevention
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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
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Describe the three E's of injury control
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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 Enforcement and legislation: include laws at all jurisdictional levels regarding driving while intoxicated, booster seats, primary seatbelt use, and distracted driving. For sports this includes rules regarding illegal hits, examination after impact, and return-to-play requirements after a head injury Education: these can be community-based initiatives such as public service announcements for improved seatbelt use, education regarding risks of distracted driving, programs to commit to no texting while driving, and promotions for bicycle helmet giveaways with instructions for proper use p. 11
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How can the trauma nurse have an impact when it comes to the legislative process?
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By advocating for stronger laws and more consistent enforcement p. 11
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Define kinematics
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The study of energy transfer as it applies to identifying actual or intentional injuries p. 25
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Define biomechanics
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The general study of forces and their effects p. 25
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Define mechanism of injury (MOI)
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How external energy forces in the environment are transferred to the body p. 25
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Newton's First Law of Motion
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A body at rest will remain at rest, and a body in motion will stay in motion p. 26
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Newton's Second Law of Motion
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Force = Mass X Acceleration p. 26
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Newton's Third Law of Motion
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For every action, there is an equal and opposite reaction p. 26
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Law of Conservation of Energy
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Energy can neither be created nor destroyed, but it can change form p. 26
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Describe energy forms
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- Mechanical (energy transfer from one object to another in the form of motion) - Thermal (energy transfer of heat in environment to the host) - Chemical (heat energy transfer from active chemical substances such as chlorine, drain cleaner, acids, or plants) - Electrical (energy transfer from light socket, power lines, or lightning) - Radiant (energy transfer from blast sound waves, radioactivity such as a nuclear facility, or rays of the sun) p. 26
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External energy forces can be exerted on the body by the following forces
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- 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
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The degree to which tissues resist destruction under circumstances of energy transfer depends on...
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Their proximity to the impact and their structural characteristics p. 27
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Structural strengths of tissue are described in what three ways?
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-Compression -Tensile -Shear p. 27
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Compression strength refers to the tissue's ability to:
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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
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Tensile strength describes the tissue's ability to:
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Resist pulling apart when stretched - Tendons, ligaments, and muscles can tear when they are overstretched (Achilles tendon) p. 27
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Shear strength describes the tissue's ability to:
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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
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Types of injuries include
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- Blunt trauma - Penetrating trauma - Thermal trauma - Blast trauma p. 28
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Lateral impacts (T-bone) are associated with
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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
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Depending on the motorcycle design and rider positioning, the lower extremities can collide with the handlebars, resulting in...
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Femur and pelvis fractures and hip dislocations p. 31
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Cavitation refers to the...
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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
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The U.S. Department of Defense classifies blast injuries in five levels:
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- 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. - Quinary injuries are those associated with exposure to hazardous materials from radioactive, biologic, or chemical components of a blast. ch. 4, p. 33
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Compression may occur from the effects of chemical substances and can cause..
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Edema, restricting or obstructing the airways, oxygenation, and ventilation. This can result from aspiration of liquids or inhalation of powder or noxious gas. ch. 4, p. 33-34
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The Haddon Matrix broadened the approach and placed emphasis on countermeasures, such were more effective than changing human behavior. Haddon describes three phases of the injury event:
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Pre-event, Event, Post-event For each phase of the event, countermeasures for prevention can be applied. They include: The host (human) The agent (motor vehicle) The physical environment (socioeconomic environment) ch. 4, p. 34
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Initial assessment - approach to trauma patient care that requires a process to identify and treat or stabilize life-threatening injuries in an efficient and timely manner. It is divided into the following process points:
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- Preparation and triage - Primary survey (ABCDE) with resuscitation adjuncts (FG) - Reevaluation (consideration of transfer) - Secondary survey (HI) with reevaluation adjuncts - Reevaluation and post resuscitation care - Definitive care of transfer to an appropriate trauma center ch. 5, p. 39
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The A-I mnemonic helps the trauma nurse rapidly assess for and intervene in life-threatening injuries and identify all injuries in a systematic manner.
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A: airway and alertness with simultaneous cervical spinal stabilization B: breathing and ventilation C: circulation and control of hemorrhage D: disability (neurological status) E: exposure and environmental control F: full set of vital signs and family presence G: get resuscitation adjuncts: L - lab studies (ABGs) and obtain specimen for blood type and cross match M - monitor for continuous cardiac rhythm and rate assessment N - naso or orogastric tube consideration O - oxygenation and ventilation analysis: pulse oximetry and end-tidal carbon dioxide (ETCO2) monitoring and capnography P - pain assessment and management H: history and head-to-toe assessment I: inspect posterior surfaces ch. 5, p. 39
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When does the approach to trauma care typically begin?
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With notification that a trauma patient is arriving to ED ch. 5, p. 39
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What does 'safe practice' mean?
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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
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What does 'safe care' mean?
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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
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During primary survey...
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Life-threatening conditions are identified and immediately corrected, beginning immediately upon the patient's arrival to the trauma room. ch. 5, p. 40
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What is the most major cause of preventable death after injury?
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Uncontrolled hemorrhage ch. 5, p. 40
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Explain the MARCH mnemonic
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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
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While in ED, alignment and protection of the cervical spine can be accomplished by which 2 ways?
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- Manual stabilization - Immobilization ch. 5, p. 42
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Explain the AVPU mnemonic
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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 ABC ch. 5, p. 42
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Use the jaw-thrust maneuver to open airway and assess for obstruction when the patient is...
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Unable to open the mouth, responds only to pain, or is unresponsive. ch. 5, p. 42
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Once patient has airway in place, assess for proper placement by...
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- 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
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If patient's airway is NOT patent:
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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 3. Consider a definitive airway (ET tube securely placed in trachea with cuff inflated) - The following conditions or situations require a definitively secured airway --apnea -- GCS score < 8 -- severe maxillofacial fractures -- evidence of inhalation injury/facial burns -- laryngeal or tracheal injury or neck hematoma -- high risk of aspiration and patient's inability to protect airway -- compromised or ineffective ventilation -- anticipated of deterioration of neurological status ch. 5, p. 43
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What are the late signs that may indicate a tension pneumothorax?
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JVD and tracheal deviation ch. 5, p. 43
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If breathing is absent:
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- Open airway using jaw-thrust maneuver while maintaining manual cervical spinal stabilization - Insert and oral airway adjunct - Assist ventilations with bag-mask device - Prepare for definitive airway ch. 5, p. 44
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If breathing is present:
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1. Administer O2 at 15L/min via nonrebreather mask -- inability to maintain adequate oxygenation, causes hypoxemia resulting in anaerobic metabolism and acidosis -- Titrate oxygen delivery for stabilized trauma patients to avoid the detrimental physiologic effects of hyperoxia 2. Determine if ventilation is effective -- ETCO2 (end-tidal carbon dioxide) measurement between 35-45 shows effective ventilation. Level above 50 signifies depressed ventilation -- SpO2 of 94% of higher is associated with effective ventilation ch. 5, p. 44
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The major assessment parameters that produce important information within seconds of a patient's arrival are...
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1. Level of consciousness 2. Skin color 3. Pulse ch. 5, p. 44
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The assessment of circulation during the primary survey includes...
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Early evaluation of the possibility of hemorrhage in the abdomen and pelvis in any patient who has sustained blunt trauma. In those cases, an emergent abdominal or pelvic assessment may be preformed to include a focused assessment with sonography for trauma (FAST) examination or a radiograph of the pelvis. ch. 5, p. 44
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A rapid, thready pulse may indicate (a. _______), and an irregular pulse may warn of potential (b. _______).
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a. HYPOVOLEMIA b. CARDIAC DYSFUNCTION ch. 5, p. 45
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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...
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Dilutional coagulopathy which worsens metabolic acidosis and may cause hypothermia ch. 5, p. 45
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_________ therapy is now suggested for fluid resuscitation to replace patient losses, including administering PRBCs, plasma, and platelets.
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COMPONENT THERAPY ch. 5, p. 45
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Assess pupils for...
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Equality, shape, and reactivity (PERRL) ch. 5, p. 45
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Consider ABGs. A decreased level of consciousness may be an indicator of...
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Decreased cerebral perfusion, hypoventilation, or acid-base imbalance. ch. 5, p. 46
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Hypothermia combined with ______ and ______ is a potentially lethal combination.
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HYPOTENSION and ACIDOSIS ch. 5, p. 46
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Explain the LMNOP mnemonic
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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
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ABGs provide values of oxygen, CO2 and base excess, which are...
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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
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When does the secondary survey (HI) begin?
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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
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Additional history includes the following (MIST mnemonic) prehospital report:
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- MOI - Injuries sustained - Signs and Symptoms (in the field) - Treatment (in the field) ch. 5, p. 47
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SAMPLE mnemonic regarding patient's history
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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
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What are odors you want to be sure to document?
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Alcohol, gasoline, other chemicals ch. 5, p. 48
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Explain the B2-Transferrin test
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Gold standard for identifying CSF otorrhea or rhinorrhea ch. 5, p. 48
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What are some circumstances that may lead to unreliable pulse ox readings?
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- Poor peripheral perfusion - BP cuff inflated above sensor - CO poisoning (carboxyhemoglobin) - Methemoglobinemia - Severe dehydration Pulse ox provides evidence of SaO2 but not PaO2. The non-liner relationship between the two measurements is reflected in the oxyhemoglobin-dissociation curve. ch. 6, p. 65
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Oxyhemoglobin-dissociation curve indicates the correlation of tissue oxygneation (PaO2) as it saturates the hemoglobin molecule (SO2). P50 describes the oxygen pressure when the hemoglobin molecule is 50% saturated. Normal P50 is 26.7 mm Hg. A shift in the curve notes changes in the relationship:
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Shift to the RIGHT occurs in an environment of HIGH metabolic demand. Hemoglobin's affinity for oxygen decreases, making it easier to release the bound oxygen to the tissues. A shift to the right occurs in response to: - Increased carbon dioxide (hypercapnia) - Increased temp (hyperthermia) - Increased 2,3-diphosphoglycerate levels (a substance in blood that helps O2 move from hemoglobin to the tissues) - Decreased pH (acidemia) Shift to the LEFT occurs in an environment of LOW metabolic demand. Hemoglobin's affinity for oxygen increases, making it harder to release bound oxygen to the tissues. A shift to the right occurs in response to: - Decreased carbon dioxide (hypocapnia) - Decreased temp (hypothermia) - Decreased 2,3-diphosphoglycerate levels - Elevated pH (alkalosis) - Carbon monoxide and methemoglobinemia ch. 6, p. 65
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Trauma nurse should be attempting to maintain NORMOTHERMIA and NORMOCARBIA, which...
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Decreases risk of.. HYPOTHERMIA ACIDOSIS COAGULOPATHY ch. 6, p. 65
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Use the DOPE mnemonic to troubleshoot ventilator or capnography alarms
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D - Displaced tube O - Obstructed or kinked tube P - Pneumothorax E - Equipment failure, such as patient becoming detached from equipment or loss of capnography waveform ch. 6, p. 66
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Maintain PaO2 between
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100-200 mm Hg for ABGs ch. 6, p. 66
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RSI pretreatment medications Cough reflex can be blocked using IV...
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LIDOCAINE 1.5 mg/kg ch. 6, p. 67
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What are two examples of obstructive shock that may result from trauma?
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TENSION PNEUMOTHORAX and CARDIAC TAMPONADE ch. 7, p. 73
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__________, which can occur in resuscitation, is a common IATROGENIC cause of INCREASED intrathoracic pressure resulting in COMPRESSION of the heart and DECREASED cardiac output.
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HYPERVENTILATION ch. 7, p. 74
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Describe DISTRIBUTIVE SHOCK
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Occurs as result of maldistribution of an adequate circulating blood volume with loss of vascular tone or increased permeability. ch. 7, p. 75
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Describe ANAPHYLACTIC SHOCK
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Results from release of inflammatory mediators (e.g. histamine) which contracts bronchial smooth muscles and increases vascular permeability and vasodilation. ch. 7, p. 75
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Describe SEPTIC SHOCK
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Caused by systemic release of bacterial endotoxins, resulting in an increased vascular permeability and vasodilation. ch. 7, p. 75
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Describe NEUROGENIC SHOCK
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Occurs with SCI results in the loss of SNS control of vascular tone, which produces venous and arterial vasodilation. ch. 7, p. 75
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Early treatment for septic shock includes...
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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
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The increase of the diastolic blood pressure with a narrowing pulse pressure...
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May be one of the first CONCRETE measurements signaling that the patient's circulatory status is compromised. ch. 7, p. 76
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Activation of the SYMPATHETIC NERVOUS SYSTEM causes the ADRENAL glands to release TWO catecholamines - EPINEPHRINE and NOREPINEPHRINE. These cause...
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- 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
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One of the earliest responses to inadequately pefused tissue is...
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TACHYPNEA ch. 7, p. 78
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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...
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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
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Resuscitation-associated coagulopathy is associated with the trauma triad of death. It includes...
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HYPOTHERMIA impairs thrombin production and platelet function ACIDOSIS impairs thrombin production COAGULOPATHY results in depletion of clotting factors through hemodilution and impaired ability to produce clotting factors ch. 7, p. 78
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Stage I: Compensated Shock
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- Anxiety, lethargy, confusion, restlessness from oxygen being shunted to brainstem - Systolic BP usually within normal range - Rising diastolic BP, results in narrowed pulse pressure, which is a reflection of peripheral constriction - A bounding and/or slightly tachycardic pulse - Increased RR - Decreased urine output ch. 7, p. 79
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Stage II: Decompenstated or Progressive Shock
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- LOC deteriorates patient becomes obtunded or unconscious as cell switch to anaerobic metabolism with increasing levels of lactic and pyruvic acids - Normal or slightly decreased systolic BP - Narrowing pulse pressure that continues until peripheral vascular vasoconstriction fails to provide cardiovascular support - HR > 100 beats/min - Weak, thready pulses - Rapid, shallow respirations - Cool, clammy, cyanotic skin - Base excess not within normal range of -2 to +2 - Serum lactate levsl > 2 to 4 ch. 7, p. 79
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Stage III: Irreversible Shock
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- Obtunded, stuporous, comatose - Marked hypotension and HF - Bradycardia with possible dysrhythmias - Decreased and shallow RR - Pale, cool, clammy skin - Kidney, liver, and other organ failure - Severe acidosis, elevated lactic acid levels, and worsening base excess on ABGs - Coagulopathies with petechiae, purpura, or bleeding ch. 7, p. 79
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Replacement with packed cells and saline without also transfusing with _______ and _______ further dilutes the patient's ability to clot blood.
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PLATELETS and PLASMA ch. 7, p. 79
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Because calcium is a vital part of the clotting casade, hypocalcemia, as a result of a massive transfusion, can actually worsen hypovolemic shock by...
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Permitting continued bleeding Signs of hypocalemia include- dysrhythmias, muscle tremors, and seizures ch. 7, p. 81
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Disadvantages of auto-transfusion include:
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- 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
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Explain what Tranexamic acid (TXA) is
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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
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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...
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Indicative of Shock ch. 7, p. 82
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What lab studies are used to guide resuscitative efforts in shock?
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- 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
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Following the primary survey, FAST examination may be used to rapidly assess for bleeding from damage to the...
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Heart, liver, kidneys, and spleen. FAST also increasingly used to detect pneumothorax, especially tension pneumothorax. ch. 7, p. 84
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Output less than 0.5 mL/kg per hour for two consecutive hours indicates...
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OLIGURIA ch. 7, p. 84
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Pain Theories include...
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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
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Classifications of acute pain are based on the source and origin and include...
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SOMATIC pain originates from skin and muscloskeletal structures VISCERAL PAIN originates from organs and may lead to referred pain ch. 8, p. 93
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Explain oligoanalgesia
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the concept of undertreatment of pain ch. 8, p. 94
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Physiologic effects of pain by system: Cardiovascular
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HYPERCOAGULATION INCREASED CARDIAC WORKLOAD INCREASED OXYGEN DEMAND ch. 8, p. 97
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Physiologic effects of pain by system: Respiratory
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SPLINTING HYPOVENTILATION HYPERCARBIA RESPIRATORY ACIDOSIS INCREASED RISK OF ATELECTASIS & PNEUMONIA ch. 8, p. 97
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Physiologic effects of pain by system: Musculoskeletal
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IMPAIRED MUSCLE FUNCTION IMMOBILITY FATIGUE MUSCLE SPASM ch. 8, p. 97
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Physiologic effects of pain by system: Gastrointestinal
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DECREASED MOTILITY ch. 8, p. 97
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Physiologic effects of pain by system: Genitourinary
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DECREASED URINARY OUTPUT URINARY RETENTION FLUID OVERLOAD ch. 8, p. 97
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Physiologic effects of pain by system: Endocrine
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INCREASED RELEASE OF HORMONES AND MEDIATORS ch. 8, p. 97
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Physiologic effects of pain by system: Metabolic
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GLUCOGENESIS HYPERFLYCEMIA GLUCOSE INTOLERANCE INSULIN RESISTANCE MUSCLE PROTEIN CATABOLISM INCREASED LIPOLYSIS ch. 8, p. 97
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Physiologic effects of pain by system: Immune
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DECREASED RESPONSE ch. 8, p. 97
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Explain the Cushing response
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Loss of auto regulation (cerebral blood flow) can result in cerebral and brainstem ischemia, initiating a central nervous system response known as Cushing response. It is characterized by a triad of assessment findings: - widening pulse pressure - reflex bradycardia - diminished respiratory effort Ch. 9, p. 107
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Describe the MOI associated with brain, cranial, and maxillofacial trauma
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BLUNT injury - falls, MVCs, sports-related injuries, recreation PENETRATING injury - firearms or exploding objects or projectiles Ch. 9, p. 108
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Pathophysiologic concepts that affect the patient with brain, cranial, or maxillofacial injuries include issues related to...
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- HYPOTENSION and CBF - HYPOXIA and HYPERCARBIA - ICP Ch. 9, p. 108
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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.
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50 and 160 mm Hg Ch. 9, p. 108
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If autoregulation fails and MAP is elevated, _______ can result.
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EDEMA Ch. 9, p. 109
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As ICP rises, CPP ________, resulting in cerebral ischemia, hypoxemia, and lethal secondary insult.
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DECREASES Ch. 9, p. 109
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Early assessment findings of increased ICP include:
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- HEADACHE - NAUSEA/VOMITING - AMNESIA - BEHAVIOR CHANGES (IMPAIRED JUDGEMENT, RESTLESSNESS, DROWSINESS) - ALTERED LEVEL OF CONSCIOUSNESS ( HYPO/HYPERAROUSABILITY) Ch. 9, p. 109
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Late assessment findings of increased ICP include:
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- 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
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Mastoid process ecchymooses
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Battles sign, indicates middle fossa fracture Ch. 9, p. 113
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What can you assess to ensure the brainstem is intact?
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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
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Describe FOCAL BRAIN INJURIES
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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
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Assessment findings of a INTRACEREBRAL HEMATOMA
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- PROGRESSIVE, RAPID DECLINE IN LOC - HEADACHE - SIGNS OF INCREASING ICP - PUPIL ABNORMALITIES - CONTRALATERAL HEMIPARESIS - HEMIPLEGIA - ABNORMAL POSTURING Ch. 9, p. 114
question
Assessment findings of a EPIDURAL HEMATOMA
answer
- 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
question
Assessment findings of an ACUTE SUBDURAL HEMATOMA
answer
- SEVERE HEADACHE - CHANGES IN LOC - IPSILATERAL DILATED or NONREACTIVE PUPIL - CONTRALATERAL HEMIPARESIS Ch. 9, p. 114
question
Assessment findings of a CHRONIC SUBDURAL HEMATOMA
answer
- ALTERED or STEADY DECLINE IN LOC - HEADACHE - LOSS OF MEMORY or ALTERED REASONING - MOTOR DEFICIT: CONTRALATERAL HEMIPARESIS, HEMIPLEGIA, OR ABNORMAL MOTOR POSTURING OR ATAXIA - APHASIA - IPSILATERAL UNILATERAL FIXED and DILATED PUPIL - INCONTINENCE - SEIZURES Ch. 9, p. 114
question
Assessment findings of a HERNIATION SYNDROME
answer
- ASYMMETRIC PUPILLARY REACTIVITY - UNILATERAL or BILATERAL PUPILLARY DILATION - ABNORMAL MOTOR POSTURING - other evidence of neurologic deterioration (loss of normal, reflexes, paralysis, or change in LOC) Ch. 9, p. 115
question
Assessment findings of a DIFFUSE INJURY
answer
Injuries that occur over a wide spread area, not always identifiable on CT because damage involves contusions or hearing and stretching of micro vascular, not a localized hematoma. These injuries commonly follow a direct blow to the head and are often sports-related. Patients can have varying degrees of symptoms that last minutes to hours. Assessment findings include: - TRANSIENT LOC - HEADACHE, DIZZINESS - NAUSEA, VOMITING - CONFUSION, DISORIENTATION - MEMORY LOSS and CONCENTRATION DIFFICULTY - IRRITABILITY and FATIGUE Ch. 9, p. 115
question
Assessment findings for MILD, MODERATE, and SEVERE TRAUMATIC BRAIN INJURY INCLUDE:
answer
MILD - GCS 13-15 - Brief (<30 min) LOC - POST-TRAUMATIC AMNESIA < 24 hours - No change on neuron aging studies MODERATE - GCS score 9-12 - Wide variety of symptoms, including ALTERATIONS IN CONSCIOUSNESS, CONFUSION, AMNESIA, and FOCAL NEUROLOGICAL DEFICITS - May deteriorate to severe head injury over time SEVERE - GCS score <8 - Significant alterations in consciousness - ABNORMAL PUPILLARY RESPONSE - ABNORMAL POSTURING Ch. 9, p. 115
question
Explain what second impact syndrome is
answer
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
question
POSTCONCUSSIVE SYNDROME assessment findings include:
answer
- 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
question
Assessment findings of DIFFUSE AXONAL INJURY
answer
- 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
question
Explain why antipyretics are not effective in treating hyperthermia in acute brain injury.
answer
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
question
Why is CONTINUOUS ICP MONITORING important?
answer
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
question
What are the two priorities in treating patients with TBI?
answer
Facilitating OXYGENATION and VENTILATION Ch. 9, p. 120
question
What is the difference between penetrating and perforating in regards to ocular injuries?
answer
Penetrating - having ENTRANCE WOUND, an INTRAOCULAR FOREIGN BODY when they are present Perforating - having ENTRANCE and EXIT WOUND Ch. 10, p. 125
question
True or false: ALL eye injuries, even the most minor, require a visual acuity examination.
answer
TRUE Ch. 10, p. 125
question
Up to 25% of the general population have UNEQUAL PUPILS, called ANISOCORIA; this is benign and caused by...
answer
- TRAUMA - INCAL HERNIATION - OCULOMOTOR NERVE (CN III) PALSY - MEDICATIONS - SOME NEBULIZERS (IPRATROPIUM) Ch. 10, p. 126
question
What can you do to easily see eyes that have abrasions?
answer
Stain them with fluorescein Ch. 10, 129
question
Treatment for CORNEAL ABRASIONS include:
answer
- TOPICAL OPHTHALMIC ANTIBIOTICS If causes by contact lenses, treat for Pseudomonas - CYCLOPLEGIC OPHTHALMIC AGENT to decrease spasms and pain - TOPICAL OPHTHALMIC NSAIDS such as ketorolac, diclofenac to reduce swelling - ORAL ANALGESICS - NO PATCHING; evidence shows they heal faster unmatched - Follow up with OPHTHALMOLOGIST in 24 hours Ch. 10, p. 129
question
Interventions for INTRAOCULAR FOREIGN BODY include
answer
- Elevating HOB - CONSULT - IMMOBILIZE FOREIGN BODY IF LARGE WITH POTENTIAL to become unstable - PATCH UNAFFECTED EYE to LIMIT concomitant eye movement - PEFORM GLOBE CLOSURE ASAP - ADMINISTER SYSTEMIC and TOPICAL ANTIBIOTICS - SYSTEMIC ANALGESICS Ch. 10, p. 130
question
Explain OBITAL FRACTURE
answer
- NOT CONSIDERED OPHTHALMOLOGIC EMERGENCY unless there is IMPAIRED VISION or GLOBE RUPTURE - Usually result from DIRECT BLOW TO EYE - Complication of this type of fracture is ENTRAPMENT OF THE INFERIOR RECTUS or INFERIOR OBLIQUE MUSCLE Assessment findings include: - PERIORBIAL ECCHYMOSIS - DIPLOPIA WITH UPWARD GAZE - ENOPHTHALMOS - INFRAORBITAL NUMBNESS - DECREASED EOM Treatment includes: - ORAL ANTIBIOTICS - COOL COMPRESSES - CONSULT with possible surgical repair if pt continues to have DIPLOPIA or ENOPHTHALMOS 1-2 weeks after swelling has decreased - Discharge instructions include: advise pt to AVOID BLOWING NOSE, SNEEZING, and/or PERFORMING A VASALVA MANEUVER BEARING DOWN Ch. 10, p. 130-131
question
Explain HYPHEMA
answer
Collection of blood in anterior chamber of eye - classified as spontaneous or traumatic Assessment findings include: - PAIN, PHOTOPHOBIA - NOTICEABLE COLLECTION OF BLOOD IN EYE CHAMBER - BLURRY VISION due to blood in chamber - INCREASED IOP, NAUSEA, and SEVERE PAIN with grade 4 Treatment includes: - ELEVATING HOB 30 degrees - 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
question
Explain RETROBULBAR HEMATOMA
answer
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
question
Explain GLOBE RUPTURE
answer
- 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
question
What symptoms usually indicate an INTRAOCULAR foreign body is present?
answer
- IRREGULAR PUPIL - SHALLOW ANTERIOR CHAMBER - POSITIVE SEIDEL TEST Ch. 10, p. 132
question
Explain eye irrigation when used for the removal of chemicals, foreign bodies, and debris from eye
answer
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
question
What are the rules concerning standard imaging in relation to eye injury
answer
- 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
question
What is the most common cause of thoracic trauma?
answer
MVC's Others include: Falls, crush injury, assaults, gunshot and stabbing wounds, ped vs. vehicle collisions Ch. 11, p. 140
question
If a penetrating wound is found below the 4th intercostal space, penetration into the _________ is suspected until proven otherwise.
answer
ABDOMINAL CAVITY Ch. 11, p. 140
question
Penetrating injury to the chest wall and lacerated lung tissue can cause the loss of ________________. Thus, the collection of air or blood in the pleural space causes ______________.
answer
A. NORMAL NEGATIVE INTRAPLEURAL PRESSURE B. LUNG COLLAPSE Ch. 11, p. 141
question
Tears or lacerations of the tracheobronchial tree disrupt the...
answer
Integrity of the upper and lower airways... Patients initially present with dramatic symptoms, such as... - SIGNS OF AIRWAY OBSTRUCTION - HEMOPTYSIS - CYANOSIS - SUBCUTANEOUS EMPHYSEMA from massive air leaks into tissues of face, chest, and neck Ch. 11, p. 141
question
Signs of increased work of breathing, tachypnea, SOB, tachycardia, hypotension, and unilateral decrease in breath sounds on injuries side...
answer
Signifies decreased cardiac output. Caused when air or blood accumulates in thoracic cavity causing increase in INTRAPLEURAL pressure on side of injury. If this pressure is allowed to expand without intervention, it can produce a MEDIASTINAL SHIFT which compresses heart and great vessels, resulting in a DECREASE in VENOUS RETURN (PRELOAD) and SUBSUQUENT DECREASE IN CARDIAC OUTPUT. Ch. 11, p. 141
question
What are late signs of MEDIASTINAL SHIFT?
answer
NECK VEIN DISTENTION from increased intrathroatic pressure and TRACHEAL DEVIATION Ch. 11, p. 141
question
Explain pericardial tamponade and its assessment findings
answer
When there is a rapid accumulation of blood in pericardial sac, resulting in compression of heart making it difficult for heart to fill during diastole, causing decreased cardiac output. Assessment findings include: - HYPOTENSION - TACHYCARDIA - MUFFLED HEART SOUNDS - NECK VEIN DISTENTION Ch. 11, p. 141
question
Explain how to assess circulation and control of hemorrhage in relation to thoracic trauma
answer
Auscultation for: - MUFFLED HEART SOUNDS or MURMURS 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
question
Explain emergency thoracotomy
answer
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
question
During the secondary survey in patient with thoracic or neck trauma, what questions do you want to ask?
answer
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
question
Explain TRACHEOBRONCHIAL INJURY and what are the assessment findings and interventions
answer
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
question
BLUNT ESOPHAGEAL INJURY
answer
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
question
FLAIL CHEST
answer
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 Ch. 11, p. 144
question
TENSION PNEUMOTHORAX
answer
Occurs when air enters INTRAPLEURAL space but cannot escape on expiration, increasing pressure causes lung on injuries side to collapse. If pressure not relieved, mediastinum can shift toward the uninjured side compressing heart, great vessels, and ultimately the opposite lung. As pressure rises, venous return is hampered, cardiac output decreases, and hypotension occurs. Assessment findings include: - ANXIETY, SEVERE RESTLESSNESS - SEVERE RESPIRATORY DISTRESS - SIGNIFICANTLY DIMINISHED OR ABSENT BREATH SOUNDS on injured side - HYPOTENSION - DISTENDED NECK, HEAD, UPPER EXTREMITY VEINS (may not be evident if patient has experienced significant blood loss) - TRACHEAL DEVIATION or shift toward injured side - CYANOSIS (late sign) Interventions - Immediate chest X-RAY if pt somewhat stable - prepare for immediate needle thoracentesis 14 g needle inserted into 2nd intercostal space in mid clavicular line on affected side over the top of the rib to avoid neurovascular bundle that runs under rib - prepare for chest tube placement, which is the definitive treatment ch. 11, p. 145
question
HEMOTHORAX
answer
caused by blood accumulating in the intrapleural space. Results from injury to lung, costal blood vessels, great vessels and from laceration to liver or spleen combined with diaphragm injury. Assessment findings include - ANXIETY or RESTLESSNESS - DYSPNEA, TACHYPNEA - CHEST PAIN - SIGNS OF SHOCK- tachycardia, cyanosis, diaphoresis, hypotension - DECREASED BREATH SOUNDS ON INJURED SIDE Interventions - Prepare for needle thoracentesis and chest tube insertion - Ensure 2 large IV catheters and blood is available before thoracentesis to treat large volume blood loss if needed ch. 11, p. 146
question
PULMONARY CONTUSION
answer
commonly occur from rapid deceleration or direct blunt impact such as MVCs or falls - it develops when capillary blood leaks into lung parenchyma with edema and inflammation, it may be localized or diffuse The subtle assessment findings associated with pulmonary contusions usually develop over time rather than immediately after injury. Assessment findings - DYSPNEA - 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
question
CARDIAC TAMPONADE
answer
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
question
AORTIC DISRUPTION
answer
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
question
RUPTURED DIAPHRAGM
answer
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
question
When someone suffers a GSW, below what part of the body is considered an abdominal injury that requires an exploratory laparotomy?
answer
Below the nipple line ch. 12, p. 155
question
What are causes of peritoneal membrane irritation?
answer
- 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
question
Examples of referred pain include...
answer
- 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
question
When patient is receiving massive blood transfusions it is important to closely monitor which electrolytes? Why?
answer
High K, Low C Potassium : released from cellular destruction of banked blood occurs naturally when blood ages Calcium : calcium citrate used in banked blood to prevent clotting, this citrate binds with free calcium reducing serum levels ch. 12, p. 158
question
How can you check for laxity or instability for possible pelvic fractures?
answer
gentle pressure over iliac wings DOWNWARD and MEDIALLY ch. 12, p. 159
question
What is the standard of care in the hemodynamically STABLE patient who sustained blunt liver injury?
answer
Non-operative management - For patients with penetrating liver injuries or blunt abdominal trauma with signs of hypodynamic instability, surgery is indicated. Appropriate fluid resuscitation and interventions to promote hemostasis are essential in surgery prep ch. 12, p. 162
question
What is one unique post-operative risk following a splenectomy? Explain.
answer
PNEUMOCOCCAL SEPSIS - Asplenic compromised immune system has difficulty destroying encapsulated bacteria (Streptococcus pneumonia, Nesisseria meningitides, and Haemophilus influenza) therefore vaccinations against these bacteria are required. - Following splenectomy, patients encouraged to receive annual flu, meningitis, and pneumonia vaccines every five years. ch. 12, p. 163
question
Explain pancreatic injuries
answer
- Penetrating pancreatic injuries often sustain concurrent duodenal injuries - Less than 10% of those with a pancreatic injury will have a single-system injury - Suspicion for spinal fractures when the pancreas is crushed between anterior abdominal wall and spinal column ch. 12, p. 164
question
What are some assessment findings for patients who sustain a pancreatic injury?
answer
- Serial serum amylase levels increasing over time may indicate but this does not constitute a definitive diagnosis - Serial abdominal exams are preformed in conjunction with serial serum amylase levels to appropriately confirm pancreatic injury - slight abdominal pain and tenderness becoming more significant within 48 hours of injury - epigastric pain radiating to back - abdominal pain tenderness on deep palpation - increasing or worsening abdominal wall muscle rigidity, spasm, or involuntary guarding ch. 12, p. 16
question
Explain definitive care on pancreatic trauma
answer
- 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
question
Are the lumen contents of the small bowel considered sterile? What is the pH?
answer
neutral pH, and sterile ch. 12, p. 164
question
Pertaining to abdominal trauma, What does non-operative management include? When does operative management occur?
answer
Non- serial abdominal exams Op- occurs in patients who exhibit signs of peritonitis or hemodynamic instability ch. 12, p. 164
question
What diagnostic exam is helpful to inspect abdominal spaces for spillage and to examine loops of bowel?
answer
Laparoscopy ch. 12, p. 164
question
What is used to diagnosis renal injuries? What are the cons? How are rectal injuries often managed?
answer
Sigmoidoscopy Cons- unprepared bowel may not detect injury Often managed with colostomy and distal rectal washout ch. 12, p. 165
question
Explain stable and unstable pelvic fractures
answer
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
question
Assessment findings for renal injuries include
answer
- 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
question
Imaging studies for bladder and urethral injuries include
answer
- 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
question
Prophylactic administration of what can reduce the risk of contrast-induced nephropathy when patients serum creatinine is above 1.2mg?
answer
N-acetylcysteine along with hydration ch. 12, p. 170
question
55% of spinal injuries occur to which part of spine?
answer
cervical ch. 13, p. 179
question
hyperEXTENSION
answer
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
question
hyperFLEXION
answer
etiology/cause- forceful forward flexion with head striking an immovable object rest of injury- wedge fractures, facet dislocations, subluxation (due to ligament rupture), teardrop, odontoid or transverse process fractures example- head-on MVC with head hitting windshield, creating starburst effect ch. 13, p. 179
question
ROTATIONAL
answer
etiology/cause- combination of forceful forward flexion with lateral displacement of cervical spine rest of injury- posterior ligament rupture and/or anterior fracture, dislocation of vertebral body example- MVC to front or near lateral area of vehicle results in conversion of forward motion to a spinning-type motion ch. 13, p. 179
question
AXIAL LOADING
answer
etiology/cause- direct force transmitted along the length of vertebral column rest of injury- deformity of vertebral column, secondary edema of spinal cord resulting in neurologic effects example- diver striking head on bottom of pool ch. 13, p. 179
question
Explain NEUROGENIC SHOCK and what are the assessment findings
answer
Occurs with SC damage at T6 or higher, resulting in sympathetic regulation disruption of vagal tone leading to loss of vascular resistance and generalized vasodilation Assessment findings - BRADYCARDIA - HYPOTENSION - WARM, NORMAL COLOR SKIN - CORE TEMPERATURE INSTABILITY ch. 13, p. 181
question
SPINAL SHOCK
answer
When spinal cord is injured, cascade of events takes place - Blood supply to cord can be disrupted - Axons are severed or damaged - Conduction of electrical activity of neurons and axons is compromised - All of the above result in loss of function which can last from several hours to several days - A transient hypotensive period and poor venous circulation may be seen - Disruption of thermal control centers results in sweating and lack of ability to regulation body temp - Transient loss of muscle tone (flaccidity) and complete or incomplete paralysis with reflex losses - Bowel and bladder dysfunction - Return of sacral reflexes, bladder tone, and presence of hyperreflexia indicates resolution of spinal shock - Presence of rectal tone and intact perineal sensation indicates sacral sparing ch. 13, p. 181
question
Spinal cord neurons DO NOT regenerate; therefore, severe injury with cellular death may result in...
answer
- temporary or permanent loss of function - flaccidity - loss of reflexes ch. 13, p. 181
question
Central cord syndrome
answer
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
question
Anterior cord syndrome
answer
loss of pain and temperature sensation with weakness, paresthesia, and urinary retention ch. 13, p. 182
question
Brown-squared syndrome
answer
Contralateral loss of pain and temperature sensation and ipsilateral paralysis with reduced touch sensation ch. 13, p. 182
question
What are signs of worsening hypoxia with nerve injuries?
answer
Increased pain even when pulses remain present, often the first sign of increased compartment pressures ch. 14, p. 196
question
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....
answer
OSTEOMYELITIS and SEPSIS ch. 14, p. 197
question
Why do partial amputations have more severe bleeding than complete amputations?
answer
The severed arteries retract with complete amputations ch. 14, p. 197
question
What are complications related to crush injuries?
answer
Compartment syndrome, hyperkalemia, rhabdomyolysis K levels peak 12 hours after injury ch. 14, p. 198
question
RHABDOMYOLYSIS
answer
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
question
Sudden vision changes may indicate________ in the cerebral vascular
answer
A POSSIBLE FAT EMBOLISM ch. 14, p. 199
question
How high should you elevate limb in compartment syndrome?
answer
At level of heart, any higher can reduce circulation and tissue perfusion. Also ice is strongly contraindicated ch. 14, p. 200-201
question
What do you do with open wounds?
answer
Cover in saline-soaked dressings ch. 14, p. 201
question
How should you wrap an amputated part?
answer
Wrap it in slightly saline-moistened sterile gauze, placed in sealed plastic bag THEN place in a second bag containing ice water ch. 14, p. 201
question
Non-invasive near-infrared spectroscopy is used to...
answer
measure decreased tissue blood flow, useful to diagnose compartment syndrome ch. 14, p. 202
question
For skin, the immediate goal in treating surface trauma is to... and this is accomplished by...
answer
OBTAIN AND MAINTAIN HEMOSTASIS, APPLY DIRECT PRESSURE TO SITE ch. 14, p. 208
question
What should you avoid using with fingers, toes or other areas where vasoconstriction could cause impaired distal blood circulation?
answer
LIDOCAINE with EPI ch. 14, p. 211
