Basic Trauma Nursing, 4th Edition

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1 28 CONTACT HOURS Item #N1671 Basic Trauma Nursing, 4th Edition Author: Erik J. Usher, RN, BS, CEN, CPEN, EMT-P, CFRN Course Objectives: Describe the epidemiology of trauma, mechanisms of injury, principles of disaster management, and key components of a trauma care system. Describe initial assessment of the trauma patient, and post-trauma nursing care. Describe the nursing management of shock. Describe the nursing management of the patient with a head injury. Describe the nursing management of the patient with eye, maxillofacial, and neck injuries. Describe the nursing management of the patient with thoracic trauma. Describe the nursing management of the patient with abdominal trauma. Describe the nursing management of the patient with spinal cord injuries. Describe the nursing management of the patient with musculoskeletal trauma. Describe the nursing management of the patient with burn and cold injuries. Identify the nursing management of trauma in special populations (pregnant women, pediatrics, geriatrics, and bariatrics). Identify the psychosocial issues affecting the trauma nurses, patients and caregivers of patients who have experienced a traumatic injury. ABOUT THE AUTHOR Erik J. Usher, RN, BS, CEN, CPEN, EMT-P, CFRN, has more than 27 years of widespread clinical trauma experience, most recently as a rotor-wing flight nurse/paramedic for Bayflite Aeromedical Program out of St. Petersburg, Florida. Erik began his trauma career in 1988 in Bristol, Connecticut, working for a busy hospital-based EMS agency. While continuing to work EMS, Erik obtained a diploma in nursing at St. Francis Hospital School of Nursing, where he then started his trauma nursing career in the emergency department of one of the state s largest and busiest Level I trauma centers. In 1998, Erik began working for University Medical Center of Southern Nevada in Las Vegas, the busiest Level I trauma center based on ISS Severity at the time in the United States. In concert with working in the freestanding Resuscitation Department, Erik began his flight nursing career for Mercy Air in 1998, where he helped establish the Las Vegas medevac flight program. Erik became the manager of the Las Vegas base while also maintaining his skills in the trauma center as a nurse and in EMS as a street paramedic. Erik has been an active speaker at national conventions as well as a lead instructor for advanced procedural cadaver laboratories throughout the country. Erik maintains active credentials as an instructor for the Emergency Nurses Association Trauma Nursing Core Course as well as with the American Heart Association as a Pediatric Advanced Life Support and Advanced Cardiac Life Support instructor. Erik maintains board certifications as a Certified Emergency Nurse, Certified Pediatric Emergency Nurse, and Certified Flight Registered Nurse. He holds a bachelor s degree in health administration and has been published in several textbooks and medical journals. Erik J. Usher was a Clinical Manager for Teleflex Medical up until October He has agreed to present content that is current, evidencebased practice and without bias. Based on the original work of Judy Mikhail. ABOUT THE PEER REVIEWER Alicia R. Dean, RN, MSN, CNS, APRN, earned her bachelor of science degree in nursing from Southeastern Louisiana University and her master of science degree in nursing with a concentration in adult health trauma from the University of Alabama at Birmingham. Her clinical background spans more than 30 years working in intensive care units and emergency departments in several Level I trauma centers. She has been a clinical nurse specialist for over 20 years. She spent most of those years as the clinical nurse specialist in ED/Critical Care/Trauma at Charity Hospital/University Medical Center, a Level I trauma center in New Orleans. She is currently the Director for Continuing Nurse Education at LSUHSC School of Nursing. She is active in the Emergency Nurses Association, serving on a local, regional, and national level. She has been on the board of directors for the Louisiana Council of Emergency Nurses for over 20 years and is a past state president. She served as a planning committee member for the 2012, 2013, and 2014 National ENA Leadership Conference. She also served as the Planning Committee Chairperson for the 2013 National ENA Annual Conference and as a Planning Committee Member for the 2014 National ENA Annual Conference. Alicia R. Dean has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book CE Express

2 Nurse Planner: Kim V. Cheramie, MSN, RN-BC The planner who worked on this continuing education activity has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. Copy Editor: Lumina Datamatics HOW TO RECEIVE CE CREDIT FOR THIS COURSE Read and study the course Complete the self-assessment Attest to having read the course materials Enter the course completion code found at the end of this course Answer the course evaluation questions Print your certificate of completion

3 BASIC TRAUMA NURSING, 4TH EDITION Author: Erik J. Usher, RN, BS, CEN, CPEN, EMT-P, CFRN Item #N Contact Hours FINANCIAL comprehensive content on nursing trauma care, Course Introduction T including mechanisms of injury, common injuries rauma is a global problem defined as any injury seen, and resuscitation and management of injured EFFECT OF INJURY T caused by a transfer of energy to the body. It is patients. The course serves as a reference for trauma he cost of trauma care is overwhelming when ranked as the fourth leading cause of death worldwide registered nurses working in the emergency room, viewed over a patient s lifetime. Statistically, and is the number one cause of death among people trauma intensive care units, and for those practicing most trauma patients are young and many will 1 to 44 years of age in the United States (CDC, 2014). in nontrauma clinical areas who desire to know become disabled, resulting in a substantial loss Trauma disproportionately affects the young and is more about trauma care. The course also serves as a of productive years (CDC, 2013). Each year in therefore an enormous financial burden to society. preparation for trauma certification. the United States, the inpatient cost to care for Trauma is often perceived by the public to victims of trauma is estimated at $37,511,328,659 Course content includes basic concepts of trauma systems, triage, initial assessment of pediatric occur suddenly and without warning as the result (Velopulos et al., 2013). The national economic of random chance or an act of fate. It is now recognized that many so-called accidents are, in fact, impact is estimated to exceed $406 billion annually, and adult trauma, shock, trauma to specific anatomic regions, and burns and cold injuries, maternal and a cost that takes into consideration money spent predictable and, therefore, preventable (ACS, n.d.). on medical care as well as lost wages, insurance pediatric trauma, elder trauma, psychosocial aspects administration costs, property damage, fire, and Trauma care is provided over a continuum from of trauma care, disaster management, and nursing costs employers must incur. With trauma care costs preventative to rehabilitative. Prevention and education represent the first phase of reducing mortality care of the recovering trauma patient. soaring, the Patient Protection and Affordable Care and morbidity in many aspects of medicine, with References Act (PPACA) authorized $224 million in federal trauma care being no exception. Most trauma care American College of Surgeons (ACS). (n.d.). Alcohol funding for trauma and emergency medical services programs and activities (Mir, 2011). These centers and systems employ someone in the area and injury. Retrieved from of injury prevention and education on trauma prevention. In many cases, the first clinicians a trauma alcoholinjury.ashx org/~/media/files/quality%20programs/trauma/ funds include financial assistance to reauthorize the National Trauma Center Stabilization Act and provide Trauma Care Center Grants and Trauma patient encounters are in the emergency medical American Trauma Society (ATS). (2014). Trauma Service Availability Grants. The PPACA also reauthorizes the Trauma Care Systems Planning and services (EMS) branch. These individuals will be centers. Retrieved from the ones to stabilize and transport the patient to the org/centers/index.aspx Development Act (TCSP), provides grants to support state development of trauma systems, and hospital. EMS then transfers or transports the patient Centers for Disease Control and Prevention (CDC). to the emergency department staff, who will further (2014). Ten leading causes of death and injury. Retrieved from Care Pilot Program (RECPP). incorporates the new Regionalization of Emergency resuscitate and stabilize the patient. Depending on the severity of the injury resulting from the insult, the wisqars/leadingcauses.html patient may move to the operating room, the critical care unit, or the nursing unit with progression to rehabilitation. In some instances, the initial workup may Chapter 1: The HEALTH PROBLEM INJURY AS A PUBLIC I reveal no underlying acute pathology, and the patient Epidemiology and njury is the leading cause of death and disability may be discharged with follow-up outpatient care. among children and young adults in the United Etiology of Trauma Ideally, serious trauma is treated in an American States. Trauma is the leading cause of death in persons College of Surgeons-verified trauma center. Despite between the ages of 1 and 44 years, and it disproportionately affects the young (IIHS, HLDI, 2013). the proliferation of adult and pediatric Level I, II, CHAPTER OBJECTIVE U and III trauma centers in the United States (the pon completion of this chapter, the learner will Injuries initially peak between the ages of 14 latest numbers indicate that there are 1,675 trauma be able to describe the epidemiology of trauma and 29, primarily from motor vehicle-related incidents, and they see another peak between the ages of centers [202 verified by the American College of and basic mechanisms of injury. Surgeons, 1,388 not verified, and 85 with ACS verification only]), the majority of patients are treated LEARNING OBJECTIVES for 42% (344,592) of cases in the National Trauma 40 and 50, when falls begin to increase. Falls account at nontrauma hospitals (ATS, 2014). If the patient s initial treatment is at a nontrauma center, early stabilization Upon completion of this chapter, the learner will be able to: Data Bank (NTDB), with injuries higher in children under the age of 7 years and adults over the age of and transfer to a designated trauma center 1. Identify the national impact of trauma. 75. Motor vehicle-related injuries account for 27% is highly recommended. 2. Recognize the common causes of trauma in the (220,923) of cases in the NTDB, with a dramatic rise Trauma nurses work in many environments, United States. between the ages of 15 and 33, peaking around age including prehospital, emergency department, operating room, anesthesia, critical care, floor, and reha- trauma under 44 years of age, functional and actual 19 (Nance, 2014). With the majority of victims of 3. Specify the phases of the trimodal death distribution of trauma. bilitation. Trauma nursing as a discipline is challenging and exciting in the anticipation of the next lost years of life are substantial. 4. Recognize basic mechanisms of injury and effects upon the body. unknown case, regardless of whether in the acute WORLDWIDE INCIDENCE setting or long-term rehabilitation backdrop. Trauma 5. Identify the impact of restraints and air bags in nurses work closely with other team members to motor vehicle crashes. AND SEVERITY Unintentional injury, or injuries that are unplanned, assess and care for the patient. An organized and is anticipated to become the third leading cause standardized approach is essential, and strong fundamental skills are requisite. These abilities critically rauma often occurs without recognized warning INTRODUCTION T of death in all age groups worldwide by Injury does not discriminate based on age, race, sex, or affect the treatment and outcomes of injured patients, and causes life-altering damage to the patient economic status. Injuries are a significant cause of particularly in the first hour after the incident. and the patient s family, in addition to billions of mortality and morbidity, of which more than 90% In this fourth edition of the basic trauma course, dollars in lost annual productivity. Trauma is no occur in low- and middle-income countries (LMICs; current evidence-based practice has been included accident and, as such, requires careful evaluation to Wesson et al., 2014). Motor vehicle crashes account as well as the addition of a chapter covering bariatric trauma. The goal of this course is to provide assess the causes and contributing factors to develop a plan for prevention strategies. for the majority of injuries and deaths worldwide. Firearms remain an extremely lethal mechanism of page 15 CE Express

4 16 Basic Trauma Nursing injury. Deaths resulting from firearms are a particular problem in the United States, with 34,338 firearm injuries reported and 5,393 deaths in 2014, yielding a 15.71% death rate (Nance, 2014). The availability of guns in the United States compared to other nations is thought to be a contributing factor to this problem. TRAUMA AND THE U.S. HEALTHCARE SYSTEM Over 70 million injuries occur in the United States each year. In the most recent Centers for Disease Control and Prevention (CDC) trauma study from 2011, it was reported that there were million emergency department (ED) visits, with 40.2 million visits related to injury (CDC, n.d.a). The majority of patients seen with injury were between 25 and 44 years of age (28.3%), with males exceeding females in ED visits for injury. All ED injury visits were at a rate of 13.1 per each 100 persons evaluated (CDC, 2011). TRAUMA DEATHS Injuries are typically classified as intentional, injuries planned (suicide or homicide), or unintentional, injuries unplanned (e.g., motor vehicle crashes or falls). In 2014, there were 36,381 deaths related to injury in the United States; 12,245 of those who died were female and 24,136 were male, leading to a death rate for males that was almost double that of females (Nance, 2014). Data related to leading causes of death for all ages show that trauma is fifth after cardiovascular disease, cancer, cerebrovascular diseases, and chronic lower respiratory diseases (CDC, 2013). National Trauma Data Bank The National Trauma Data Bank s annual report analyzes the largest aggregation of trauma data ever assembled. It is collected from trauma centers and provides the most compelling overview of trauma in the United States. Figure 1-1 shows the frequency of trauma by selected mechanisms of injury: falls are first, followed by motor vehicle crashes. Figure 1-2 reveals the lethality of firearms compared to other mechanisms of injury (Nance, 2014). WHEN TRAUMA PATIENTS DIE The Trimodal Death Distribution of Trauma Trauma deaths can be categorized into three phases: immediate, early, and late. Fifty percent of deaths occur immediately at the scene, followed by 30% occurring early, within hours of the injury. Finally, 20% occur weeks later, during hospitalization (Peitzman & Schwab, 2013). 1. The immediate, or first, phase of deaths occurs within the first few minutes up to an hour after injury. These deaths likely would occur even with immediately available medical care, and their occurrence can be affected only with injuryprevention measures. Injuries that can cause immediate death include aortic dissection, high cervical spine injuries, and severe head injuries. 2. The early or second phase of deaths occurs within the first 4 hours of the incident. These deaths include injuries that, if identified and treated quickly, would have allowed the victim a FIGURE 1-1: Incidents by Selected Mechanism of Injury PERCENT % Fall 27.12% Motor Vehicle Traffic 7.11% Struck by, against chance for survival and therefore are potentially preventable. These injuries include pneumothorax, hemothorax, splenic lacerations, liver lacerations, and focal head injuries such as epidural and subdural hematomas. 3. The late or third phase of death occurs weeks after injury, typically in the intensive care unit from multiple organ failure and sepsis. Transport, other MECHANISM OF INJURY 4.66% 4.33% 4.21% Cut/pierce Firearm Note. Adapted from Nance, M.L. (2014). National Trauma Data Bank 2014 annual report. Retrieved from FIGURE 1-2: Case Fatality Rate by Selected Mechanism of Injury CASE FATALITY RATE (%) % 4.76% Fall Motor Vehicle Traffic 1.51% Struck by, against 2.57% Transport, other 2.11% Cut/pierce 15.71% Firearm MECHANISM OF INJURY Note. Adapted from Nance, M.L. (2014). National Trauma Data Bank 2014 annual report. Retrieved from MECHANISM OF INJURY Trauma is defined as any injury that results from transfer of energy to the body (see Table 1-1). Exposure to different types of energy such as kinetic (e.g., crashes, falls, and gunshot wounds), chemical, thermal, electrical, or radiant can result in injury. The injury occurs because of the body s inability to tolerate exposure to excessive acute energy transfer.

5 Basic Trauma Nursing 17 TABLE 1-1: ENERGY TRANSFER AND MECHANISM OF INJURY Energy Transfer Mechanism of Injury Kinetic energy (KE) Motor vehicle crashes Falls KE = mass velocity 2 Pedestrian injuries 2 Bicycle crashes Motorcycle crashes Assaults Firearms Thermal energy Fire Chemical energy Chemical substances Electrical energy Lightning Exposure to electricity Radiant energy Exposure to sun rays Oxygen deprivation Drowning Asphyxiation In the example of a vehicle striking an object, the rapidly decelerating vehicle and its occupants absorb the energy transfer. This kinetic energy is transformed into shock waves that the automobile and the body s tissues must absorb. In contrast to insult as a causative agent, injury can also result from the absence of required elements, such as lack of oxygen in drowning and lack of heat in frostbite. Kinetic energy transfer is expressed by the equation KE = mv 2 (where KE = kinetic energy, m = mass, and v = velocity). This indicates that in a motor vehicle crash, velocity carries more significance than the weight of the vehicle involved. Motor vehicle crashes involving unrestrained occupants and speeds of greater than 40 mph predictably result in injury. With increasing awareness of the need for restraint and air bag use, it is typical now to see crashes that occur at up to 60 mph without injuries. Air bags are designed to keep the head, neck, and chest from slamming into the dash, steering wheel, or windshield in a front-end crash (NHTSA, n.d.). The seat belt is meant to stop the occupant with the vehicle, providing a safe stopping distance more than four or five times greater than without seat belt use. A crash that stops the vehicle and its occupants must transfer all its kinetic energy, and the work-energy principle then dictates that a longer stopping distance decreases the impact force (Nave, 2014). Kinetic energy transfers are the most common cause of trauma and will be emphasized throughout this text. Patterns of injury are related to the type of impact the vehicle s occupants sustained. Effects of an injury also depend on personal and environmental factors such as age, sex, nutrition, premorbid conditions, and geographic considerations (e.g., rural versus urban). OVERVIEW OF KINETIC ENERGY TRANSFERS IN TRAUMA Motor Vehicle Crashes Three Phases of Collision Vehicular collisions are subdivided into three phases (NAEMT, 2014): 1. The vehicle collides with an object or another vehicle. 2. The unrestrained occupant collides with the inside of the vehicle. 3. The occupant s internal organs strike one another or with the wall of their encasing chamber. Frontal Impact Frontal impacts are the most commonly occurring crashes, accounting for 51% of crashes and 53% of fatalities in 2013 (IIHS, HLDI, 2013). In a frontal collision, such as a head-on or offset (also called a 10 o clock or a 2 o clock crash), although the vehicle slows or stops abruptly, the occupant, depending on restraint use, will continue to move and will follow either an up-and-over or a down-andunder pathway. If the crash is more offset, the head commonly strikes the A-frame pillar that separates the windshield from the side window, causing head injury. Figure 1-3 shows the up-and-over pathway and the down-and-under pathway. Up-and-Over Pathway Unrestrained occupants follow a path in which the body s forward motion carries it up and over the steering wheel or dashboard. The head usually strikes the windshield, and the chest and/or abdomen strike the steering wheel. Down-and-Under Pathway Occupants move down in the seat and forward. The lower extremities are the initial point of impact, with the knees or feet receiving the initial energy exchange. The continued forward motion of the torso onto the extremities may result in ankle dislocation, knee dislocation, femur fracture, and/or hip dislocation. Both restrained and unrestrained occupants can follow the down-and-under pathway. As the use of restraints has increased, the number of survivors of major crashes has increased (without restraint, they would likely have been dead on arrival). With this increased survival, however, has come a corresponding increase in severe lower orthopedic injuries consistent with movement along the down-and-under pathway. Side Impact Side-impact collisions occur when a vehicle is struck on the side (see Figure 1-4). Side-impact collisions account for more than one quarter of passenger figure 1-4: SIDE IMPACT CRASH car accidents, with slightly more than half of these crashes involving the left side. Because the vehicle s side has no crush zone, forces transfer directly to the occupant, thus accounting for one quarter of collision fatalities. When assessing for injury, an observation of intrusion into the passenger compartment can be helpful. The greater the intrusion into the passenger compartment, the greater the likelihood of injury. When assessing injury potential, it is important to further define the lateral impact relative to the position of the occupant in the car (e.g., being struck on the near side or far side). In side-impact collisions, restraints offer minimal protection because there is only about 12 in. (30 cm) between the person s body, the car door, and the intruding other vehicle. Newer side-impact air bags are beginning to decrease injuries in side-impact crashes. A 2011 study found that the higher a vehicle s safety rating, the more significantly affected passenger survival rates were. Based on driver-only ratings (crashes with only a driver present in the vehicle), drivers of vehicles with good safety ratings were 70% less likely to die when involved in left-side crashes than drivers of vehicles with poor safety ratings, after controlling for driver and other vehicle factors. Compared with vehicles rated poor, driver death risk was 64% lower for FIGURE 1-3: the UP-AND-OVER PATHWAY AND THE DOWN-AND-UNDER PATHWAY Note. From Mistovich, Joseph J.; Karren, Keith J.; & Hafen, Brent. Prehospital emergency care, 10th edition Reprinted with permission of Pearson Education, Inc., New York, New York. b. Note. From International Trauma Life Support (ITLS), ; Campbell, John, R. International Life Support for Emergency Care Providers, 7th; Printed and electronically reproduced by permission of Pearson Education, Inc., New York, New York.

6 18 Basic Trauma Nursing vehicles rated acceptable and 49% lower for vehicles rated marginal (Teoh & Lund, 2011). Four body regions can sustain injury in a lateralimpact collision: Neck. The torso may move out from under the head, causing lateral flexion and rotation. Head. The head commonly impacts the frame of the door. Chest. Compression of the thoracic wall may result in rib fractures, pulmonary contusion, and shear injury to the aorta. Abdomen and pelvis. Intrusion of the door may compress and fracture the pelvis. Occupants struck on the driver s side are vulnerable to splenic injuries (left side), and those struck on the passenger side are more likely to receive an injury to the liver (right side). Rollover and Ejection Rollover collisions are highly unpredictable in terms of injury patterns, as there may be trauma to the vehicle s occupant from a multiplicity of directions (Peitzman & Schwab, 2013). There is a high correlation between rollover collisions and occupant ejection. Of occupants totally ejected from a vehicle, 77% were killed (NAEMT, 2014). Conversely, restrained occupants often sustain minimal to no injuries in a rollover crash. Clearly, restraints save lives just by keeping a person in the car. Rear Impact Although rear-impact crashes are the most commonly occurring crashes, they generally result in minor injuries. Rear-impact collisions occur when a slower-moving or stopped car is struck from behind by a vehicle moving at a higher rate of speed. Upon impact, the vehicle in front accelerates forward like a bullet discharged from a gun. If the occupant of the impacted car does not have the headrest in position to keep the head in alignment with the torso, then neck hyperextension occurs, resulting in neck injury. If the vehicle continues on to strike another car or the driver slams on the brake, a secondary frontal impact collision occurs as well. Restraint Use In 2013, of occupants involved in motor vehicle crashes, 49% were not restrained (down from 52% in 2012). During daytime crashes, 40% were not restrained (down from 43% in 2012), and 59% were not restrained during nighttime crashes (down from 60% in 2012; NHTSA, 2014). Increased seat belt use likely has contributed to the observed declines in injuries. Seat belt use reduces the likelihood of serious injury in a crash by approximately 50% (CDC, n.d.b). Worn properly, seat belts anchor the body into the car and allow the pelvis and chest to absorb the pressure of the impact, resulting in few, if any, injuries. When seat belts are worn loosely or are strapped above the anterior iliac crests of the pelvis, compression injuries of the abdominal organs may also occur. Lap belts should ideally not be worn alone. The diagonal shoulder strap should always be worn, in addition to the lap belt, to prevent extreme hyperflexion of the torso, which can injure the lumbar spine and small intestine. Air Bags Air bags should always be used in conjunction with seat belts. They are not effective for unrestrained occupants and are considered a secondary restraint system. They are highly effective in headon crashes. Because air bags deflate immediately after impact, they are not effective in multipleimpact collisions or rear-impact collisions. Caution should be used with children and infants riding in cars with air bags. Children younger than 12 years of age should be in the back seat. Never place a rear-facing infant car seat in the front seat because the air bag will deploy directly into the back of the infant s head. Drivers need to keep at least 10 in. (25 cm) between themselves and the steering wheel air bag at all times. Drivers of short stature should invest in pedal extenders to maintain the appropriate distance. Motorcycle Crashes Motorcycle crashes account for a significant number of motor vehicle deaths each year. Motorcycle crashes involve head-on impacts, angular sideswipes, ejections, and the protective maneuver of laying the bike down. In head-on collisions, the driver s body typically travels up and over the handlebars, with potential for secondary injury to femoral vessels and lower extremities as they catch the handlebars during separation. In angular collisions, the driver is often caught and crushed between the motorcycle and the object struck or struck by. In ejections, the driver is thrown from the motorcycle like a projectile. Once thrown from the motorcycle, the driver may be subjected to secondary and tertiary injuries from other vehicles, debris, and environmental hazards. Motorcycle injuries often vary in pattern, making injury prediction difficult. When laying the bike down, the driver is taking a protective stance and turns the motorcycle sideways, dragging his or her inside leg on the ground. This action slows down the driver and causes separation from the motorcycle. Injuries sustained include friction burns (known as road rash) and minor fractures. Helmets have been shown to markedly decrease severe head injuries. Pedestrian Injuries In 2013, 4,735 pedestrians were killed in the United States (NHTSA, 2013). More than 90% of pedestrian injuries are from vehicles moving at speeds less than 30 mph, and a large percentage involve children. Of the pedestrians killed, 34% had a blood alcohol concentration (BAC) of 0.08% or higher (NHTSA, 2013). The variety of injuries seen is affected by the following three phases of impact: First: Bumper impact. Bumper height versus pedestrian height is an important factor in determining the specific injury. Adults are typically hit at the knee and thigh level. Children, on the other hand, usually sustain more head, chest, and abdominal injuries. Second: Hood and windshield impact. Torso and head injuries occur when the victim is thrown up and onto the hood and windshield of the vehicle. Third: Ground impact. Head and spine injuries are common as the pedestrian finally falls to the ground. Falls Injuries sustained from falls depend on the distance of the fall, surface struck, and position on impact. Falls are the leading cause of nonfatal injury, resulting in approximately 8.8 million injuries and 23,443 deaths annually throughout all age groups (Peitzman & Schwab, 2013). Landing position; headfirst, feet-first, or sideways falls; and the type of surface encountered upon landing are all significant for the types of injuries that will be sustained. Head-first falls are obviously related to head and spine injuries. Feet-first falls are correlated with calcaneus, femur, and spine injuries. With lateral impact falls, the force is distributed over a much larger surface area and, therefore, there is overall decreased severity of injury. Blast Injuries Blast injuries are becoming more common with the increased incidence of terrorist acts throughout the world. A blast explosion can be divided into four phases (see Figure 1-5). 1. Primary blast injury. Primary blast injuries occur when the air-filled viscera is injured as a direct result of the blast wave. Eardrum perforation is common and serves as a marker of the proximity of the individual to the site of detonation. Primary blast injuries include pneumothorax, acute respiratory distress syndrome, air embolism, and perforated intestines. 2. Secondary blast injury. Secondary blast injury is penetrating trauma caused by fragments of bomb casing or projectiles. 3. Tertiary blast injury. Tertiary blast injury occurs when the victim becomes a projectile and is thrown into other objects or the ground. Injury occurs at the point of impact. 4. Quaternary injury. Thermal and other environmental exposures contribute to quaternary injuries. These injuries may include burns or inhalation injuries (Peitzman & Schwab, 2013). Penetrating Trauma Low-Energy Weapons: Stab Wounds Low-energy weapons include knives and ice picks. These weapons produce damage with their sharp points and/or cutting edges. Because they are low-energy weapons, they are usually associated with less severe trauma than high-energy penetrating weapons. Injury can often be predicted by tracing the path of the weapon into the body (see Figure 1-6). It is important to try to ascertain the length of the knife used. Remember that the entrance wound may be small, but internal damage can be great. Men tend to stab with an upward thrust, whereas women tend to stab downward (NAEMT, 2014). High-Energy Weapons: Firearms High-energy weapons include handguns and rifles. In general, damage is caused to the tissue directly in the path of the bullet and also to the tissue around the bullet s path. The variables of profile, yaw and tumble, fragmentation, and cavitation, influence the extent and direction of the injury. The amount of injury sustained is a direct result of how the kinetic energy is transferred to the body and the specific tissue. Profile. Describes a projectile s initial size at the time of impact. Yaw. The orientation of the longitudinal axis of the missile to its trajectory. As yaw increases, the amount of tissue crushed increases, and thus the permanent cavity increases (Peitzman & Schwab, 2013).

7 Basic Trauma Nursing 19 Figure 1-5: Blast Injury Phases Never assume that the bullet followed a linear path between the entrance and exit wound. Injury pattern is difficult to predict in penetrating trauma. The preferred practice is to count the number of wounds, identify them by their precise location, and refrain from labeling them entrance or exit wounds. SUMMARY It is important to know the mechanisms of injury and causes of trauma so that the healthcare provider can have a heightened index of suspicion for specific injuries. Additionally, valuable mechanism-of-injury information can be obtained from prehospital personnel, law enforcement officials, reliable bystanders, and of course the patient. If it is not deliberately obtained, this perishable data may be lost, which will lead to an incomplete picture of the patient s injuries. It is helpful to understand the big picture of trauma s incidence and severity in the world, along with its impact on the healthcare delivery system. Understanding why and when trauma occurs helps the healthcare provider not only to focus on the immediate care provided to the patients but also on how to prevent trauma in the future through educational outreach programs. Note. From Mistovich, Joseph J.; Karren, Keith J.; & Hafen, Brent. Prehospital emergency care, 10th edition Reprinted with permission of Pearson Education, Inc., New York, New York. FIGURE 1-6: KNIFE INJURY Tumble. Bullet characteristic that refers to its rotation end over end in the tissue, thus causing increased tissue damage during transition. Fragmentation. Refers to the breaking up of the projectile as it enters the body, which produces multiple smaller objects that cause even further damage. Cavitation. High-velocity bullets create a permanent track and also produce a much larger temporary cavity. This temporary cavity expands well beyond the limits of the actual bullet track and damages (by expansion and distortion of anatomy) and injures (or creates temporary or permanent pathology) a wider area than is initially apparent. Entrance and Exit Wounds To determine the path of injury, knowledge of the victim s and attacker s position, as well as the weapon used, is helpful. It can be useful to determine whether a particular injury is an entrance or exit wound. An entrance wound is typically a round or oval with a surrounding 1- to 2-mm blackened area of burn or abrasion at the periphery that is caused by the spinning bullet passing through the skin. Exit wounds, on the other hand, are usually ragged, are pressed open as the result of tissue tearing, and have no abrasion (see Figure 1-7). A patient with two penetrating wounds may have either two separate gunshot wound entrances with no exits, or he or she may have one gunshot wound with an entrance and an exit. Figure 1-7: Entrance and Exit Wounds Entrance Abrasion Burn Tattooing Chapter 2: Key Components of a Trauma Care System CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to identify the components of a trauma care system. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Differentiate the components of a trauma system. 2. Recognize effective injury prevention strategies. 3. Choose appropriate bystander actions at the scene of a car crash. 4. Identify key principles of scene triage performed by emergency medical services. 5. Describe care provided at the four levels of trauma care centers. 6. List variables unique to rural trauma care. Tearing Splitting Exit

8 20 Basic Trauma Nursing A INTRODUCTION formal trauma care system produces a coordinated continuum of care that encompasses all levels of injuries, including minor injuries, which can be treated at local hospitals, to severe injuries that require a designated trauma center. In 2013, 53.24% of all trauma visits were classified as moderate to severe (31% and 22.24%, respectively), which would benefit from a Level I or Level II trauma center (Nance, 2014). This means that 46.76% of all trauma patients were evaluated across the integrated system from local hospitals to either Level III or Level IV trauma centers. Therefore, it is expected in an inclusive system that participation will be encouraged, and the capabilities of the smaller hospitals will be enhanced. INCLUSIVE TRAUMA SYSTEM The most significant improvement in the care of injured patients in the United States has occurred through the development of trauma systems. On February 6, 2015, the American College of Surgeons (ACS) Committee on Trauma released a position statement stressing the importance of trauma center designation based on population-based need (ACS-COT, 2015). Because the goal of emergency and trauma clinicians has always been optimized patient care, historically designated trauma centers have been attached to or part of large university and hospital systems. According to Dr. Robert J. Winchell, MD, FACS, Chair of the ACS Trauma Systems Evaluation and Planning Committee, the ACS developed this statement to support state and local agencies as they work to make designation decisions and develop policy at the state and national level that ensures a focus on centers allocated on the basis of need (ACS, 2014). There has been a significant shift in focus toward organized trauma care across the continuum. As of March 1, 2014, there were 400 verified trauma centers in the United States, with over 200 site visits being conducted annually (ACS, 2014). This trend is encouraging and signals a significant move toward an organized national trauma system. THE TRAUMA CONTINUUM OF CARE Trauma care ideally begins with injury prevention. Injury prevention is believed to be the only means available to affect the large number of deaths that occur immediately at the scene of injury. Bystanders and then emergency medical services (EMS) personnel provide the next level of care. EMS personnel deliver the trauma patient to the emergency department (ED) at the closest hospital. The patient may be stabilized and then transferred to a tertiary referral center or admitted to the hospital. From the ED, the severely injured patient may go to the operating room or interventional radiology suite and then the intensive care unit (ICU), or directly to the ICU, followed by the surgical unit and, finally, rehabilitation if needed. Each phase in the continuum builds upon the prior ones to provide optimal patient outcomes (see Figure 2-1). Injury Prevention Data collection and analysis that lead to increased public awareness, education, communitybased programs, and safety legislation are critical components in the primary prevention of traumatic injury. From a public health perspective, injury is not considered an accident; rather, it is seen as a disease, much like cancer or heart disease, or other public health scourges such as malaria or tuberculosis (Mattox, Moore, & Feliciano, 2013). Most trauma deaths and injuries are preventable, and the use of the term accident should be avoided because it implies that injuries occur by chance or are due to unknown causes. For example, the phrase motor vehicle crash is now used in place of motor vehicle accident. The trauma community has admittedly failed to capture the public s attention regarding injury prevention. Today, the public is more aware of risks related to cancer and cardiac disease; unfortunately, people are not so aware of risks related to trauma. Breast self-examinations, blood pressure checks, and cholesterol screenings permeate the public s consciousness, yet having two or three alcoholic drinks at a restaurant and then driving home without wearing a seat belt is common. The public must come to see trauma as an everyday risk. In the 1960s, William Haddon conceptualized an approach to public health and injury. He developed and promulgated a phase-factor matrix that incorporated the classic epidemiologic framework of host, agent, and environment in a time sequence that encompasses three phases: pre-event, event, and postevent (Mattox, Moore, & Feliciano, 2013; see Figure 2-2). The host is the trauma patient, the agent is the injury mechanism (such as the vehicle or gun), and the environment is where the injury occurs. In this model, each of the three factors influences the likelihood of injury during each of the three phases of a trauma: pre-event, event, and post-event. Table 2-1 provides an example of such interactions for motor vehicle crash prevention. Haddon s matrix provides a firm basis for the modern approach to injury control. Practical Consideration in Injury Prevention Implementing strategies from Haddon s matrix in the real world involves a variety of practical considerations. Interventions can be thought of as being either active or passive on the part of the person being protected. Active interventions involve a behavior change and require people to perform an act, such as wearing a helmet, fastening a seat belt, or using a trigger lock on a handgun. Passive interventions require no action on the part of those being protected and are built into the design of the offending agent or the environment, such as air bags or separation of vehicle routes from pedestrian walkways. In general, passive interventions are considered more reliable than active ones. The Three E s of Injury Prevention Injury prevention is a scientific approach to identifying groups or populations of persons at high risk for injury and then identifying strategies to eliminate or reduce the incidence of trauma. Most injury control strategies can be classified as one of the following measures: 1. Education. Education is the foundation of injury prevention efforts. Education efforts are aimed at the general public with the understanding that knowledge supports behavior change. Mothers Against Drunk Driving is an example of an organization that uses the education prevention strategy to great success. An informed and aroused public has led a crusade for tougher drunk driving laws that have resulted in fewer alcohol-related fatalities. Although such efforts are attractive in theory, they may yield disappointing results if the education is not targeted to a specific audience, persistent, and linked to other approaches. 2. Enforcement. Enforcement is an effective injury prevention strategy. Education alone may affect some individuals to act, but for many others, the threat of enforcement is the only effective deterrent for risky behavior. Different strategies work for different people. For example, when educational programs alone had minimal effect, seat belt laws have resulted in significantly more people using seat belts. 3. Engineering. Engineering, although a more expensive measure, often has the most lasting benefits. However, engineering efforts may have to be augmented with legislative initiatives for implementation on a large scale. The legislative mandate requiring air bags in vehicles is an example. Safety enhancements in highway design are another engineering effort that has resulted in increased safety while driving. System Access Rapid notification of an injury to the correct emergency response agency is vital to a favorable outcome for the trauma patient. One way this can be achieved is by providing enhanced 911 emergency services, which provide the operator with the caller s location. System access has grown steadily in the past decade with the proliferation of cellular phones and vehicles equipped with technology that alerts police, fire, and EMS upon air bag deployment. Bystander Care An area of concern to off-duty clinicians is their role when encountering an incident, specifically their duty to act and litigation. The actions one takes should be guided by safety, personal accountability, and doing what is right, not potential litigation. For example, consider the following scenario: You are driving along when you come across a motor vehicle crash that has just occurred, and there are injuries. Perhaps you are the first, and maybe the only, one on the scene. The immediate actions you take can mean the difference between life and death. The sooner a victim is treated, the greater the chance for survival. The first hour, termed the golden hour, is critical in preventing serious injuries from turning into fatalities. Simple life-saving steps include: Decide to help. Stop, even if others are already assisting. A helper always needs a helper. Do not fear legal problems if you do something wrong. Good Samaritan laws in most states protect people from litigation when they stop to help, as long as they act in good faith. Consider your safety and that of other responders. Look for downed electrical wires, smoke, fire, the smell of gasoline, trees that might fall, and signs of hazardous materials. If it is too dangerous to stop, drive on to get help or get to a phone and call for help. Do not move victims. Never transport a victim in your vehicle. Put up warnings or have other responders warn drivers of the accident without putting them in danger. Park vehicles at a safe distance from the crash site and away from moving traffic, with hazard blinkers on. If you are first on the scene, raise your car s hood to signify a problem.

9 Basic Trauma Nursing 21 FIGURE 2-1: Phases of the Trauma Care Continuum Pre-Injury Prehospital In-Patient Trauma Care Post-Acute Care EMS prehospital sandardized protocols and medical direction Emergency department resuscitation in guidelines and triage/ transfer guidelines to a trauma center as needed Trauma center surgical teams ready 24/7 Rehabilitation care considered on admission Steps down unit or general surgical floor for continued care Injury prevention INJURY! Enhanced 9-1-1, standardized dispatch protocols, and bystander care guidelines Standardized triage and transport protocols reflective of patient needs, facility resources, and bypass Trauma center team 24/7 alerted and ready to go before patient arrival for immediate treatment Adult and pediatric surgical ICUs maintain admission capability 24/7 ICU triage is a continuous process; protocols in place and enforced Mental, behavioral health (substance abuse), and social services consults as needed Home with or without rehabilitation Discharge from hospital with plans for follow-up care Community reintegration plans in place In-patient rehabilitation facility Death Note. From U.S. Department of Health and Human Services, Health Resources and Services Administration. (2006). Model trauma system planning and evaluation. Retrieved from Figure 2-2: Epidemiological Triangle Host A causal relationship Environment Agent Note. From Centers for Disease Control and Prevention. (2013). BAM! Body and mind: Infectious disease epidemiology: Lesson 1: Understanding the epidemiologic triangle through infectious disease. Retrieved from Call for help. While calling for help is important, assisting the seriously injured is more critical. If you are alone, provide life-saving procedures first and call for help when all victims are breathing and major bleeding has been stopped. If more than one helper is available, the more capable person should provide medical attention while the other summons help. Make sure whoever calls for help can tell the 911 dispatcher the exact location of the incident, the number of victims and their conditions, and what help is being given. Make sure the person stays on the line to answer all of the dispatcher s questions and then follows any instructions he or she receives. Assess the victims. Check for consciousness. Is the victim able to answer you? Check for breathing. Hold your hand in front of the person s mouth and nose to see if you can feel breathing. Look for victims with head injuries (a cracked windshield is an obvious sign) or those who are paralyzed. If a person is talking or screaming, he or she is breathing. Move on to others who may not be breathing. If it does not compromise your personal safety, look for victims who have been thrown clear of the crashed vehicle or under the dashboard. Indications include an empty driver s seat, open doors, missing windshields, or an unoccupied infant seat. Provide life-sustaining care, if needed. Most importantly, stay within your scope of practice! Victims who are not breathing need your help first. Don any personal protective equipment you may have. Then, moving to the victim, maintain an open airway. Remove items that might be blocking the airway, such as food or gum. If the person is not breathing, start rescue breathing. Continue rescue breathing until the victim can breathe without your help or professional assistance arrives and can take over for you. Once the victim is breathing, put on protective gloves, if available, and check for bleeding. Control bleeding by applying direct pressure to the wound using a gauze bandage, cloth, towel, or article of heavy clothing. If the person is able, instruct him or her to continue to apply pressure to the wound so that you can tend to other victims or seek help, but do stay with the victim until he or she is breathing and excessive bleeding is controlled. Develop a bystander kit. Develop and keep a kit in your vehicle. This can be a complete kit, a basic kit, or anything in between. The simpler kits cost considerably less to assemble and could easily fit into a glove compartment, while still providing most of the essential needs for bystander care. Typical kit items include a flashlight, gloves, gauze bandages, tape, an airway mask for rescue breathing, towels, and a blanket. Prehospital Phase Emergency medical service providers must: 1. ensure the safety of the scene, patient(s), bystanders, and responding personnel. 2. assess the mechanism of injury and injury status of the patient(s). 3. triage the patients if necessary and provide appropriate emergency treatment. 4. determine the closest, most appropriate facility capable of caring for the specific type of injury and transport the injured person(s) as rapidly as possible. Triage and transport guidelines are a vital part of a coordinated trauma care system. As a general rule, the order of priorities with multiple trauma victims is the same as with an individual patient: airway (A) takes priority over breathing (B) and circulation (C). Therefore, the patient with an airway problem is managed before a patient with a circulatory problem.

10 22 Basic Trauma Nursing Table 2-1: Sample Haddon s Matrix for Motor Vehicle Crash Prevention Dr. William Haddon, Jr.: Lifetime crusader for safer automobiles and first director of the National Highway Traffic Safety Administration. A physician and engineer with degrees from the Massachusetts Institute of Technology, Harvard Medical School, and Harvard School of Public Health PHASES FACTORS Pre-Event Event Post-Event Host Vehicle Physical Environment Social Environment Driver vision Alcohol Impairment Driver experience/ability Driver knowledge Restraint/helmet choice Driver rested and attentive Maintenance of brakes and tires Speed of travel Load characteristics Anti-lock braking system (ABS) Electronic stability control (ESC) Adequate roadway markings Divided highways Roadway lighting Intersection configuration Road curvature Adequate shoulders and rumble strips Public/community attitudes on drinking and driving Impaired driving laws Graduated licensing laws Speed limits Enforcement and adjudication of traffic laws Support for injury prevention programs Principles of Triage Degree of threat to life posed by the injury. Always uses the ABCs of care to guide priorities. Salvageability. Precedence should be given to those with the greatest likelihood of survival. A patient in full arrest at the trauma scene will most likely not survive, and treatment should be deferred until others with life-threatening injuries are taken care of. Injury severity. Treat life-threatening injuries first. Consider the saying life over limb to remind yourself to rank threats to life, such as obstructed airway or tension pneumothorax, above injuries to extremities, such as amputations or pulseless extremities. Spread out energy in time and space with seat belt/air bag use Child restraint use Vehicle size Crashworthiness of vehicle-crash space, crush resistance, safety rating Guard rails, median barriers Presence of fixed objects near roadway Roadside embankments Adequate seat belt and child seat laws Motorcycle helmet laws Crash victim s overall health Age of victim Gas tanks designed to minimize fires OnStar or other automated crash notification and GPS locator Availability of effective EMS systems and staffing Effective incident site management Distance to quality trauma care Rehabilitation programs available Policies and funding supporting emergency and medical response systems Public support for trauma care and rehabilitation EMS training Resources and programs for psychological recovery from trauma Note. Adapted from National Committee for Injury Prevention and Control. (1989). Injury prevention: Meeting the challenge. American Journal of Preventive Medicine, 5(3 Suppl), 1-303; Christoffel, T., & Gallagher, S. S. (1999). Injury prevention and public health. Gaithersburg, MD: Aspen. Availability of resources. Any patient whose needs exceed local available care must be considered for prompt transfer to a higher level of care. Produce the greatest number of survivors with the resources you have available. Research reveals that trauma patients have better outcomes when they are cared for in trauma centers. The patient should be transported by EMS to the closest appropriate hospital, preferably a verified trauma center. The patient should bypass local nontrauma hospitals if access to a trauma center can be achieved within 30 minutes from the scene of injury. The right resources to care for the trauma patient as outlined by the ACS Committee on Trauma (COT) include essential trauma team activation, personnel with an appropriate skill mix, necessary equipment in the trauma room, available and appropriate surgical care, skilled postresuscitation care, and rehabilitation and supportive care (ACS, 2012). Stabilization and Transfer When definitive care cannot be rendered at the closest appropriate hospital, the patient must be transferred to a verified trauma center. A major principle of trauma management is to do no further harm. The level of care the patient receives should consistently improve with each step, from the scene of the incident to the first hospital and on to the second hospital. When the need for transfer is recognized, arrangements should be expedited and not delayed for unnecessary diagnostic procedures. Acute Care Trauma Centers An inclusive trauma care system requires verification or designation of definitive trauma care facilities and confirmation of their commitment to certain standards of care. However, all hospitals remain an integral part of the system. Hospitals can apply to become a Level I to Level IV trauma center. However, the current recommendation is to have trauma centers based on population needs, with an emphasis on a systems approach. This approach implies that there should be limitations on the number and level of verified trauma centers within a given geographic area (ACS-COT, 2014). A TRAUMA CENTER LEVELS Level I trauma center provides the most comprehensive level of care, whereas a Level IV trauma center provides minimal advanced life support care until transport to a higher level of care is possible (Table 2-2). Per the 2014 ACS-COT guidelines: Level I Serves as the lead hospital within a region or state system. Admits a minimum of 1,200 trauma patients yearly or 240 trauma patients with an Injury Severity Score of more than 15. Has 24-hour in-house attending surgeon availability, with a maximum acceptable response time of 15 minutes from patient arrival; the surgeon must be present in the ED for major resuscitations, be present at operative procedures, and actively involved in the critical care of all seriously injured patients. Maintains all subspecialists to treat trauma patients. Maintains a trauma improvement program. Maintains a surgically directed critical care team. Leads in injury prevention and outreach activities. Participates in resident training. Conducts trauma research. Level II The standards for the provision of clinical care to injured patients for Level I and Level II trauma centers are identical aside from the fact that Level II trauma centers do not have to: meet the admission requirements of Level I trauma centers,

11 Basic Trauma Nursing 23 Table 2-2: Criteria for Interhospital Transfer Clinical circumstances that warrant interhospital transport when the patient s needs exceed available resources: Category Specific Injuries and Other Factors Central nervous Head injury system Penetrating injury or depressed skull fracture Open injury with or without cerebrospinal fluid leak Glasgow Coma Scale score < 15 or neurologically abnormal Lateralizing signs Spinal cord injury or major vertebral injury Chest Widened mediastinum or signs suggesting great-vessel injury Major chest wall injury or pulmonary contusion Cardiac injury Patients who may require prolonged ventilation Pelvis/abdomen Unstable pelvic-ring disruption Pelvic-ring disruption with shock and evidence of continuing hemorrhage Open pelvic injury Solid organ injury Extremities Severe open fractures Traumatic amputation with potential for replantation Complex articular fractures Major crush injury Ischemia Multisystem Head injury with face, chest, abdominal, or pelvic injury injuries Injury to more than two body regions Major burns or burns with associated injuries Multiple proximal long-bone fractures Comorbid Age > 55 years factors Age < 5 years Cardiac respiratory disease Insulin-dependent diabetes Morbid obesity Pregnancy Immunosuppression Secondary deterioration (late sequelae) Mechanical ventilation required Sepsis Single or multiple organ system failure (deterioration in central nervous, cardiac, pulmonary, hepatic, renal, or coagulation systems) Major tissue necrosis Note. From American College of Surgeons, Committee on Trauma. (2012). Advanced trauma life support (9th ed.). Chicago, IL: Author. maintain a surgically directed critical care service, participate in resident training, or conduct trauma research. Level II trauma centers do have to: have 24-hour in-house attending surgeon availability, with a maximum acceptable response time of 15 minutes from patient arrival; the surgeon must be present in the ED for major resuscitations, be present at operative procedures, and actively involved in the critical care of all seriously injured patients; maintain all subspecialists to treat trauma patients; maintain a trauma improvement program; and participate in injury prevention. Level III Provides initial management for the majority of trauma patients. Maintains transfer agreements with available Level I and II trauma centers. Maintains continuous general surgical coverage with prompt response to the ED with a maximum acceptable response time of 30 minutes from the time the patient arrives in the ED. Ensures a trauma improvement program. Level IV Provides initial stabilization and transfer of trauma patients. Maintains 24-hour emergency coverage by a physician or midlevel provider. Maintains well-defined transfer plans to Level I and Level II trauma centers. There are currently 400 verified trauma centers in the United States, with numerous hospitals pursuing provisional status as they await formal verification (ACS, 2014). Rehabilitation Rehabilitation is the process by which physical, sensory, and mental functional capacities are restored or redeveloped after damage. Rehabilitation has been shown to benefit patients in ways such as reduced length of hospital stays and improved functional outcomes. Appropriate and early rehabilitation enhances a survivor s potential to achieve maximal recovery, personal autonomy, vocational independence, and an independent lifestyle. Rehabilitation facilities are unavailable in many regions of the United States. Many rural trauma patients must travel hundreds of miles to access rehabilitation care, putting tremendous strain on a family s resources and endurance. TRAUMA SYSTEM EVALUATION The development of trauma systems has led to a significant reduction in the number of preventable deaths after injury. A preventable death rate of less than 1% to 2% is now widely accepted as ideal in a trauma system. A successful trauma system monitors the performance of all aspects of trauma care. The process of quality improvement requires accurate data collection, which is achieved by using a trauma registry. A trauma registry is a computerized database maintained in every trauma center and used to evaluate the functioning of the trauma care system on a regional and statewide basis. Trauma centers use trauma registries for internal monitoring and processing improvement activities. They are also useful for prevention education, research, medical cost control, and efforts to improve patient care. The data compiled from each trauma system are then forwarded to the ACS National Trauma Data Bank (NTDB). As of 2013, 750 hospitals were submitting data to the NTDB. Of these, 230 were Level I centers, 265 were Level II, 205 were Level III, and 32 were Level I or II pediatric-only trauma centers (Nance, 2014). Trauma System Effectiveness Published data on trauma system effectiveness remains difficult to interpret because of the complexity and variability in study design, type of analysis, and definition of outcome variables. A report on the care of fatally injured patients in a rural state found that 22% of those who had injuries that did not affect the central nervous system and who reached the emergency department alive had potentially survivable injuries (Mattox, Moore, & Feliciano, 2013). The cost of trauma care is high, thus raising questions about the effectiveness and value of a regionalized approach to trauma care. In a study with data from 5,043 trauma patients over 14 states and 69 trauma centers, it was found that the

12 24 Basic Trauma Nursing added cost for treatment at a trauma center versus nontrauma center was $36,319 per life-year gained and $36,961 per quality-adjusted life-year gained. This information led to the conclusion that regionalization of trauma care is not only clinically effective, it is also cost effective (McKenzie et al., 2010). Case Study 1 Without a trauma system At 10:00 a.m., a 911 emergency dispatcher receives a call that there has been a motor vehicle crash. Other than the location, no details are given, and the phone call is terminated. The police are dispatched and arrive on the scene 5 minutes later. When the police arrive and realize the seriousness of the incident, they radio for an ambulance. The ambulance arrives on the scene at 10:13 a.m. The crew finds the patient unconscious with shallow breathing, but reactive to pain. They suspect internal injury and bleeding. The EMS providers notify the nearest hospital at 10:18 a.m. and relay vital information. The patient is finally removed from the vehicle at 10:26 a.m., and at 10:30 a.m., the ambulance is on the way to the nearest hospital. Per protocol, the EMS providers secure an airway while maintaining cervical immobilization, start IVs, and manage life-threatening injuries. At 10:40 a.m., the ambulance arrives at the hospital. After the physicians in the emergency room assess the patient, they realize the injuries are too severe to be treated at their facility. They call for a helicopter to transport the patient to a trauma center. At 11:05 a.m., the helicopter arrives; at 11:20 a.m., they are headed for the trauma center. One hour and 20 minutes have elapsed before the patient is on the way to receiving definitive care. This patient dies. With a trauma system At 10:00 a.m., the 911 emergency dispatcher receives a call that there has been a motor vehicle crash. Because the general public has been educated on how to access the trauma system, the caller gives important and vital information to the dispatcher, who can then determine who should be dispatched to the scene. At 10:05 a.m., the police, an ambulance, and fire department personnel arrive on the scene. They find the patient unconscious with shallow breathing, but reactive to pain. They suspect internal injury and bleeding. The EMS providers start appropriate PreHospital Trauma Life Support (PHTLS) and protocol-directed trauma care, and at 10:08 a.m., they call for a helicopter to arrive and transport the patient directly to the trauma center. The trauma center has been notified of the incoming patient and is prepared for the arrival. Meanwhile, by 10:15 a.m., the patient has been removed from the car. The helicopter arrives and transports the patient to the trauma center, arriving at 10:39 a.m. The patient is assessed and determined to need surgery. The operating room crew has been standing by and at 10:49 a.m., the patient is taken to surgery. This patient receives definitive care in 49 minutes and is in serious but stable condition. Several issues in these scenarios impacted survival, including: bystander education; enhanced 911 capability; EMS communication; EMS trauma training; EMS trauma triage protocols; EMS trauma destination protocols; trauma transfer agreements between hospitals; helicopter activation protocols; trauma center activation; immediate availability of surgeons, staff, and equipment; immediate operating room availability; and ICU and rehabilitation care. Trauma is a time-sensitive disease. Case Study 2 You are the only nurse in the emergency department of a 40-bed community hospital. You have one doctor and an ER tech available to assist you. Ten minutes ago, you were called and told that ambulances would be arriving with patients from a motor vehicle crash. No other information is available. Minutes later, multiple ambulances arrive with five patients who were in a car traveling 60 mph before it crashed into a tree. Directions: Triage and rank the patients in the priority that they should be treated by placing a number (1 through 5, with 1 being your highest priority and 5 being your lowest priority) on the rule provided before each patient case. The injured patients are as follows. Patient A 50-year-old female was the unrestrained driver of the car and was thrown against the windshield. She is in severe respiratory distress. Prehospital personnel report the following suspected injuries: significant maxillofacial trauma with bleeding from the nose and mouth, an angulated deformity of the left forearm, abrasions to the chest. Vital signs: blood pressure (BP) 150/78 mm Hg, heart rate (HR) 125, respiratory rate (RR) 42, Glasgow Coma Scale (GCS) score 8. Patient B A 23-year-old male passenger who was apparently thrown from the front seat and found 30 feet from the car. On admission, he is awake and alert, and he complains of chest and abdominal pain. He also complains of pain on any movement of his hips. Vital signs: BP 112/92 mm Hg, HR 140, RR 25. Patient C A 42-year-old female occupant was found under the car. On admission, she is extremely confused and responds slowly to verbal stimuli. Apparent injuries include multiple abrasions to the face, chest, and abdomen. Breath sounds are absent on the left, and her abdomen is tender to palpation. Vital signs: BP 90/48 mm Hg, HR 142, RR 36, GCS score 10. Patient D An 18-year-old female was extricated from the back seat of the vehicle. She is 8 months pregnant and complains of abdominal pain. Injuries include multiple abrasions to her face and anterior abdominal wall. You are told that her abdomen is tender to palpation. She is in active labor. Vital signs: BP 114/80 mm Hg, HR 102, RR 24. Patient E A 9-year-old boy was extricated from the floor of the back seat of the car. He was alert and talking at the scene. He now responds to painful stimuli only by crying out. Injuries include abrasions and an angulated deformity of the right lower leg. There is dried blood around his nose and mouth. Vital signs: BP 120/72 mm Hg, HR 182, RR 34. Answers to Case Study 2 Priority 1: Patient A Rationale: This female has a major upper airway obstruction. Airway is always the first priority in initial assessment of trauma. With bleeding from her mouth and nose, she is at high risk for fractures and swelling of the nasal and oral airways. Immediate assessment and intervention for airway should be undertaken. Priority 2: Patient C Rationale: This female presents with absent breath sounds on one side along with hypotension, which makes her the second priority. The combination of these two signs and symptoms would make one suspicious of a tension pneumothorax, which should be assessed for and treated promptly with a needle thoracostomy or chest tube insertion. Priority 3: Patient E Rationale: This child has sustained a significant head injury as evidenced by his change in level of consciousness (LOC). Initial priority should be to secure and protect his airway. Early consideration should be given to transporting this patient to a trauma center with pediatric capability. Priority 4: Patient B Rationale: This patient is stable and shows few signs of hemodynamic abnormality. The history of being thrown from the car, however, and findings consistent with suspected pelvic fracture, puts this patient at risk for severe injury and possible hemorrhagic shock. He will need fluid resuscitation and frequent reevaluation for signs and symptoms indicating deterioration. Priority 5: Patient D Rationale: This patient is in active labor, possibly precipitated by the motor vehicle crash. After examination and stabilization, care should turn to ensuring that there are no signs of fetal distress. Delivery is imminent; however, this patient should wait until the other more critical patients are cared for. Rural Trauma Care Rural populations and healthcare providers are less prepared to treat trauma. Roughly 62.5 million people (about 20% of the U.S. population) live in rural areas. While only 20% of our population resides in rural regions, more than 60% of the trauma deaths in America occur in these remote geographic segments of the country (PCORI, 2013). The relative risk of a rural victim dying in a motor vehicle crash is 15 to 1 compared with a crash victim in an urban area. In fact, risk of death from a motor vehicle crash is inversely related to population density. Trauma in rural settings presents a unique set of challenges. Risk of death is distinctly increased, probably as a result of prehospital factors such as delayed recognition and inconsistency of EMS response and care. Many rural areas suffer from a lack of professionally trained EMS personnel and instead rely heavily on trained volunteers. However, the lack of willing volunteers threatens the entire system and can lead to a severely disrupted response. Lack of trauma-trained physicians and hospital resources also contributes to a higher death rate. Development and designation of rural trauma centers can be instrumental in reversing this trend. The trauma care education that goes hand-in-hand with

13 Basic Trauma Nursing 25 designation is probably most responsible for trauma patients better outcomes. The guiding philosophy in such a system should be one of minimal acceptable care, with early recognition of major trauma and expeditious transfer of these patients. This does not alleviate the responsibility rural trauma centers have to deal quickly and effectively with patients for whom ongoing blood loss is an immediate threat to life and to exert a damage control approach as an initial phase of treatment. A Case Study 3 48-year-old banker was hunting with friends in a national forest in the Rocky Mountains. While separated from his friends, he climbed a tree to survey the land. Seventy minutes later, his companions found him unconscious at the bottom of a tree, after an apparent fall. One of the party rode out for help, which arrived in the form of a basic life support unit from the local ski area, approximately an hour after the patient was found. The patient had to be extricated from a ravine and carried several hundred yards to the ambulance, which then drove for an hour to the nearest hospital, a Level III trauma center. Communication with the hospital was not possible until 15 minutes before arrival. His GCS score at the scene and in the emergency department was 8. He was hemodynamically normal, but a computed tomography (CT) scan of the head showed a large epidural hematoma with more than a 5 mm shift. No other injuries were identified. Following consultation with a neurosurgeon at the nearest Level II center (150 miles away), a general surgeon trained in emergency limited craniotomy (and following established local protocols) drilled a burr hole and enlarged it sufficiently to permit evacuation of the clot and control of the hemorrhage. Poor weather had grounded all helicopter transfer, so the patient was transferred directly from the operating room to an ambulance, which drove him to the neurosurgeon for a formal craniotomy. He survived and is now independent, although he is no longer able to function in his former capacity. What issues can you identify in the above case study that demonstrate special considerations related to rural trauma? Answers to Case Study 3 The identified challenges included: unaccompanied victim; hours or days to discovery; inaccessibility to rescuers; great distance to hospital; and lack of trauma team and trained surgeon; additionally, adverse weather prevented air transport. A SUMMARY trauma system is composed of a number of components that must work together to meet the needs of all patients, regardless of severity of injury, geographic location, or population density. When a person is injured in the United States, he or she should be able to access an organized trauma care system that delivers the right care to the right patient at the right time. Everyone should work together to achieve that benchmark. An inclusive system integrates all levels of trauma care for seamless delivery. People should expect no less. Chapter 3: Initial Assessment of the Trauma Patient CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe the initial assessment of the trauma patient. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Identify patients at high risk for clinical deterioration who require priority treatment. 2. Differentiate the assessment steps performed in the primary versus the secondary assessment. 3. Describe interventions to manage life- threatening conditions. 4. Indicate the appropriate use of adjunct equipment or tests during the initial assessment. INTRODUCTION Organized initial assessment of the trauma patient is essential for recognizing life- threatening injuries and for determining priorities in care. It consists of two sections, the primary and secondary surveys. The entire assessment should be completed within 2 to 5 minutes of patient contact. It is an orderly, systematic approach to the patient to ensure identification of all injuries. TRIAGE The objective of triage (which means to sort ) is to prioritize patients with a high likelihood of early clinical deterioration. Prompt recognition of patients who are immediately at risk of loss of life (e.g., loss of airway or hemorrhagic shock) or limb (e.g., ischemia) or will need immediate operative or lifesaving interventions is paramount (Mattox, Moore, & Feliciano, 2013). Clinical findings that stimulate clinicians to perform an accelerated workup include multiple injuries, extreme age (either young or old), evidence of severe neurologic injury, unstable vital signs, and preexisting cardiac or pulmonary disease. When performing a triage of patients with several different types of injuries, the primary survey s priorities help determine precedence (e.g., a patient with an obstructed airway receives greater priority for initial attention than a relatively stable patient with a traumatic amputation). In trauma centers, a team of clinicians evaluates patients who are critically injured and simultaneously performs interventions and diagnostic procedures, even while the assessment is going on. That is, evaluation and treatment are done simultaneously, beginning with systems that pose the most immediate threat to life if damaged. Systems are rapidly examined for serious abnormalities (primary survey); a more detailed examination (secondary survey) is done after the patient is stable (Jordan, 2013). In small hospitals or in nonhospital situations, the trauma team and its resources can become quickly overtaxed. Even in a better equipped organization, the trauma team can be overwhelmed and its resources rapidly used up. Furthermore, factors basic to the institution, such as provider skill level and available equipment, have an impact on how triage is conducted. Added into the mix is the provider s understanding of the odds of each patient s survival. The objective of triage then becomes to provide the greatest good for the greatest number. In a situation where there are multiple severely injured patients, this process can sometimes mean bypassing seriously injured patients who may not survive in order to treat less critical, but potentially salvageable, patients. Triage under conditions of limited resources can be challenging and agonizing. INITIAL ASSESSMENT The approach to trauma patient care requires a process to identify and treat or stabilize life-threatening injuries in an efficient and timely manner (ENA, 2014). The initial assessment is divided into two phases, primary and secondary surveys (assessments; see Table 3-1). The primary survey should be performed in 2 to 5 minutes. Injuries identified in the primary survey should be treated upon discovery. The secondary survey follows with a detailed slower examination. Each section of the primary survey will be explained in further detail in the following sections. Primary Survey Airway While assessing and managing the patient s airway, care should be taken to prevent excessive movement of the cervical spine. The patient s head and neck should not be hyperextended, hyperflexed, or rotated to establish and maintain the airway. While holding the head, ask the patient to speak. This not only verifies patency of the airway but also provides immediate information on level of consciousness (LOC). If the patient is unconscious, open the airway and inspect for foreign bodies and mechanical disruptions such as facial, mandibular, or tracheal/laryngeal fractures, which may result in airway obstruction. Observe for: ability to speak and altered phonation; loose teeth or foreign objects; blood, vomit, or other secretions; edema; and tongue obstructing the airway in the unconscious patient. Interventions Patent Airway If the patient can speak, then the airway is patent. Maintain cervical spine immobilization. If the patient is awake and breathing and has assumed a position that maximizes ability to breathe, do not compromise this position. Signs of airway obstruction range from subtle to obvious (see Table 3-2). Partially or Totally Obstructed Airway Logroll the patient onto his or her back while maintaining cervical spine stabilization. Remove any headgear to allow access to the airway. A patient wearing a motorcycle or sports helmet who requires airway management should have his or her head and neck held in a neutral position while the helmet is removed. This is a two-person procedure. One person provides in-line manual immobilization from below while the second person expands the helmet laterally and removes it from above. Keep the head in neutral position. Open the airway by either the jaw thrust or chin lift method:

14 26 Basic Trauma Nursing Table 3-1: OVERVIEW OF THE INITIAL ASSESSMENT Primary Assessment Airway Assess airway with simultaneous cervical spine immobilization. Can the patient talk? If obstructed, consider chin lift, jaw thrust, suction, oropharyngeal airway, and intubation, all while keeping the neck immobilized. Breathing Assess breathing rate, depth, effort, accessory muscle use, symmetry of chest wall movement, and bilateral breath sounds. Close any open wounds and provide oxygen, intubation, and ventilation as needed. Circulation Palpate central and peripheral pulses. Assess level of consciousness. Look for obvious signs of bleeding. Check skin temperature and color. Disability Perform a rapid neurologic assessment: Glasgow Coma Score (GCS) Best eye opening Best verbal response Best motor response Exposure Provide exposure and environmental controls. Remove the patient s clothes and keep him or her warm. Secondary Assessment Head, face, neck Chest Abdomen, pelvis, perineum Extremities Posterior Inspect and palpate the head, face, and neck. Check pupils. Assess GCS. Assess extraocular movements. Inspect for jugular venous distention. Palpate the cervical spine for tenderness. Inspect, auscultate, and palpate the chest wall. Observe rise and fall. Assess accessory muscles. Palpate for subcutaneous emphysema. Inspect, auscultate, and palpate the abdomen. Auscultate bowel sounds. Palpate for rigidity and tenderness. Palpate pelvis stability. Inspect and palpate. Compare right to left. Palpate pulses. Assess neurovascular status. Logroll the patient. Inspect and palpate the back and spine. Check rectal sphincter tone. Jaw Thrust Stand behind the patient s head and place the palms of your hands on either side of the patient s head. Place your thumbs over the cheekbones and position your fingers under the lower jaw, displacing the mandible forward. Pull the mandible up using your thumbs as fulcrums to pull against. Using this method with mouth-to-face mask ventilation allows for a good seal with adequate ventilation. Chin Lift Stand at the side of the patient. Place one hand on the patient s forehead to stabilize the head. Grasp the chin and lower lip with the other hand and lift the mandible. Reassess airway patency. Suction: Anticipate Vomiting Be prepared for possible vomiting in all injured patients. The presence of gastric contents in the oropharynx confirms a significant risk of aspiration with the patient s next breath. If secretions are noted in the oropharynx, immediately logroll the patient onto his or her side and suction the airway with a rigid-type (tonsil tip or Yankauer) suction catheter. Patients with facial injuries may have associated cribriform plate fractures, and the use of soft suction catheters through the nose should be avoided to prevent accidental insertion into the cranial vault. Caution: Suction down the sides of the oral cavity, being careful to avoid stimulating the gag reflex. Airway Adjuncts Nasopharyngeal Airway Used for patients who are partially responsive with an intact gag reflex. Ideal for inebriated patients who are sleeping off their inebriation or patients who are postictal, but to be avoided in patients with facial trauma, basilar skull fractures, or deviated septum. Select the largest size possible that will fit easily through the patient s nares. The size of the patient s little finger can be used as a rough guide. Select the correct length by measuring from the tip of the patient s nose to the tip of the earlobe. Lubricate the airway prior to insertion. Insert the airway with the beveled edge toward the septum. Direct the airway posteriorly and rotate it toward the ear until the flange rests against the nostril. Reassess airway patency. Oropharyngeal Airway Used for patients who are unresponsive with no gag reflex and when intubation is not immediately available. Remember that in the unconscious patient, the tongue is the number one cause of obstructed airway. Therefore, this airway is inserted to keep the tongue off the back of the throat. It is a useful complement to bag-valve mask ventilation. In centers where intubation can take place promptly, oral pharyngeal airway placement is often skipped in favor of moving straight to intubation. Select the correct size by measuring from the tip of the earlobe to the corner of the mouth. There are three methods of airway insertion: 1. Method one (adults only). Insert the oral airway curved side down. The tip will slide along the hard palate. Insert it until the plastic flange is at the patient s lips. Rotate it 180 so that the curve of the oral airway follows the curvature of the tongue (Reichman, 2013). 2. Method two. Use a tongue depressor to hold the tongue against the floor of the mouth and insert the airway with the curve of the tube following the natural curve of the airway. This is the preferred method of insertion for children and adults. 3. Method three (adults only). A hybrid of the above two methods, the oropharyngeal airway is turned sideways and inserted at the corner of the mouth and then rotated 90 into position as the curve of the tube is advanced into the natural curve of the hypopharynx. This is an alternative method for use in adults. Caution: Regardless of insertion technique, always reassess the airway for patency after oropharyngeal airway insertion to ensure that the tongue is not pushed down into the back of the throat.

15 Basic Trauma Nursing 27 Breathing Airway patency alone does not ensure ventilation. Adequate exchange of gases is mandatory to maximize oxygen transfer and carbon dioxide elimination. Breathing assessment uses the three senses of sight, hearing, and touch (see Table 3-3). The oxygen device should be selected based on the patient s ventilatory effort. If a patient is breathing at approximately 10 or more breaths per minute, an oxygen mask may be used as supplemental oxygen. If a patient is breathing at 10 or fewer breaths per TABLE 3-2: ASSESSMENT OF AIRWAY OBSTRUCTION Method Sign Condition Look Tachypnea A subtle but early sign of airway or ventilatory compromise Look Agitation Suggests hypoxia Look Decreased level of consciousness Suggests hypercarbia from hypoventilation Look Cyanosis Suggests hypoxemia due to inadequate oxygenation Nail beds Circumoral (around mouth) Listen Noisy breathing Suggests partially obstructed airway Listen Snoring, gurgling, crowing Suggest partial occlusion of the pharynx or larynx sounds (stridor) Listen Hoarseness Suggests laryngeal obstruction Listen Abusiveness or belligerence Suggests hypoxia and/or head injury and should not be presumed to be from intoxication Feel Air from mouth Suggests movement of air with expiratory effort Feel Trachea position Deviation suggests tension pneumothorax Feel Midfacial fractures Fractures of the mandible, especially bilateral, causing loss of normal muscle support and ability to protrude the tongue, thereby obstructing the airway TABLE 3-3: BREATHING ASSESSMENT IN TRAUMA Method Sign Condition Look Respiratory rate and depth Normal rate is 12 to 20 breaths per minute. Fewer than 12 breaths per minute suggests CNS trauma. More than 24 breaths per minute suggests developing respiratory and systemic compromise. Tachypnea is rapid, shallow breathing. Assess for chest trauma, especially rib fractures, which cause pain and can lead to rapid, shallow ventilation and hypoxemia. Look Abnormal breathing pattern Cheyne-Stokes (alternating pattern of hyperpnea and breathing apnea) suggests possible intracranial injury. Look Diaphragmatic Abdominal breathing suggests possible cervical cord injury. Look Accessory muscle use Observe for: bulging sternocleidomastoid muscle, intercostal or sternal retractions, nasal flaring in infants, and labored breathing, which should be regarded as an imminent threat to the patient s oxygenation. Look Symmetrical chest movement Both sides of the chest should rise and fall equally. Always stand at the head or foot of the bed to view both sides simultaneously. Asymmetry suggests splinting or possible tension pneumothorax. Paradoxical chest wall movement suggests flail chest. Look Skin color This is a late sign and should not be relied upon. Listen Bilateral breath sounds Decreased or absent breath sounds over one or both sides should alert personnel to the presence of thoracic trauma. Feel Chest wall Assess chest wall integrity; inspect for abrasions, ecchymosis, and penetrations; palpate for subcutaneous emphysema (crackling, popping sounds) or crepitus (fractured bone ends grinding). Feel Jugular veins Bulging jugular veins suggest tension pneumothorax or cardiac tamponade. Feel Trachea position Trachea deviated away from the side of injury suggests tension pneumothorax. minute, then bag-valve mask ventilation should be performed prior to intubation. Oxygen Delivery Methods Nonrebreather Mask The nonrebreather mask is preferred for delivering the highest concentration of oxygen to a spontaneously breathing nonintubated patient. Nonrebreather masks with a reservoir bag with oxygen flow rates into the bag of 12 to 15 L/min can provide up to 95% oxygen to the patient. This is the minimum recommended for all trauma patients who require supplemental oxygen. Bag-Valve Mask Ventilation Bag-valve mask ventilation is required if the patient is not adequately ventilating. The bag-valve mask should have an oxygen reservoir and be connected to an oxygen source. Effective bag-valve mask ventilation requires a tight seal of the face mask along with adequate compression of the bag. The average delivered volume is between 500 and 800 ml. With a two-handed squeeze, more than 1 L of oxygen can be delivered. Maintain an oxygen flow rate of 12 to 15 L/min to keep the reservoir bag inflated. Caution: Overcompression of the reservoir bag is a common practice that can cause insufflation of air into the stomach and increases the risk of regurgitation. One-Person Bag-Valve Mask Ventilation: Stand at the patient s head and place the narrow end of the mask over the bridge of the patient s nose. Grasp the mask firmly with your thumb and first finger around the mask, forming a C, while spreading your remaining fingers around the mandible and applying slight upward pressure and forming an E. Compress the bag with the other hand. Individuals with small hands may find it necessary to compress the bag against their body to adequately generate a large enough tidal volume. Two-Person Bag-Valve Mask Ventilation: One person is at the patient s head and holds the mask in place with his or her thumbs on either side of the mask, while pulling the mandible up slightly. The second person stands to the patient s side and compresses the bag with both hands to inflate the lungs. The two-person technique is the preferred method. Temporary EMS Airway There have been great advancements in the technology related to, education about, and use of alternate temporary airways. Historically, these airways have been thought of as rescue airways, but many EMS systems have adopted them for routine use in airway management. Supraglottic Airways The supraglottic airway has become very popular, with new devices and technologies on the market. Examples of current supraglottic airways are: Laryngeal mask airway (LMA); LMA Fastrach; Air-Q; Air-Qsp; I-Gel; Supraglottic Airway Laryngopharyngeal Tube (SALT); and King LT and LTD.

16 28 Basic Trauma Nursing Combitube With the advent and proliferation of alternate airways, the Combitube is less commonly used as a back-up airway when oral intubation has failed. The Combitube is a dual-lumen tube that can be passed blindly into the esophagus or the trachea to allow bag-valve mask ventilation via ports from one lumen or the other. Most hospitals switch these out for regular orotracheal intubation after the patient arrives at the emergency department. Definitive Airway Definitive airways include orotracheal intubation, nasotracheal intubation, and surgical airway. The need for a definitive airway in trauma is based on clinical findings of: apnea; inability to maintain a patent airway by other means; protection of the lower airway from aspiration of blood or vomitus; impending or potential compromise of the airway, such as in inhalation injury, facial fractures, or sustained seizure activity; closed-head injury with a decreased LOC as defined as a Glasgow Coma Scale (GCS) score below 9 (see Table 3-4); and/or failure to maintain adequate oxygenation by bag-valve mask ventilation. The urgency of the situation and skills of the available provider dictate the specific route and method to be used. The potential for concomitant cervical spine injury is also of concern in the patient requiring an airway. Regardless of which intubation method is used, if endotracheal intubation is not accomplished within 30 seconds or in the time required to hold your breath before exhaling, discontinue attempts, ventilate the patient with a bag-valve mask device, and try again. TABLE 3-4: GLASGOW COMA SCALE Best Eye Response Spontaneously 4 To voice 3 To pain 2 Remain closed 1 Verbal Response Oriented 5 Confused 4 Inappropriate words 3 Makes sounds 2 No response 1 Motor Response Obeys commands 6 Localizes stimulus 5 Withdraws from stimulus 4 Abnormal flexion 3 Abnormal extension 2 No response 1 Total Score 3 to 15 Orotracheal Intubation The nurse may assist with orotracheal intubation by helping assemble equipment, testing the cuff integrity with temporary inflation, maintaining cervical spine immobilization, and performing the Sellick maneuver (cricoid pressure with the fingers) during intubation to suppress vomiting and aid in visualization of the cords. Although there has been some disagreement on the efficacy of cricoid pressure (CP) and the Sellick maneuver, one study showed 10 different techniques in 32 observations with varying success rates (Brisson & Brisson, 2010). Multiple specialty societies have advised that CP is not effective in preventing aspiration. Instead, it may exacerbate laryngoscopic views and impair bag-valve mask ventilation. Some experts believe that CP should be applied in trauma patients and those at risk for aspiration; however, CP if necessary should be altered or removed to facilitate intubation. With the ever-growing medical complexity of the patient population it is important to recognize that standards and algorithms can never completely take the place of an actively vigilant provider and must continue to be viewed as guidelines for best practice (Stewart, Bhananker, & Ramaiah, 2014). Typical endotracheal tube sizes for women are 7.0 to 8.0 mm; for men, they are 8.0 to 9.0 mm. The proper placement of the endotracheal tube must be carefully confirmed. No single technique is 100% reliable under all circumstances. The following points provide techniques for endotracheal tube placement confirmation. The person performing the intubation visualizes the tube passing through the vocal cords. Auscultate the stomach and bilateral lung fields as follows: First, auscultate the (stomach) epigastric area to confirm the absence of gurgling. If stomach gurgling is heard and chest wall expansion is not evident, inadvertent esophageal intubation should be assumed, the tube should be immediately removed, and the patient should be bagged. Next, auscultate for equal bilateral breath sounds at: the second intercostal space, midclavicular line and the fifth intercostal space at the anterior axillary line bilaterally. Look for symmetrical chest rise and fall with the application of positive pressure ventilation (bagging). Be aware that some patients may be able to breathe spontaneously in spite of esophageal intubation. Rise and fall of the chest with spontaneous ventilation alone does not confirm tube placement. Use temporary adjuncts for confirming tube position, including esophageal detector devices (EDD) and end tidal CO 2 colorimetric devices. The EDD is an inexpensive, easy to use, self-inflating bulb aspiration device placed over the end of the endotracheal tube. Return of air suggests placement in the trachea. No return indicates esophageal placement. End tidal CO 2 colorimetric devices are quick color-changing devices placed at the end of the endotracheal tube. They indicate the presence of CO 2 in exhaled air with one color and low or no CO 2 with another color. Pitfalls of end tidal CO 2 devices include: On rare occasions, patients with gastric distention can have elevated CO 2 levels in the esophagus. These elevated levels clear rapidly after several breaths; therefore, the results of colorimetric devices should not be relied on until after at least six breaths. During low-flow states, such as cardiac arrest or hypovolemic shock, CO 2 may not be detected, even when the endotracheal tube is adequately placed. This is also true in the presence of large amounts of secretions, such as with hemoptysis or pulmonary edema. End tidal CO 2 capnography provides a continuous and objective measure of ventilation that can alert a provider immediately to an airway problem (Langham et al., 2011). When placement is confirmed, inflate the cuff, secure the tube, and continue ventilation. Caution: Confirmation of tube placement is a dynamic process that requires ongoing patient assessment. Reconfirmation should be performed whenever the patient is moved or if tube dislodgement is suspected (see Table 3-5). Rapid Sequence Intubation Intubation using pharmacologic agents has rapidly gained favor and is now the standard in trauma care (see Table 3-6). Rapid sequence intubation (RSI) is the preferred method of endotracheal intubation in the emergency department because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis). This is helpful in trauma patients because they often have full stomachs and are at greater risk of vomiting and aspiration. Patient indications for RSI in trauma include: failure to maintain an airway because of swelling, bleeding, decreased LOC, and/or inadequate ventilation or oxygenation. difficult intubation because of uncooperative behavior induced by hypoxia, traumatic brain injury, hypotension, and/or intoxication. Rapid sequence intubation is not indicated if the patient is already unconscious and apneic. In this situation, there is no time for preoxygenation, pretreatment, or induction and paralysis. Instead, bag-valve mask ventilation and intubation should be performed immediately without medications. Nasotracheal Intubation Nasotracheal intubation has fallen out of favor and is rarely used today; however, it may be justified on the rare occasion that the adult patient s mouth cannot be opened for mechanical or physiological reasons, and the patient cannot be ventilated by any other means. Its application is limited to the breathing patient and involves blind placement of the tube through the nose and into the trachea. Caution: Nasotracheal intubation is contraindicated in the apneic patient and whenever severe midfacial fractures or suspicion of a basilar skull fracture exist.

17 Basic Trauma Nursing 29 TABLE 3-5: CONFIRMATION OF ENDOTRACHEAL TUBE PLACEMENT Elements to Assess Oral Endotracheal Right Mainstem Intubation Tube Replacement Visualization of the tube Yes Yes No passing through the cords Epigastric gurgling Absent Absent Present Breath sounds Tube Expansion Presence of bilateral breath sounds Condensation in the tube with exhalation Bilateral chest wall expansion Presence of breath sounds on the right side only Condensation in the tube with exhalation Unilateral (right) chest wall expansion Esophageal Placement Absent bilateral breath sounds Gastric fluids in the tube Abdominal wall expansion Oxygen saturation Normal Poor Absent End-tidal carbon dioxide Normal Normal Absent detection Speech Inability to talk Inability to talk Phonation (ability to talk) Radiographic confirmation Average endotracheal tube insertion depth Chest X-ray helpful but cannot exclude esophageal intubation Female: 8.2 to 9.0 in. (21 to 23 cm) Male: 8.6 to 9.4 in. (22 to 24 cm) Chest X-ray confirms right mainstem intubation Greater than 10.2 in. (26 cm) Chest X-ray cannot confirm or exclude esophageal intubation; misreading the X-ray is possible due to projection of the esophagus over the tracheal air column Greater than 10.2 in. (26 cm) TABLE 3-6: SAMPLE PROTOCOL FOR RAPID SEQUENCE INTUBATION Steps Rationale Ensure two patent IV lines and cardiac and pulse oximetry monitoring Preoxygenate with 100% oxygen by nonrebreather mask for 3 to 5 minutes Pretreat with lidocaine Pretreat with atropine Induction of sedation: Midazolam (Versed) Fentanyl (Sublimaze) Etomidate Chemical paralysis: Succinylcholine (short duration) Vecuronium (intermediate duration) Sellick maneuver (cricoid pressure) Confirm tube placement immediately Repeat doses of paralytic agents as needed to maintain paralysis Patient monitoring for safety Allows for 3 to 5 minutes of apnea without significant desaturation Reduces the cardiovascular response to intubation; used when increased intracranial pressure is suspected Reduces bronchospasm and airway reactivity following tracheal intubation In pediatric intubation, prevents bradycardia and excess secretions Sedation Muscle relaxation and paralysis Used with suspected increased intracranial pressure Used with open globe injuries to temporize the pressure rise during fasciculations After administration of paralytic agents, used to decrease the potential for aspiration Continuous electrocardiogram and pulse oximeter monitoring is required during and after rapid sequence intubation Doses of long-acting paralytic agent, such as vecuronium, to continue paralysis (requirements vary with individual patients) Supralaryngeal/Supraglottic Airways These alternate airways are inserted into the hypopharynx and reside supraglottically or supralaryngeally. They are used as a back-up device when endotracheal intubation is unsuccessful and effective bag-valve mask ventilation is difficult or impossible to do. Aspiration remains a possibility; therefore, the gag reflex is present. A topical anesthetic or sedative is used to mute the response. The mask is lubricated and inserted with the opening facing the patient s tongue. Because there has been a proliferation of these devices, all healthcare providers are encouraged to follow manufacturer recommendations and have sufficient training prior to using the specific device in their particular department. Surgical Airway Inability to intubate the trachea is an indication for creating a surgical airway. Trauma conditions that dictate a surgical airway include any condition that prevents the endotracheal tube from being passed through the cords (e.g., edema, fractures of the larynx and adnexal structures, uncontrollable hemorrhage, and obstruction). Surgical cricothyroidotomy is the invasive mainstay airway; however, less invasive methods such as needle cricothyroidotomy and transtracheal jet insufflation are options in the temporizing scenario. Tip: Please note that tracheostomy is not considered an emergency airway procedure. Tracheostomy is an elective procedure that should be carried out only in an operating room in a controlled setting. Emergency tracheostomies are discouraged because they are difficult to perform under duress, are often associated with profuse bleeding, and are too time consuming. Surgical Cricothyroidotomy Surgical cricothyroidotomy is performed by making a skin incision that extends through the cricothyroid membrane. A curved hemostat may be inserted to dilate the opening. Then a small endotracheal tube or tracheostomy tube, preferably 0.2 to 0.3 in. (5 to 7 mm) can be inserted. Caution: Surgical cricothyroidotomy is not recommended for children younger than 12 years of age, to avoid damaging the cricoid cartilage, which is the only circumferential support to the upper trachea. Percutaneous Airway Needle Cricothyroidomy/Transtracheal Jet Insufflation Transtracheal jet insufflation is insertion of a needle through the cricothyroid membrane (needle cricothyroidotomy) into the trachea. This is a useful technique in emergency situations to provide oxygen on a short-term basis until a definitive airway can be placed. It is also the procedure of choice in children younger than 5 years of age when endotracheal intubation is unsuccessful. Jet insufflation is a temporary stopgap measure that allows for up to 45 minutes of extra time so that intubation can be accomplished on an urgent rather than an emergent basis. The jet insufflation technique is performed by placing a 12- or 14-gauge plastic cannula (angiocath) through the cricothyroid membrane into the trachea below the level of the obstruction. This is followed by connection of the cannula to the wall oxygen at 15 L/min at 40 to 50 psi, with a Y connector attached between the oxygen source and the plastic cannula. A thumb placed over the open end of the Y connector on the

18 30 Basic Trauma Nursing side of the hole achieves intermittent insufflation 1 second on and 4 seconds off. Some exhalation occurs during the 4 seconds that the oxygen is not being delivered under pressure. Caution: Carbon dioxide will slowly begin to accumulate and limits the use of this technique, especially in patients with head injuries. Circulation Circulation assessment in the primary survey involves rapid assessment of the injured patient s hemodynamic status. Key elements include LOC, skin color, pulse, and evidence of bleeding. Level of Consciousness When blood volume is reduced, cerebral perfusion and LOC will be impaired. Remember, however, that a conscious patient also may have lost a significant amount of blood. Skin Color Skin assessment can provide signs of inadequate organ perfusion such as pale skin; cool, clammy skin, and delayed capillary refill. Ashen gray skin of the face and white skin of the extremities are ominous signs of hypovolemia. Any patient with pink skin, especially of the face and extremities, is unlikely to be clinically hypovolemic. Pulse The patient s carotid and radial pulses should be evaluated simultaneously for presence and quality. (A rough rule of thumb is that if the radial pulse is palpable, it provides an estimate of the systolic blood pressure to be at least 80 to 90 mm Hg). A radial pulse that is tachycardic and weak indicates that the patient may be progressing into a shock state. Unexplained tachycardia in the trauma patient is indicative of hemorrhage until proven otherwise and should be quickly investigated. The primary goal is to maintain tissue oxygenation via intravascular euvolemia; thus, vasopressors should be considered only after volume has been restored. Bleeding Rapid external blood loss must be identified and can be managed with direct manual pressure. Internal hemorrhage should be suspected if the patient s hemodynamic status indicates hypovolemic compromise and there are no obvious signs of external hemorrhage. Major sites of blood loss include the thoracic, abdominal, and retroperitoneal cavities, as well as major bones of the pelvis. Reduce the pelvic volume in patients with displaced pelvic ring fractures by internally rotating the lower extremities, tying the ankles together, and wrapping a sheet tightly around the pelvis (or by using one of the commercially available pelvic binders). Care must be taken to avoid their use in lateral compression pelvic fractures because they may worsen the injury. Immobilize all fractures. Tourniquet Use Tourniquet use in civilian medicine has varied over the years, until 2008, when a study showed that rapid prehospital tourniquet use was associated with improved hemorrhage control. There was also evidence that 57% of battlefield deaths might have been prevented by earlier tourniquet use (Beekley et al., 2008). In 2010, guideline changes were made on evidence of the benefit of early tourniquet use for critically injured bleeding trauma patients (Rossaint et al., 2010). After the Boston Marathon terrorist bombing, it was encouraged that our civilian system s approach of early tourniquet use be followed rigorously, as 29 patients were found to have recognized extremity exsanguination at the scene. In total, 27 tourniquets were applied to the exsanguinating patients on scene, and out of all 243 patients, there was a mortality rate of 0% (King, Larentzakis, Ramly, & Boston Trauma Collaborative, 2015) Fluid Resuscitation Initiate two large-bore 12- or 14-gauge IV catheters. Antecubital peripheral placement is preferred. All infused fluids should be warmed. Adults: Recent literature and recommendations encourage a more balanced fluid resuscitation and avoiding aggressive resuscitation. Crystalloid resuscitation is still recommended, but now with a starting volume of 1 L (ACS, 2012). Children: Crystalloid fluid bolus of 20 ml/kg infused rapidly. Administer blood products as needed. Consider transfusion of type-specific or emergency uncrossmatched blood; type O positive or negative may be used for males older than 16 years of age and women older than 50 years of age; type O negative is used for children younger than 16 years of age and women of child-bearing age. Prepare for surgical intervention if internal hemorrhage is identified. Monitor temperature and aggressively treat hypothermia. Disability Neurologic Evaluation A rapid neurologic evaluation is performed at the end of the primary survey. This neurologic evaluation establishes the patient s LOC and pupillary size and reaction. The Glasgow Coma Scale (GCS) provides a quick, simple method for determining the LOC (refer to Table 3-4 on page 28). The total score results from a cumulative score of the best eye response, best verbal response, and best motor response. The lowest possible score is 3, and the highest is 15. The GCS is predictive of patient outcome, especially the motor response. When there is asymmetry in either eye opening or motor scores, the best score is used. The GCS should be obtained early in a patient s evaluation and preferably before administration of sedatives or paralytics. Remember that a GCS score of less than 8 indicates coma, and early airway and ventilator support should be considered. Sample GCS Scoring A 33-year-old female pedestrian presents to the trauma center after being struck by a car at 50 mph. There is a large bleeding head wound noted in the right parietal region. She does not respond to verbal stimuli. Pressure is applied to her nail beds. See the following patient responses and fill in the GCS score to the left of the response. Then calculate the patient s total GCS score and grade the severity of her brain injury. Score Action She opens her eyes. She moans and grunts. She pulls her hand away. Total GCS Answers: Eye = 2, Verbal = 2, Motor = 4 Total GCS score is 8, indicating severe brain injury. Remember that a decrease in LOC may indicate any or all of the following: Cerebral injury Hypoxia Drugs Alcohol Hypoglycemia Postictal state Hypercarbia Tip: All changes in LOC in trauma patients should be assumed to indicate a head injury until proven otherwise. Exposure/Environmental Control The patient should be completely undressed, and sometimes clothing must be cut off to facilitate a thorough examination. Keep the patient warm with the use of warm blankets or forced warm air blankets. Monitor the patient s temperature. History Review the patient s past medical history for the following: Medications Allergies Past medical conditions Previous surgeries and hospital admissions Use of drugs or alcohol Smoking Last menstrual period Last intake of food and fluids Adjuncts to the Primary Survey Pulse Oximetry A pulse oximeter is a device that indirectly measures levels of hypoxia. More specifically, it is a noninvasive photoelectric device that measures arterial oxygen saturation and pulse rate in the peripheral circulation. It consists of a monitor (that may or may not be portable) and a sensing probe that clips onto the patient s finger, toe, or earlobe. Pulse oximetry continuously measures oxygen saturation (O 2 sat) of arterial blood, not the partial pressure of arterial oxygen (PaO 2 ). It provides useful information by its rough indirect relationship to PaO 2. For example, a saturation of 95% or greater by pulse oximetry correlates to adequate peripheral arterial oxygenation (PaO 2 greater than 70 mm Hg). The advantage of pulse oximetry is its ability to provide an immediate assessment of therapeutic interventions and detection of unsuspected hypoxia (see Table 3-7). Caution: Nurses must avoid a false sense of security regarding pulse oximetry: 1. Remember that pulse oximetry measures the percentage of O 2 saturation, not the PaO 2. Hemoglobin molecules are so efficient at carrying oxygen that a molecule is 90% saturated when the partial pressure of oxygen is only 60 mm Hg (100 is normal). Therefore, if you are used to thinking about PaO 2 (where 90 to 100 mm Hg is normal), then you may think that a pulse oximetry reading of 90% is normal, when, in fact it is actually critically low. 2. Pulse oximetry does not monitor the effectiveness of ventilation. Pulse oximetry provides a good estimation of adequate oxygenation but

19 Basic Trauma Nursing 31 TABLE 3-7: PULSE OXIMETRY AND INTERVENTIONS Pulse Oximeter Reading Intervention > 94% Adequate, continue to maintain. < 93% Cause for concern; assess for: Airway patency, possible need for suction, supplemental oxygen, or assisted ventilation. < 90% Critical concern; immediate intervention required: Open airway, suction, bag-valve mask ventilation, or proceed to intubation. Assess for tension pneumothorax and prepare for decompression. no direct information about ventilation (particularly when supplemental oxygen is being administered). For example, a patient receiving oxygen by face mask can become increasingly drowsy from accumulated sedation, resulting in ventilations fewer than 10 breaths per minute (heading toward arrest), while still maintaining an oxygen saturation of 96%. 3. A time lag occurs between patient physiologic changes and when the displayed SaO 2 numerical value decreases. The partial pressure of oxygen can have fallen a great deal before oxygen saturation starts to fall. For example, if a healthy adult patient is given 100% oxygen to breathe for a few minutes and then ventilation ceases for any reason, several minutes may elapse before oxygen saturation starts to fall. In this situation, pulse oximetry warns of a potentially fatal complication several minutes after it has happened. 4. Finally, many conditions interfere with the reliability of pulse oximetry (see Table 3-8). End-Tidal Carbon Dioxide Monitoring (Capnography) Capnography, or continuous end-tidal carbon dioxide (ETCO 2 ) monitoring, provides quantitative information about levels of CO 2 at the end of respiration and provides waveforms and trends. End-tidal CO 2 detection confirms the presence of CO 2 in exhaled air, which indicates that the airway has been intubated successfully; however, it does not ensure the correct position of the endotracheal tube. In a patient being ventilated, the sensor is placed between the bag-valve mask or ventilator and the endotracheal tube. A normal ETCO 2 reading in a critical trauma patient is between 30 and 40 mm Hg. Current literature encourages monitoring trauma patients after tracheal intubation because there is evidence of the benefit of using the data to drive goal-directed therapies (Beckers, Brokmann, & Rossaint, 2014). Cardiac Monitor The trauma patient should be placed on a cardiac monitor and observed for dysrhythmias and excessive tachycardia. Arterial Blood Gases Arterial blood gas (ABG) studies are useful with the sickest of trauma patients. Oxygenation and ventilation as well as tissue perfusion are assessed. ABGs will be discussed further in Chapter 4. Urinary Catheter Urine output is a sensitive indicator of a patient s volume status. Urinary catheterization is contraindicated in patients when urethral transection is suspected; therefore, a rectal examination should be performed prior to insertion of a Foley catheter. Urethral injury should be suspected if: there is blood at the urinary meatus (particularly in males), there is blood in the scrotum, and/or the prostate is high riding or cannot be palpated. Gastric Catheter A nasogastric tube is indicated to reduce stomach distention and decrease the risk of aspiration. Nasogastric tube placement is contraindicated when a facial fracture such as a cribriform plate fracture is suspected. Orogastric tube placement is preferred in patients lacking a gag reflex. Radiologic Studies The two primary X-rays ordered in all trauma resuscitations include a chest X-ray and a pelvic X-ray. Cervical spine films remain controversial and are starting to fall out of favor because of a 10% miss rate. Increasingly, computed tomography (CT) scanning of the cervical spine is utilized instead. Caution: Transfer to definitive care should not be delayed by excessive radiologic procedures. Most trauma centers prefer to perform and interpret their own X-rays. Need for Transfer During the primary survey and resuscitation phase, the need for transfer to another facility should be considered early. Preexisting transfer agreements with trauma centers help speed the process. Secondary Survey (Head-to-Toe Assessment) Head and Face Inspect and palpate the external cranium for signs of injury. Note any lacerations, contusions (see Figure 3-1 for mastoid ecchymosis or Battle s sign), depressions, instabilities, foreign objects, or asymmetries. The mid-face and orbits need to be assessed for gross instabilities, bony crepitus, periorbital ecchymosis (see Figure 3-2 for raccoon eyes), or obvious angulations. In addition to a pupillary exam for equality, reactivity, and accommodation, inspect the globe for pathology. The globe, iris, and sclera should be inspected for dysconjugation, lateralization, extraocular movements (assigning for ocular muscle entrapment), presence of nystagmus, and scleral/corneal trauma. The nose and ears should be inspected for otorrhea and rhinorrhea (presence of drainage). If drainage is present, it should be described in color and consistency while performing a halo test for the presence of cerebrospinal fluid (CSF). The mandible should be assessed for malocclusion (either observed by the clinician or advised by the patient). Inspect the dentition to note any missing, damaged, or loose teeth. Inspect the mouth for obvious trauma, edema, or foreign objects (noting ornamental lingual or uvula piercings that may preclude advanced airway management if the need should arise). Figure 3-1: Battle s Sign Table 3-8: CONDITIONS THAT IMPEDE PULSE OXIMETRY RELIABILITY Condition Rationale/Action Poor peripheral perfusion due to Avoid attaching sensor probe onto an injured extremity. conditions such as shock, vasoconstriction, and hypotension you are using to monitor blood pressure. The pulse oximetry Try to avoid attaching the sensor probe onto the same arm that reading will go down while the blood pressure cuff is inflated. Severe hypothermia (< 30 C) Inaccurate readings will result. Carbon monoxide poisoning This will give falsely high readings because the sensing probe cannot distinguish between oxyhemoglobin and carboxyhemoglobin. Profound anemia (hemoglobin Inaccurate readings will result. < 5 g/dl) High ambient light High-intensity lights, such as operating room lights, placed directly over the sensing probe, will affect the readings. Nail polish or dirty fingernail Clean the nail with acetone before attaching the probe. Excessive patient movement Probe dislodges easily, affecting reading accuracy. Battle s sign Figure 3-2: Raccoon Eyes

20 32 Basic Trauma Nursing Check for the presence of cerebrospinal fluid draining from the nose or ear by allowing the drainage to drip onto a white cloth or barrier. A halo sign is indicative of CSF in the drainage if the drip diffuses into a bull s-eye shape with a red center and a yellowish ring that develops in a circle around the drainage (the halo). It is not recommended to pack the nose or ear to block the drainage. When performing the secondary survey, it is important to continue to maintain airway, ventilation, and oxygenation as indicated while controlling any hemorrhage. Neck Inspect and palpate the neck for external signs of trauma, suppleness of the soft tissue, and whether the trachea is mid-line. Note any lacerations, hematomas, subcutaneous emphysema, or foreign objects. While maintaining manual in-line cervical stabilization, temporarily undo the cervical spine collar after cautioning the patient not to move his or her head or neck. Carefully palpate the back of the neck for tenderness and the presence of step-offs (uneven or misaligned vertebrae). Resecure the collar when this part of the assessment is completed. Chest Inspect the external chest wall for evidence of appreciable contusions, lacerations, abrasions, hematomas, penetrating wounds, sucking chest wounds, foreign objects, visual asymmetries, or paradoxical motions. Palpate for any crepitus, instabilities, or flail segments while noting any tenderness. A detailed auscultative assessment of the lungs and heart should be done for the absence of anticipated sounds or the presence of adventitious sounds (rhonchi, crackles, muffled tones, stridor, wheezes, or bowel sounds in the thorax). Cover any open chest wound with an air occlusive dressing taped on three sides only (see Figure 3-3). Assist with needle decompression of the pleural space or insertion of a chest tube as indicated. Abdomen Inspect the abdomen for distention and signs of external trauma in the form of contusions, abrasions, hematomas (umbilical ecchymosis or Cullen s sign), lacerations, protrusions (preexisting or acute ventral/umbilical hernias), penetrating wounds, or foreign objects. Palpate for tenderness (starting at Figure 3-3: Dressing for TREATment of Open Pneumothorax Note. From American College of Surgeons. Advanced trauma life support, 9th edition p. 98. Used with permission. the quadrant furthest from noted injury or advised tenderness) and rigidity. Auscultate each quadrant for the presence or absence of anticipated bowel sounds. Assess the flanks for ecchymosis (Grey-Turner sign is indicative of retroperitoneal hemorrhage). Assist with abdominal ultrasound, diagnostic peritoneal lavage, or abdominal CT scans as necessary. Prepare the patient for transfer to the operating room, if indicated. Pelvis Inspect for any evidence of external trauma while assessing for pelvic instability and tenderness by applying gentle pressure over the iliac wings downward and medially (ENA, 2014). Wrap a sheet around the pelvis or apply a pelvic binder if indicated for pelvic fractures to reduce pelvic volume and control hemorrhage (see Figures 3-4 and 3-5). Perineum/Rectum/Vagina Assess for the presence of contusions, hematomas, lacerations, urethral or vaginal/rectal bleeding, and priapism. Palpate the anal sphincter for the presence or absence of tone. Figure 3-4: Pelvic Compression with Bed Sheet Note. From Limmer, Daniel J.; O Keefe, Michael F.; Grant, Harvey T.; Murray, Bob; Bergeron, J. David; & Dickinson, Edward T. Emergency care, 12th edition Reprinted with permission of Pearson Education, Inc., New York, New York. Figure 3-5: Pelvic Binder Extremities Inspect the upper and lower extremities for evidence of blunt or penetrating injury, including lacerations, contusions, deformities, or gross angulations while palpating for tenderness and bony crepitus. Check each periphery for the presence of intact circulation, movement, and sensation. Assess pulse quality and capillary refill in the extremities, and measure them for inequalities against the central pulses and core capillary refill. Be certain to reassess all the aforementioned distal signs after realigning and splinting an extremity. Apply or readjust splints as indicated. Maintain immobilization of the thoracic and lumbar spine. Administer tetanus immunization as ordered. Posterior While maintaining manual in-line cervical stabilization, logroll the patient to examine posterior surfaces, including palpation of the spine and rectal examination. Several people are required to support the torso, with one person designated to support the head to maintain cervical spine alignment (see Figure 3-6). The patient should remain immobilized until spine fractures have been excluded by radiologic and physical examination. Care should be taken to prevent prolonged time on the backboard, which can lead to skin breakdown and further complications. A 2013 position statement from the National Association of EMS Physicians (NAEMSP) and the American College of Surgeons, Committee on Trauma (ACS, COT), recommended more judicious use of spinal restriction in the prehospital setting. Specific criteria are delineated in the document for EMS personnel to use to help guide the decision to use or not to use a backboard with trauma patients (NAEMSP & ACS COT, 2013). With this shift in prehospital procedures, incoming trauma patients may not be on long spine boards. A patient should be removed from the spine board by logrolling, or the spine board should be padded if continued use is anticipated. It is recommended that the backboard be removed when the patient is rolled for examination of the posterior surface during the initial assessment. In most trauma centers, the board is removed within 20 to 30 minutes of arrival. The patient should continue to be logrolled as required until the spine is cleared. PATIENT REEVALUATION It cannot be stressed enough that frequently reevaluating the patient is necessary to avoid missing injuries. When vital signs suddenly deteriorate, one should immediately return to the primary survey and prepare to intervene. Many injuries are not apparent on first assessment and become apparent only over time. Distracting injuries, such as painful femur fractures, may keep a patient from voicing other concerns that will become obvious later. Verbal and nonverbal feedback from the patient during physical examination is helpful as healthcare personnel work to identify injuries. Therefore, judicious use of analgesics is recommended during the initial assessment to avoid masking the patient s response to physical examination. Continuous monitoring of vital signs, urinary output, and pulse oximetry is essential because the patient can deteriorate at any time. Nursing should remain vigilant and monitoring of the patient should continue until all injuries are identified and the patient s care is relinquished to either the operating room, intensive care unit, or floor.

21 Basic Trauma Nursing 33 Figure 3-6: Backboarding Note. From Limmer, Daniel J.; O Keefe, Michael F.; Grant, Harvey T.; Murray, Bob; Bergeron, J. David; & Dickinson, Edward T. Emergency care, 12th edition Reprinted with permission of Pearson Education, Inc., New York, New York. SUMMARY In summary, being able to perform a rapid but thorough initial assessment is a vital skill for the trauma nurse to master. Early identification of and intervention to address life-threatening injuries are responsible for the decreasing early death rate noted among trauma patients who are treated at trauma centers across the United States. Utilizing a systematic assessment ensures that the patient s injuries will be identified and treated, resulting in an optimal outcome with the least disability. Chapter 4: Shock CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe the principles of shock management in the trauma patient. LEARNING OBJECTIVES Upon completion of this chapter the learner will be able to: 1. Define shock. 2. Recognize the effects of compensatory mechanisms on vital signs. 3. Discriminate between the four classes of hemorrhagic shock. 4. Differentiate between the major types of shock. 5. Discuss the confounding factors in the trauma patient s response to hemorrhage. 6. Choose appropriate nursing interventions to treat hemorrhagic shock. INTRODUCTION Shock is a syndrome resulting from inadequate perfusion of the tissues. This inadequacy leads to a decrease in the supply of oxygen to the cells. The body responds to this situation with compensatory mechanisms to improve perfusion, especially in high-demand areas such as the heart and brain. The nurse should be prepared to assess, identify, and intervene in shock states. DEFINITION AND BASIC PHYSIOLOGY Shock is defined as inadequate tissue perfusion resulting from insufficient oxygen delivery, uptake, and utilization to meet the metabolic demands of cells and organs (Klabunde, 2012). There is decreased circulating blood volume (supply) or increased utilization of oxygen and nutrients by the cell (demand). Shock is a problem of decreased perfusion to the cells, not just decreased blood pressure. It is inadequate perfusion of end organs such as the brain, heart, lungs, and kidneys. Predominantly, the physiologic deficit resulting from inadequate perfusion is metabolic acidosis. When tissue hypoxia is present, normal cell physiology is altered, and a shift from aerobic to anaerobic metabolism occurs. The primary byproduct of this shift is lactic acid with progression to lactic acidosis. The negative effects of acidosis on the cardiovascular system include decreased cardiac contractility, decreased cardiac output, vasodilatation, and hypotension. The body responds initially by using compensatory mechanisms to improve perfusion. If the compensatory mechanisms fail to restore perfusion, organ dysfunction and cell death occur. COMPENSATORY MECHANISMS OVERVIEW As cardiac output decreases, the body responds with compensatory mechanisms. Decreased blood flow stimulates baroreceptors located in the aorta and carotid bodies to send a message to the medulla in the brain, thereby activating the sympathetic division of the autonomic nervous system. Sympathetic nervous system activation (commonly referred to as the fight-or-flight response) shunts blood flow to the vital organs (the heart and the brain) and directs blood away from nonpriority organs such as the skin and gastrointestinal tract. The response to blood loss is increased heart rate in an attempt to preserve cardiac output. Tachycardia, therefore, is an early clinical circulatory sign of shock. The release of endogenous catecholamines (epinephrine and norepinephrine) increases peripheral vascular resistance, or vasoconstriction. Initially, vasoconstriction is selective, shunting blood to the heart and brain and away from the splanchnic circulation. Circulating β-adrenergic amines (epinephrine, norepinephrine) also increase cardiac contractility and trigger release of corticosteroids from the adrenal gland, renin from the kidneys, and glucose from the liver. Increased glucose may overwhelm ailing mitochondria, causing further lactate production (de Moya, 2013). Vasoconstriction causes the skin to become cool and clammy. The lungs increase the rate and depth of respirations, attempting to provide the oxygen needed by the cells. Decreased renal blood flow results in decreased urine output. These compensatory mechanisms are visible through the changes in the patient s vital signs (see Table 4-1). Tip: Diagnosis is mostly clinical, based on evidence of insufficient tissue perfusion (obtundation, oliguria, peripheral cyanosis) and signs of compensatory mechanisms (tachycardia, tachypnea, diaphoresis; de Moya, 2013). DIFFERENTIATION OF SHOCK SYNDROMES Shock is broken down into four classifications, and care should be taken to pinpoint the causative nature of the shock state to aid in the proper corrective actions. Hemorrhage remains the major cause of preventable death following trauma (Bougle, Harrois, & Jacques, 2013). Hemorrhagic shock is a subset of hypovolemic shock; however, care should be taken to rule out other causes of shock in the remaining three classifications (distributive shock, obstructive shock, and cardiogenic shock). ETIOLOGIES OF SHOCK Hypovolemic Shock Hypovolemic shock is a generic term indicating end-organ tissue perfusion inadequacy caused by decreased circulating blood volume (ACS, 2012). The etiology of the decrease is multifaceted (vomiting, diarrhea, third spacing as seen in burns, etc.); however, in trauma, the most common cause is hemorrhage. Hemorrhagic shock in and of itself is commonly divided into four distinct classes. The classes (I-IV) are defined based on clinical manifestations in concert with actual or approximated blood loss (see Table 4-2). Class I Class I involves blood loss up to 750 ml, or up to 15% blood volume depletion. Aside from the potential for slight anxiety, vital signs remain within statistical norms (ACS, 2012). Hydration with oral fluids or crystalloid fluids may be necessary. Class II Class II involves a 750 to 1,500 ml blood loss, or from 15% to 30% blood volume loss. There is tachycardia less than 120 bpm, decreased pulse pressure, tachypnea remaining less than 30 bpm, a possibility of decreased urinary output, and mild anxiety. Systolic blood pressure is not affected. Crystalloid fluid replacement is recommended (ACS, 2012). The

22 34 Basic Trauma Nursing TABLE 4-1: ASSESSMENT OF VITAL SIGNS IN SHOCK Blood pressure (BP) BP change is considered a late sign of shock Systolic pressure does not drop until: 30% of blood volume is lost in adults 40% to 45% of blood volume is lost in children Pulse rate Erratic sign affected by pain, fever, drugs, and emotions Tachycardia trended over time has value Pulse pressure Narrowed pulse pressure noted early in shock Result of diastolic pressure rising, not systolic pressure falling Respiratory rate Increased rate and depth initially Decreased rate and depth as shock progresses Mentation Initially, agitation and anxiousness noted in early shock Progressively decreased level of consciousness as shock progresses Rule out other causes: hypoxia, head injury, drugs, alcohol TABLE 4-2: HEMORRHAGIC SHOCK IN INJURED PATIENTS CLASS I CLASS II CLASS III CLASS IV Blood loss (ml) Up to ,500 1,500-2,000 > 2,000 Blood loss (%) Up to 15% 15%-30% 30%-40% > 40% Pulse rate < 100 > 100 > 120 > 140 Blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or increased Decreased Decreased Decreased Respiratory rate > 35 Urine output (ml/hr) > Negligible Central nervous Slightly anxious Mildly anxious Anxious; confused Confused; lethargic system Fluid replacement (3:1 rule) Crystalloid Crystalloid Crystalloid & blood Crystalloid & blood Note. From American College of Surgeons, Committee on Trauma. (2012). Advanced trauma life support (9th ed., p. 61). Chicago, IL: Author. Used with permission. decrease in pulse pressure results from an increase in diastolic pressure, not a drop in systolic pressure. This represents the body s compensatory response of vasoconstriction. The patient s anxiety or agitation may be indicative of decreased cerebral blood flow. Class III Class III involves a 1,500 to 2,000 ml blood loss, or from 30% to 40% blood volume loss. The patient presents with significant tachycardia (120 to 140 bpm), hypotension, tachypnea (30 to 40 bpm), mental status changes (anxious, confused; ACS, 2012), urine output decreased to 5 to 15 ml/hour, and skin that may feel cool and clammy. It is important to stress that when a drop in systolic pressure is finally noted, Class III hemorrhage has occurred. Typically, the patient requires hemorrhage control with balanced crystalloid fluid resuscitation, usually in concert with blood replacement (ACS, 2012). Class IV Class IV involves a blood loss greater than 2,000 ml, or over 40% blood volume loss. This loss represents life-threatening hemorrhage, with the patient presenting in extremis (close to death). Symptoms include extreme tachycardia (greater than 140 bpm), hypotension, and narrowed pulse pressure that may deteriorate to an undetectable diastolic pressure. The skin is noticeably cool and clammy. Urine output is negligible, and there is a marked depressed level of consciousness (confusion and lethargy; ACS, 2012). Resuscitation and hemorrhage control are started with crystalloid fluid and blood products, and rapid surgical intervention is paramount. Confounding Factors in Trauma Patients Responses Several factors affect trauma patients responses, including age, athletic ability, pregnancy, medications, and pacemakers (see Table 4-3). Sites of Blood Loss The three main areas where blood loss is highly suspected in trauma are the chest, abdomen, and pelvis. Major soft tissue injuries and fractures, however, can compromise hemodynamics as well, when blood is lost into the site of the injury. For example, a fracture of the tibia or humerus can produce a blood loss of 750 ml into surrounding tissue. Patients with femur fractures can lose up to two to three units of blood as a result of the injury, which can be life-threatening (ENA, 2014). Also, be aware that several liters of blood can accumulate in a retro peritoneal hematoma associated with a pelvic fracture. The four major areas for bleeding are the midline retroperitoneum, the upper lateral retroperitoneum, the pelvic retroperitoneum, and the portal retrohepatic area (Mattox, Moore, & Feliciano, 2013). In addition, significant edema may occur in injured soft tissues. The degree of this additional volume loss is related to the magnitude of the soft tissue injury. The tissue injury is associated with systemic inflammatory response and production of cytokines. The cytokine production leads to increased permeability and fluid shift out of the intravascular space into the interstitium, further diminishing fluid volume status. Tip: Note that hypotension in the presence of apparent isolated head injury alone likely points to another injury and requires further assessment and work-up. Cardiogenic Shock Cardiogenic shock results from ineffective perfusion caused by diminished contractility of the heart. Cardiogenic shock is rarely seen following trauma but may occur following blunt cardiac injury, myocardial infarction, or dysrhythmia. Blunt cardiac injury should be suspected when the mechanism of injury is rapid deceleration involving the chest (such as in a high fall or motor vehicle crash) or direct impact to the chest wall (baseball or other moderate to rapidly moving object). Continuous electrocardiograph monitoring is often quick to obtain and is useful in detecting dysrhythmias. Although in many cases difficult to obtain quickly, echocardiography can be useful in detecting mechanical disruption of the heart or the presence of tamponades. For cardiogenic shock, medications may be required to increase contractility (e.g., dobutamine, milrinone, levosimendan), reduce afterload, maintain adequate systemic and coronary perfusion pressure, increase diastolic relaxation, and increase or decrease heart rate (Bersten & Soni, 2014). Caution should be taken when giving fluid bolus to patients with underlying cardiac issues, specifically congestive heart failure (CHF). Obstructive Shock Obstructive shock results from hypoperfusion of the tissue due to an obstruction in either the vasculature or heart (ENA, 2014). Immediate corrective action is taken after prompt recognition of the underlying pathology. Commonly, obstructive shock has one (or more) of three distinct etiologies: tension pneumothorax, cardiac tamponade, or tension hemothorax (ENA, 2014). Delay in early recognition and corrective therapies can lead to sudden deterioration and death. Cardiac Tamponade Cardiac tamponade is most commonly associated with penetrating trauma to the chest and involves blood or fluid filling the pericardial sac surrounding the heart and compromising the ability of the heart to fill, contract, and adequately pump blood. Hypotension, distended neck veins, and muffled heart tones are hallmarks of this injury, which is also known as Beck triad. However, jugular vein distension (JVD), muffled heart tones, and hypotension are present in only 10% to 30% of patients with confirmed tamponade (Peitzman & Schwab, 2013). A quick ultrasound of the chest, included as part of the focused assessment sonography in trauma (FAST) exam, is helpful to quickly identify fluid in the pericardial sac. Treatment measures include needle pericardiocentesis, but any patient who experiences a pericardial tamponade and needs a pericardiocentesis requires surgical evaluation of the heart (ACS, 2012).

23 Basic Trauma Nursing 35 TABLE 4-3: CONFOUNDING FACTORS IN TRAUMA PATIENTS RESPONSES Factor Caution Age Elderly trauma patients exhibit limited cardiac reserve and often are unable to generate tachycardia in response to blood loss. Consider early invasive monitoring to avoid excessive or inadequate volume restoration. Athlete Blood volume and cardiac output are increased in athletes. Their ability to compensate for hypovolemia may mask significant blood loss. Pregnancy The normal physiologic hypervolemia of pregnancy (steady plasma volume increase seen throughout pregnancy) can mask signs of blood loss. Medication Beta-blockers and calcium channel blockers can alter the hemodynamic response to bleeding by blunting tachycardic response. Pacemaker Patients with pacemakers may not generate tachycardia in response to blood loss. Tension Pneumothorax Tension pneumothorax occurs when air escapes from a defect in the bronchial tree, becomes trapped in the pleural space, and is not allowed to escape. This causes the lung to collapse, the pleural space to fill with trapped air, and the intrapleural pressure to rise. As the intrathoracic pressure rises, venous return is hampered, cardiac output decreases, and hypotension occurs (ENA, 2014). The patient presents with acute respiratory distress, jugular venous distention, subcutaneous emphysema, absent breath sounds, hyperresonance to percussion, and tracheal shift away from the side of injury. Immediate decompression is indicated for patients who exhibit these findings upon assessment (ENA, 2014). Delaying intervention for X-ray confirmation could be a potentially fatal error. Distributive Shock Distributive shock occurs as a result of maldistribution of an adequately circulating blood volume with the loss of vascular tone or increased permeability (ENA, 2014). Distributive shock traditionally presents in anaphylaxis (anaphylactic shock), sepsis (septic shock), or spinal cord injury (neurogenic shock). Although in trauma the most likely manifestation will be neurogenic shock, do not discount an underlying pathology of sepsis or, more often, anaphylaxis as a prodrome to the traumatic event. Neurogenic Shock Neurogenic shock may occur as a result of injury to the spinal cord that results in loss of motor and sensory ability. Additionally, sympathetic nervous system function is impaired, resulting in a loss of vasomotor tone that causes peripheral vasodilation, maldistribution of blood volume to the periphery, and hypotension. Corresponding stimulation of the parasympathetic system can result in bradycardia. The classic picture of neurogenic shock is hypotension, without tachycardia or cutaneous vasoconstriction. The skin can appear mottled, thus presenting a shock of a different color. A narrowed pulse pressure is not seen in neurogenic shock. Adequate blood pressure may not be restored by fluid administration alone. Cautious use of vasopressors after moderate fluid replacement may be justified. Atropine may be used to counteract hemodynamically significant bradycardia. Remember that patients with spinal cord injury often have concomitant chest and abdominal injuries. Therefore, patients with suspected neurogenic shock should be treated initially for hypovolemia. This is detailed further in Chapter 9. Septic Shock Sepsis represents a spectrum of disease ranging from systemic inflammatory response syndrome (SIRS) to septic shock (Maggio & Carvalho, n.d.). Typically not seen in the acute trauma patient, it has become a point of emphasis for the long-term care, mortality, and morbidity of trauma patients. The root pathophysiology of sepsis is systemic inflammatory response syndrome in concert with an identified or unidentified infectious agent. Sepsis can progress to either severe sepsis or, if untreated, septic shock. Septic shock is caused by the systemic release of bacterial endotoxins, which results in increased vascular permeability and vasodilatation (ENA, 2014). The resulting systemic vasodilatation creates distributive shock state. Treatment for septic shock includes early administration of antibiotics and the potential need for norepinephrine to vasoconstrict the peripheral vasculature, increase the volume of blood returning to the heart, and improve cardiac output (Mattox, Moore, & Feliciano, 2013). INITIAL MANAGEMENT OF SHOCK Control of ongoing hemorrhage is a central component of resuscitating the patient in shock. The diagnosis and treatment of shock often occur simultaneously; treatment is instituted as soon as shock is identified, typically before the source of hemorrhage is identified (Mattox, Moore, & Feliciano, 2013). Starting with the ABCs, an organized assessment helps ensure immediate identification of and corrective actions for life-threatening injuries. Circulation management involves stopping obvious external hemorrhage with whichever means are warranted for the source. Intravenous fluid resuscitation should ensue, followed by immediate surgery or angiography for embolization as necessary. Preventing hypothermia is essential and requires the use of fluid warmers as well as warming blankets. Gastric distention and aspiration are a risk in unconscious patients, so nasogastric or orogastric tubes should be inserted early. Urinary catheters are required for monitoring urine output and hematuria, and to decompress the bladder. Cardiac monitoring and continuous pulse oximetry monitoring are also essential. Vascular Access At a minimum, two large-bore peripheral IV catheters should be inserted, preferably in the antecubital veins. The preference is for 12- or 14-gauge short catheters. The flow rate is directly related to the size of the vessel in which the catheter is being inserted. Antecubital peripheral IV catheters are preferred over central venous lines, which can cause the added complications of iatro genic pneumothorax or hemothorax. With the emergence of intraosseous (IO) technologies, this route has come into favor for its ability to provide rapid access and high flow rates. In a retrospective review, it was noted that IO access can be used to administer a wide variety of life-saving medications quickly, easily, and with low complication rates. This highlights its valuable role as an alternative method of obtaining vascular access, which is vital when resuscitating the critically injured trauma patient (Lewis & Wright, 2014). Use of fluid warmers and rapid infusion devices is also recommended in the face of massive resuscitation. As IV lines are started, blood samples should be drawn for type and crossmatch, additional laboratory analyses, toxicology studies, and the testing of childbearingage females for pregnancy. Additionally, arterial blood gas analysis is beneficial for all critically ill trauma patients. Fluid Therapy Traditionally, hypovolemic trauma care has been based on aggressive fluid resuscitation, early and fast. In 2012, the American College of Surgeons, Committee on Trauma, took a different stance when it emphasized the concept of balanced resuscitation. Current recommendations suggest an initial fluid resuscitation bolus of 1 to 2 L of warmed fluid, including fluid given by prehospital providers (ACS, 2012). Volume replacement with crystalloids during resuscitation might become harmful in large amounts because of coagulopathy. A fine balance must be achieved between hemodynamic and hemostatic resuscitation. Permissive hypotension refers to permitting some degree of hypotension in such adult patients [those with penetrating trauma] in an attempt to attain this fine balance (Kua, Ong, & Ng, 2014). It is most important to gauge fluid resuscitation according to the patient s response via continued assessment of vital signs, urine output, and level of consciousness. However, recent military experience in Iraq and Afghanistan has led the medical community to rethink this current therapy of crystalloid fluid resuscitation. A crystalloid solution will help restore blood pressure in the circulation but does nothing to perfuse oxygen-deprived tissues or help stop hemorrhage. Because of recent military experience and evidence, changes in clinical care included the shift to resuscitation with 1:1:1 component therapy (1 unit of packed red blood cells, 1 unit of platelets, and 1 unit of fresh frozen plasma), use of fresh whole blood, and the application of both medical devices and pharmaceutical adjuncts to reduce bleeding (Prat, Pidcoke, Sailliol, & Cap, 2013). Permissive Hypotension The standard approach (fluid therapy for acute hemorrhage trauma patients) may contribute to continuous bleeding and consequently to increased mortality. Increasing hydrostatic pressure on blood clots with aggressive administration of intravenous fluid adversely affects the endogenous coagulopathy that has already occurred through excessive fibrinolysis and anticoagulation, particularly in patients with penetrating trauma (Stavros et al., 2013). With this in mind, the concept of allowing the patient to remain in a hypotensive state while preserving end-organ perfusion has come to be known as permissive hypotension. Current trauma guidelines delineate specific

24 36 Basic Trauma Nursing fluid resuscitation parameters for all trauma patients. Life-threatening hemorrhage, in the presence of penetrating trauma, can also be managed by maintaining a state of permissive hypotension (systolic blood pressure less than 80 mm Hg) while the patient is transferred from the accident site to the operating room (Stavros et al., 2013). Urine Output Urine output reflects the degree of tissue perfusion and is a useful endpoint in shock resuscitation. Using the patient s weight is the best way to calculate desired urine output. In adults, 0.5 ml/kg/hr of urine indicates adequate perfusion. In children, 1.0 ml/kg/ hr is appropriate. For infants, younger than 1 year of age, 2 ml/kg/hr is appropriate. Urine output is one of the prime indicators of resuscitation and should be monitored every 30 minutes to hourly in the unstable patient. Acid-Base Balance Early in hypovolemic shock, patients may have transient respiratory alkalosis due to hyperventilation. As shock progresses and the body shifts to anaerobic metabolism, inadequate tissue perfusion results, and excess production of lactic acid occurs, resulting in the undesirable consequence of metabolic acidosis. Persistent acidosis, as measured by arterial blood gas analysis, is an indication of inadequate resuscitation or ongoing blood loss, until proven otherwise. Base Deficit Base deficit is a useful, easily obtained test that helps guide trauma resuscitation. Base deficit is defined as the amount of base (in milliosmoles) required to titrate 1 L of whole blood to a normal ph of 7.4 with the sample maintained at 37 C, fully saturated with oxygen, and equilibrated with an atmosphere containing carbon dioxide at a PCO 2 of 40 mmhg (Mattox, Moore, & Feliciano, 2013). It is used to estimate oxygen debt in patients who have been injured or those who are experiencing shock. If the number is negative, the patient has a base deficit. The base deficit can be determined with each blood gas and is therefore quickly available during resuscitation. The normal range is 3 to +3 mmol/l. Base deficits are typically stratified into mild ( 3 to 5), moderate ( 6 to 14), and severe (> 15). The more negative the number, the sicker the patient is. A progressively negative number means either inadequate fluid replacement or ongoing blood loss. A base deficit of 15 is considered severe and is associated with increased mortality. Base deficit can serve as an endpoint measurement of the adequacy of cellular perfusion and predicts the success of resuscitation (ENA, 2014). Blood Replacement The decision to administer blood should be considered early and is based upon the patient s classification of hemorrhage. Blood is given to restore oxygen carrying capacity of the intravascular volume. The choice of type of blood is dependent on the urgency of the situation. Emergency Uncrossmatched Blood For patients in extremis when there is no time to wait for complete blood typing, emergency uncrossmatched blood is warranted. Type O universal donor blood should be immediately available. Type O positive blood (which is readily available in the donor supply) is preferred for male trauma patients 16 years of age or older, whereas type O negative blood (which is more scarce in supply) should be reserved for women of childbearing age and children to avoid sensitization and future complications. Type-Specific Blood Type-specific blood has the major ABO and Rh factors identified. Type-specific blood is preferred for patients who respond initially to fluids but then deteriorate and require blood quickly. It is generally available within 10 minutes in most blood banks. Crossmatched Blood Fully crossmatched blood is preferable whenever possible. However, the complete crossmatch process takes approximately 1 hour in most blood banks. Therefore, a blood specimen should be drawn on arrival for all trauma patients. Massive Transfusion All patients with substantial injury requiring major surgical repair should be considered for massive transfusion protocols (MTPs). Many trauma centers have these protocols in place, and they can be implemented in the emergency department or operating room, where prescribed amounts of component therapy are delivered and continued until the patient stabilizes. Achieving these goals may require massive transfusion of blood products. Although use of blood products may be lifesaving, dose-related adverse effects are well described (Elmer, Wilcox, & Raja, 2013). MTPs are based on the premise of balancing the resuscitation with packed red blood cells, platelets, and plasma in specific ratios. Protocols vary based on the ratio of each component given during the resuscitation. Although variations exist, the most common ratio used is 1:1:1 (Elmer, Wilcox, & Raja, 2013). Tranexamic Acid Tranexamic acid (TXA) is a synthetic version of the amino acid lysine. It is an antifibrinolytic that inhibits activation of plasminogen, a substance that is responsible for dissolving clots (ENA, 2014). In 2010, there was a very large 270-hospital study covering 40 countries that looked at the effects of early administration of a short course of TXA on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. The conclusion was that TXA safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, TXA should be considered for use in bleeding trauma patients (CRASH-2 et al., 2010). In 2014, the early use of TXA was studied, and it appears that early administration of TXA reduces mortality primarily by preventing exsanguination on the day of the injury (Roberts, Prieto-Merino, & Manno, 2014). Hypothermia Prevention All trauma patients are at risk for developing hypothermia, which is defined as a temperature less than 95 F (35 C). Hypothermia is a frequent pathophysiologic consequence of severe injury and subsequent resuscitation. Hypothermia causes decreased tissue oxygenation, acidosis, and increased coagulopathy, which results in increased mortality and morbidity (ENA, 2014). Of all warming techniques, the most aggressive and effective include administration of warmed IV fluids and warmed humidified air, and the use of convective air heating blankets. Although removing wet clothes, turning up ambient room temperature, and applying warmed blankets are techniques that are commonly employed, they are less effective in rapid reversal of hypothermia. Typically, all the aforementioned strategies are used in combination to fight hypothermia (see Table 4-4). DEFINITIVE CARE Definitive care for a hemorrhaging trauma patient should be immediate transfer to a facility capable of surgery or interventional radiology. A patient with uncontrolled hemorrhage should not remain long in the emergency department but should be moved promptly to the operating room or angiography suite for definitive treatment. SUMMARY Hypovolemia is the most common cause of shock in trauma patients. Trauma nurses must manage hypovolemia with immediate hemorrhage control, fluid and blood replacement therapy, and timely preparation for embolization or surgery. The goal of therapy is prompt restoration of organ perfusion with delivery of oxygen. The nurse s role on the trauma team is paramount when caring for the patient in shock. With rapid recognition and early intervention, nursing actions can be integral in improving the shock patient s outcomes. Chapter 5: Head Injury CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe the principles of head injury management. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Recognize the signs and symptoms of increased intracranial pressure. 2. Recognize the importance of the Glasgow Coma Scale assessment. 3. Differentiate focal from diffuse intracranial injuries. 4. Identify appropriate interventions for patients with head injuries. INTRODUCTION In the United States, 1.7 million people sustain a traumatic brain injury (TBI) annually (CDC, n.d.). Every day, 138 people in the United States die from injuries that include TBI; TBI contributes to about 30% of all injury deaths (CDC, 2014). The cost in terms of death and disability, along with medical, rehabilitative, loss of productivity, and psychosocial impacts, is tremendous. With the advent of improved emergency medical services (EMS) training and technology, more patients with traumatic brain injury and spine injury are surviving. With this increased survival rate comes increases need for specialized extensive rehabilitation in concert with lifelong complex medical care. Per the Centers for Disease Control and Prevention (2014): From 2006 to 2010, falls were the leading cause of TBI, accounting for 40% of all TBIs in the

25 Basic Trauma Nursing 37 TABLE 4-4: WARMING STRATEGIES BY DEPARTMENT Trauma resuscitation room Operating room or interventional radiology suite Critical care unit Increase room temperature in the trauma resuscitation room. Minimize any draft in the trauma room. Keep the doors shut. Administer humidified oxygen warmed to 74 F (23 C) via ventilator circuit in an intubated patient. Remove all wet clothing upon patient arrival. Minimize body exposure when possible for examination and procedures. Apply warm blankets. Promote use of convective air heating devices. Monitor temperature, continuously if possible. Administer all fluids and blood through a warmer to 76 F (24 C). Increase room temperature when possible (angiography suites are routinely kept cold to optimize machine function). Cover the patient s head and use heating blankets that permit surgical exposure. Monitor continuous core temperature. Ventilate with warmed humidified oxygen at 74 F (23 C). Administer all fluids and blood through a warmer at 76 F (24 C). Assess for the onset of hypothermia, acidosis, and coagulopathy. Anticipate alternative techniques to temporarily close the abdomen. Increase patient s room temperature. Keep door of room closed. Continue head covering and convective warming blanket use. Coordinate and minimize exposure for all procedures. Monitor core temperature continuously. Administer all fluids and blood through a warmer at 76 F (24 C). Ventilate with warmed, humidified oxygen at 74 F (23 C). United States that resulted in an ED visit, hospitalization, or death. Falls disproportionately affect the youngest and oldest age groups: More than half (55%) of TBIs among children age 0 to 14 are caused by falls. More than two-thirds (81%) of TBIs in adults age 65 and older are caused by falls. Unintentional blunt trauma (e.g., being hit by an object) was the second leading cause of TBI, accounting for about 15% of TBIs in the United States for 2006 to Close to a quarter (24%) of all TBIs in children younger than 15 years of age were related to blunt trauma. Among all age groups, motor vehicle crashes were the third overall leading cause of TBI (14%). When looking at just TBI-related deaths, motor vehicle crashes were the second leading cause of TBI-related deaths (26%) for 2006 to About 10% of all TBIs are due to assaults. They accounted for 3% of TBIs in children younger than 15 years of age and 1.4% of TBIs in adults 65 years and older for 2006 to About 75% of all assaults associated with TBI occur in persons 15 to 44 years of age. The faster a head injury is identified and assessed and interventions are initiated, the better the potential for survival with less disability. ANATOMY AND PHYSIOLOGY The severity of head injuries is high because there is little support or protection for the head. Understanding the basic anatomy and physiology of the head and brain is essential to be able to provide the most appropriate assessments and initial interventions for head injuries. Scalp The scalp is the thickest layer of body covering, but it thins with age and balding. It provides spongy protection for the skull. There are five layers: skin, subcutaneous tissue, galea aponeurotica, ligaments, and periosteum. The tissue is highly vascular, and it has poor ability to vasoconstrict; it does not take a large laceration to cause a lot of bleeding. Uncontrolled bleeding can result in significant blood loss; however, direct pressure can usually control the bleeding. Skull The skull, or cranium, functions as a container to hold and protect the brain. It is composed of the frontal, parietal, temporal, and occipital bones. Cranial bones join with the facial bones to form the cranial vault, which is a rigid cavity. An opening called the foramen magnum allows the spinal cord to pass through. Other important areas are the depressions in the interior base of the skull called the anterior, middle, and posterior fossae. The anterior fossa contains the frontal lobe, which coordinates voluntary movements and controls judgment, affect, and personality. The parietal, temporal, and occipital lobes are in the middle fossa. The parietal lobe controls sensory interpretation; the temporal lobe controls hearing, behavior, emotions, and dominant-hemisphere speech; and the occipital lobe is responsible for vision. The brainstem and cerebellum, which are in the posterior fossa, are discussed in the section about the brain. The temporal area is especially thin, making it extremely vulnerable. The base of the skull is rough and has irregularities that can bruise and lacerate the brain when the head is jarred suddenly or is in rapid deceleration. The solid structure of the adult skull makes it unable to tolerate expansion of the brain or increased volume without serious problems. Meninges Inside the skull are three highly vascular layers of membrane, the meninges that surround and protect the brain, and the spinal cord (see Figure 5-1). The outer layer is the dura and is the thickest and toughest of the three layers. The meningeal arteries are located in a space between the skull and the dura called the epidural space. Lying under the dura is a weblike transparent serous membrane called the arachnoid. The third layer, the pia, is attached to the brain and the arachnoid in some areas. Brain Made up of billions of nerve cells, the adult brain weighs about 3 pounds and occupies approximately 80% of the intracranial space. The brain uses approximately 20% of the body s total oxygen supply and is heavily dependent upon glucose metabolism for energy (Copstead & Banasik, 2013). Brain cells cannot go more than 4 to 6 minutes without oxygen before irreversible damage occurs, unless they are in a hypothermic state and metabolism is drastically slowed. The brain has three distinct parts: the cerebrum, brainstem, and cerebellum. The cerebrum is divided into two hemispheres: the left and right. Each hemisphere has lobes named for their corresponding part of the skull. As discussed previously, they control specific intellectual, sensory, and motor functions. The brainstem joins the spinal cord and thus serves as a key reflex and relay center for the central nervous system (CNS). Consciousness, breathing, heart rate, and autonomic functions are controlled here. The cerebellum surrounds the brainstem in the posterior fossa and coordinates activities below the level of consciousness, such as posture and equilibrium. Inside the brain are a series of four interconnected cavities called ventricles. Cerebrospinal fluid (CSF) is produced in the choroid plexus in the lateral ventricles and circulates around the brain beneath the arachnoid membrane (subarachnoid space) and through the central canal of the spinal cord (Copstead & Banasik, 2013). It bathes the outer surface of the brain and acts as a shock absorber between the brain and the skull. It also serves as a blood-brain barrier against harmful substances. Cranial Nerves Twelve pairs of cranial nerves originate in the brainstem, with each separate nerve having a name and a Roman numeral identifier. These nerves provide for unconscious control over sensory and motor activities. Their functions and the areas they affect are important to know because assessment of cranial nerve function indicates brainstem activity and neurologic function; such knowledge is instrumental in the accurate assessment of damage from a head injury. The most accessible cranial nerve for assessment of a patient with a head injury is the third (or oculomotor) nerve, which controls pupillary constriction. In a patient with an altered level of consciousness, a nonreactive, sluggish, pinpoint, or dilating pupil can indicate several underlying pathologies, including damage or pressure to the third nerve. This nerve is frequently injured or impinged in head trauma patients. A sudden

26 38 Basic Trauma Nursing Figure 5-1: The Meninges of the Brain Note. From Mistovich, Joseph J.; Karren, Keith J.; & Hafen, Brent. (2014). Prehospital emergency care, 10th edition Reprinted with permission of Pearson Education, Inc., New York, New York. enlargement (dilation) of one pupil (anisocoria) is an ominous sign that requires immediate intervention (ENA, 2014; see Figure 5-2). FIGURE 5-2: Pupil Changes in Head Injury Pediatric Differences A child s head is disproportionately large for the body size, and the neck is comparatively weak. The cranial bones are thinner, and the brain tissue is thinner, softer, and more fragile than in an adult. Consequently, there is a greater chance that cerebral edema from injury will develop in a child than in an adult. However, the overall outcome for children with head injuries is better than that for adults with the same injury scores (Verive, Stock, & Singh, 2014). CONDITIONS OF HEAD INJURIES Increased Intracranial Pressure Unconsciousness stems from pathology in either the cerebral cortex or the reticular activating system in the brainstem. The three components inside the enclosed skull are CSF, brain tissue, and blood volume. Expansion of any one of the components causes a rise in intracranial pressure (ICP) if the volume of the other two remains constant. Because the brain is in an enclosed area, as pressure increases in the head, it causes the cerebral blood flow and available oxygen to decrease, which, in turn, causes the level of consciousness to diminish. This is called the Monro-Kellie doctrine (see Figure 5-3). Swelling in one part of the brain compresses another area because the skull cannot expand. If the whole brain swells, or if there is a rapidly growing hematoma, it takes up the limited intracranial space, compressing the blood vessels and decreasing blood flow. Pressure in skull arteries is considerably higher than ICP. When ICP increases enough to equal the pressure in the skull s arteries, these vessels are squeezed, further restricting blood flow. The body responds to the decrease in blood flow and the resulting drop in blood pressure by stimulating the sympathetic nervous system. This causes even more vasoconstriction, which further increases blood pressure. Additionally, the pulse slows because of the pressure on the vagus (X cranial) nerve. Respiratory response alters the breathing pattern. Tip: The triad of rising blood pressure, slowing pulse rate, and changing respiratory pattern is an extremely late sign of increasing ICP. Earlier signs and symptoms of increasing ICP may include decreased level of consciousness, pupil changes, weakness, nausea, vomiting, headache, seizures, and an abnormal respiratory pattern. Increasing ICP causes a decreased level of consciousness and deficits in vital functions, and it can lead to brain death from inadequate cerebral Bilateral equal pupils Normal heart rate Normal blood pressure Mass noted Bilateral equal pupils Normal heart rate Normal blood pressure perfusion. If untreated, increased ICP can lead to a herniation syndrome; supratentorial herniation is the most common in trauma (ENA, 2014). SPECIFIC HEAD INJURIES Most brain injuries are caused by blunt trauma to the head, especially in motor vehicle crashes. When a vehicle hits an object, the vehicle stops, but the occupant continues forward, crashing into the interior of the vehicle. As the person hits the interior of the vehicle and stops, the brain continues to move forward, striking inside the skull. As the brain hits the skull during the deceleration injury, it absorbs energy and rebounds to the opposite side of the skull. The first contact of the brain with the skull is called the coup, and the rebound collision with the skull is called the contrecoup. Penetrating injuries create wounds through the skull. Usually a fracture occurs, and the projectile may drive bone fragments along with a foreign body into the brain, causing damage along the way. Intracranial bleeding and structural damage may result. When impalement is the source of the penetrating injury, the clinician should leave any protruding penetrating objects in place and stabilize them (ENA, 2014). CLASSIFICATIONS OF HEAD INJURY Head injuries are classified in several ways. They can be classified by mechanism, severity, and morphology (see Table 5-1). Mechanism of Injury Head injury can be broadly categorized as blunt or penetrating. Blunt injury is associated with motor vehicle crashes, falls, and blunt assaults. Penetrating injury usually results from gunshot and stab wounds. Severity of Injury The Glasgow Coma Scale (GCS) ranges from 3 to 15 and provides a measure of the patient s level of consciousness as well as a predictor of morbidity and mortality after brain injury (see Table 5-2; ENA, 2014). GCS scores range from 3 to 15. They provide a measure of the patient s level of consciousness, and they predict morbidity and mortality after brain injury (Copstead & Banasik, 2013). When there is right/left asymmetry (one side is weaker than the other), use the best motor response to calculate the GCS score because it is a more reliable predictor of outcome. The total score results from a cumulative score of the best Figure 5-3: Monro-Kellie Doctrine (Intracranial Compensation for Expanding Mass) Elevated ICP with Normal ICP state Normal compensated ICP state decompensated state Mass expands Unequal pupils Heart rate decreased Blood pressure increased Skull Blood Mass CSF Brain

27 Basic Trauma Nursing 39 TABLE 5-1: CLASSIFICATION OF HEAD INJURIES Mechanism Example Blunt Motor vehicle crashes, falls, assaults Penetrating Gunshot wounds Severity Glasgow Coma Scale Score Mild 13 to 15 Moderate 9 to 12 Severe 3 to 8 Morphology Type Scalp Lacerations Skull Fractures Vault Linear versus stellate Depressed versus nondepressed Open versus closed Basilar With and without cerebrospinal fluid leak With and without seventh cranial nerve palsy (Bell s palsy) Intracranial Lesions Focal Epidural Subdural Acute Subacute Chronic Contusions/intracerebral hematomas Diffuse Concussion Hypoxic ischemic injury eye response, best verbal response, and best motor response. The lowest possible score is 3, and the highest is 15. A GCS score of 13 to 15 indicates mild head injury, a GCS score of 9 to 12 is categorized as moderate, and a GCS score below 8 is generally accepted as indicating severe brain injury or coma. One limitation of the GCS is the inability to accurately assess intubated patients and aphasic patients due to the required verbal component (Kornbluth & Bhardwaj, 2011). Morphology Scalp Laceration As stated earlier, the scalp is vascular and bleeds profusely, even with a small laceration. A scalp laceration may cause a considerable amount of blood loss and needs to be managed with direct pressure, followed by definitive wound closure. Skull Fractures A skull fracture may not be immediately obvious. The clinical picture directly correlates to the type of fracture, area, and structures damaged. The presence of a fracture suggests that significant force was involved in the injury. Although most patients with simple linear fractures and no neurologic impairment are not at high risk of brain injuries, patients with any fracture associated with neurologic impairment are at increased risk of intracranial hematomas (Wilberger & Dupre, 2013). TABLE 5-2: GLASGOW COMA SCALE Best Eye Response Spontaneously 4 To voice 3 To pain 2 Remain closed 1 Verbal Response Oriented 5 Confused 4 Inappropriate words 3 Make sounds 2 No response 1 Motor Response Obeys commands 6 Localizes stimulus 5 Withdraws from stimulus 4 Abnormal flexion 3 Abnormal extension 2 No response 1 Total Score 3 to 15 Vault Skull Fractures Fractures of the cranial vault may be linear or stellate and may be open or closed. Do not underestimate the significance of a skull fracture. It takes considerable force to fracture the skull. Linear skull fractures are most common and typically occur over the lateral convexities of the skull. For most skull fractures, it is not the fracture, but rather the underlying blood clot or brain contusion, that raises concern (Peitzman & Schwab, 2013). If the impact has enough force, the fracture may be depressed, with bony fragments being driven into the brain. The depressed fracture will require surgical intervention if bone fragments become lodged in the brain tissue. Indications for surgical repair of skull fractures are evidence of CSF leak, cosmetic deformity, or contaminated bone or scalp fragments pushed into the brain (Peitzman & Schwab, 2013). Basilar Skull Fractures Basilar fractures may result from an extension of a linear fracture to the floor of the skull. Most commonly, these fractures occur through the floor of the anterior cranial fossa from craniofacial injuries and may cause enough damage for CSF to leak through either the nose (rhinorrhea) or ears (otorrhea). Carotid artery and cranial nerve injuries are frequently seen with basilar fractures, in particular, facial nerve paralysis (cranial nerve VII). Basilar fractures may not be visualized easily on an X-ray or computed tomography (CT) scan, so clinical findings may have to be relied on for diagnosis. Bleeding can cause dramatic distinguishing changes in the patient s appearance. When blood leaks into the periorbital tissue, it causes what is known as raccoon s eyes. Another characteristic is Battle s sign, that is, ecchymosis behind the ear that is seen 12 to 24 hours after the initial injury. Neurologic changes with a basilar fracture range from slight alteration in mental status to agitation or severe combativeness, depending on the injury to underlying brain cells. Intracranial Injuries Intracranial injuries may be classified as focal or diffuse, although these two forms frequently coexist. Focal injuries cause brain damage to a single localized area of the brain, at the site of the injury. Unlike focal injuries, the brain damage is more widespread with diffuse injuries. FOCAL INJURIES Epidural Hematoma Epidural hematomas result from a direct strike to the head, causing a bleed between the skull and dura mater (see Figure 5-4). The hematoma is frequently (90%) associated with fractures of the temporal or parietal skull that lacerate the middle meningeal artery (ENA, 2014). The hematoma does not actually contact the brain itself, so these patients often have the best outcomes if treated early. Signs of a rapidly growing hematoma and increasing ICP are a loss of consciousness that is followed by a lucid period (usually a hallmark of an epidural bleed), followed by another loss of consciousness; development of contralateral hemiparesis; and a dilated and fixed pupil on the side of impact (ipsilateral). The triad of increasing blood pressure, slowing pulse rate, and changes in respiratory pattern is an ominous sign of elevated ICP. Extension of the hematoma is associated with brainstem herniation and poor outcomes (Copstead & Banasik, 2013). Signs and symptoms of an epidural hematoma depend on the rate of blood accumulation. Clinical manifestations are usually seen within 6 hours of injury. Significant epidural hematomas require immediate surgical intervention (ENA, 2014). Subdural Hematoma Occurring more frequently than other intracranial injuries, subdural hematomas have the highest morbidity and mortality of all intracranial hematomas. They are usually the result of venous bleeding between the dura and the brain (see Figure 5-4), which is often caused by a shearing of the bridging veins across the dura. Subdural hematomas are classified as acute, subacute, and chronic. The brain damage underlying an acute subdural hematoma is typically much more severe than with epidural hematomas. Acute Subdural Hematoma Acute subdural hematoma is commonly the type of bleed sustained by athletes who suffer a catastrophic head injury (Zuckerman et al., 2012). Historically, mortality rates have been greater than 50%, though CT imaging can now help with diagnosing patients at earlier stages of disease. In addition, the treatment of subdural hematomas may be improving because of regionalization of care in centers of excellence. According to Ryan and colleagues (2012), While the mortality rate may be lower, the burden of subdural hematomas on functional independence and quality of life remains to be better delineated [or studied]. Clinically, the patient has loss of consciousness, hemiparesis, and fixed, dilated pupils. Subacute Subdural Hematoma A subacute subdural hematoma also is caused by high-impact trauma, but it develops more slowly,

28 40 Basic Trauma Nursing Figure 5-4: Hematomas Within the Cranium Note. From Limmer, Daniel J.; O Keefe, Michael F.; Grant, Harvey T.; Murray, Bob; Bergeron, J. David; Dickinson, Edward T. Emergency care, 12th edition Reprinted with permission of Pearson Education, Inc., New York, New York. from 48 hours to 2 weeks. The patient experiences a progressive decline in level of consciousness proportionate to the growth of the hematoma. Because the brain is able to compensate for the gradual collection of blood, neurologic functions deteriorate slowly. These patients tend to have a better prognosis than those with acute subdural hematomas. Chronic Subdural Hematoma In a chronic subdural hematoma, weeks to months after what seemed like a minor head injury, blood slowly accumulates in the subdural space or between the layers of the dura. Because the causative injury occurred prior to the symptoms becoming evident, the actual incident may have been forgotten. Older adults and chronic alcoholics frequently have this type of injury and, because their brains have decreased in size due to atrophy, more blood can collect in the intracranial space before symptoms become noticeable. The frequency of older adults injuries is also attributed to the proliferation of anticoagulant use. The increased incidence is due to brain atrophy, fragility of the bridging veins, and coagulation alterations (ENA, 2014). At particular risk are patients receiving anticoagulants such as warfarin (Coumadin) who sustain a minor fall. Because these falls are minor, patients often do not present for evaluation, and the bleeds are not easily identified. These patients can have a benign initial presentation and then deteriorate several hours after arrival. Therefore, elderly patients, especially those receiving Coumadin, who have experienced apparently minor falls, should be managed with a heightened sense of urgency and care. Older TBI patients on anticoagulation therapy and prescription antiplatelet (ACAP) agents before their injury experience a comparatively higher rate of inpatient mortality and other adverse outcomes caused by the effects of antiplatelet agents [without concurrent TBI] (Peck et al., 2014). Contusions When the brain hits against the cranium, it becomes bruised, particularly in accelerationdeceleration trauma. Cerebral contusions occur in up to 30% of brain injuries. The majority of contusions occur in the frontal and temporal lobes. Over a period of hours or days, contusions can evolve to form intracerebral hematomas with enough mass effect to require immediate surgical evacuation. Therefore, patients with contusions should undergo frequent repeat CT scanning to evaluate changes. Depending on the size and location of the contusion, neurological deficits may not be evident. Increased ICP will result from a large contusion. Symptoms include alteration of consciousness, nausea, vomiting, vision and speech difficulties, and weakness. DIFFUSE INJURIES Diffuse brain injuries range from mild concussions, in which the head CT scan is usually normal, to severe hypoxic ischemic injuries. Concussion A concussion occurs from a direct blow or acceleration-deceleration injury in which there may be a temporary loss of consciousness and associated memory deficiency. There is no underlying brain damage, and the injury is not severe. The patient may have temporary retrograde, antegrade, or combined amnesia and is likely to experience headache, nausea, vomiting, and visual or concentration disturbances. It is important to determine any incidence and length of loss of consciousness and memory deficits as well as to evaluate the patient s neuro logic status. The duration of amnesia is considered a good measure of injury severity. Postconcussive syndrome is described as a later set of symptoms, a late-phase posttraumatic disorder, that evolves out of the early phase in a minority of patients and has a more prolonged (months to years), sometimes worsening set of somatic, emotional, and cognitive symptoms (Katz, Cohen, & Alexander, 2015). Assessment findings may include nausea, dizziness and persistent headache, memory and judgment impairment, attention deficits, insomnia and sleep disturbance, loss of libido, anxiety, irritability, depression, emotional lability, noise and light oversensitivity, and attention or concentration problems (ENA, 2014). These symptoms can vary considerably among patients and may persist for days, weeks, or months after concussion. The persistence of these symptoms relates to the degree of neuronal damage and the patient s emotional distress. Traumatic brain injury has been described as the signature wound of the current conflicts in Iraq and Afghanistan (Wallace, 2015). Hypoxic Ischemic Injury Severe diffuse injury usually occurs from a hypoxic insult to the brain due to prolonged shock or loss of airway after the trauma. This is also referred to as diffuse axonal injury. The CT scan initially may appear to be normal or may show diffuse swelling with loss of the normal white-gray interface. In very high-velocity impact injuries, multiple punctate hemorrhages may occur throughout the cerebral hemispheres. This is known as shear injury. Shear injuries have uniformly poor outcomes. PATIENT ASSESSMENT Airway The patency of the patient s airway should be examined first. In unconscious individuals, the tongue may completely occlude the airway. Noisy ventilations indicate partial obstruction by either the tongue or foreign material. Emesis, hemorrhage, and swelling from facial trauma are common causes of airway compromise in patients with brain injury. Level of Consciousness Assessing level of consciousness involves determining the highest level of response with the least amount of stimulus. The GCS offers a standardized method for evaluating level of consciousness (ENA, 2014). Even the subtlest change from the initial assessment provides early indication of deterioration or improvement in the patient s condition (see Table 5-3). Pupil/Eye Position Pupillary assessment is a rapid and easily accessible evaluation. The clinician will look for pupillary equality or inequality (anisocoria). In 49% of patients presenting with a unilateral fixed dilated pupil (see Figure 5-2 on page 38), the CT-defined condition was most commonly diffuse brain injury with no obvious lateralizing condition (Helmy et al., 2012). Bilateral fixed and pinpoint pupils may indicate a pontine lesion or adverse effects of drugs (opiates). Posturing Posturing and unequal motor responses indicate brain injury. Decorticate (flexion) and decerebrate (extension) posturing are ominous signs of brain injury; however, decerebrate posturing is worse and may signify cerebral herniation. Flaccid paralysis usually indicates spinal cord injury. Respiratory Rate Patients with GCS scores less than 8 require immediate intubation. If the neurological deterioration is not identified immediately, respiratory changes will be noted. Respirations may slow and then become rapid, uneven, and noisy, or the patient may develop respiratory embarrassment or deteriorate into cardiopulmonary arrest. Blood Pressure Hypotension in the presence of an isolated head injury should make one suspect that there is a missed injury elsewhere. Hypotension is not associated with head injuries alone, and its cause should be aggressively pursued. Blood pressure elevation in head injuries can be indicative of increasing ICP. Increased blood pressure, slowing pulse rate, and changing respiratory pattern are all ominous signs of elevated ICP.

29 Basic Trauma Nursing 41 Table 5-3: GCS Classification of Traumatic Brain Injury (TBI) Mild TBI Moderate TBI Severe TBI GCS 13 to 15 Most prevalent TBI Fatigue GCS 9 to 12 Loss of consciousness greater than 30 minutes GCS 3 to 8 Coma: Unconscious state No meaningful response Headaches Physical or cognitive impairments which may or may not No voluntary activities Visual disturbances resolve Memory loss Benefit from rehabilitation Poor attention/concentration Sleep disturbances Dizziness/loss of balance Irritability/emotional disturbances Note. From Lenrow, D. (2015). Glasgow Coma Score. Retrieved from Heart Rate As previously discussed, the development of bradycardia may reflect increased ICP. Bradycardia with hypertension can be due to a rapidly expanding hematoma. Pulse rate is an important factor to be evaluated with other assessment data to determine if it is related to the head injury. It cannot be overemphasized that continuous assessment and recording of results are essential in the management of the patient s care. Monitoring Intracranial Pressure A catheter is inserted into the ventricle of the brain and connected to a monitor for continuous ICP monitoring. Normal ICP is approximately 10 mm Hg. Pressures greater than 20 mm Hg are generally considered abnormal. ICP monitoring is recommended for patients with a GCS score less than 8 after resuscitation and an abnormal admission CT scan. ICP should be continuously monitored for the first 3 to 5 days after a severe head injury. A minimum of hourly documentation of ICP is required. Cerebral perfusion pressure (CPP) can be a more useful value and will be discussed later. TREATMENT STRATEGIES Avoid Secondary Brain Injury: Hypotension and Hypoxia Brain injury is adversely affected by secondary insults such as hypotension and hypoxia. Oxygenation and IV hydration are essential in preventing secondary injury. Patients with severe head injury and hypotension on admission have more than double the mortality of patients without hypotension. The addition of hypoxia to hypotension substantially increases the mortality further. Therefore, it is imperative that cardiopulmonary stabilization occurs quickly in severely brain-injured patients. Preventing Aspiration The head-injured patient has a high incidence of vomiting, and care must be taken to prevent aspiration. Turn the backboard or logroll the patient to the side and suction aggressively to keep the airway clear. Suction the airway completely before bagging or attempting intubation. Avoid the insertion of tubes into the nose if midface fractures are suspected. Orogastric tube placement is often indicated to help avoid aspiration of gastric contents. Oxygenation Provide high-flow oxygenation and monitor oxygenation with a pulse oximeter. Protect the airway if the patient s level of consciousness deteriorates. Intubation is indicated for all patients with head injuries who have a GCS score of less than 8. After the airway is secured, the patient must be ventilated appropriately. Inadvertent hyperventilation by clinical personnel is common. It must be avoided because it can create a secondary injury due to vasoconstriction, and it is associated with poorer outcomes. Conversely, hyperventilation is indicated in the presence of signs of herniation, such as a unilaterally dilated pupil, an asymmetric motor examination, or declining GCS; but hyperventilation will be only transiently effective and should be considered only as a bridge to more definitive treatment. Hypocapnia can cause harm and should be strictly limited to the emergent management of life-threatening intracranial hypertension pending definitive measures or to facilitate intraoperative neurosurgery (Curley, Kavanagh, & Laffey, 2010). Circulation Even a single episode of systolic blood pressure below 90 mm Hg can result in poor outcomes for patients with head injuries. Identify and control all sources of blood loss and vigorously resuscitate to keep the systolic blood pressure above 90 mm Hg. Scalp vessels bleed profusely but can be compressed easily with continuous direct pressure. Avoid direct pressure over obvious deformity, palpable bony defects, or instability. Instead, apply pressure around the wound, taking care to exert pressure only on stable bone. Excessive blood loss from scalp injuries is particularly a problem in children with head injuries. Maintain Cerebral Perfusion Cerebral perfusion pressure (CPP) is the difference between the mean arterial blood pressure (MAP) and ICP (CPP = MAP ICP). As ICP increases, CPP decreases, leading to cerebral ischemia. Therefore, it is important to avoid hypotension to minimize the pathologic effects of increasing ICP. Strategies to address decreasing CPP are discussed next. Fluid Resuscitation to Optimize Mean Arterial Blood Pressure As with any trauma patient, IV fluids and blood administration ensure adequate perfusion of all organs. Lactated Ringer s and/or normal saline are the preferred solutions in patients with head injuries because they are isotonic. Hypotonic solutions, such as dextrose 5% in water, should be avoided because they reduce the osmolarity of intravascular volume, which encourages fluid leakage out of the intravascular space, thereby exacerbating cerebral edema. Continuous invasive blood pressure monitoring is essential, as is close observation of urine output and base deficit to monitor fluid resuscitation. According to Lewandowski-Belfer and colleagues (2014), The efficacy of administering single bolus doses of 14.6% or 23.4% hypertonic saline (HTS) to treat refractory intracranial hypertension has been demonstrated in the literature and has emerged as an important therapeutic option in treating patients with head injuries. Strategies to Control Increased Intracranial Pressure Elevate the head of the bed to 30 degrees. This promotes venous return and helps decrease ICP. Reverse Trendelenburg can be used if a spine injury has not been ruled out. Consider sedation and paralysis of the intubated patient to avoid any straining or movement that will increase ICP. Hyperventilation should be avoided and is reserved for only brief periods for acute severe neurologic deterioration. It is imperative in severe TBI patients to ensure eucapnia, that is, maintaining CO 2 levels in a normal state (35 to 40 mm Hg). Even placing the patient on a ventilator does not ensure proper eucapnia; therefore, the use of end-tidal carbon dioxide (EtCO 2 ) is a must (DeWall, 2010). Mannitol, an osmotic diuretic, can be used to reduce elevated ICP. The typical dosing range is 0.5 to 1 gm/kg IV (Cline et al., 2013). Bolus administration, rather than continuous infusion, is preferred. It is also preferable to administer mannitol through a central line because extravasation can cause skin sloughing. Because of its osmotic diuretic effects, monitor urine output and hemodynamic status carefully when using large doses of mannitol in hypotensive patients. A barbiturate coma may be used on occasion when increased ICP is refractory to other measures. Insertion of a ventriculostomy catheter allows for drainage of excess cerebrospinal fluid. Seizure Control Posttraumatic epilepsy occurs in about 15% of patients with severe head injuries (ACS, 2012). Administration of anticonvulsant therapy is anticipated and may last several days. DEFINITIVE CARE Anticipate the need for prompt CT scans and an immediate need for surgery. Consider early transfer to a trauma center with neurosurgery capabilities. DISCHARGE CARE Assessment and discharge teaching with TBIs focuses on ruling out severe brain injury and informing them about signs and symptoms that should send them back to the medical provider (Bay & Strong, 2011). It is a good idea to have the patient s family involved in the instruction process. Discharge instructions may include:

30 42 Basic Trauma Nursing Upon discharge from the hospital: Have a relative or friend stay with you until it is safe for you to be on your own. You will start out on a light diet. You may add to your diet as you feel better. Do not drink alcoholic beverages, including beer and wine. Avoid strenuous activities. Do not lift heavy objects. Do not take any medication that will make you sleepy. Call your doctor with any questions you might have about your medicines. Do not drive or operate machinery. Avoid medicine containing aspirin or antiinflammatory medications, such as ibuprofen (Motrin, Advil) or naproxen (Aleve, Naprosyn). You may use acetaminophen (Tylenol) or the medicine your doctor has recommended for mild pain. See your doctor right away or come back to the emergency department if you have any of the following: persistent nausea or vomiting; increasing confusion, drowsiness, or any change in alertness; memory loss; dizziness or fainting; staggering or difficulty walking; a headache that feels different or that get worse; trouble talking or slurred speech; convulsions or seizures, such as twitching or jerking movements of the eyes, arms or legs, or body; a change in the size of one pupil when compared to the other eye; arm or leg weakness or numbness; stiff neck or fever; problems with your eyesight, such as blurry or double vision; bleeding or clear liquid drainage from your ears or nose; increased sleepiness (more than expected) or you are hard to wake up; unusual sounds in the ear; and/or any new or worse symptoms. BRAIN DEATH When the brainstem and the entire cerebrum cease to function, brain death results. The patient goes into a coma, becomes incapable of spontaneous respiration, and no longer has any brainstem reflexes (e.g., pupillary response and cough reflex). Even though spinal reflexes (e.g., deep tendon, plantar flexion, and withdrawal) may not be lost, the patient will no longer be able to survive on his or her own (Maese, 2014). The clinical criteria for the declaration of brain death include: 1. clinical or neuroimaging evidence of an acute central nervous system catastrophe that is compatible with the clinical diagnosis of brain death; 2. exclusion of complicating medical conditions that may confound clinical assessment (no severe electrolyte, acid-base, or endocrine disturbances); 3. no drug intoxication or poisoning; 4. core temperature greater than 32 C (90 F); and 5. coma, absence of brainstem reflexes, and apnea. Brain death is a clinical diagnosis. It is recommended that a repeat clinical evaluation be done 6 hours after the initial determination. Note that this interval is arbitrary and that a confirmatory test is not mandatory. Instead, it is desirable in patients in whom specific components of clinical testing cannot be performed reliably or evaluated. Confirmatory tests include angiography, electroencephalography, transcranial Doppler ultrasonography, technetium brain scan, and somatosensory evoked potentials. SUMMARY Injuries to the head are the leading cause of traumatic deaths and significant disabilities. Motor vehicle crashes are the predominant cause of these injuries when people between 15 and 24 years of age are involved. Knowledge of the anatomy and physiology of the head along with the dynamics of head injuries is fundamental to identifying types of head injuries and conducting effective initial and secondary assessments. All patients with potential or obvious head trauma need to be monitored continuously because of the potential for a rapid change in status. The faster the head injury is identified and assessed, and interventions are initiated, the better the potential for minimized injuries and survival. Chapter 6: Eye, Maxillofacial, and Neck Trauma CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to discuss the identification and management of eye, maxillofacial, and neck injuries. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Discuss common ophthalmic injuries and their interventions. 2. Identify common maxillofacial injuries and appropriate treatment approaches. 3. Describe the assessment and treatment of common neck injuries. INTRODUCTION Eye, maxillofacial, and neck injuries are seen frequently in the emergency department. Due to the complexities and importance of maxillofacial anatomy, assessment and treatment of injuries in this region mandates special attention. The face contains systems that control specialized functions, including seeing, hearing, smelling, breathing, eating, and talking. In addition, the vital structures in the head and neck region are intimately linked. Lastly, as facial recognition and personal identification largely rely on the structural makeup of the face, the psychological impact of disfigurement can be devastating. Mechanism of Injury Worldwide, 1.6 million people are estimated to be blind from ocular trauma, and another 19 million people suffer from severely impaired vision in one eye due to trauma (Mattox, Moore, & Feliciano, 2013). Most eye injuries are minor and result in no permanent vision damage. Men are reported to be four times more likely to suffer from ocular trauma compared to women. Most injuries result from sharp objects (54.1%), followed by blunt objects (34.4%); chemical injuries account for 11.5% of ocular injuries (Mattox et al., 2013). Facial trauma patterns on a global scale demonstrate that males sustain these injuries 2.8 times more than females. The most common cause of facial injuries is violence, at 39.7%, followed by falls at 27.9%; road traffic accidents account for 27.2% (Arslan et al., 2014). Up to 25% of women with facial trauma are victims of domestic violence, so further screening may be needed to assess for interpersonal violence. Facial trauma includes trauma to the facial bones, neurovascular structures, skin, subcutaneous tissue, muscles, glands, and upper airway. It takes significant force to fracture the midface or maxilla, and as a result, multisystem injuries usually accompany these types of fractures. More than 50% of patients with these injuries have multisystem trauma that requires coordinated management between emergency physicians and surgical specialists in oral and maxillofacial surgery, otolaryngology, plastic surgery, ophthalmology, and trauma surgery (Adamo, 2013). Significant injury to the neck (excluding the cervical spine) is relatively infrequent. Thoracic and neck trauma can cause significant life-threatening injuries, necessitating emergent intervention (ENA, 2014). In blunt neck trauma, vascular injuries are potentially devastating but are uncommon overall, occurring in 0.08% to 1.5% of blunt neck trauma cases, depending on how aggressively asymptomatic patients are screened (Salinas & Brennan, 2012). Crashes involving automobiles, motorcycles, and pedestrians account for over half of blunt injuries to the neck and chest (Hammond, 2013). For low-velocity penetrating neck trauma (LVPNT), mortality rates range from 3% to 6%. With the past two decades development of advanced radiographic techniques, and with most acute care facilities practicing selective neck explorations, mortality rates have decreased (Salinas & Brennen, 2012). This chapter will discuss selective blunt and penetrating neck injuries; specific head and spinal injuries are discussed in other chapters. ANATOMY The globe of the eye, or eyeball, is approximately 1 in. (2.5 cm) in diameter and sits in the bony structure of the skull called the orbit (see Figure 6-1). It is covered by the sclera, also known as the white of the eye. The cornea is the clear front portion that covers the pupil and iris. The interior of the eye contains the anterior chamber, which is filled with a watery fluid called the aqueous humor. Behind the lens is the largest part of the eyeball, the vitreous body, which is filled with a clear jelly called the vitreous humor. The maxillofacial region can be divided into three parts: the upper face, where fractures involve the frontal bone and sinus. the midface, which is divided into upper and lower parts. The upper midface is where maxillary Le Fort II and Le Fort III fractures, and fractures of the nasal bones, nasoethmoidal, and orbital floor occur.

31 Basic Trauma Nursing 43 Figure 6-1: Anatomy of the Eye Note. From Mistovich, Joseph J.; Karren, Keith J.; Hafen, Brent. Prehospital emergency care, 10th edition Reprinted by permission of Pearson Education, Inc., New York, New York. Le Fort I fractures occur in the lower part of the midface. the lower face, where fractures are isolated to the mandible. Le Fort fractures will be discussed later in the chapter. The neck is divided into three zones (see Figure 6-2). Zone I runs from the clavicle to the cricoids. Zone II includes the cricoids to the angle of mandible. Zone III is the angle of mandible to the skull base. The neck contains several vital structures in a relatively small space. OCULAR INJURIES AND INTERVENTIONS Foreign Body Foreign bodies to the eye most often are small particles, such as pieces of dirt, dust, or metal shavings. The particle may be seen on the surface of the cornea with the naked eye, or it may require a Figure 6-2: Zones of the Neck Note. From Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D. M., Cydulka, R. K., & Meckler, G. D. Tintinalli s emergency medicine: A comprehensive study guide, 7th edition. Retrieved from Copyright The McGraw-Hill Companies, Inc. All rights reserved. magnifier, such as a slit lamp, to be identified. The patient will have pain (especially when the eyelid is opening and closing), copious tearing, and sensitivity to light. The pain is similar to that of a corneal abrasion. Caution must be taken while removing foreign objects from the eye, as removal may result in a corneal abrasion (ENA, 2014). Corneal Abrasion Abrasions are common and cause pain, tearing, a foreign body sensation, photophobia, and decreased visual acuity. A scratch or scrape to the cornea is likely to be caused by a foreign object and is a common occurrence. An abrasion is rarely visible to the naked eye, but with the use of fluorescein staining, proper diagnosis can be made. The goals of treatment are to relieve pain, prevent bacterial superinfection, and speed healing (Wipperman & Dorsch, 2013). These goals are achieved with analgesia, antibiotics, and most importantly education on proper protection to prevent future events. Patching is not recommended for uncomplicated corneal abrasions (Wipperman & Dorsch, 2013). Hyphema Blunt trauma that causes bleeding into the anterior chamber of the eye is referred to as a hyphema. The size of a hyphema ranges from small to complete involvement of the anterior chamber. Blood in the anterior chamber may be seen in persons with light-colored eyes; however, in those with dark eyes, it can be extremely difficult to see. If the entire anterior chamber fills with blood, the outflow tracts that normally drain fluid from the eye may become obstructed with partially clotted blood, leading to secondary glaucoma and vision loss (Hammond, 2013). The success of hyphema treatment, as judged by the recovery of visual acuity, is good in approximately 75% of patients (Nash & Shepherd, 2014). The customary treatment of patients with traumatic hyphema has included hospitalization, bed rest, bilateral patching, topical cycloplegics, topical steroids, systemic steroids, and sedation (Nash & Shepherd, 2014). Clinical management is directed toward reducing the risk of rebleeding. Retinal Detachment Blunt trauma can cause retinal detachment, especially in patients who are nearsighted and those who have had previous ocular injury or cataract surgery. Inquire about history of trauma, including whether it occurred several months before the symptoms or coincided with the onset of symptoms. Documentation of head or ocular trauma may lead to legal investigation, especially in children (Pandya & Tewari, 2014). Patients with retinal detachment complain of flashing lights and a curtain interfering with some portion of the visual field. Diagnosis is made by indirect ophthalmoscopy through a dilated pupil. Chemical Injury Most ophthalmic injuries are not emergencies. However, chemical injury is a true ocular emergency, with care in the first minutes altering the outcome. While almost any chemical can cause ocular irritation, serious damage generally results from either strongly basic (alkaline) compounds or acidic compounds (Randleman, Loft, & Broocker, 2014). The primary signs and symptoms of a chemical injury to the eye include severe burning pain, swelling of the lids, and rapid onset of vision impairment. It is easy to permanently damage the delicate tissues of the eye. Emergency treatment for chemical burns is flushing the eye with sterile water or normal saline solution. However, if nothing else is available, tap water should be used. Copious irrigation takes priority even over assessment. The eye may need to be held open so that it can be adequately flushed. Irrigation should be gentle, not forceful, to prevent increased pain or further damage to the tissue. Irrigation should be continued for as long as it takes to get the conjunctival ph to a normal range of 7.4 to 7.6. If the substance with which the patient had contact was a dry chemical, brush off all particulates prior to flushing. Ciliary spasm can be managed with the use of cycloplegic agents; however, oral pain medication may initially be necessary to control pain (Randleman, Loft, & Broocker, 2014). MAXILLOFACIAL INJURIES AND INTERVENTIONS Soft-Tissue Trauma Careful evaluation of wounds should be made before any treatment ensues. All lacerations and contusions should be evaluated for potential fractures underneath. If possible, repair facial injuries within the first 8 hours after the initial insult. If the patient is unstable, repair of extensive wounds may be loosely accomplished while critical procedures are being performed (Sutphin, Lee, Bogdan, & Lucas, 2013). Contaminated tissues present a hazard for infection if primary repair is undertaken. The probability of contamination is directly related to the length of time that has elapsed since injury. Therefore, delayed primary closure is indicated for patients seen late after injury, those with extensive tissue edema, and those with wounds that are crushed, with badly contused wound edges or devitalized tissue. Limited debridement to remove devitalized tissue, followed by wet dressings and antibiotics, is effective. Thorough cleaning of soft tissue wounds is imperative before repair is attempted. All forms of facial injuries (e.g., abrasions, lacerations, and avulsions) should be well irrigated with isotonic sodium chloride solution

32 44 Basic Trauma Nursing before any tissue is handled. This serves both to cleanse the wound and to provide better visualization (Sutphin et al., 2013). Bony Maxillofacial Injuries Nasal Fracture The nasal bones are the most easily fractured of the facial bones and, not surprisingly, the most commonly fractured (Booth, Eppley, & Schmelzeisen, 2012). The usual mechanism of injury is blunt trauma, and nasal deformity, deviation, and bony crepitus with movement are the usual findings. The extent of the bony or cartilaginous deformity determines the appropriate treatment (Booth et al., 2012). Inspection and palpation are the best ways to diagnose a broken nose. Uncomplicated nasal fractures are treated with antibiotics, pain medicine, and decongestant nasal spray. In healthy adults, fracture healing occurs in approximately 3 weeks. Athletes involved in contact sports should have adequate head and face protection for several weeks after returning to play (Haraldson, 2014). Mandibular Fracture The second most frequent type of facial fracture is mandibular. Fractures tend to occur at the local site of impact and areas of weakness, and are often multiple. (Figure 6-3 shows the patterns of mandibular injuries using the Le Fort code.) A forceful blow from a motor vehicle crash, a sports injury, or an altercation is the usual mechanism of injury. Loss of bony support in a mandibular fracture can be life threatening if it displaces posteriorly and blocks the airway. Malocclusion is the most prominent symptom, but symptoms vary with the location of the fracture. The face may be asymmetric, with swelling and ecchymosis. Treatment first involves aggressive airway management, which may include oral intubation or surgical airway, followed by definitive surgery via open reduction with internal plate and screw fixation. Avoid nasotracheal intubation in patients with upper face or upper midface fractures. Nasotracheal intubation can result in nasocranial intubation or severe nasal hemorrhage. Figure 6-3: Le Fort Injury Patterns Maxillary Fracture It takes great force to cause a midface fracture, and usually other fractures are involved. There are three different types of maxillary, or Le Fort, fractures (see Figure 6-4). Le Fort I is a lower-third fracture that is horizontal. The body of the maxilla is separated from the base of the skull above the palate but below the zygomatic process attachment. Signs and symptoms include possible lip lacerations or fractured teeth, independent movement of the maxilla from the rest of the face, and malocclusion. Le Fort II is a middle-third fracture, including the central maxilla, nasal area, and ethmoid bones. Signs and symptoms include massive facial edema, malocclusion, nasal swelling, and sometimes cerebrospinal fluid (CSF) rhinorrhea. Le Fort III is an orbital complex fracture that causes total craniofacial separation, which is a rare injury. This fracture is frequently associated with leakage of CSF and a fractured mandible. Signs and symptoms include massive facial edema, mobility and depression of zygomatic bones, ecchymosis, diplopia, open bite or malocclusion, and CSF rhinorrhea. Most patients will require surgery for definitive repair. Nurses should check CSF drainage for the halo sign and glucose; remember that CSF mixed with blood produces a halo or ring sign on the sheet, and a dextrostik of the CSF will reveal a measurable glucose concentration, whereas nasal secretions do not. Figure 6-5: Orbital Blowout and Increased Orbital Volume Air-fluid level maxillary sinus Enophthalmos Herniated orbited contents Note. From Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D. M., Cydulka, R. K., & Meckler, G. D. Tintinalli s emergency medicine: A comprehensive study guide, 7th edition. Retrieved from accessmedicine.com. Copyright The McGraw- Hill Companies, Inc. All rights reserved. Orbital Blowout Fracture Orbital blowout and zygoma fractures can occur separately but are often found together. On occasion, the blow to the eye causes increased pressure to the globe. This pressure can fracture the most fragile part of the orbit, which is typically the part underneath the eyeball (orbital floor; Colby, 2013). Blunt trauma is the predominant causative etiology of orbital blowout fractures. Increased pressure can cause the orbit s contents to prolapse into the maxillary sinus, causing entrapment of the inferior rectus muscle, inferior oblique muscle, infraorbital nerve, orbital fat, and connective tissue (see Figure 6-5). The globe also may become entrapped. When the globe is perforated, blowing the nose or manipulating the eyes can result in intraorbital air. If there is subcutaneous orbital emphysema, a fracture of the sinus arch should be suspected. Nose blowing, coughing, sneezing, vomiting, and straining can force air from the sinuses through the fracture into the orbital space. If there is bulging of the eye and limitation of motion, ocular involvement is a consideration. Double vision, pupil asymmetry, sunken appearance of the globe, anesthesia of the cheek and upper lip, or drooping of the lid are all indicators of a blowout fracture. Surgical repair involves open reduction or removal of the fractured segments. Neck Injuries and Interventions Penetrating trauma of the neck is classified as injury to Zone I, II, or III (see Figure 6-2 on page 43). Each zone has a group of vital structures that can be injured and may determine the type of trauma management (Alterman & Daley, 2012). It is prudent for clinicians to familiarize themselves with each zone and its vital structures that can be damaged. Historically, penetrating neck trauma was explored operatively; however, platysmal penetration is no longer an absolute indication for Figure 6-4: Le Fort Fractures Note. From Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D. M., Cydulka, R. K., & Meckler, G. D. Tintinalli s emergency medicine: A comprehensive study guide, 7th edition. Retrieved from medicine.com. Copyright The McGraw-Hill Companies, Inc. All rights reserved. Le Fort I Fracture Le Fort II Fracture Le Fort III Fracture Note. From Pollack, Andrew N. Critical care transport Jones & Bartlett Learning, Burlington, MA. Reprinted with permission.

33 Basic Trauma Nursing 45 neck exploration (Peitzman & Schwab, 2013). Four-vessel cerebral angiography is indicated with clinical evidence of significant vascular injury (i.e., hard signs) in Zone I and Zone III, as well as in selectively managed Zone II injuries. However, helical computed tomographic (CT) angiography is less invasive and is showing promise in defining vascular neck injury. Possibly, in the future, this technique may replace angiography (Alterman & Daley, 2012). Caution is required when treating a penetrating injury to the neck. Often, there are no findings suggestive of injury to a vital structure, and many of these injuries remain silent until they cause complications later. Specifically, injuries to the larynx, trachea, esophagus, cervical spine, and carotid arteries must be ruled out; therefore, it is necessary to perform diagnostic tests within the first 8 to 12 hours following admission. ASSESSMENT Primary Assessment Ensuring adequate oxygenation, ventilation, and protection from aspiration are the first priorities when treating an injured patient while maintaining in-line cervical stabilization (Peitzman & Schwab, 2013; ENA, 2014). There are many causes of airway obstruction in cases of head and neck injury. Airway obstruction should be addressed immediately with jaw thrust or chin lift and prompt suctioning. When the facial structures are damaged or the tongue is left without support, occlusion of the airway is likely. Foreign objects such as avulsed teeth or dentures also can obstruct the airway. A fracture of the naso-orbital complex compromises the airway due to hemorrhage. Altered mental status or injury may decrease the gag reflex, leaving the airway unprotected. Identify serious injuries that threaten the patient s life or limbs and stop any uncontrolled bleeding. Secondary Assessment After the neck is stabilized, the airway opened, the patient adequately ventilated, and hemorrhaging controlled, the secondary assessment should be conducted. Maxillofacial injuries seldom are life threatening, unless there is a compromised airway. However, other associated fractures are likely. INTERVENTIONS Stabilize the neck with cervical collar placement. Monitor the airway for patency. Midfacial fractures can cause airway obstruction. If there is airway compromise, perform immediate jaw thrust and prepare to intubate. Once the spine has been cleared, elevate the head of the bed to reduce swelling, bleeding, and congestion, as well as to promote drainage. Suction as needed to clear the airway. If the patient is alert, promote self-suction with a tonsil tip catheter. Apply ice packs and direct nasal pressure to control swelling and bleeding from the nose. Avoid insertion of a nasogastric tube or nasal airway in a patient with a suspected midfacial or basilar skull fracture. Place an orogastric tube instead. Apply a sterile dressing to control facial or scalp bleeding with direct pressure, except where there is an obvious fracture, a ruptured or penetrated eyeball, leaking CSF, or exposed brain tissue. Secure impaled objects to prevent movement. Save loose or dislodged teeth. Put them in moist gauze or a container with normal saline solution or milk, and label them with the date, time, and patient s name. They possibly may be reimplanted if the procedure is performed quickly. When applying pressure to bleeding from the neck, be sure to restrict blood loss but also try not to occlude the airway. Keep in mind the potential of air being sucked into the jugular vein and the formation of an air embolus. Keep the wound covered with a wet, sterile dressing. Never shave the eyebrows of a patient with facial trauma. It is unnecessary because hair is inert, and the eyebrows are needed as landmarks for repair. Remove contact lenses. Instruct the patient not to bend forward, cough, or perform a Valsalva maneuver because these actions may raise intraocular pressure. Instill prescribed topical anesthetic drops for pain control and to facilitate eye examination, except in open globe injuries. Instill normal saline solution drops or artificial tears to keep the corneas moist, as indicated. Cover the eyelids with a sterile, moist saline dressing to prevent corneal drying and ulceration. Lightly patch or shield both eyes to reduce movement and photophobia in patients with retinal injuries. SUMMARY Eye, maxillofacial, and neck injuries are the most frequent types of injuries seen in the emergency department. Maxillofacial injury can be dramatic in appearance, often because of hemorrhaging or disfigurement from fractures. Although usually not life threatening, the involvement of facial bones, neurovascular structures, skin, subcutaneous tissue, and glands can be complicating factors in the management of patients with multiple injuries. Chapter 7: Thoracic Trauma CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to identify the signs and symptoms of common chest injuries and appropriate interventions to manage thoracic trauma. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Identify physical assessment findings that help identify thoracic injuries. 2. Recognize the signs and symptoms of common chest injuries. 3. Choose appropriate interventions to manage chest injuries. INTRODUCTION The thoracic cavity, or chest, contains organs, structures, and vessels of the pulmonary, cardiovascular, and gastrointestinal systems. These systems, structures, and vessels are vital to life; therefore, any damage to the chest is potentially serious. Because the body is unable to store oxygen, a chest injury that interferes with normal respiration or the functioning of any of these three systems is emergent. Thoracic trauma is a significant cause of mortality. Thoracic injuries are responsible for approximately 25% of all trauma death and contribute to 25% of deaths annually in the United States (Peitzman & Schwab, 2013). Many trauma patients with thoracic injuries die after reaching the hospital. Appropriate management immediately upon arrival at the emergency department can prevent unnecessary deaths (Ursic & Curtis, 2010). Only 10% to 15% of patients with chest injury will require thoracotomy or sternotomy (Peitzman & Schwab, 2013). The majority of thoracic injuries are treated with analgesia, aggressive respiratory therapy, endotracheal intubation, and tube thorocostomy (Peitzman & Schwab, 2013). ANATOMY AND PHYSIOLOGY The thorax, which extends from the top of the sternum to the diaphragm, is one of two major body cavities; the other is the abdominal cavity. Boundaries are the 12 pairs of ribs that articulate with the sternum anteriorly and the thoracic spine posteriorly. The 11th and 12th pairs of ribs do not reach around anteriorly and are connected to the rib above. These are sometimes referred to as floating ribs. The clavicles overlie the upper boundaries in front and join with the scapulae in the muscle tissue of the back. The superior border of the thorax is continuous with the neck. The lower boundary is the diaphragm, which separates the thoracic and abdominal cavities. Patients with penetrating injuries below the nipple line anteriorly or below the scapula posteriorly most likely also have abdominal damage. Figure 7-1 depicts the anatomy of the thoracic cavity. Within the thorax are structures, organs, and vessels of the pulmonary, cardiovascular, and gastrointestinal systems. The pleural space contains the pulmonary organs, and the mediastinal space contains the cardiovascular and gastrointestinal organs. Important structures in the thorax are the ribs, sternum, lungs, pleurae, intercostal and accessory muscles, diaphragm, trachea, esophagus, heart, and great vessels. Twelve pairs of ribs form the rib cage, which is meant to function as a chest protector. The centrally located sternum provides additional protection but can function as a weapon to the heart and lungs if it is fractured. Essential to life because they provide oxygen to the body and remove carbon dioxide, the lungs fill most of the chest and are covered by the visceral pleura. The trachea funnels air in and out of the lungs, and it subdivides into bronchi and bronchioles. The esophagus, which lies behind the trachea, is a tube for transporting food into the gastrointestinal system. The heart lies under and slightly left of the sternum, with important vessels entering and leaving it and the lungs. PULMONARY SYSTEM One lung occupies each half (hemithorax)of the chest cavity. Between the lungs is a space, the mediastinum, where the heart, great arteries and veins, many nerves, esophagus, trachea, and major bronchi are located.

34 46 Basic Trauma Nursing Figure 7-1: The Chest Note. From Mistovich, Joseph J.; Karren, Keith J.; Hafen, Brent. Prehospital emergency care, 10th edition Reprinted by permission of Pearson Education, Inc., New York, New York. The lungs hang freely within the chest cavity. Because they are not muscle, they have no ability to expand or contract on their own. A thin membrane, the parietal pleura, lines the inner surface of the chest cavity. The same kind of serous membrane, the visceral pleura, also covers the surface of each lung. Between the visceral pleural surface of the lungs and the parietal pleural surface of the chest wall is the so-called pleural space. In reality, it is a potential space because the visceral pleura and the parietal pleura actually lie against each other, sealed tightly with a thin film of fluid. An analogy would be two panes of glass stuck together by a thin coating of water. When the chest wall expands, the lung is pulled with it and made to expand by the pulling force of the two pleural layers. Under normal conditions, no real space exists between the pleural layers because the fluid causes them to adhere to each other. However, if traumatized, the potential space can hold 3,000 ml (or more) of fluid in an adult. For example, if the chest wall is lacerated, blood can separate the pleural surfaces and fill the space. A hole in the chest wall or a torn lung can cause air to enter the pleural space. In either case, the pleurae are no longer sealed together, and the means for them to expand the lungs is lost. If enough blood or air collects, the lungs can be compressed such that they cannot expand at all during inspiration. At this point, there will not be enough oxygen to maintain life. The mechanics of breathing are threedimensional. As discussed, the lungs do not contain muscle tissue and cannot expand or contract on their own. The intercostal and accessory muscles of the thorax, along with the movement of the diaphragm, cause expansion in three directions: out, up, and down. The attachment of the lungs to the pleural surfaces causes them to follow the expanding motion of the chest wall, permitting air to enter the airways and the alveoli. Although the diaphragm is skeletal (or voluntary) muscle (in that one can control taking a deep breath, coughing, and breathing patterns at will), it also performs an automatic function. Breathing occurs while one is asleep or awake. Conscious variations in breathing, such as holding one s breath, cannot continue indefinitely. When the balance of oxygen and carbon dioxide is disturbed enough, automatic regulation of respiration takes over. NEGATIVE PRESSURE The chest can be thought of as a bell jar in which the lungs are suspended. The only natural opening into the chest is the trachea, through which air moves in and out of the lungs. Ordinarily, the pressure in the chest cavity is slightly less than the atmospheric pressure. When the chest wall muscles and diaphragm contract during inspiration, the ribs expand and the diaphragm drops, so the thoracic space enlarges and the volume the chest can hold is increased. The increased space causes the intrathoracic pressure to drop further, and a slight vacuum develops. The result is that the higher outside pressure drives air through the trachea, filling the lungs. As the air moves in, the inside pressure begins to equal the pressure outside, at which time, the air stops moving. The principle is that any gas will move from a higher-pressure area to a lower-pressure area until the pressures are equal. In the case of ventilation, when the pressures are equal, inspiration stops. At this point, expiration begins. The intercostal muscles and diaphragm relax, the chest contracts and becomes smaller, the pressure inside becomes higher than the pressure outside, and the air is expelled. The key point is that the trachea is the only natural opening for air to enter the chest cavity. If there is another opening from an injury, the air cannot get to the interior of the lung through the trachea because air or blood enters the pleural space through the injury, breaks the pleural seal, compresses the lung, and effectively stops normal chest expansion. CARDIOVASCULAR SYSTEM The cardiovascular system is the engine that keeps the body running, delivering oxygen and nutrients and disposing of cellular waste and carbon dioxide. Working as a closed circuit, the heart pumps the blood and makes the system go. The system is not simple. It is a complex arrangement of systemic circulation (the transport of blood throughout the body to exchange oxygen, nutrients, and waste products) and pulmonary circulation (the transport of blood through the lungs to exchange oxygen and carbon dioxide). The heart, large vessels, trachea, esophagus, thymus, and lymph nodes are situated in the mediastinum. The heart is positioned slightly on the left half of the chest, with the right ventricle lying beneath the sternum. The pericardium (a tough, layered sac that cannot expand) surrounds and protects the heart in a manner similar to the pleurae around the lungs. It is made up of an inner layer, the visceral pericardium, and an outer layer, the parietal pericardium. As with the pleural space, the pericardial cavity is a potential space between the two pericardial layers that is filled with a small amount of serous fluid. The fluid serves to prevent friction during heartbeat. The parietal pericardium attaches to the sternum, great vessels, and diaphragm to hold the heart in place. The right heart is a low-pressure system, receiving deoxygenated blood and pumping it to the lungs for oxygenation. Oxygenated blood returns to the left heart (a high-pressure system) to be pumped through the systemic circulation. Cardiac output and function depend on contractility, heart rate, preload, and afterload. Preload is the volume reached after diastolic filling of the ventricles. Afterload is the resistance the heart pumps against to push the blood out. There are three anatomical portions of the aorta: the ascending aorta, the aortic arch, and the descending aorta. Just distal to the arch, the aorta is tethered by the ligamentum arteriosum and is quite immobile; thus, it is at risk for disruption. Traumatic aortic rupture is the second most common cause of death in victims of blunt chest trauma

35 Basic Trauma Nursing 47 from motor vehicle crashes (Benjamin & Roberts, 2012). Acceleration and deceleration forces to the descending aorta cause the vast majority of aortic injuries. Sudden high-velocity deceleration is accompanied by hyperflexion of the spine, leading to sudden chest compression and traction on the aortic isthmus, the point at which the mobile aortic arch meets the fixed proximal descending thoracic aorta (Benjamin & Roberts, 2012). MECHANISM OF INJURY The chest can be injured by blunt trauma, penetrating objects, and compression mechanisms. The extent of injury depends on the force, direction, duration, and physical area where the traumatic energy impacts. Blunt Trauma A majority of chest injuries are caused by blunt trauma; crashes involving automobiles, motorcycles, and pedestrians account for over half of blunt injuries to the chest (ENA, 2014). A deceleration injury results from a collision between a rapidly moving body part and a stationary object. Energy rebounds through the thorax and may crush soft tissues against the spine, rupturing organs. Blunt trauma with force sufficient to fracture the rib cage, sternum, or costal cartilage can result in heart or lung contusion. Horizontal deceleration injury occurs when a person in motion is subjected to the massive traumatic force caused by sudden excessive deceleration, for example, an unrestrained driver in a frontal motor vehicle crash. Vertical deceleration, which is a fall from great height (greater than 5 stories), can shear the aorta and great vessels from the heart. A fracture of the first rib is always considered a hallmark of more serious injury. Penetrating Object Any sharp object can cause a penetrating injury when enough force is applied. Penetration injuries can result in localized or widespread damage. They can be caused by bullets, knives, shards of metal or glass, or a variety of other objects that can pierce the chest. Penetrating injuries can lacerate, impale, puncture, or rupture an organ, structure, or vessel. Stab wounds may not appear damaging but can have significant morbidity and mortality from deep penetration into the chest and its contents. Obtain a chest X-ray (CXR) early in the evaluation of all patients sustaining thoracic injury and identify sites of missile penetration with radio-opaque markers (Peitzman & Schwab, 2013). However, it can be difficult to determine entry and exit wounds from bullets because they may fragment, change direction, and lose energy as they travel through body cavities of differing densities. During assessment, identify the location of each penetrating wound and avoid labeling them as entry or exit wounds or attempting to determine a bullet s path. Compression In a severe form of blunt trauma, the chest is rapidly and forcefully compressed, such as by a steering wheel in a car crash or when something extremely heavy falls on the chest. The process is a sudden, severe compression of the chest, producing a rapid increase in intrathoracic pressure. Multiple fractures and flail chest can result. The increased intrathoracic pressure can cause the upper body to become swollen and cyanotic, the neck veins to distend, and the eyes to appear to be bulging. This is sometimes referred to as traumatic asphyxia. Injury to the Back of the Chest Direct blows to the back of the chest can cause contusions or rib fractures as well as spine and airway injuries. Rarely does the scapula (which is protected by large muscles) receive a blow severe enough to fracture. When scapular fracture does happen, there also may be damage to the underlying chest wall and lung. Direct back blows to the lower rib cage can result in injuries to the spleen and kidneys. INITIAL ASSESSMENT AND MANAGEMENT First, perform a primary survey with resuscitation of vital functions, then a detailed secondary survey, and finally, definitive care. The basic tenet of chest trauma treatment identifies hypoxia as the most serious feature of chest injury, and early interventions are designed to prevent or correct it. Because most chest trauma interventions are outside of the scope of nursing practice, the ability to assess for hypoxia, along with prompt notification and anticipation of physician interventions, are essential for management. Life-threatening thoracic injuries are treated by airway control or an appropriately placed chest tube or needle. The secondary survey is influenced by a high index of suspicion for specific injuries. CATEGORIES OF CHEST TRAUMA Major thoracic injuries can be divided into two categories (see Table 7-1): the lethal seven and the hidden six (Peitzman & Schwab, 2013). TABLE 7-1: MAJOR THORACIC INJURIES Lethal Seven Hidden Six Airway obstruction Tension pneumothorax Cardiac tamponade Open pneumothorax Massive hemothorax Flail chest Traumatic rupture of the aorta Major tracheobronchial disruption Blunt cardiac injury Diaphragmatic tear Esophageal perforation Pulmonary contusion Note. Peitzman, A. B., & Schwab, C. W. (2013). The trauma manual: Trauma and acute care surgery (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Primary Survey and Interventions: Life-Threatening Injuries Airway Obstruction Control of the airway is foremost in trauma care, with simultaneous control of the cervical spine. The tongue is the most common cause of airway obstruction in the unconscious patient. Dentures, avulsed teeth, tissue, secretions, and blood also can contribute to airway obstruction, and a bilateral mandibular fracture can allow the tongue to collapse into the hypopharynx. Stridor, hoarseness, subcutaneous emphysema, altered mental status, accessory muscle use, apnea, and cyanosis are physical findings that may be seen in airway obstruction. Immediately open the airway, suction as needed, and proceed toward oral intubation. Open Pneumothorax/Sucking Chest Wound Large penetrating defects of the chest wall result in an open pneumothorax or sucking chest wound. During inspiration, air enters the pleural space through the wound, as well as through the trachea (ENA, 2014). Generally, stab wounds are self-sealing; however, a sucking, bubbling sound can sometimes be heard when one is examining the wound. Shotgun wounds are larger. If the opening is approximately two thirds the diameter of the trachea, air will pass preferentially through the chest wall defect. This leads to ineffective ventilation, hypoxia, and hypercarbia. Air entering through the wound remains in the pleural space, and the lung does not expand. When the patient exhales, some air leaves through the wound. As the air moves in and out, the mediastinum moves with ventilation, compressing the opposite lung and great veins leading to the heart. The process of air moving in and out of an open chest wound makes a sucking sound. Completely cover open chest wounds with a nonporous dressing (plastic wrap, petroleum jelly gauze) and tape securely on three sides. This measure is temporary, with variable effectiveness, and definitive repair is completed as quickly as possible in the form of a chest tube and wound closure or surgical repair (ACS, 2012). Continuously monitor the patient for signs of deterioration. If respiratory and hemodynamic status deteriorate, presume a tension pneumothorax is developing, remove the occlusive dressing, and reassess. Tension Pneumothorax Tension pneumothorax is a potentially lifethreatening emergency. Prompt, correct, and efficient treatment can save a person s life. A pneumothorax becomes life threatening when the visceral pleura or a lung injury allows air to enter the pleural space and it cannot leave. The air leaks from the lung into the pleural space. Because the air is trapped in the pleural space, the space expands with every breath, compressing the lung to the point of complete collapse. The pressure in the affected side rises with each breath so that the collapsed lung presses against the mediastinum and compresses the heart and other lung. As the pressure in the chest cavity increases, it may compress the vena cava, impairing venous return to the heart. The decrease in venous return to the heart decreases cardiac output. If the mediastinal shift is great enough, the great vessels can become compressed sufficiently to prevent venous return to the heart; cardiac arrest will occur if left untreated. Tension pneumothorax must have an intact, wellsealed chest to occur. However, it is not limited to closed-chest injuries. A chest with an open wound and a severe lung laceration can develop a tension pneumothorax after the wound has been sealed with gauze. The lung continues to leak air into the pleural space that is sealed with the dressing; the pleural air cannot escape, causing a tension pneumothorax to develop. Signs and Symptoms of Tension Pneumothorax Respiratory distress Tachycardia Hypotension

36 48 Basic Trauma Nursing Asymmetry of chest wall motion Absence of breath sounds on the injured side Neck vein distention Hyperresonance on percussion of the injured side Cyanosis or dusky color (late sign) Tracheal deviation away from the injured side (late sign) Because of similarity in their signs, tension pneumothorax and cardiac tamponade should be considered as differentials when the patient presents with the aforementioned symptomatology. Differentiation can be made by absent breath sounds over the affected area of the chest and a hyperresonant note on percussion if a tension pneumothorax exists. Tension pneumothorax is a clinical diagnosis, and treatment should not be delayed by waiting for a chest X-ray. The goal of treatment is to decompress the trapped air, thus increasing the pressure in the pleural space. Treatment of Tension Pneumothorax Rapidly insert a large-gauge needle (#12 or #14) into the pleural space through the second intercostal space, mid-clavicular line (over the top of the third rib). Currently, it is recommended to use the fifth intercostal space, anterior axillary line, to increase success of the initial decompression (Inaba et al., 2011; Inaba et al., 2012). Immediately follow with a chest tube inserted into the fifth intercostal space (usually at nipple level), just anterior to the midaxillary line. If the tension pneumothorax occurs after an open wound has been bandaged, remove the dressing and reassess the patient. Cover open chest wounds with an air-occlusive dressing taped on three sides. After the chest tube is in place, cover on four sides. High-flow oxygen should be administered by nonrebreather mask. Figure 7-2: Paradoxical Motion in Flail Chest Note. From Limmer, David J.; O Keefe, Michael F.; Grant, Harvey T.; Murray, Bob; Bergeron, J. David; Dickinson, Edward T. Emergency care, 12th edition Reprinted by permission of Pearson Education, Inc., New York, New York. Flail Chest When two or more adjacent ribs are broken, each in two or more places, the part of the chest wall lying between the fractures becomes a freefloating, or flail, segment. The injury also can be a bilateral detachment of the sternum from the costal cartilage. Both types of injuries are most often the result of a massive crush injury or a high-speed motor vehicle crash. The loose segment collapses and does not expand with the chest wall during inhalation; it remains motionless. Movement of the loose segment opposite to the normal movement of the chest wall is called paradoxical movement (see Figure 7-2). This paradoxical movement may not be visualized initially in the emergency department but may appear up to 12 to 16 hours after the injury. It is most apparent after the patient fatigues and requires assisted ventilations. Flail chest is serious. It takes substantial energy to fracture ribs in several places and produce a flail segment. However, the lung contusion underlying the fractures is of most concern. The lung under the segment does not expand properly during inhalation, which decreases the efficiency of ventilation. Chest radiography may identify the rib fractures but initially miss the contusion. Chest computed tomography (CT) scanning can more sensitively identify pulmonary contusions and is often repeated after admission to monitor development of pulmonary contusion. Pulmonary contusion causes bleeding and swelling into the lung tissue and often worsens over the first 36 hours after the injury. As the contusion worsens, there is loss of compliance, increased airway resistance, and decreased gas exchange. Hypoventilation, followed by atelectasis, hypoxia, and cyanosis, can occur. The patient should be followed carefully for respiratory failure. Mechanical ventilation is reserved for patients with persistent respiratory insufficiency or failure after adequate pain control or when complications related to excessive narcotic use occur (Bjerke, 2014). Liberal use of intercostal nerve blocks or epidural catheter insertion for analgesia administration along with aggressive pulmonary toilet and serial monitoring of blood gases can indicate whether the patient will ultimately require intubation and mechanical ventilation. Occasionally, when multiple ribs are fractured, displaced, or overriding, effective ventilation remains compromised. Repairing of selected ribs with plates and screws can hasten recovery. Chest wall reconstruction has been shown to decrease mechanical ventilation and intensive care unit (ICU) requirements. Massive Hemothorax The presence of blood in the pleural space may occur in open or closed chest trauma and often accompanies pneumothorax (see Figure 7-3). Massive hemothorax results from a rapid accumulation of more than 1,500 ml of blood, or one third or more of the patient s blood volume, in the chest cavity. Blood in the chest cavity comes from lacerated or torn vessels in the chest wall or cavity, bronchi, or a laceration of the lung. Common sites of major blood loss in the chest are laceration of the systemic or hilar vessels. Severe bleeding into the chest cavity causes hypovolemic shock. Signs and Symptoms of Massive Hemothorax Absent breath sounds on the side of injury. Asymmetry of chest wall motion, with decreased movement on the side of injury. Dullness to percussion on the side of injury. Shock, hypotension, tachycardia. Neck veins: May be flat as a result of severe hypovolemia. May be distended if there is an associated tension pneumothorax. Treatment of Massive Hemothorax Insertion of a large-caliber (36 French) chest tube at the fifth intercostal space at the anterior or midaxillary line (ENA, 2014). Fluid and blood volume resuscitation with large-caliber IV lines. Reinfusion of blood (via an autotransfusion device; hospital specific) that has been collected from the chest tube. Surgeon notification of any continued chest. bleeding of 200 ml/hr or more for 2 consecutive hours. Thoracotomy when up to 1,200 to 1,500 ml of blood has been collected and the patient is hemodynamically unstable. Cardiac Tamponade Tamponade means pathologic compression. Cardiac tamponade (also known as pericardial tamponade) is a rapidly progressive and life-threatening compression. The pericardium is a tough, fibrous, flexible, but inelastic membrane surrounding the heart. As with the pleural space, there is a potential space with a small amount of fluid between the pericardium and the heart. When the heart s blood vessels are damaged or if the myocardium is torn, blood enters the pericardial space. In the case of blunt trauma, there is no hole in the pericardium for the blood to empty from the space. With penetrating trauma, the hole in the pericardium may not be large enough for the blood to drain from the pericardial space at the rate it enters. As the blood fills and cannot empty from the pericardial space, it rapidly begins to compress the heart because of the inelastic pericardium. The ventricles are squeezed, making it more difficult for the heart to refill. Thus, less blood is pumped out of the heart, and there is decreased cardiac output. Less

37 Basic Trauma Nursing 49 Figure 7-3: Conditions Produced by Chest Injuries Note. From Limmer, David J.; O Keefe, Michael F.; Grant, Harvey T.; Murray, Bob; Bergeron, J. David; Dickinson, Edward T. Emergency care, 12th edition Reprinted by permission of Pearson Education, Inc., New York, New York. and less blood is pumped out with each contraction of the heart, leading to an obstructive shock state. Initially, there may be no symptoms other than those related to the chest injury. Because the pericardial sac is a fixed fibrous structure, only a relatively small amount of blood is required to restrict cardiac activity and interfere with cardiac filling. Removal of small amounts of blood or fluid, often as little as 15 to 20 ml, by pericardiocentesis may result in immediate hemodynamic improvement. Common Signs and Symptoms of Cardiac Tamponade Decreased systolic blood pressure (hypotension occurs secondary to the myocardial compression and decreased cardiac output) Increased diastolic blood pressure (narrowed pulse pressure) Muffled heart tones (heart sounds are distant sounding or muffled because the blood in the pericardium insulates the sound) Distended neck veins (jugular vein distention occurs because the compressed ventricles cannot expand normally to accommodate the blood entering the heart, and venous blood backs up in the vena cava and jugular veins) On physical examination, tamponade classically presents as Beck s triad, which consists of jugular venous distension, muffled heart tones, and hypotension. However, only one third of the patients with tamponade will have all three features, and 10% of the patients will not have any of them (Doniger, 2010). Associated injuries and other causes, such as hypovolemia, may preclude the finding of jugular venous distention. Other assessment diagnostic techniques include the following: Checking for pulsus paradoxus in the spontaneously breathing patient, which is a decrease in systolic blood pressure greater than 10 mm Hg occurring during spontaneous inspiration. Inserting a central venous line with measurement of central venous pressure (CVP). CVP is elevated in cardiac tamponade, but it can be elevated for a variety of reasons. Assessing cardiac rhythm. Pulseless electrical activity is suggestive of cardiac tamponade but does have other causes. Performing focused assessment sonography for trauma (FAST), which includes an ultrasound of the heart and can quickly identify cardiac tamponade. Cardiac echocardiography allows for immediate diagnosis of pericardial effusions and cardiac tamponade (Perera, Lobo, Williams, & Gharahbaghian, 2014). FAST, on the other hand, is an important and valuable diagnostic alternative to diagnostic peritoneal lavage (DPL) and CT that can often facilitate a timely diagnosis for patients with blunt trauma (Jang & Angemi, 2014). The FAST examination is immediately available in most emergency departments. Treatment for Cardiac Tamponade The treatment for cardiac tamponade is surgery. Prepare the patient for the operating room for a thoracotomy, pericardiotomy, and/or repair of the injured heart. If surgical intervention is not available, pericardiocentesis can be therapeutic as well as diagnostic, but it is not definitive therapy for cardiac tamponade. The initial administration of IV fluid is helpful because it raises the venous pressure and improves cardiac output transiently while preparations are made for surgery or transfer to an appropriate facility where a qualified surgeon is available. Resuscitative Emergency Department Thoracotomy Closed chest cardiopulmonary resuscitation for cardiac arrest or pulseless electrical activity is generally ineffective in a hypovolemic bleeding patient with penetrating chest wounds. Patients with penetrating thoracic injury who arrive pulseless, but with myocardial electrical activity, may be candidates for immediate emergency department thoracotomy. A surgeon and immediate access to a staffed operating room must be present at the time of the patient s arrival to determine the potential success of this controversial maneuver. A left anterior thoracotomy is performed to gain access. Restoration of intravascular volume is continued, and endotracheal intubation and mechanical ventilation are essential. Nurses must quickly set up an open thoracotomy tray with rib spreaders and ensure that universal precautions are in place. Aggressive fluid resuscitation ensues with crystalloid and blood products as well as timely transfer to the operating room for definitive repair. Commotio Cordis Commotio cordis, sudden blunt impact to the chest that causes sudden death in the absence of cardiac damage, typically involves young, predominantly male, athletes in whom a sudden, blunt, nonpenetrating, and innocuous-appearing trauma to the anterior chest results in cardiac arrest and sudden death from ventricular fibrillation (Yabek, 2013). This phenomenon has gained increasing awareness due to increased incidence. A high index of suspicion is essential when encountering an athlete (professional or recreational) who has sustained blunt force trauma to the chest. The mechanism of ventricular fibrillation appears to be an increase in the heterogeneity of repolarization caused by induced abnormalities of ion channels activated by abrupt increases in left ventricular pressure (Link, 2014). For victims of witnessed ventricular fibrillation arrest, as occurs in commotio cordis, early cardiopulmonary resuscitation (CPR) and rapid defibrillation can significantly increase the chances of survival (Yabek, 2013). Secondary Survey: Life-Threatening Chest Injuries Aortic Rupture Traumatic aortic rupture usually is caused by a severe deceleration injury from a motor vehicle crash or a fall from great height. The heart and aortic arch suddenly move forward, causing shearing at the point of the aorta s attachment to the heart. Only about 20% of patients with blunt aortic injury survive long enough following the injury to be treated (Neschis, 2013). For those who survive immediately, salvage is frequently possible if aortic rupture is identified and treated early. In a very few, the tear is small and covered over by the outer fibrous layer of the aorta. This covering will last for only a brief time and then give way, after which the patient will bleed out. Specific signs and symptoms are frequently absent. A high index of suspicion, prompted by a history of decelerating force and characteristic radiologic findings, followed by arteriography, help to make the diagnosis. The following signs on initial chest X-ray should prompt further evaluation: 1. Widened mediastinum 2. Obliteration of the aortic knob 3. Deviation of the trachea or esophagus to the right 4. Fractures of the first or second rib or scapula If there is the slightest suspicion of aortic injury, the patient should be evaluated at a hospital capable of repairing the injury. Diagnostic Tests for Aortic Tear Aortogram There is debate about whether aortography or chest CT scanning is best for diagnosing an aortic tear. The aortogram remains the gold standard in the diagnosis of aortic rupture. Aortography was the criterion standard against which other modalities were measured, but with the advent of transesophageal echocardiography (TEE) and CT scanning, this modality is now rarely used; however, aortography is still the preferred modality for the preoperative evaluation of thoracic aortic aneurysms and for precise definition of the anatomy of the aneurysm and great vessels (Singh & Novelli, 2013). Helical CT Helical CT scanning of the chest is rapidly gaining favor as the diagnostic test of choice and

38 50 Basic Trauma Nursing has been shown to be an accurate rapid screening method for patients with suspected blunt aortic injury in many large Level I trauma centers. Chest CT scanning, however, depends on the grade of CT scanner available and the expertise of the radiologist performing the study. Not all hospitals have recent high-end helical CT scanners or available highly trained radiologists; therefore, angiography should be used as an alternative. Transesophageal Echocardiography Transesophageal echocardiography (TEE) is recommended in unstable patients with clinical suspicion of an aortic tear. TEE is an effective diagnostic ultrasound test that allows evaluation of the heart muscle and blood flow from a probe that is passed into the esophagus. The benefit of TEE is that it is portable, reliable, and rapid. It is a useful alternative to angiogram when hospitals have difficulty obtaining aortography, particularly at night and on weekends. Results, however, depend on operator skill. Tracheobronchial Disruption Tracheobronchial disruption usually occurs in the setting of blunt chest trauma and may be overlooked due to coexisting injuries and nonspecific symptoms (Soler, Sell, Maestre, & Ruiz-Manzano, 2012). There may be massive crepitus and subcutaneous emphysema along the outer chest wall, frothy or bloody sputum in the airway, and noisy breathing. Airway compromise and ineffective breathing may take place. Urgent bronchoscopy is indicated for diagnosis, and surgical intervention for treatment (Soler et al., 2012). Any area of the tracheobronchial tree can be damaged with blunt or penetrating trauma. Because of its proximity to major blood vessels, injury can cause exsanguinating hemorrhage into the chest and mediastinum or into the airway itself, producing asphyxia. Signs and symptoms include severe dyspnea, hemoptysis, subcutaneous emphysema, or tension pneumothorax with mediastinal shift. A pneumothorax associated with a persistent large air leak after tube thoracostomy suggests a tracheobronchial injury until proven otherwise. Bronchoscopy confirms the diagnosis of the injury. More than one chest tube may be necessary to overcome a large air leak and expand the lung. Temporary intubation of the opposite mainstem bronchus may be required to provide adequate oxygenation. If the injury is small, it may seal itself; otherwise, surgical repair is the definitive treatment. Blunt Cardiac Injury Blunt trauma to the anterior chest from steering wheels, falls, assaults, and other direct blows can bruise the heart. Signs and symptoms are not specific to the injury. History of significant blunt trauma to the chest is an important indicator. However, the patient may not display an indication of chest wall injury. Chest pain, abrasions, and contusions to the chest and fractures are all seen in other chest injuries. Chest pain in blunt cardiac injury is similar to angina but is usually reproducible with palpation and does not clear with the use of coronary vasodilators. Mild blunt cardiac injury can produce a dysrhythmia and normal echocardiogram, whereas a severe injury, while rare, can mimic an acute myocardial infarction and will demonstrate abnormalities on echocardiogram (usually abnormal ventricular wall motion). Patients presenting with dysrhythmias require at least 12 to 24 hours of further telemetry monitoring. Common dysrhythmias include sinus tachycardia, atrial fibrillation, junctional rhythms, and premature ventricular contractions. These dysrhythmias often depend on where the heart and conduction system are injured. Echocardiogram is helpful in determining the degree of myocardial wall dyskinesia or other wall motion abnormalities. Historically, cardiac enzymes, specifically creatine kinase-mb (CK-MB) fraction (which is released into the bloodstream with cardiac muscle injury), were used to detect blunt myocardial injury. Current studies have demonstrated that neither CPK analysis nor measurement of circulating cardiac troponin T are useful in predicting which patients have or will have complications related to blunt cardiac trauma (Keith et al., 2012). Diaphragmatic Rupture A traumatic diaphragmatic rupture is more commonly seen on the left side because the stomach and large bowel are more prone to herniate through a ruptured diaphragm. Because the liver is the largest solid organ in the abdomen, it provides some protection from diaphragmatic rupture on the right side. Large tears may cause herniation of abdominal contents into the thorax; a chest X-ray will reveal the nasogastric tube above the diaphragm. Other indicators are dyspnea, decreased breath sounds on the affected side, abdominal or epigastric pain radiating to the left shoulder, and bowel sounds in the lower chest. Direct operative repair of diaphragmatic injuries is necessary. Esophageal Injury Esophageal injuries are infrequent, can be insidious, and carry a high morbidity and mortality. Most often, penetration is the cause of injury, but a severe blow to the lower abdomen also can disrupt the esophagus. Other causes are accidental damage from an instrument during a procedure, caustic ingestion, crush injury, and blast injury. Esophageal injuries can cause mediastinitis from contamination by saliva and gastric contents and can contribute to empyema or purulence in the pleural space. Esophageal injury should be suspected when: 1. a patient who received a severe blow to the lower sternum or epigastrium demonstrates evidence of shock, sepsis, and pain disproportionate to the apparent injury; 2. there is a large pneumothorax or hemothorax, with or without associated rib fractures; 3. particulate or food matter appears in the chest tube; and 4. the presence of mediastinal air is confirmed by esophagram or CT scan. Esophageal injury requires a diligent workup to be diagnosed and, usually, surgical repair. Delayed identification leads to further complications and prolonged hospitalization. Pulmonary Contusion Pulmonary contusion is defined as traumatic lung parenchymal damage with edema and hemorrhage but without lung laceration. Injury to lung parenchyma becomes progressively worse because of rupture and bleeding into the lung tissue, alveoli, and small airways. The airways collapse, and ventilation is compromised, resulting in hypoxemia. As the inflammatory response develops, edema worsens, gas exchange is impaired, and the patient s condition deteriorates. Therefore, respiratory failure may be subtle and develops over time, rather than occurring instantaneously. Pulmonary contusion severity peaks at 48 to 72 hours postinjury. Careful monitoring and reevaluation of the patient is warranted. Pulse oximetry, arterial blood gas values, and end-tidal carbon dioxide monitoring are necessary for optimal management. Mechanical ventilation should be anticipated if the patient fails to improve. Dyspnea, hemoptysis, hypoxia, and possible chest wall ecchymosis or abrasions are present in the clinical picture. Whenever a patient has a history of chest trauma, pulmonary contusion should be suspected. Chest X-ray will not identify a pulmonary contusion until the patient becomes symptomatic, whereas a CT scan is more sensitive. Patients with significant hypoxia should be intubated and ventilated within the first hour after injury. Rib Fracture Rib fractures, commonly seen in patients with trauma, most often are caused by direct blunt, compression, or crush injury. Motor vehicle crashes and falls in older adults are common mechanisms of injury. The fractures may be single or multiple. It should be assumed that injury to the clavicle or above involves closed-head injury, neck injury, and facial fractures. The upper ribs are considered the first three ribs, which are strong, protected by the shoulder girdle, and not as likely to be fractured. A fracture to the upper ribs indicates a powerful blow and, possibly, an accompanying serious head and neck injury. In addition, suspect trauma to the subclavian vein or aorta. Fractures of the first and second ribs are rare but may be associated with serious damage to the brachial plexus of nerves or the subclavian vessels; such fractures may also be associated with head, facial, or thoracic aorta injuries (Serfin & Guo, 2014). The middle ribs are the middle six ribs (4th through 9th), which are most likely to sustain a fracture. The lower ribs are the last three ribs (10th through 12th). Maintain a high index of suspicion for liver and spleen injuries in patients with lower right-sided and left-sided rib fractures, respectively. Rib Fracture Signs and Symptoms Deformity and contusion or laceration may be present at the rib fracture injury site. Deep breathing and movement usually are painful, so the patient will take shallow breaths and lean toward the side of the injury. Respiratory rate and patterns should be assessed to evaluate the injury s impact on ventilation. Note all signs of dyspnea (Legare & Sawatzky, 2010). Pain management is important and may require epidural anesthesia or intercostal nerve blocks. Good pulmonary toilet of coughing, incentive spirometry, and deep breathing is essential to prevent pneumonia and atelectasis. Occasionally, the end of a fractured rib punctures or tears a lung or the chest wall, causing a hemothorax or pneumothorax. Sternal Fracture Enormous anterior chest impact is necessary to fracture the sternum, such as occurs when a steering wheel impacts the chest. In the presence of a sternal

39 Basic Trauma Nursing 51 fracture, there is a significant possibility of blunt cardiac injury. Chest X-ray, CT scan, echocardiogram, and electrocardiogram should be anticipated with all steering-wheel injuries to the chest to detect blunt cardiac injury. Pneumothorax A simple pneumothorax is the presence of air in the pleural space. The source of air can be external through an open chest wound, from a laceration of the lung tissue (such as by a fractured rib), or from a ruptured lung. The air separates the parietal and visceral pleura and collects in the pleural space, causing the lung to collapse. As air pressure in the pleural space increases, the lung collapses further and may fully collapse. Air can also accumulate in the mediastinum. If the chest wall defect is small, the body is sometimes able to reseal itself. The patient typically complains of shortness of breath and pain, and breath sounds are diminished on the affected side. Tachycardia and tachypnea are usually evident. Placement of a chest tube connected to underwater drainage (in the 4th or 5th intercostal space) is the treatment of choice to reexpand the lung. The patient should be in semi-fowler s position to prevent pressure against the diaphragm from the abdominal organs. High-flow oxygen is administered. The patient should be monitored constantly for the development of tension pneumothorax. Chest decompression should be considered prior to transporting the patient as part of routine stabilization procedures. ASSESSMENT The effectiveness of thoracic trauma care is directly related to the patient s ability to breathe. Initial assessment is directed to airway and ventilation, the standard ABC assessment. Assume head and neck injury until the patient s airway is cleared. The upper airway must be cleared and maintained. Ventilation support and oxygen should be given if the patient has respiratory distress and before further assessment is conducted. Thoracic trauma often includes multiple injuries. Patient history and knowledge of the mechanism of injury are important in determining the full scope of damage to the patient. Knowing the object that caused the trauma, the speed of the force, and the physical site of initial injury is essential information. In the prehospital setting, gather information from the scene, the patient, and bystanders. If in the emergency department, be sure to get a full report and documentation from EMS and the patient (if possible). Patients with obvious or suspected chest injuries must be immediately and quickly assessed in an organized and thorough manner, followed by rapid essential interventions. Speed in assessment is essential. THORACIC ASSESSMENT OVERVIEW When conducting a thoracic assessment, evaluate the patient for: Impaled object in chest Open wound into the chest External evidence of underlying trauma (ecchymosis/hematoma) Signs of tension pneumothorax after a dressing is applied to an open chest wound Obvious deformity of the chest wall, rib cage, or neck; trachea displaced from the midline Unequal chest expansion Paradoxical movement of flail chest Labored breathing (rate, depth, and effort) Decreased breath sounds on the affected side Hemoptysis or ineffective cough Hypoventilation and splinting of the injured side Air hunger, agitation, and decreased level of consciousness Hypotension, muffled heart sounds, and distended neck veins Weak rapid pulse with falling blood pressure Cyanosis of the face and neck Sucking chest wound Subcutaneous emphysema identified by a crackling in the subcutaneous tissues upon palpation INTERVENTIONS Although there are many types of chest injuries, the same principles of care apply to all of them: Rapidly conduct the ABCs, open and maintain the airway, and stabilize breathing and circulation. Apply high-flow oxygen; provide respiratory support when necessary. Insert two large-bore IV catheters and administer warmed fluids. Palpate neck veins for distention, which can indicate compression or obstruction of return blood flow to the heart. Apply three-sided air-occlusive dressing to an open chest wound; remove if signs of tension pneumothorax develop. Assist with needle thoracostomy if tension pneumothorax develops. Assist with positive-pressure bag-mask ventilation. Use direct pressure to control bleeding from the chest wall. Stabilize impaled objects to minimize movement. Never remove impaled objects. Anticipate thoracotomy and prepare to transfer patient to available operating room if the patient is hemodynamically unstable AND has any of the following: Massive hemothorax (greater than 1,500 ml blood returned on insertion of chest tube) Ongoing bleeding from the chest at greater than 200 ml/hr for 2 or more hours Suspicion of cardiac tamponade Acute deterioration from penetrating transmediastinal chest wounds Chest wall disruption Radiographic evidence of great vessel injury Suspected air embolism Impalement wounds to the chest SUMMARY Thoracic injuries account for 25% of all trauma deaths annually in the United States (Weiser, 2014). Thoracic trauma is high-risk because of the vital organs in the chest and the high potential for respiratory involvement. There is a high incidence of other injuries associated with chest trauma. Chest injuries are common among multiple system trauma patients and are associated with life-threatening problems, both from the direct trauma and the resulting complications. Organized, rapid assessment and intervention are essential, as is the ability to recognize acute signs and symptoms specific to thoracic trauma. Despite the many types of thoracic injuries, almost all require the same initial care. The aim of emergency care is directly related to the patient s ability to ventilate effectively. The body cannot store oxygen and needs a continuous supply. Any injury to the chest requires evaluation as serious trauma. Internal bleeding from lacerations to the chest organs and major blood vessels is potentially deadly. Hemorrhaging can compress the lungs and vessels. A few minutes are often all that separates the patient from life and death. Chapter 8: Abdominal Trauma CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe the key components of assessing and managing abdominal trauma. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Describe common mechanisms of injury to the abdomen. 2. Recognize characteristics of common abdominal injuries. 3. Describe how to assess for abdominal injuries. 4. Recognize the appropriate diagnostic tests used to identify abdominal injuries. 5. Describe how to manage case examples of abdominal trauma. INTRODUCTION Abdominal trauma is probably one of the most frequently underappreciated or missed groups of injuries. Life-threatening abdominal injuries can sometimes be slow to declare themselves. When the injuries are undetected, they have a high potential for causing serious complications and even death. Blunt abdominal and pelvic trauma usually results from motor vehicle crashes (MVCs), falls, and assaults (ENA, 2014). Vehicular trauma is by far the leading cause of blunt abdominal trauma in the civilian population. Auto-to-auto and auto-to-pedestrian collisions have been cited as causes in 50% to 75% of cases (Legome, Udeani, & Salamone, 2014). Blows to the abdomen and falls are responsible for 15% and 6% to 9%, respectively (Diercks & Clarke, 2014). Patients involved in high-energy blunt abdominal injury have multiple problems that make assessing for injury challenging. Blunt trauma often presents a greater challenge because potential injuries are more difficult to diagnose than those caused by penetrating trauma. Physical examination findings are notoriously unreliable. One reason is that mechanisms of injury often result in other associated

40 52 Basic Trauma Nursing injuries that may divert the physician s attention from potentially life-threatening intra-abdominal pathology (Legome et al., 2014). MECHANISM OF INJURY Blunt Injury Blunt intra-abdominal injuries can result from three different mechanisms: compression, shear, or rupture from increased intra-abdominal pressure. Compression and Rupture In motor vehicle crashes, internal organs that are pressed by the vertebral column into the steering wheel or dashboard during a frontal collision may rupture (especially solid organs such as the pancreas, spleen, liver, and kidneys). Shear Injury to the abdominal organs occurs at their points of attachment to the mesentery or vascular system. During a collision, the forward motion of the body stops, but the organ continues to move forward, causing tears at the points of attachment. Organs that can shear this way are the kidneys, small intestine, large intestine, liver, and spleen. Rupture From Increased Intra-Abdominal Pressure An injury also can result from a buildup of pressure in the abdomen. The diaphragm is a thin muscle located across the top of the abdomen, and it separates the abdominal and thoracic cavities. The diaphragm is the weakest of all structures surrounding the abdominal cavity. It may be torn or ruptured as intra-abdominal pressure increases, which may result in the abdominal organs entering the thoracic cavity, reducing the space available for lung expansion, or causing the displaced organs to become ische mic from compression of their blood supplies. Remember that blunt abdominal injury is deceptive because damage can be severe, even life-threatening, especially if there is internal hemorrhage from an injured solid organ. Vital signs must be watched closely for signs of bleeding such as hypotension and tachycardia. Deceleration events may rupture solid organs or vessels in the abdominal cavity because of tearing forces exerted against stabilizing ligaments and vessels, causing intra-abdominal bleeding. When hollow organs are ruptured or lacerated, their contents spill into the peritoneal cavity, causing an inflammatory reaction and often peritonitis. The hollow organ s contents determine the expected physical findings, for example, stomach contents versus bowel contents. Blunt trauma from a motor vehicle crash is influenced by where the patient is sitting, the speed of the vehicle, use and type of seat belt, air bag deployment, and whether the patient was ejected from the vehicle. Although seat belt use has decreased fatalities, it can cause injuries to the colon, small bowel, stomach, liver, spleen, vascular structures, and spinal cord. Penetrating Injury Penetrating injuries range from a slight laceration of the abdominal wall to deep penetration through the peritoneum into the abdominal cavity. It may be difficult to determine if the wound extends into the abdominal cavity, but with stab or gunshot wounds (GSW), it should be assumed the peritoneum has been penetrated. During full expiration, the diaphragm rises to the fourth intercostal space; therefore, penetrating wounds below the nipple line may result in injury to the abdomen. Penetrating wounds into the flank or buttocks can also enter the abdominal cavity and hit a major vessel, a segment of the bowel, or a solid organ. Damage includes laceration, impalement, puncture, and rupture. When possible, it is useful to obtain injury information about GSW, including the type of gun, caliber, proximity to the patient when fired, and number of shots that hit the patient, because this information is important to aid in determining the likely extent of injury. In addition, it is necessary to identify the length, width, and composition of other penetrating objects. Stab Wound Versus Gunshot Wound Stab wounds to the abdomen most commonly involve the liver (40%), small bowel (30%), diaphragm (20%), and colon (15%) (Offner, Stanton- Maxey, & Bjerke, 2014). Stab wounds cause tissue damage by lacerating and cutting. GSW, on the other hand, most commonly involve the small bowel (50%), colon (40%), liver (30%), and abdominal vascular structures (25%; Offner et al., 2014). Gunshot wounds have greater velocity and more kinetic energy, and thus there is potentially greater damage surrounding the track of the missile because of temporary cavitation. Injuries sustained as a result of GSW are more likely to require surgical intervention than stab wounds because 85% of anterior GSW penetrate the peritoneum (Mattox, Moore, & Feliciano, 2013). Genitourinary and Reproductive Trauma Genitourinary trauma and reproductive organ injury comprise only a small percentage of trauma cases. The anatomical location of these structures and organs makes life-threatening injuries infrequent. Trauma occurs most often to the kidneys or bladder. Because the bladder is hollow, it is more likely to be seriously damaged when full and distended than when empty and collapsible. As with intra-abdominal injuries in the peritoneal cavity, organs and structures in the retroperitoneal space are difficult to assess for damage. Injuries are usually not isolated to a particular organ but are associated with multiple injuries. It takes such great force to damage a kidney that this injury usually is associated with a fractured rib or other abdominal injuries. Blunt or penetrating force to one area of the abdomen or pelvis often results in an injury to more than one organ, vessel, or structure (ENA, 2014). OVERVIEW OF ABDOMINAL ANATOMY AND ORGAN INJURY PATTERNS External Anatomy of the Abdomen The abdominal cavity extends from the diaphragm down to the pubic area. It is bounded by the spine in the back and the ribs and abdominal muscle wall in the front. When referring to descriptive geographic areas of the abdomen, it is classically thought of as being divided into quadrants: left and right upper quadrants and left and right lower quadrants. Internal Anatomy of the Abdomen The three distinct regions of the abdomen are the peritoneal cavity, the retroperitoneal space, and the pelvic cavity. The pelvic cavity contains components of both the peritoneal cavity and retroperitoneal space (see Figure 8-1). Peritoneal Cavity The peritoneal cavity can be further divided into two parts, upper and lower. The upper peritoneal cavity, which is covered by the lower aspect of the bony thorax, includes the diaphragm, liver, spleen, stomach, and transverse colon. This area is commonly referred to as the thoracoabdominal component of the abdomen. The lower peritoneal cavity contains the small bowel, parts of the ascending and descending colons, the sigmoid colon and, in females, the internal reproductive organs. Retroperitoneal Space The retroperitoneal space is the area posterior to the peritoneal lining of the abdomen. It contains the abdominal aorta; the inferior vena cava; most of the duodenum, pancreas, kidneys, and ureters; the posterior aspect of the descending colon; and the retroperitoneal components of the pelvic cavity. Injuries to the retroperitoneal structures are difficult to recognize because the area is remote from physical examination, and injuries do not initially present with signs or symptoms of peritonitis. Pelvic Cavity The pelvic cavity, surrounded by the pelvic bones, is essentially the lower part of the retroperitoneal and intraperitoneal spaces. It contains the rectum, bladder, iliac vessels and, in females, internal reproductive organs. Retroperitoneal hemorrhage associated with a fractured pelvis is a major concern in this portion of the abdominal cavity. Blood Supply Major vascular structures that supply the abdomen are the abdominal aorta, which bifurcates into the iliac arteries (to supply the lower extremities); the celiac trunk; and the inferior and superior mesenteric arteries, which supply the abdomen. The inferior vena cava is formed by the union of two common iliac veins and is the major vein in the abdomen. The mesentery, also called greater and lesser omentum, is formed from the peritoneum and carries blood vessels and nerves to the abdominal organs. It is a folded sheet of fragile tissue that surrounds organs and suspends them from the body wall. The structure of the omentum allows the organs to hang freely, thus permitting movement within the abdominal cavity. Organs Hollow Abdominal organs can be described as hollow or solid. Hollow organs can be described as pouches, reservoirs, or tubes. They typically conduct or store material, such as a food bolus being passed through the esophagus and temporarily being stored in the stomach. The bladder, as another example, serves as a temporary reservoir for urine. Hollow organs are less vascular and less likely to bleed than solid organs. Hollow organs include the stomach,

41 Basic Trauma Nursing 53 FIGURE 8-1: REGIONS OF THE ABDOMEN Note. From American College of Surgeons, ATLS: Advanced trauma life support for doctors, 9th edition, 2012, p Used with permission. duodenum, small and large intestines, appendix, rectum, gallbladder, bile ducts, urinary bladder, ureters, and, in females, the uterus. Solid Solid organs are masses of tissue and are where much of the body s glandular chemical work takes place. They include the liver, spleen, pancreas, kidneys, ovaries, and adrenal glands. The liver, spleen, and kidneys are vascular solid organs and thus can be a source of significant bleeding with trauma to the abdomen. Solid organs tend to fracture (crack) when struck, whereas hollow organs tend to rupture or collapse. Solid and vascular structures bleed, and hollow organs empty their contents. The consequences can be intra-abdominal bleeding, peritonitis, and sepsis. SPECIFIC INJURIES Diaphragm The diaphragm is a thin muscle located across the top of the abdomen, and it separates the abdominal and thoracic cavities. The diaphragm is the weakest of all structures surrounding the abdominal cavity. Diaphragm rupture can be the result of blunt or penetrating trauma but most commonly occurs as a result of high-speed MVCs (Galketiya, Kerr, & Davis, 2012). Diaphragmatic rupture occurs almost exclusively on the left side because the liver protects the diaphragm and abdominal contents from herniating into the chest on the right side. If the diaphragm is lacerated, abdominal contents enter the chest cavity, causing impaired breathing due to lung compression and the loss of negative pressure. Signs and symptoms of such an injury include decreased breath sounds on the affected side and complaints of dyspnea with cyanosis. A shift in heart sounds may occur, and bowel sounds may be heard in the hemithorax. Diagnosis is confirmed by a chest X-ray that shows stomach migration into the chest or a nasograstric tube in the chest. Diagnosis can be difficult because diagnostic peritoneal lavage and focused assessment sonography in trauma (FAST) are not very sensitive for diaphragm injury. A computed tomography (CT) scan is more helpful. Laparoscopy and thoracoscopy are the diagnostic and therapeutic choices of trauma surgeons (Dwivedi, Banode, Gharde, Bhatt, & Ratanlal Johraourkar, 2010). Definitive treatment is surgical repair. Stomach The stomach is a hollow organ in the left upper quadrant that is protected by the lower left ribs. Stomach size changes with the amount of contents and, when empty, is better able to compress and absorb energy during trauma. Injuries to the stomach occur in 20% of patients with penetrating mechanism to the abdomen, and in only 1% of blunt trauma does gastric perforation occur (ENA, 2014). The stomach has an extensive blood supply, so hematemesis and blood in nasogastric aspirate are likely when the stomach is injured. Subdiaphragmatic air may be seen on a chest X-ray with blunt gastric rupture. Surgical exploration and intervention is required. A ruptured stomach releases hydrochloric acid, which causes immediate, painful peritonitis. Small Bowel The small bowel, or intestine, is a long, hollow organ and has three sections: the duodenum, jejunum, and ileum. The jejunum and ileum are located in the peritoneal cavity, and the duodenum is located in the retroperitoneal space. Hanging from its mesentery, the small bowel lies entirely free within the abdomen and is approximately 22 ft (7 m) long. This part of the mesentery contains arteries branching from the aorta and veins that carry blood to and from the liver. The small bowel has the greatest probability of injury in penetrating trauma (50% with GSW and 30% with stab wounds; Offner et al., 2014). Small perforations can occur from blowouts of closed loops (seat belt injuries), whereas larger perforations are caused by direct blows or shearing injury. Small bowel injury should be considered when there is bruising from a lap belt (seat belt sign). There may also be an associated fracture of the lumbar spine known as a Chance fracture. Chance fractures are transverse fractures in the lumbar region that also increase suspicion for small bowel injuries due to the force required to result in fracture (Mattox et al., 2013). Small bowel injury is not easily identified on CT scans; it is better seen after oral contrast is administered. A high index of suspicion, along with clinical examination of increasing abdominal pain and increasing white blood cell count, help identify the injury. Colon The large intestine is a major hollow organ that interfaces with the small intestine proximally and ends at the sigmoid colon. About 5 ft (1.5 m) in length, the large intestine lies around the border of the small bowel. It has three sections: the cecum, colon, and rectum. Its primary function is to absorb the remaining 5% to 10% of fluid from the intestinal contents and form stool. The transverse colon is located in the peritoneal cavity, whereas the ascending and descending portions are located in the retroperitoneal cavity. Penetrating and blunt trauma to the abdomen may result in injuries to the colon. Blunt force to the abdomen may cause the bowel to rupture, to be torn from fixation points on other structures, or to avulse from the abdominal wall (ENA, 2014). Only a small percentage of colon injuries are caused by blunt mechanisms. Rectal injuries are a small percentage of colon injuries, but blunt rectal perforation can be associated with pelvic fractures, concussion (explosive) injuries, devascularization from a mesentery injury, or foreign objects. Liver The liver is the largest organ in the body, comprising almost 3% of the total body weight, and it is located in the upper right quadrant of the abdomen. The liver is extremely vascular and is essentially a large, dense mass of blood vessels and cells. All of the blood pumped to the gastrointestinal (GI) tract is pumped through the liver before returning to the heart. The location of the liver makes it vulnerable to trauma, more likely from penetrating than blunt mechanisms. The liver is the most commonly injured organ in blunt abdominal trauma and the second most commonly injured organ in penetrating abdominal trauma. Operative intervention to manage a liver injury is needed in about 14% of patients, including those who initially present with hemodynamic instability or those who fail nonoperative management (Christmas & Jacobs, 2015). Liver hematoma or lacerations are divided into grades, Grade I through VI. Grade I indicates a minor trauma, and Grade VI is the most severe (ENA, 2014). The higher the grade of liver injury, the higher the mortality. The liver is encapsulated by a tough fibrous sheath and is vascular. Injury may affect only the capsule, or it can cause a contused, lacerated, or fractured liver (see Table 8-1). Ultrasound of the abdomen increases the potential for correct diagnosis. Right rib fractures or a blow to the right upper quadrant should raise an alert to liver damage. Most likely, there is pain and tenderness in the area of the liver to the point of guarding, along with bruising and nausea. If the damage is severe, there will be hemodynamic instability. Gallbladder The liver s connection to the intestine is the bile duct. The gallbladder is an outpouching of the bile duct and a reservoir for bile. Trauma to the gallbladder is rare. Spleen The primary function of the spleen is immunologic (i.e., the production and destruction of blood cells), but it is not necessary to sustain life. If removed, the spleen s functions are taken over by the liver and bone marrow. In less emergent situations, splenorrhaphy is the preferred method of surgical care. Multiple techniques are described in the literature, but they all attempt to tamponade active bleeding, either by partial resection and selective vessel ligation or by putting external pressure on the spleen via an absorbable mesh bag or sutures (Bjerke & Bjerke, 2014a, 2014b). Every effort is made to preserve the spleen, if possible, to aid the body s immune response and decrease the risk of postsplenectomy sepsis. The spleen, located in the left upper quadrant just beneath the diaphragm and in front of the lower ribs, is a major solid organ but is smaller than the liver. The largest mass of lymphatic tissue in the body, the spleen is highly vascular and is enclosed in a capsule that is supported by three ligaments. Although the ribs protect the spleen, the ligaments

42 54 Basic Trauma Nursing Table 8-1: Organ Injury Scaling: Liver Grade Type of Injury Description of Injury AIS-90* I Hematoma Subcapsular, <10% surface area 2 Laceration Capsular tear, <1 cm parenchymal depth 2 II Hematoma Subcapsular, 10-50% surface area; intraparenchymal 2 <10 cm diameter Laceration Capsular tear 1-3 cm parenchymal depth, <10 cm length 2 III Hematoma Subcapsular, >50% surface area or expanding. Ruptured 3 subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm or expanding Laceration >3 cm parenchymal depth 3 IV Laceration Parenchymal disruption involving 25-75% of hepatic lobe or Couinaud s segments in a single lobe V Laceration Parenchymal disruption involving >75% of hepatic lobe or 5 >3 Couinaud s segments within a single lobe Vascular Juxtahepatic venous injuries; i.e., retrohepatic vena cava/ 5 central major hepatic veins VI Vascular Hepatic avulsion 6 *AIS-90: Abbreviated Injury Scale. Note. Adapted from Moore, E. E., Cogbill, T. H., Jurkovich, G. J., Shackford, S. R., Malangoni, M. A., & Champion, H. R. (1995). Organ injury scaling: Spleen and liver (1994 revision). Journal of Trauma, 38(3), can be torn from the spleen in blunt injury, causing severe hemorrhage. Although the spleen is relatively small, it may get larger with age and disease. Splenic injury occurs in as many as 25% of the average 800 to 1,200 admissions for blunt trauma per year (Bjerke & Bjerke, 2014a). Blunt injury to the spleen is usually the result of compression or deceleration force that occurs in motor vehicle crashes, falls, and direct blows to the abdomen. Like the liver, the spleen is encapsulated. A splenic injury can affect just the capsule, or it can cause a hematoma, laceration, or fracture. Injury to the left upper quadrant and lower ribs is likely to include the spleen. There may be pain in the left upper quadrant or referred pain to the left shoulder, also known as Kehr s sign. Bruising and signs of hypovolemia, with tachycardia and hypotension, may be apparent. Physical examination is not specific for splenic trauma. In an unstable patient, an ultrasound will provide the most rapid diagnosis of hemoperitoneum. Splenic injuries are graded on severity of I to V, with Grade I being the least severe and Grade V the most severe (AAST, 2015; see Table 8-2). If the spleen is ruptured or if there is a penetrating injury, without immediate intervention, the patient could exsanguinate rapidly. Management depends on the hemodynamic stability of the patient, age, associated injuries, the degree of hemoperitoneum, and the severity of the splenic injury. In the past, treatment for any splenic injury was splenectomy. However, splenectomy should be avoided if possible, particularly in children, the elderly, and patients with hematologic malignancy, to avoid the resulting permanent susceptibility to bacterial infections and the increased risk of overwhelming postsplenectomy sepsis (Malinoski, 2013). Kidneys The kidneys lie in a fatty tissue layer on the left and right side of the posterior wall of the abdomen, just above the waist at the costovertebral angle. They are enclosed in a strong fibrous capsule. The kidneys are well protected by the vertebrae and muscles of the back and abdominal viscera in the front. Kidneys are vascular, and approximately 20% of cardiac output passes directly through them from the aorta. Most injuries to the kidneys (85% to 90%) typically result from blunt trauma incurred from motor vehicle crashes, falls, or assaults (Armenakas, 2013b). Renal injuries are also graded based on severity, from I to V. Grade I through III injuries are managed conservatively, whereas Grade V injuries may end in surgery (Prakash et al., 2015). Common signs with renal injuries are flank tenderness (especially at the costovertebral angle), presence of Grey-Turner s sign (flank ecchymosis, usually between ribs 11 and 12, which is indicative of retroperitoneal bleeding), and hematuria, although absence of these does not rule out renal injury (Mattox et al., 2013). Pancreas The pancreas is a flat, solid, firmly fixed organ that lies deep in the abdomen behind the stomach, below the liver, and in front of the first and second lumbar vertebrae. Its head is attached to the duodenum, and the tail reaches to the spleen. Penetrating trauma to the pancreas is more common than blunt injury. Blunt injury, however, is more common in children, as a result of crush injury between the spine and another object, such as a steering wheel or handlebar. Diagnosis is based on the mechanism of injury and the high rate of associated intra-abdominal injury. Pancreatic injuries are rarely isolated. If the injury is confined to the pancreas, initial signs may be nonspecific. Within 24 hours of the injury, the patient will complain of midepigastric or back pain. There may be development of bruising around the umbilicus (Cullen s sign). Persistently elevated or rising serum amylase levels should also prompt consideration of pancreas injury. An abdominal CT scan may not identify significant pancreatic trauma in the immediate postinjury period (up to 8 hours); it should be repeated later if pancreatic injury is suspected. Often, a laparotomy is necessary to repair pancreatic damage. When surgery is necessary, major efforts are made to save the pancreas because of its vital endocrine and exocrine functions. Ureters Small flexible muscular tubes, the ureters drain urine from each kidney into the bladder. The ureters are so well protected, lying deep in the retroperitoneal space, that they are rarely injured from blunt trauma. Most ureteral injuries are from penetrating trauma, mainly GSW. Table 8-2: Organ Injury Scaling: Spleen Grade Type of Injury Description of Injury AIS-90* I Hematoma Subcapsular, <10% surface area 2 Laceration Capsular tear, <1 cm parenchymal depth 2 II Hematoma Subcapsular, 10-50% surface area; intraparenchymal 2 <10 cm diameter Laceration Capsular tear, 1-3 cm parenchymal depth not involving 2 a parenchymal vessel III Hematoma Subcapsular, >50% surface area or expanding; ruptured 3 subcapsular or parenchymal hematoma; intraparenchymal hematoma >5 cm or expanding Laceration >3 cm parenchymal depth or involving trabecular vessels 3 IV Laceration Laceration of segmental or hilar vessels producing 4 major devascularization (>25% of spleen) V Laceration Completely shattered spleen 5 Vascular Hilar vascular injury that devascularized spleen 5 *AIS-90: Abbreviated Injury Scale. Note. Adapted from Moore, E. E., Cogbill, T. H., Jurkovich, G. J., Shackford, S. R., Malangoni, M. A., & Champion, H. R. (1995). Organ injury scaling: Spleen and liver (1994 revision). Journal of Trauma, 38(3),

43 Basic Trauma Nursing 55 Urinary Bladder The urinary bladder is supported by ligaments and protected behind the symphysis pubis in the pelvic cavity. Ureters enter at the base, posteriorly, on each side of the bladder. Urine capacity ordinarily is about 500 ml, and emptying occurs through the urethra. The bladder has an abundant blood supply, primarily from branches of the internal iliac artery. Blunt trauma is a more common mechanism than penetrating trauma, usually resulting from a sudden deceleration, as in a high-speed MVC or a fall. It can also result from an external blow to the lower abdomen (Armenakas, 2013a). Extraperitoneal rupture is generally caused by pelvic fracture. Intraperitoneal rupture is associated with a full bladder at the time of impact. Ninety-five percent of bladder injuries are associated with gross hematuria. Bladder injuries are highly associated with pelvic fractures. Penetrating injuries to the bladder should be operatively explored and repaired. All penetrating trauma and intraperitoneal ruptures due to blunt trauma require surgical exploration and repair. Most extraperitoneal ruptures require only catheter drainage if urine is draining freely and the bladder neck is spared (Armenakas, 2013b). Urethra In the male, the urethra is about 8 in. (20 cm) long and passes through the penis on the exterior of the body. In the female, the urethra is short, about 1.5 in. (3.8 cm). Protected internally by the symphysis pubis, the woman s urethra opens in front of the vagina. Urethral injuries are more common in males than females. The mechanism of urethral injury is usually blunt trauma and is often associated with pelvic fractures or straddle injuries. The gold standard for diagnosis is the retrograde urethrogram. Rectum Rectal injuries are uncommon in blunt trauma (Mattox et al., 2013). Rectal injuries are often a result of penetrating injury, such as GSW or stab wounds to the pelvic or gluteal area (Mattox et al., 2013). Rectal injuries are often managed with a colostomy and distal rectal washout (Wallis, Kelly, & Jones, 2010). Gross blood on rectal examination after a penetrating abdominal buttock or pelvic wound indicates a colorectal injury. Gross blood on rectal examination in the presence of pelvic fracture should prompt a proctoscopy in an effort to identify the rectal injury. Associated Injury: Pelvic Fracture Abdominal injuries frequently accompany pelvic fractures. Closed fracture of the pelvis is often the result of direct compression from a heavy impact that crushes the bones. The force of energy can be a fall from a height or a direct impact to the pelvis. Indirect force can also cause injury. For example, when the knee strikes the dashboard, the force is transmitted along the femur, driving the femoral head into the pelvis, which causes it to fracture. Not all fractures are from violent trauma; a simple fall can cause a closed fracture, especially in older adults. A great deal of blood loss may occur from the large vessels in the retroperitoneal space adjacent to the pelvis. These vessels are easily torn or lacerated, with the blood draining into the retroperitoneal space. Disruption of the iliolumbar vein causes bleeding in 60% of patients with unstable pelvic fractures; posterior fractures are more likely than anterior fractures to cause bleeding (Cullinane et al., 2011). Pelvic fractures may be open or closed; open pelvic fractures have a significantly higher mortality rate (ACS, 2012). Most pelvic fractures are closed because heavy muscles surround and protect the pelvis. Occasionally, pieces of the pelvis lacerate the rectum, vagina, or bladder. The bladder may also rupture. The bladder, rectum, vagina, and blood vessels are all susceptible to damage when the pelvic ring is fractured. It should be assumed that a patient with a pelvic fracture has associated abdominal injuries until such injuries have been ruled out. Temporizing measures that can help achieve pelvic stabilization include the application of a pelvic stabilizer (commercially made or improvised) and internal rotation of the lower limbs (ACS, 2012). Vascular Structures All of the abdominal vascular structures are subject to trauma from blunt or penetrating forces. Often, the identification of specific vascular damage is not made until the patient is in surgery to repair other damage. In a stable patient, a diagnostic CT scan and arteriography are used to identify the extent of vascular injury. CT angiography is a modality that provides accurate diagnosis with minimal dye load. When disrupted, the aorta, inferior vena cava, iliac arteries, and hepatic veins hemorrhage severely, and death can be rapid if the damage is not repaired immediately. Emergency department management of vascular injuries includes intravenous access, initiation of massive transfusion, and getting the patient to the operating room as soon as possible. ASSESSMENT PRINCIPLES Hemodynamic Assessment Repeatedly assess the ABCs to determine hemodynamic stability. Hemodynamic stability dictates diagnostic management and treatment, which will be discussed further in the management section of this chapter. Physical Examination The abdominal examination should be performed in a standardized sequence: inspection, auscultation, percussion, and palpation. Serial examinations by the same clinician improve sensitivity. Remember that in the presence of drugs, alcohol, altered mentation, and spinal cord injury, signs and symptoms of injury may be less apparent, making abdominal examination more difficult. 1. Inspection includes observing for distention, abrasions, contusions, lacerations, impaled foreign bodies, and evisceration of abdominal contents. Seat belt sign: Bruising and swelling diagonally across the chest and/or abdomen indicates seat belt injury from deceleration. A recent study concluded that a cohort of patients with seat belt sign have solid organ injury requiring urgent intervention. It is advised that the seat belt sign is of value and should be documented after any MVC (Biswas et al., 2014). Older studies associate the seat belt sign with up to a 60% chance of abdominal injury. The seat belt sign may best serve as a marker of high risk of injury, which should prompt careful reassessment of the patient over time. Cullen s sign: Bruising and discoloration around the umbilicus, which may indicate bleeding into the abdominal wall. Grey-Turner s sign: Bruising of the flank; is associated with bleeding into the retroperitoneal tissue. Evisceration: Assess for evisceration, which is the result of extensive laceration of the abdominal wall that causes abdominal contents to protrude through the wound. Impalement: Assess for impalement, which is associated with abdominal injuries. Wounds: All wounds should be thoroughly documented. Penetrating injuries cause wounds that make it notoriously difficult to assess for internal damage. Avoid labeling wounds as entrance or exit sites. Logroll the patient and examine posterior surfaces for additional wounds. 2. Auscultation of the abdomen in a noisy healthcare environment can be difficult. Auscultation of bowel sounds in the thorax may indicate the presence of a diaphragmatic injury. Abdominal bruit may indicate underlying vascular disease or traumatic arteriovenous fistula (Legome et al., 2014). Intraperitoneal blood can produce gastric ileus and thus silence the bowel sounds. However, other injuries to adjacent structures also cause ileus, so hypoactive bowel sounds are not exclusively diagnostic for abdominal injury. 3. Percussion identifies the presence of air, fluid, or tissue and is even more difficult to perform in a seriously injured patient than is auscultation. Tympanic sounds elicited over the stomach or intestine indicate an air-filled space, whereas a dull sound is noted over solid organ structures, such as the liver or spleen. Dullness throughout the four quadrants indicates free fluid in the abdomen. In trauma, this implies hemoperitoneum (presence of blood in the peritoneal cavity). Tympanic sounds throughout may represent air in the abdominal cavity, which in trauma suggests a perforated viscus. 4. Palpation is useful to determine the presence of tenderness. Palpation may reveal local or generalized tenderness, guarding, rigidity, or rebound tenderness, which suggests peritoneal injury (Legome et al., 2014). Pain upon abdominal palpation is caused by blood or abdominal contents irritating the sensitive peritoneal membrane. Rebound tenderness is elicited by pushing the peritoneal membrane against an abdominal structure and then quickly removing the palpating hand during compression of the abdomen. A tender abdomen with guarding, distention, and signs of peritoneal irritation can indicate intra-abdominal injury. Perineal and Rectal Examination Presence of blood at the urethral meatus strongly suggests a urethral tear or a bladder or renal injury. Rectal examination reveals valuable information, including sphincter tone, position of the prostate (in males), and the possibility of pelvic fracture. Gross blood may indicate bowel perforation.

44 56 Basic Trauma Nursing Vaginal Examination Inspect and palpate for lacerations of the vagina, which can occur from bony fragments from pelvic fractures. Pain Assessment Pain is a significant abdominal finding, and its cause should be actively pursued. Kehr s sign (left shoulder pain) is associated with hemoperitoneum and spleen injuries. Note the patient s position. Pain may cause guarding in an attempt to protect the injured area. The patient may have difficulty moving or have his or her knees drawn up to relieve pain and make it easier to breathe. Assess for rapid, shallow breathing, which minimizes abdominal movement in pain. TUBES Gastric Tube Gastric tube placement decompresses the stomach to reduce the chance of aspiration. The tube should be inserted prior to performing a diagnostic peritoneal lavage, to reduce the chance of perforating a distended stomach. Blood in the gastric aspirate suggests an injury to the esophagus or upper GI tract. Use caution when inserting a nasogastric tube if there are facial fractures or a basilar skull fracture. Orogastric tubes are preferred in these situations to prevent passage of the tube into the cranial vault. Urinary Catheter A urinary catheter is inserted to monitor urine output, relieve retention, and decompress the bladder prior to diagnostic peritoneal lavage. Hematuria is a sign of trauma to the genitourinary tract. Care should be taken if meatal blood is noted, as this can be indicative of urethral trauma, and a urinary catheter should be deferred. LABORATORY TESTS Baseline hematocrit. Baseline creatinine: Prior to abdominal CT or angiography with contrast, check baseline kidney function whenever possible. Urinalysis: Absence of hematuria (gross or microscopic) does not rule out genitourinary injury. Presence of hematuria mandates consideration of a genitourinary injury. Amylase/lipase and liver enzymes elevation increases the suspicion of intra-abdominal injury. Pregnancy test in women of childbearing age. Urinary drug screen and blood alcohol levels may be warranted to rule out other causes of altered mentation. Type and screen or cross-match should be done if the patient might need a transfusion. Coagulation studies may be needed for elderly patients or if medical history is suggestive of anticoagulant use. DIAGNOSTIC TESTS Table 8-3 lists diagnostic tests that are useful to aid in the identification of abdominal trauma. table 8-3: Diagnostic Tests for Abdominal Trauma Tests Comments Flat Plate Abdominal X-Ray Can detect free air under the diaphragm from a ruptured hollow organ, which mandates prompt operation Useful to detect presence of bullets to estimate trajectory Focused assessment sonography Useful in hemodynamically unstable patients in trauma (FAST) Quickly detects the presence of abdominal blood Requires specific equipment in experienced hands Is rapid, noninvasive, inexpensive Should be repeated more than once to detect slow bleeding Diagnostic Peritoneal Lavage Infrequently used Rapidly performed invasive procedure To be performed by surgical team who will operate Highly sensitive to detect intraperitoneal bleeding Not useful to identify specific injuries Does not diagnose retroperitoneal injuries CT Scan Abdominal scanning for specific organ injury Used in hemodynamically stable patients Useful to identify retroperitoneal injuries Urethrogram Used to detect injury of the urethra Cystogram Used to detect a bladder injury Intravenous Pyelogram (IVP) Used to detect injury to the kidneys, bladder, and ureter Arteriography Used to detect vascular bleeding MANAGEMENT AND INTERVENTION As with any injury, the first priorities are the ABCs of initial assessment in trauma. Airway, breathing, and circulation should be assessed and maintained. Serial vital signs, including temperature, should be monitored and recorded frequently, and any changes in trends should be noted and shared with the team. Be alert for signs of shock because delayed diagnosis is a major cause of preventable death in abdominal trauma. Specific nursing interventions: Insert urinary catheter to decompress the bladder, barring any contraindications. Insert nasogastric or orogastric tube to decompress the abdomen. Anticipate blood administration in the unstable patient. Type and cross-match for a minimum of at least four units, or according to hospital policy. Stabilize impaled objects with a sterile dressing. Cover eviscerations with a sterile dressing moistened with normal saline solution. Maintain the patient on nothing by mouth (NPO) status until directed otherwise. Maintain the patient s temperature to prevent hypothermia and avoid worsening potential coagulopathy. Warm all IV fluids, use warmed humidified oxygen, increase the ambient room air temperature, and apply warming devices such as forced warmed airflow blankets and head wraps. Administer pain medication as needed to relieve acute pain. Repeated low-dose IV analgesia can be used safely, without masking abdominal symptoms for repeated abdominal exams. Also consider nonpharmacologic strategies to promote comfort, such as abdominal splinting with pillows, repositioning, ice, immobilization, and distraction techniques. Explain all procedures and tests. DEFINITIVE TREATMENT The hemodynamic stability of the patient will dictate choice of further diagnostic testing and definitive treatment. BLUNT ABDOMINAL TRAUMA Hemodynamically Stable 1. If the patient is stable, has an initial normal exam, and is a reliable historian (i.e., without distracting injury, drugs, alcohol, or altered mentation), then he or she may be admitted and followed with serial abdominal exams. 2. If the patient is stable but has an equivocal physical exam, then further diagnostic workup with FAST or CT scanning is required. If these tests are negative, the patient may be admitted and followed with serial abdominal exams. If these tests are positive, the patient will undergo selective management of the specific injury. 3. If the patient is hemodynamically stable but has demonstrated frank peritoneal signs on the initial exam, anticipate that the patient will undergo urgent exploratory surgery. Hemodynamically Unstable (Tachycardic, Hypotensive) 1. If the patient is hemodynamically unstable and abdominal injury is not obvious, the patient will

45 Basic Trauma Nursing 57 undergo an immediate FAST examination. If the FAST is positive, anticipate the patient going immediately to the operating room. If, however, the FAST is negative, look for another source of blood loss. The patient should be closely observed while being resuscitated. A repeat FAST scan should be performed 30 minutes after the initial FAST. The repeat scan can detect a slow bleed or progressive hemoperitoneum that easily can be missed with the first FAST. 2. If the patient is hemodynamically unstable and has an obvious grossly distended abdomen or evisceration is present, the patient should be taken urgently to surgery. PENETRATING ABDOMINAL Trauma Gunshot Wounds Most GSW to the abdomen are managed operatively, but each case should be evaluated individually. In some trauma centers, hemodynamically stable patients are admitted for observation and, if they become unstable, are brought to the operating room. Any GSW below the nipple line is considered an abdominal injury and requires exploratory laparotomy (Wallis et al., 2010). Stab Wounds Only half of the stab wounds that penetrate the peritoneum cause damage that requires surgical intervention (Lawson, Windle, Lovato, & Shlamovitz, 2014). Therefore, options include local wound exploration in the emergency department, serial physical examinations, and/or a CT scan. NONOPERATIVE MANAGEMENT Pediatric surgeons have long practiced nonoperative management of blunt splenic injury. Although the rate of nontherapeutic laparotomies after penetrating wounds to the abdomen should be minimized, this should never be at the expense of a delay in the diagnosis and treatment of injury (Como et al., 2010). The principle of nonoperative management stems from surgeons noting that bleeding had often stopped by the time of the laparotomies, and a negative laparotomy carries its own risk of morbidity and mortality, which should be considered preventable. Nonoperative management should be practiced only at a trauma center with immediate access to an operating room, and the patient should be placed in a monitored setting. The move toward nonoperative management has placed the trauma nurse in an important position. The nurse is responsible for a high level of patient surveillance and provides early warning activation for surgery when necessary. TRANSFER CONSIDERATIONS If the patient with abdominal trauma initially arrives at an institution without surgical capability, the patient requires prompt transfer to a higher-level facility, preferably a trauma center. If it is obvious that the patient will be transferred to another facility, time-consuming tests, such as CT scans, should NOT be performed at the first facility. Performing unnecessary or time-consuming tests is a frequent cause of delay in transfer of trauma patients. In addition, the surgeon who will ultimately provide definitive care for the patient should guide these tests. If tests are performed at the first facility, then copies of all tests should travel with the patient to the next facility. SUMMARY Abdominal injuries present many assessment challenges and represent 25% of all traumatic injuries. There should be a high index of suspicion in patients with penetrating thoracoabdominal injuries as well as blunt force trauma to the abdomen and flanks. The trend toward nonoperative management places nurses in a position of importance in ensuring the patient s safe recovery. Chapter 9: Spinal Trauma CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to discuss characteristics of spinal cord injuries, including implications for assessment and management. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Identify basic spinal anatomy and physiology. 2. Identify mechanisms of spinal cord injury. 3. Describe levels and types of spinal cord injury. 4. Discuss aspects of initial and secondary assessment for the trauma patient with a spinal cord injury. 5. Explain principles of management for spinal cord injuries. INTRODUCTION Spinal cord injuries (SCI) are often catastrophic because nearly 50% of the injuries involve the cervical spine, and nearly 50% of those injuries result in quadriplegia. Based on data in the National Spinal Cord Injury database, the incidence of spinal cord injury in the United States is approximately 40 cases per million population, or about 12,500 patients per year (NSCIS, 2014). Males are approximately four times more likely than females to have SCI. Overall, males account for 79% of reported injuries in the national database (NSCIS, 2014). Motor vehicle crashes are the most common cause of SCI, followed by falls (Chin & Mesfin, 2014). Since the development of emergency medical services (EMS) as a system in the early 1970s, along with advanced prehospital and emergency department care, more people who sustain spinal cord injuries survive, and many survive in better condition. The rapid advanced medical interventions, along with spinal cord rehabilitation systems across the country, have decreased complications and brought about better recovery potential for those injured compared to those injured before the 1970s. Life expectancies for patients with SCI continue to increase but are still below those of the general population. Patients who sustain SCI with high tetraplegia (C1 to C4) when they are 20 years of age have a life expectancy of approximately 35.7 years. Patients who sustain low tetraplegia (C5 to C8) at age 20 have a life expectancy of 40 years, and for patients with paraplegia, the number is 45.2 years (NSCIS, 2014). Individuals who are 60 years old at the time of injury have a life expectancy of approximately 7.7 years (with high tetraplegia), 9.9 years (with low tetraplegia), and 12.8 years (with paraplegia). In persons with SCI, the suicide rate is higher among individuals who are younger than 25 years (Chin & Mesfin, 2014). Today, society knows more about and is more accepting of making adaptations for and including people with SCI in the workforce, sports, and socially. ANATOMY AND PHYSIOLOGY Overview A system is a combination of interrelated parts that form a complex or unitary whole. The body s nervous system is a perfect example of a complex unitary whole that has several components or interrelated systems. It literally controls all the body s activities. Anatomical Divisions Anatomically, the nervous system has two divisions: the central nervous system (CNS) and the peripheral nervous system (PNS). (See Figure 9-1.) The CNS consists of the brain and spinal cord. The brain is the controlling organ of the body, serving as the center of consciousness, directing voluntary and involuntary activities, perceiving one s surroundings, and controlling reactions to those surroundings. It receives and sorts information and directs the body s response. The brain enables people to experience thoughts and feelings. Three major subdivisions of the brain are the cerebrum, cerebellum, and brainstem. The brainstem is the continuous portion of the brain that joins with the spinal cord and functions as an important relay and reflex center. It is the most primitive part of the CNS and controls all of the bodily functions necessary for life. The spinal cord is the part of the CNS that transmits messages back and forth between the brain and the body. As in the brain, the spinal cord has cell bodies, but it is mostly made up of nerve fibers extending from the brain to just below the brainstem, where it forms the spinal cord. Many nerve cells in the CNS have long fibers that continue outside the system to form cables of nerve fibers linking the CNS to various organs in the body. The linking cables of nerve fibers reaching outside the CNS make up the PNS. This system includes the nerves that enter and leave the spinal cord and those that connect the brain and organs without passing through the cord, such as the optic nerve. There are 31 pairs of peripheral nerves, called spinal nerves, and 12 pairs of cranial nerves. The cranial nerves arise from the brainstem. Each cranial nerve has a name and corresponding Roman numeral, and they pass directly through holes in the skull to their innervations. They can be sensory nerves, motor nerves, or both. Mostly, cranial nerves are specialized and have particular functions in the head and face. The 31 pairs of spinal nerves provide pathways for responses to specific stimuli. Each nerve has paired roots that extend from either side of the spinal

46 58 Basic Trauma Nursing FIGURE 9-1: anatomy of the nervous system Note. From Limmer, David J.; O Keefe, Michael F.; Grant, Harvey T.; Murray, Bob; Bergeron, J. David; Dickinson, Edward T. Emergency care, 12th edition Reprinted by permission of Pearson Education, Inc., New York, New York. cord to transmit sensory and motor impulses. The paired nerves correspond to specific segments of the spinal cord. The number of nerves are: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Three categories of peripheral nerves are sensory, motor, and connecting nerves. Sensory nerves carry messages sent from the body to the CNS. Sensory nerves are complex and are made up of many types of cells, such as those in the retina, ear, skin, muscles, joints, and organs. They do as the name implies and detect sensations of heat, cold, position, motion, pressure, light, hearing, balance, taste, smell, and so on. Each cell has distinctive nerve endings that perceive only one type of sensation and send only one type of message. Cranial sensory nerves go directly to the brain and do not pass through the spinal cord. The nerves sending messages from the CNS to the muscles are motor nerves. Each muscle in the body has its own motor nerve. An impulse in the motor strip of the brain s cerebral cortex is sent along the spinal cord to a cell body. The receiving cell body in the spinal cord then transmits the impulse to the motor nerve of the specific muscle it causes to contract. In the brain and spinal cord are cells (connecting nerves with short fibers) that connect the sensory nerves with the motor nerves. Some connect directly in the spinal cord without having to go through the brain, allowing the nerves to transmit impulses between nerves within the CNS. Connecting nerves in the spinal cord form a reflex arc between sensory and motor nerves of the extremities. When an irritating stimulus is transmitted from the sensory nerve along the connecting nerve and directly to the motor nerve, immediate response occurs, even before the information can be sent to the brain. Examples of reflex reactions are responses that occur when a person touches something extremely hot or when a physician taps the patellar tendon. Functional Divisions Aside from the anatomical divisions of the nervous system, there are functional divisions: the somatic and autonomic nervous systems. Activities that are voluntary and which one has control over, such as walking and writing, are controlled by the somatic nervous system. The peripheral nerves send sensory information to the brain for interpretation. The brain then responds, stimulating the voluntary muscles to act. In the involuntary, or autonomic, nervous system, one has no conscious or deliberate control over the functions it governs, such as digestion, dilation, constriction of blood vessels, and perspiring. Some of the cells forming the autonomic system are inside the CNS, and others lie alongside the spinal cord near the point where the spinal nerve roots exit. There are two branches of the autonomic system: the sympathetic and the parasympathetic. Along the vertebral column, a chain of ganglia (a collection of nerve-cell bodies) forms the main sympathetic trunks that extend from the base of the skull to the coccyx. They are supplied by the thoracolumbar portion of the spinal cord nerve roots. The sympathetic system responds to stress and threatening situations by causing the pupils to dilate and the blood vessels to constrict, stimulating sweating, increasing the heart rate, causing sphincter muscles to constrict, and preparing the body to respond to stress. This is commonly referred to the fight-or-flight response. The parasympathetic system is the other side of the autonomic coin, the balancing side. Parasympathetic nerve cells are found in the brainstem and the sacral area of the spinal cord. They cause the pupils to constrict and blood vessels to dilate, slow the heart rate, and relax the sphincters and other responses. This is sometimes referred to as the be-still-and-chill response. Autonomic functions include slowing or increasing the heart rate and strength of contractions, dilating or constricting blood vessels in skeletal muscles and abdominal organs, changing bronchial diameter, relaxing or contracting the urinary bladder, dilating or constricting the pupils, and increasing or decreasing saliva and digestive juices. Any injury that interferes with the function of the autonomic system can interfere with the body s ability to respond to stress. To summarize, the nervous system is anatomically divided into the CNS and the PNS. Functionally, the nervous system is made up of the somatic and autonomic components. The Spinal Cord The purpose of the spinal cord is to transmit nerve messages, or impulses, back and forth between the brain and the body to control functions and movements. Impulses are electrical, moving along nerve fibers within the spinal cord. Nerve fibers in the spinal cord are grouped in tracts. Sensory input from the body to the spinal cord is received by the ascending tracts, and brain commands for body motor functions travel through the descending tracts. Although it is not necessary to know the names of all the tracts, it is important to know that the functions of the three tracts relate to position sense, pain sense, and movement, and all three should be assessed after an injury. The base of the skull has an opening, the foramen magnum, through which the spinal cord exits to enter the spinal canal down to the lumbar vertebrae. Meninges covering the brain continue down to surround the cord, which is about 1 in. (2.5 cm) in diameter. Fluid that bathes and cushions the brain also surrounds the cord, which is why it is called cerebrospinal fluid (CSF). The spinal cord is housed in the spinal column, which protects the cord with 33 vertebrae that are aligned by strong ligaments that connect, support, provide stability, and prevent excessive flexion or extension of the vertebrae. The vertebrae support the head and body, allowing a person to walk upright. Segments of the vertebrae are: 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 fused coccygeal (see Figure 9-2). Between each of the cervical, thoracic, and lumbar vertebrae are broad, flat intervertebral discs made of fibrocartilage. They act as shock absorbers for the vertebrae. The vertebral artery and spinal rami arteries that enter between the vertebrae provide the vascular supply. Different from other areas of the body, spinal arteries cannot develop an adequate collateral blood supply when they are injured or obstructed. Mechanism of Injury Blunt Injury Adult Patients The major causes of adult spinal trauma include car crashes, shallow water diving or swimming, motorcycle crashes, and other falls and injuries. Rapid forward deceleration during a motor vehicle crash and rapid vertical deceleration at the end of a fall are the two primary causes of injury to the spine. Patients older than 45 years of age have more spinal injuries from falls than motor vehicle crashes. Pediatric Patients For pediatric patients, the frequency of spinal injury and injury patterns are quite different. Most pediatric spinal injuries are the result of falling from either a height or bicycle, being struck by a car, diving accidents, or sports-related injuries. Injury can occur to the spinal cord, bony column, or both at the same time. Ligament sprains usually are uncomplicated and heal without problems. Trauma to the spinal column does not always affect the cord or the nerves. Not all vertebral

47 Basic Trauma Nursing 59 Figure 9-2: Anatomy of the Spine Note. From Mistovich, Joseph J.; Karren, Keith J.; Hafen, Brent. Prehospital emergency care, 10th edition Reprinted by permission of Pearson Education, Inc., New York, New York. injuries are fractures. Trauma to the spine that is severe enough to injure the cord is usually severe enough to make the spinal column unstable. The most common spinal sites of injury are, in descending order, cervical, thoracic, thoracolumbar, and lumbarsacral. Penetrating Injury When projectiles and other penetrating forces enter the spinal cord, they can cause shearing, which can disrupt or end the structure and function of the cord. With penetrating force, bone fragments may be driven into the spinal cord, which causes further damage. Bleeding or a hematoma at the trauma site can compress the spinal cord, and the loss of blood supply can bring about irreversible damage. If damage is severe enough, the patient will have partial or complete loss of bodily sensation and/or function. Loss starts at the site of the injury and continues downward. A high level and severe injury in the cervical cord is life-threatening because the respiratory system loses its ability to function on its own. Spinal Cord Injuries Spinal Cord Injury Classified by Level Figure 9-3 summarizes the level of spinal injury and extent of paralysis. Figure 9-3: Innervating Plexuses of the Spine Note. From Pollack, Andrew N. Critical care transport Jones & Bartlett Learning, Burlington, MA. Reprinted with permission. Cervical Spine Injury (C1 to C7) The most common causes of cervical spine injury are motor vehicle crashes, followed by diving into shallow water, firearm injuries, and sports activities. There is a bimodal age distribution among patients with spinal cord injuries: the first peak occurs in patients between 15 and 24 years of age, and the second is in patients over 55 years of age (Marcon et al., 2013). The diaphragm is innervated by the phrenic nerve between C3 and C5. Therefore, trauma to the upper or middle cervical cord often paralyzes intercostal muscles, which results in hypoventilation or apnea. Many people with high cervical spine injuries die at the scene of respiratory distress before assistance arrives. There is an association between cervical spine injuries and head injuries. Concurrent injuries include closed head injuries, long bone fractures, thoracic injuries, and abdominal injuries (Mattox, Moore, & Feliciano, 2013). Approximately 5% of patients with brain injury have an associated spinal injury, and 25% of patients with spinal injury have some mild brain injury (ACS, 2012). Never assume that there is only one fracture of the spine. Approximately 10% of patients with a cervical spine fracture have a second bony column fracture elsewhere. A high index of suspicion for a second spine injury is necessary to avoid a missed injury. Remember that the patient may not be able to perceive pain, which can mask a potentially serious injury elsewhere, such as in the abdomen. Thoracic Spine Injury (T1 to T10) The thoracic spine receives additional stability from the ribs and has less capability for flexion or extension. Therefore, it is not injured as often as other parts of the spine. However, when a fracture or dislocation occurs in the thoracic spine, it usually results in a complete neurologic deficit because of the relatively narrow dimension of the thoracic canal. If thoracic injury is suspected, the neck must also be stabilized. Compression fractures are common in the thoracic region and are usually stable. Burst fractures generally occur as a result of flexion or axial loading (falls from heights). Surgery is typically required for unstable burst fractures that have significant comminution (fracture fragments), severe loss of vertebral body height, excessive forward bending or angulation at the injury site, or significant nerve injury due to parts of the vertebral body or disk pinching the spinal cord. These fractures should be treated surgically with decompression of the spinal canal and stabilization of the fracture (AAOS, 2010). Thoracolumbar Injury (T11 to L5) The lumbar and thoracic vertebrae join as a flexible joint, which makes it subject to injury. Sixty-four percent of injuries occur in the thoracolumbar (low back) region, often at T12 and L1 (Kuntz, 2013). Spinal cord damage to the lumbar region can paralyze the legs. It is useful to appreciate that the spinal cord ends just below L1, so injury below that level will not involve the cord. Chance fractures are transverse fractures through the vertebral body and are most commonly seen following motor vehicle crashes in which the patient (usually a child) was restrained by only a lap belt. Spinal Cord Injury Classified by Clinical Syndrome Figure 9-4 shows various cord syndromes and the area of cord injury. Complete Cord Transection A complete SCI results in no demonstrable sensory or motor function below the level of injury. The diagnosis should not be made until definitive imaging is obtained (i.e., magnetic resonance imaging [MRI]) and spinal shock is ruled out. Anterior Cord Syndrome Anterior cord syndrome is characterized by loss of motor function, pain, and temperature sensation below the level of the injury. Usually, anterior cord syndrome is caused by infarction of the cord in the territory supplied by the anterior spinal artery. This syndrome has a poor prognosis. Posterior Cord Syndrome Posterior cord syndrome is characterized by loss of sensory function, specifically touch, pressure, vibration, and proprioception, below the level of the injury. It is caused by a compression or hyperextension injury of the posterior cord and is a rare occurrence. Central Cord Syndrome Central cord syndrome is most often caused by hyperextension (especially in an older person) after a fall in which the person strikes his or her face. Loss of function is more pronounced in the upper extremities than in the lower extremities. Prognosis for recovery is usually good.

48 60 Basic Trauma Nursing Figure 9-4: Types of Incomplete Spinal Cord Injuries Note. From Apparelyzed.com. (n.d.). Incomplete spinal cord injury infographic: Types of incomplete spinal cord injuries. Retrieved from Used with permission. Brown-Séquard Syndrome Brown-Séquard syndrome involves cord damage that is limited to one hemisphere. It is rarely seen and usually results from penetrating trauma. Characteristics of this syndrome are ipsilateral (same side) motor loss and proprioception along with contralateral loss of pain and temperature sensation. Prognosis is fair, with some recovery usually seen. Spinal Cord Injury Without Radiographic Abnormality A child s anatomy allows for more physical flexibility than that of an adult. As a result, SCI is less likely. However, a condition known as SCI without radiographic abnormality (SCIWORA) can occur, where the child shows signs of injury without radiographic evidence. It is thought that a young child s immaturely developed spinal column can accept more flexion, extension, and temporary subluxation without demonstrable vertebral damage. Consequently, when damage occurs, it may not be obvious immediately but may progress over hours or days. The injury is more likely to occur at the cervical or thoracic levels of the spinal cord and show neurologic deficits without evidence of bony injury. An MRI is required to detect the specific point of injury. Prehospital Care Priorities include: prevention of further injury; spinal immobilization; assessment and intervention to ensure airway, breathing, and circulation; transport to the nearest appropriate facility; and/or helmet removal. Patients who are wearing a helmet and who require airway management should have the head and neck held in a neutral position while the helmet is removed via a two-person technique. If the helmet closely conforms to the head, is not obstructing the airway, and can be immobilized on the stretcher, the helmet can stay on until arrival at the emergency department. History Obtain the following information: history and mechanism of injury, medical history, drugs given prior to patient s arrival, and movement of extremities prior to arrival (if any).

49 Basic Trauma Nursing 61 INITIAL ASSESSMENT The emergency nurse should first conduct primary and secondary assessments and initiate required critical interventions. All unconscious patients should be presumed to have multisystem injury or spinal injury. After airway, ventilation, and adequate circulation are ensured, assessment shifts to the evaluation of the patient s spine and neurologic function. The patient s clothing should be carefully cut away or otherwise removed. The patient should be logrolled to assess for evidence of injury along the spinal column, including wounds, contusions, bulging, and deformity. The nurse should also palpate for tenderness if the patient is responsive. Assessment of Function A patient with an SCI may have varying levels of neurologic deficit. The level of motor function and sensation must be reassessed frequently and carefully documented because changes in level of function can occur. Perform a motor evaluation, assessing the strength and equality of movement for all four extremities; include the feet, toes, hands, and fingers. Assess sensory status to identify whether the patient can distinguish between sharp and dull, and identify where there is loss of feeling. Document whether the patient can move extremities and perceive pain. Assess rectal tone to determine if sacral sparing is present. Sacral sparing is evidenced by perianal sensation, rectal motor function, and great toe flexor activity. Preservation of sacral function indicates an injury with potential for recovery. Priapism, a reflexive penile erection, may be noted initially in male patients with complete SCI. Assessment for Associated Injuries The presence of neurologic deficits and altered vital signs due to SCI can mask other injuries. A thorough systematic workup for other potential injuries of the head, chest, abdomen, and pelvis is required. Hypotension and bradycardia associated with high SCI can mask signs of shock. All potential sites of hemorrhage must be investigated. MANAGEMENT OF SPINAL CORD INJURIES Systems Review Respiratory Insufficiency Hypoventilation due to paralysis of the intercostal muscles can result from an injury involving the lower cervical cord or upper thoracic spinal cord. Cervical spine C3 to C5 innervates the diaphragm via the phrenic nerve. Therefore, observe for potential respiratory distress in any patient with upper or middle cervical cord injury and assist with ventilation as needed. Neurogenic Shock Neurogenic shock results from impairment of the descending sympathetic pathways in the spinal cord. It includes a loss of vasomotor tone, which results in vasodilation and hypotension. A loss of sympathetic innervation of the heart, which can result in bradycardia or at least a failure to become tachycardic in response to hypovolemia, also occurs. Treatment involves administration of IV fluids. However, blood pressure may not be restored by fluid administration alone. Caution is necessary because massive fluid administration may result in fluid overload and pulmonary edema. Monitoring central venous pressure may be helpful. Judicious use of vasopressors (after moderate volume replacement) may be indicated. In some cases, atropine may be used to counteract hemodynamically significant bradycardia. Spinal Shock Spinal shock refers to flaccidity and the temporary loss of reflexes seen after SCI. The shock to the cord is only temporary, and the onset of spinal shock typically occurs at the time of injury. The duration of the loss of reflexes is variable, but it typically returns within the first few weeks of injury. An important distinguishing point between neurogenic and spinal shock is typically the lack of bradycardia, which is seen only in neurogenic shock. Some evidence of sacral sparing may be present. Skin Integrity Providers must remain vigilant about preventing secondary injury in patients with cervical spine injury (Austin, Krishnamoorthy, & Dagal, 2014). This includes applying a semi-rigid collar and long backboard. Logrolling the patient ensures neutral alignment of the entire spine. In awake, alert trauma patients without neurological deficit or distracting injury who have no back pain, tenderness, or palpable step-off, the backboard may be removed (Britt, Peitzman, Barie, & Jurkovich, 2012). Denervated skin is particularly prone to pressure necrosis. Turn the patient every 1 to 2 hours. Pad all extensor surfaces. Undress the patient to remove belts and back pocket keys or wallets. Remove the spine board as soon as possible (Chin & Mesfin, 2014). Temperature Control Poikilothermia is a condition in which body temperature attempts to mimic the environment around it. This occurs in SCI because of the disruption between the sympathetic nervous system and its control center in the hypothalamus. The lack of sympathetic function produces vasodilation, which further promotes heat loss. Urinary The bladder becomes atonic in SCI, and acute urinary retention is a concern. Placement of an indwelling catheter permits drainage of the bladder as well as monitoring of urinary output. Emotional Support Fear of the unknown is a concern for the conscious patient. Frequent verbal and physical contact with the patient to offer reassurance is of the utmost importance. Transfer Patients with spinal fractures or spinal cord injuries should be transferred to definitive care facilities, without unnecessary delay. The spine should be stabilized prior to transfer with necessary splints, backboard, and semi-rigid cervical collar. Use caution with a patient with cervical injuries above C6 because of potential respiratory embarrassment. If there is any concern about the airway, it is recommended that the airway be definitively secured with an endotracheal tube prior to transfer. SUMMARY Spinal cord and spinal column injury can be devastating. The advancement of EMS systems and rehabilitation have improved patients chances of survival and have expanded the potential for recovery. It is necessary to identify the cause and extent of an injury to the spinal cord or column and, most importantly, not to extend the degree of injury. Additionally, the patient must be carefully immobilized to prevent further damage. The future of the patient s ability to recover in the best manner possible depends on prehospital and hospital staff who understand the principles of spinal cord and column injury and can appropriately manage the patient s care. Chapter 10: Musculoskeletal Trauma CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to identify the proper procedures for managing musculoskeletal trauma. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Identify basic structures and functions of the musculoskeletal system. 2. Describe common mechanisms of injury associated with musculoskeletal trauma. 3. Explain the pathophysiologic changes and associated signs and symptoms of musculoskeletal injuries. 4. Describe the nursing assessment of the patient with musculoskeletal injuries. 5. Discuss appropriate interventions for musculoskeletal injuries. INTRODUCTION One third of patients presenting to the emergency department for treatment have an injury due to fractures, sprains, or strains (CDC, 2012). The severity of these injuries can range from mild to severe, with a myriad of etiologies. Most of the mechanisms of injury are motor vehicle crashes, assaults, falls, sports injuries, and injuries that are related to work or home. Orthopedic injuries are a significant cause of short- and long-term disabilities. Although these injuries usually are not critical (unless they are accompanied by severe hemorrhage such as in traumatic amputation), they may be urgent because of potential arterial occlusion or neurovascular damage. Quick and appropriate evaluation and intervention may prevent permanent disability. ANATOMY AND PHYSIOLOGY Musculoskeletal and related neurovascular structures involve bones, joints, tendons, ligaments, muscles, blood vessels, and nerves. Bones Bones are the 206 skeletal structures that provide support and give solidity, strength, movement,

50 62 Basic Trauma Nursing and protection to the body and its organs (see Figure 10-1). They also are involved in forming blood cells and storing calcium. Bones are richly supplied by blood vessels, nerves, and lymphatic vessels for nourishment and self-repair. Ligaments connect bones to other bones. Tendons connect muscle to bone. Joints A joint is the point of connection between two bones that are held together by fibrous connective tissue and cartilage (the joint capsule). Functions of joints are to give stability and mobility, flexion and extension, medial and lateral rotation, and abduction and adduction. Movement is aided by muscles and ligaments connected to the joint. Because of their function and location, joints are vulnerable to stress, inflammation, and trauma. Injuries occur in the form of contusions, sprains, dislocations, and penetration. Muscles Muscle facilitates movement. The body s 600 muscles are divided into three types: skeletal, smooth, and cardiac. Skeletal, or voluntary, muscle forms the major muscle mass of the body and attaches to the skeletal bones. These muscles are under the direct control of the nervous system s commands to the brain, contracting or relaxing at will and related to all body movement. Specific nerves pass directly from the brain to the spinal cord, where they connect with other nerves leaving the spinal cord and then with each skeletal muscle. Ligaments Ligaments are sheets or bands of strong fibrous connective tissue that connect bone to bone at points of articulation. Their purpose is to align the bones and allow or limit motion. Tendons Tendons are cords of fibrous tissue that attach most skeletal muscle to bone. The cords are a continuation of the fascia covering all skeletal muscles, similar to the way skin covers a sausage. At each end of the muscle, the fascia continues beyond the muscle to attach to the bone, crossing the joint as a musculotendinous unit. This muscle-tendon unit moves the joint. Cartilage Cartilage is a specialized type of dense connective tissue and has a limited vascular supply. It is found between the ribs; in the nasal septum, ear, larynx, trachea, and bronchi; and between the vertebrae. It also comprises the articulating surfaces between bones. MECHANISM OF INJURY Blunt and penetrating, direct and indirect, and twisting or high-energy trauma is involved in orthopedic and related neurovascular injuries. When there is trauma to the musculoskeletal system, damage also occurs to the surrounding tissues, such as the nerves and vessels. Musculoskeletal trauma can cause single-site or multisystem injuries and is considered high priority when hemodynamic or neurovascular compromise is present (ENA, 2014). Therefore, it is important not to focus on the assessment of a musculoskeletal injury to the exclusion of other possible injuries. Figure 10-1: The Human Skeleton Note. From Limmer, David J.; O Keefe, Michael F.; Grant, Harvey T.; Murray, Bob; Bergeron, J. David; Dickinson, Edward T. Emergency care, 12th edition Reprinted by permission of Pearson Education, Inc., New York, New York. Considerable force is involved in fractures and dislocations. In athletic trauma, twisting is often the cause of tibial fractures as well as knee and ankle ligament injuries. In cases of severe trauma, when bones are broken and torn or sheared from the surrounding tissues, amputation may occur. Other times, when bone does not break, tendons, ligaments, and muscles may be strained, sprained, or torn by the force of the trauma. High-energy injury from motor vehicle crashes, falls from heights, gunshot wounds, or other extreme forces results in severe skeletal, surrounding soft tissue, and adjacent vital organ damage. Multiple injuries generally are associated with high-energy trauma. Penetrating injuries from gunshot wounds and knives may cause shattering of bones and lacerations of muscles, tendons, and ligaments.

51 Basic Trauma Nursing 63 When a projectile passes through bone, both the bone fragments and the projectile cause tissue and structural damage. The ends of the broken bone may also protrude through the skin, inviting bacteria and infection, and bringing about additional tissue damage. ORTHOPEDIC TRAUMA AND ASSOCIATED NEUROVASCULAR PROBLEMS Crush Syndrome (Traumatic Rhabdomyolysis) Crush syndrome refers to the clinical effects of injured muscle that, if left untreated, may lead to acute renal failure. This condition is seen in individuals who have sustained a crush injury of a significant muscle mass, most often a thigh or calf. Mechanisms of injury typically occur in the industrial environment, such as with conveyor belts, grinders, wringers, and machine presses; however, this type of injury may occur in any environment. When there is tissue necrosis of a significant muscle mass, such as in crush injuries to the thigh or calf, rhabdomyolysis may occur. This is marked by extracellular fluid loss and myoglobinuria (myoglobin in the urine). Myoglobin produces dark amber urine that tests positive for hemoglobin. Rhabdomyolysis may lead to hypovolemia, metabolic acidosis, hyperkalemia, and hypocalcemia and is associated with the onset of acute renal failure and disseminated intravascular coagulation. Key points in the management of crush syndrome include: The initiation of aggressive IV fluid therapy during resuscitation is essential to flush myoglobin and products of muscle breakdown from the system to protect the kidneys and prevent renal failure (ACS, 2012). Prevent acute renal failure in rhabdomyolysis with aggressive fluid resuscitation (initially to maintain urine output at 100 ml/hour), osmotic diuretics, and alkalization of the urine (ACS, 2012). Amputation of the crushed extremity may be necessary to prevent the systemic complications listed above. Impaling Injuries Impalements may occur secondary to falling on a piercing object, be sustained from machinery or pneumatic tools (nails from a nail gun), or be sustained from an impaling object (either a weapon or other instrument). The wound will vary in size, and the depth is difficult to determine. Sometimes, the object will still be embedded in the patient when he or she arrives at the emergency department. Key points for managing impalements include: Impaled objects should not initially be removed in the emergency setting. Secure the object with padding and dressings as much as possible. Surgical intervention may be necessary for removal of the object under direct observation. Dislocations Defined as a complete loss of articular contact between two bones in a joint, dislocation causes direct injury to ligaments and capsule tissues. It is essential to assess the pulse carefully and serially. Assess pulse as well as sensory and motor function before splinting. Palpate and splint the joint in the position in which it presents until definitive treatment is available. Occasionally, if no pulse is present, returning the extremity to neutral alignment may be indicated. If reduction is necessary, it should be conducted with analgesia and sedation and careful patient monitoring. Shoulder Dislocation The shoulder is probably the most commonly dislocated joint in children and athletes, mostly because it is the joint with the greatest range of motion. There are two areas affected, anterior and posterior. Anterior As many as 96% of shoulder dislocations are anterior dislocations. These injuries frequently result from excessive external rotation when the shoulder is in a position of abduction and external rotation (Lacy, Cooke, Cooke, Schupbach, & Vaidya, 2015). Posterior Posterior dislocations are less frequent and may result from an excessive traumatic posterior force with the shoulder in internal rotation, flexion, and adduction (Robinson, Seah, & Akhtar, 2011). Management of shoulder dislocation involves: evaluating distal pulses, skin temperature, moisture, and neurologic status; taking X-rays before and after reduction is performed; and immobilizing the shoulder with a sling and swath bandage. Hip Dislocation Dislocation of a hip is a serious injury and is considered an orthopedic emergency. The dislocation may be anterior or posterior and is seen in all age groups. Large-force trauma (e.g., motor vehicle crashes and pedestrians struck by automobiles) are the most common causes of hip dislocations (Gammons, 2014). For example, in head-on motor vehicle crashes, when the leg is extended with the foot on the brake pedal or when the knee is jammed into the dashboard at the time of impact, the resulting force dislocates the hip (see Figure 10-2). The complaint is of pain in the hip. With posterior dislocation, signs include a hip that is flexed, adducted, and internally rotated; with anterior dislocation, signs include a hip that is flexed, abducted, and externally rotated. The patient cannot move the leg, and the hip feels locked. Key points in managing hip dislocation: Closed reduction should be attempted as soon as possible after a hip dislocation and certainly within the first 6 hours after injury to minimize long-term joint damage (Gammons, 2014). Splint the hip in the position of greatest comfort. Identify all other injuries. Maintain bed rest after reduction. Treat children with a spica cast. Posterior hip dislocation can cause sciatic nerve injury and permanent disability. Other complications are femoral artery and nerve damage. Blood supply to the femoral head may be impaired, causing avascular necrosis if the dislocation is not reduced within 6 hours. In this situation, a hip replacement will be necessary. Knee Dislocation Generally the result of major trauma, knee dislocations are seen in all age groups. The types of dislocations are anterior, posterior, medial, lateral, and rotary. Although the affected limb usually shows a gross deformity of the knee, along with immobility and swelling, it is important to be aware that in as many as 50% of cases, knee dislocations are reduced by the time the patient arrives in the emergency department, and the injury may not be obvious (Kelleher, 2013). The following are key points in the management of knee dislocation: Immediately splint the limb in the presenting position or the position of most comfort to the patient. Knee dislocations urgently need reduction and immobilization. Treatment is a splint or hinged brace. The patient should be on bed rest after reduction, with the leg elevated and intermittent cold packs applied for about 1 week. Arterial assessment is a high priority. The popliteal artery may be damaged in all variants of knee dislocation/subluxation, with reported incidence ranging from 7% to 64% (Kelleher, 2013). Arteriography or immediate operation is necessary if there is unequal neurovascular evaluation. There is a risk of undetected arterial injury with late occlusion in knee dislocations. Therefore, even though there may not be any signs of arterial damage, arteriography should be considered. Tibial, popliteal, and peroneal nerve injuries are common in knee dislocations, as are fractures of the tibia. Fractures A break in the integrity of the bony cortex is a fracture. The fracture may be open or closed (see Figure 10-3) and may be direct (occurring at the point of impact) or indirect (occurring at a distance from where the force is applied). An example of indirect fracture is when a person falls on an outstretched arm and the fracture is in the clavicle. In other situations, such as electric shock, a sudden, violent contraction of a muscle may fracture the associated bone. The fracture results from electrically induced tetanic muscle contractions. Most involve the proximal appendicular skeleton; distal fractures of limbs are uncommon (Peyron, Cathala, Vannucci, & Baccino, 2015). CLASSIFICATION OF FRACTURES Fractures (see Figure 10-4) are classified with respect to the following: Integrity of the skin: Open or closed Pattern: Transverse, oblique, spiral, greenstick, impacted, compression, depressed, or avulsion

52 64 Basic Trauma Nursing Figure 10-2: Dislocated Hip Figure 10-4: Fracture Classification Figure 10-3: Open versus Closed Fractures Morphology: Simple (two parts) or comminuted (three or more parts) Location: Proximal, middle, or distal; extraarticular or intra-articular Radiographic parameters: Displacement, angulation, rotation, shortening, or apposition The most important factor in the assessment of a fracture is the integrity of the skin over the break Fracture line orientation: A. Transverse. B. Oblique. C. Spiral. D. Comminuted. E. Segmental. F. Torus. G. Greenstick Note. From Cline, D., Ma, O. J., Cydulka, R., Meckler, G., Handel, D., & Thomas, S. (2013). Tintinalli s emergency medicine manual (7th ed.). New York, NY: McGraw-Hill. Reprinted with permission. TABLE 10-1: BLOOD LOSS ASSOCIATED WITH FRACTURES Fracture Internal Blood Loss (ml) Rib 125 Radius or ulna Humerus Tibia or fibula 500-1,000 Femur 1,000-2,000 Pelvis 1,000-massive and the surrounding soft tissues. The degree of soft tissue damage in closed or open fractures is important. Extensive soft tissue injury increases the risk of compartment syndrome. An open or compound fracture is any bone break where the overlying skin is damaged. Laceration may occur when the bone ends protrude through the skin or when the skin is broken from the exterior at the time of the injury. The wound may vary in size from small to gaping with exposed bone and soft tissue. The broken bone does not have to be visible in the wound to be considered an open fracture. Open fractures are more serious than closed because of the potential for hemorrhage, shock, foreign bodies, and infection (see Table 10-1). Infections can cause long-term problems for the patient. For this reason, open fractures are considered surgically urgent. Wound care includes sterile saline irrigation, sterile dressing, IV fluid replacement, antibiotics, and analgesia. Wound cultures should be done before irrigation is begun. A closed fracture is a bone break with no apparent open skin damage over the fracture. Closed injuries will typically tamponade and limit blood loss. A comminuted fracture is one in which the bone is broken in more than two fragments. Greenstick fracture is seen only in children, and the bone is partially bent and partially broken, causing the bone to bow and the pliable cortex to splinter. An epiphyseal fracture (also referred to as a Salter-Harris fracture) is seen in growing children when there is an injury to the growth plate of a long bone. If not properly treated, bone growth may be slowed or stopped. A pathologic fracture occurs when a bone is weak or diseased. Minimal force can cause the break. This type of fracture may be seen in the spine without the patient being aware of the fracture; he or she just seemed to get shorter. Pelvic Fracture Pelvic fractures can range from minor to complex, depending on the anatomic placement of the fracture. Pelvic fractures occur most often in middleaged and older adults. Overall mortality is 10% for pelvic fractures. Only 8% of all patients with closed fractures required damage control resuscitation compared with 28% of patients with open fractures (Fitzgerald, Morse, & Dente, 2014). Side-impact

53 Basic Trauma Nursing 65 motor vehicle crashes are a common cause of severe pelvic fractures. More than 50% of patients with pelvic fractures have additional injuries, particularly in vehicular trauma of pedestrians. Other causes of pelvic fractures are direct trauma, falls from a height, sudden contraction of a muscle against resistance, and sports injuries. Rami Fractures Rami fractures are isolated fractures of the inferior or superior pubic ramus. Because these bones are not directly involved with weight bearing, the fractures are generally minor. Rami fractures are not associated with significant bleeding and do not require surgery. Acetabular Fractures Acetabular (or hip socket) fractures occur when the head of the femur is driven into the acetabulum of the pelvis. They are complicated and can be associated with hip dislocation and injuries to the pelvic ring. Acetabulum fractures usually occur as a result of high-velocity trauma such as motor vehicle crashes or falls from heights (Thacker & Tejwani, 2014). These fractures are significant injuries and can result in lifelong disabilities. Surgery is generally required in which temporary skeletal traction is applied after reduction and is used to maintain the reduction and prevent soft tissue contracture. It is best to perform operative treatment 2 to 3 days after the injury so that the initial bleeding from the intrapelvic vessels subsides (Thacker & Tejwani, 2014). Pelvic Ring Fractures Pelvic ring fractures are typically classified into three categories (see Figure 10-5). Classifications of pelvic fractures are stable or unstable, depending on the condition of the pelvic ring and degree of bone and tissue damage. Neurovascular structures at risk for injury are the iliac artery, sciatic nerve, and venous plexus. Pelvic Fracture Management Palpate the pelvis during the initial assessment. Instability of the pelvis is done by applying gentle pressure over the iliac wings downward and medially (ACS, 2012). Compression should be done only once, by one clinician, and accurately documented. Repeated manipulation of pelvic fractures is to be avoided because they tend to bleed profusely, and continued movement will cause increased blood loss. Paraspinous muscle spasm, sacroiliac joint tenderness, paresis or hemiparesis, and pelvic ecchymosis also may be present. Interventions include high-flow oxygen and vital signs every 5 minutes, with observation for signs of hypovolemia. Establish two large-bore IV lines for volume replacement. Place a commercially available pelvic binder or wrap a sheet around the pelvis to close the hips and tamponade bleeding. (Caution: Pelvic X-ray is recommended before application of a pelvic binder. The primary indication for a pelvic binder is for an anterior-posterior fracture. If applied in a lateral compression fracture, more damage may occur by forcing the femoral head into the damaged acetabulum.) Figure 10-5: Pelvic Ring Fractures Note. From Cline, D., Ma, O. J., Cydulka, R., Meckler, G., Handel, D., & Thomas, S. (2013). Tintinalli s emergency medicine manual (7th ed.). New York, NY: McGraw-Hill. Reprinted with permission. Type and cross-match blood. Bleeding may be significant enough to cause hypovolemic shock, and the patient may require a massive blood transfusion (ENA, 2014). Perform radiographic studies to determine the fracture pattern. Insert a Foley catheter if there is no blood at the urinary meatus. Anticipate external fixation for unstable weight-bearing fractures. Nonweight-bearing, less severe fractures are treated nonoperatively with physical therapy. The majority of pelvic bleeding is venous and can be controlled by blood product administration and pelvic stabilization. Occasionally, arterial bleeding occurs and needs interventions that are more specialized; angiography and embolization may be indicated. Other problems with pelvic fractures are varied and may be severe, including bladder trauma, genital trauma, lumbosacral trauma, rupture of internal organs, sepsis, shock, and death. Posttraumatic arthritis, chondrolysis, and heterotopic ossification (bone formation at an abnormal anatomic site) are complications usually associated with the hips and long bones of the legs. Long-term problems include chronic pain and loss of function. Femur Fracture It takes substantial force to fracture the femur, a serious injury that usually occurs in conjunction with other musculoskeletal and soft tissue damage.

54 66 Basic Trauma Nursing Be sure to evaluate for other injuries, especially of the knee. Severe pain, inability to stand on the affected leg, swelling, crepitus, deformity, external rotation, or angulation indicate a femoral fracture. Shortening may develop due to severe muscle spasms. Femur Fracture Management Immobilize the leg with the use of a commercial traction splint. Check the pulse and movement of the toes before and after splint application. If the pulse is diminished after traction application, reduce the traction and recheck the pulse. Establish at least one IV site. Frequently check vital signs and circulation. Monitor hemodynamic stability. Femur fractures can result in significant blood loss, which can cause shock (ACS, 2012). Immobilization with traction splint and administration of analgesia will decrease severe muscle spasms, which can move bone ends, causing further soft-tissue injury, muscle damage, and pain. Neurovascular damage can include the peroneal and sciatic nerves and the popliteal artery. COMPLICATIONS OF MUSCULOSKELETAL TRAUMA Compartment Syndrome Compartment syndrome develops when the pressure within an osteofascial compartment of muscle increases due to bleeding or edema. Increased pressure on the capillaries, nerves, and muscles in the compartment leads to ischemia and subsequent necrosis. Increased pressure may occur from internal sources (hemorrhage or edema) or external sources (pressure from casts, dressings, or traction splints) and, if unrelieved, results in cellular ischemia (ENA, 2014). Common areas for compartment syndrome include the lower leg, forearm, foot, hand, gluteal region, and thigh. The symptoms develop within 6 to 8 hours of injury but may possibly be delayed up to 96 hours. Signs and symptoms include: excessive deep throbbing pain, which is greater than the pain caused by the original injury the hallmark sign of compartment syndrome is pain out of proportion to the extent of injury (ENA, 2014); pain with passive flexion; paresthesia; coolness; pallor; tight, tense swelling of the area; absent pulses (inconsistent sign); and weakness or paralysis (late sign). Changes in distal pulses or capillary refill times are not reliable in diagnosing compartment syndrome and easily can be missed in the unconscious or severely injured patient. Clinical diagnosis is based on the history of the injury and physical signs, coupled with a high index of suspicion. The physician may perform compartmental pressure measurements periodically to assess tissue pressures. Currently, many surgeons use a measured compartment pressure of 30 mm Hg as a cutoff for fasciotomy (Rasul, 2015). Without treatment, within 4 to 6 hours, irreversible tissue damage will occur from inadequate perfusion. This urgent situation should be identified and treated upon discovery. Compartment Syndrome Management Position the limb at the same level as the heart. Perform frequent neurovascular checks. Monitor the 6 P s: pain, pressure, pallor, pulses, paresthesia, and paralysis. Document and report any changes. Assist the physician to perform compartment pressure checks if indicated. Prepare the patient for emergency fasciotomy. ASSOCIATED INJURIES Amputations and Mangled Extremity Amputation trauma has the potential of significant morbidity. Dysfunctional limbs should be treated at facilities with the capability of microvascular surgery. Partial amputations may have more severe bleeding than complete amputations because, with a complete amputation, the severed arteries retract (Langdorf, Cisneros, & Rafijah, 2014). Mechanisms of injury are most frequently industrial or recreational accidents. Amputations may be partial or complete and usually involve the digits, the lower leg, the hand, or the forearm (Langdorf et al., 2014). Young patients who have distal, cleanly amputated extremities have the best return of function; multiple levels of injury, crush, or avulsing injuries have less (Langdorf et al., 2014). The decision to replant should be made by a surgeon or replantation team, if available. If an injured limb is without sensory function or is pulseless, aggressive revascularization and repair may be contraindicated. Whatever the reason for performing an extremity amputation, it should not be viewed as a failure of treatment. Amputation can be the treatment of choice for severe trauma, vascular disease, and tumors (Ertl, Brackett, Ertyl, & Pritchett, 2014). Amputation and Mangled Extremity Management High-flow oxygen, two large-bore IV lines, and control of bleeding are top priorities. Perform a careful assessment of the injured limb s sensory and motor function. Splint and support the limb in a position of anatomic function if the amputation is partial. In total amputations, the stump should be elevated and irrigated with sterile saline solution, and sterile dressings should be applied. Tourniquets may have been applied by emergency medical services and should not be removed until the patient is in a controlled setting such as the operating room. Tourniquets should be considered for bleeding mangled extremities and amputations because they could be life-saving. Tourniquets are valuable as a life-saving measure for amputations with uncontrolled bleeding (Mamczak, Born, Obremskey, & Drom skey, 2012). The amputated part should be brought with the patient to the emergency department for possible replantation. The amputated part should be wrapped in sterile gauze, wet with normal saline solution, and placed in a watertight plastic bag or container, which is then put into a container with iced saline solution. Do NOT use dry ice or distilled water, place the amputated part directly on ice, or allow it to freeze because doing so will damage the tissue. Label the container with the patient s name, time, and date. Replantation success is extremely limited. The availability of a replantation team, the type and degree of damage to the stump and amputated part, and the amount of time that has passed since the incident are the key factors in the success of replantation. Other factors are age, general physical condition, occupation, and motivation. Amputations caused by sharp cuts have a better outcome than crush injuries and avulsions. Occult Injuries Occult injuries are those injuries that are hidden, underappreciated, or missed on initial assessment. They are frequently minor musculoskeletal injuries that were overlooked when the healthcare team was initially dealing with the more lifethreatening injuries. Many patients do not initially complain of these minor injuries when they are dealing with the distracting pain of major injuries, or they may be unconscious, which makes identification even more difficult. Therefore, it is imperative to repeatedly reevaluate the patient to assess for these occult musculoskeletal injuries; some may not be identified until days after admission. PRIORITIZING ORTHOPEDIC EMERGENCIES Most orthopedic injuries will not affect the patient s ABCs. Other life-threatening emergencies always take precedence. However, there are orthopedic injuries that require immediate management: 1. Hip dislocations, because of the potential impaired blood supply and resulting avascular necrosis with permanent disability a true orthopedic emergency Need to be reduced promptly 2. Knee dislocations, because of the potential for vascular disruption Prompt arteriogram is required and surgery if necessary 3. Open fractures, because of infection and osteomyelitis Patient will need to go to the operating room for washout by an orthopedic surgeon within 6 hours of injury 4. Massive pelvic fractures, because of hemodynamic instability Apply pelvic binder to tamponade blood loss Prompt evaluation and transfer to an orthopedic surgeon ASSESSMENT PRINCIPLES As discussed in the previous chapters, assessment and maintenance of the ABCs is always the first priority. It is important not to allow dramatic orthopedic injuries to distract from more serious trauma.

55 Basic Trauma Nursing 67 Rapid assessment follows the ABCs to identify serious injuries of the head, cervical spine, chest, and abdomen and to prioritize actions. Musculoskeletal injuries are not isolated in serious traumatic incidents. Treat potentially life-threatening conditions before limb-threatening ones. Cut away the patient s clothing; do not pull it off, be careful not to disturb the injured area, and always protect the patient s privacy. Assess for open wounds and skin integrity, checking for internal as well as external bleeding. Compare the injured extremity with the opposite limb, checking for pain, point tenderness, swelling, discoloration, and temperature. Palpate injured areas gently, feeling for irregularities and signs of dislocations and fractures. If the patient is a child with a spiral fracture, look for indicators of abuse. Palpate for pulses distally and in both extremities; compare extremities. Assess neurovascular status, checking for numbness and paresthesia. Determine if the patient can wiggle his or her fingers or toes. Assess and manage the patient s pain and anxiety (Wong, Chan, & Chair, 2010). MANAGEMENT PRINCIPLES Remember that with major trauma, there will be multiple injuries. The primary goal is to limit current damage, prevent further damage, and preserve the structure and function of the injured extremity as much as possible. Gently irrigate and clean open wounds, and dress them with sterile saline gauze. Apply a tourniquet to an unstable patient s bleeding extremity. Tourniquet application can be a life-saving intervention, and is the only treatment in musculoskeletal trauma that affects the ABCs. Experiences in Iraq and Afghanistan have tourniquets being reintroduced as an early, effective treatment for extremity hemorrhage. Splint the injured extremity, immobilizing the joint above and below the injury site. Check the pulse before and after splint application. If the pulse is lost after traction is applied, release the traction and reassess the pulse. Do not attempt to straighten a dislocated or fractured limb unless there is no pulse and evidence of vascular compromise. Gently returning the extremity to neutral position may be indicated. If the limb is not already splinted, immobilize it in the most comfortable position or as the limb presents. Exposed bones should not be pushed back into the wound because to do so will aggravate the injury, increase the potential for infection, and be painful. CASE STUDY A43-year-old female experienced a head-on motorcycle crash into a tree. At the scene, she was combative and her vital signs were systolic blood pressure 80 mm Hg, heart rate 122 bpm, and respiratory rate 24 bpm. Now in the emergency department, her vital signs have improved to normal, and the patient is complaining of pain in her right arm and both legs. There is marked deformity of the right thigh and left lower extremity. Emergency medical services report a large laceration to the left leg, which now has a dressing over it. Answer the following case study questions, writing your responses on a separate sheet of paper. Compare your responses to the answers that follow: 1. List the initial nursing assessment priorities. 2. Identify the initial assessment of an extremity for injury. 3. Explain how to assess for occult orthopedic injury. 4. Define the steps for immobilization of extremity injuries. 5. Define the steps for reevaluation of extremity injuries. Answers 1. Check vital signs and ABCs first (primary survey). Confirm that the patient is hemodynamically normal before beginning the secondary survey, which is where musculoskeletal assessment occurs. 2. Examine the patient s injured extremities. Assess the neurovascular status of each extremity by checking distal pulse, movement, and sensation. 3. Assess for any open wounds, clean them, and apply dressings. 4. Immobilize each injured extremity by splinting. Immobilization prevents further soft tissue injury and contributes to hemorrhage control and pain relief. 5. Reevaluate neurovascular status (pulse check and movement) after manipulation and application of splints. SUMMARY Musculoskeletal trauma represents a substantial component of patient injuries seen in emergency departments. Most of these injuries do not threaten the patient s life or limbs, although orthopedic trauma with associated neurovascular damage is a significant cause of short- and longterm disability. Orthopedic trauma includes softtissue injuries, dislocations, fractures, and traumatic amputations. Multiple injuries may be present in addition to the musculoskeletal trauma. The primary objective for emergency care of orthopedic trauma is to restore or preserve the injured limb with the greatest integrity possible and prevent further injury. Quick and appropriate evaluation and intervention may prevent disability. Chapter 11: Burn and Cold Trauma CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe the concepts important in the management of burn and cold injuries. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Identify the normal functions of the skin. 2. Discuss the pathophysiology of burn injuries. 3. Identify types of burn and cold injuries and the criteria for estimating the extent and severity of those injuries. 4. Describe appropriate basic interventions for the patient with a burn injury. 5. Describe appropriate basic interventions for the patient with a cold injury. INTRODUCTION Evaluation of the patient with a major burn injury is initially the same as for any other trauma patient. The patient should be evaluated initially for airway, breathing, and circulation as well as have a detailed survey for other life-threatening injuries. The burn wound itself should receive low priority during the initial assessment. Burns involve much more than just injury to the skin. Burn injuries often affect structures below the skin, including muscles, bones, nerves, and blood vessels. When caring for a burn patient, always think beyond the external burn to the physiologic changes occurring internally as a result of the burn. EPIDEMIOLOGY Annually, approximately 486,000 individuals receive medical treatment for burn injuries, with an estimated 40,000 requiring hospitalization (ABA, 2015). An estimated 2,855 deaths in the United States occur from residential fires, and there are 385 burn-related deaths from other sources, including motor vehicle and aircraft crashes and contact with electricity, chemicals, hot liquids, and other substances (ABA, 2015). Fire and burn deaths are combined in these statistics because deaths from burns in fires cannot always be distinguished from deaths from smoke poisoning. Data from U.S. burn centers collected between 2003 and 2012 reveal an interesting profile of burn injury in the United States (see Table 11-1). Promptly administered effective and systematic prehospital care can reduce the extent and limits the depth of burns, thus minimizing morbidity (Shrivastava & Goel, 2010). Such principles as maintaining a high index of suspicion for airway compromise, smoke inhalation, and potential hemodynamic instability help prevent unnecessary morbidity and mortality. The majority of burns are preventable. Because of strong public education programs and legislative mandates regarding construction codes and smoke and fire detection devices, the number of burn injuries has dropped over the past three decades in the United States. ANATOMY AND FUNCTIONS OF the SKIN The skin is the largest single organ of the body. In the adult, the skin covers about 3,000 square inches (1.75 sq. m) and weighs about 6 lb. LAYERS OF THE SKIN Epidermis Of the two main layers of skin, the epidermis is the tough outermost layer (see Figure 11-1). There are several layers within the epidermis. The base epidermal layer is the germinal layer, which continuously produces new cells that rise to the surface, die, and form the watertight covering. The epidermis varies in thickness in different parts of the body.

56 68 Basic Trauma Nursing TABLE 11-1: U.S. BURN CENTER STATISTICS Variable Rate Gender Male 69% Female 31% Ethnicity Caucasian 59% African American 20% Hispanic 14% Other 7% Cause Fire/Flame 43% Scald 34% Contact 9% Electrical 4% Chemical 3% Other 7% Place of Occurrence Home 73% Occupational 8% Street/Highway 5% Recreational/Sport 5% Other 9% Overall Survival Rate 96.7% Note. Adapted from American Burn Association (ABA). (2015). Burn incidence and treatment in the United States: Retrieved from resources_factsheet.php Dermis A deeper layer, the dermis, is below the germinal layer of the epidermis and consists of collagen and elastic fibers. Within the dermis are specialized structures that give the skin its characteristic appearance: sweat glands; sebaceous glands that secrete oil to lubricate the skin, hair follicles, and blood vessels; and specialized nerve endings. Subcutaneous Tissue Lying below the dermis, subcutaneous tissue is the fatty layer that varies in thickness in different parts of the body and in each person. Fascia Below the subcutaneous layer lies the deepest layer, the fascia, which covers the muscles. FUNCTIONS Protection As the body s largest organ, the skin serves as a waterproof covering that prevents excessive water loss, helps keep out pathogens, and provides a barrier against invasion by outside organisms. The skin protects underlying tissues and organs from abrasion and other injury, and its pigments shield the body from dangerous ultraviolet rays in sunlight. Figure 11-1: The Layers of the Skin Note. From Limmer, David J.; O Keefe, Michael F.; Grant, Harvey T.; Murray, Bob; Bergeron, J. David; Dickinson, Edward T. Emergency care, 12th edition Reprinted by permission of Pearson Education, Inc., New York, New York. Temperature Regulation Skin is the major organ in the body for temperature regulation. Through sweat-producing glands and the evaporation of sweat and water, body temperature is controlled. When the environment is hot, sweat is secreted to the skin s surface for evaporation. Evaporation of sweat uses energy, which is taken from the body as heat, causing the body temperature to fall. In other words, sweating itself does not reduce the body temperature; rather, it is the process of evaporation pulling energy (heat) from the body that reduces the temperature. Sensation Sensory nerves originating in the skin carry information about the environment to the brain, including sensations of pressure, pleasant stimuli, and pain. Vitamin Production The skin produces vitamin D through exposure to ultraviolet radiation in sunlight. PATHOPHYSIOLOGY Zones of Injury When a burn occurs, it causes three concentric circles, or zones, of injury, similar in shape to a bull s-eye shooting target. Zone 1 The zone of coagulation: This zone has close contact with the heat source. Absence of blood flow to the area produces coagulation and necrosis (Vadukul & Nguyen, 2012). Zone 2 The zone of stasis: This zone borders the zone of coagulation and will often blanch on pressure or have petechial hemorrhages, which gives the appearance that circulation is intact. In a major burn, however, the circulation to this area will stop within 24 hours (Vadukul & Nguyen, 2012). Zone 3 The zone of hyperemia: This zone borders the zone of stasis. It may be difficult to identify until 72 hours after the zone of injury, when the white color becomes deep red (Vadukul, 2012). VASCULAR RESPONSE After a burn occurs, there is a brief decrease in blood flow to the burned area, followed by a marked increase in capillary vasodilatation, which can ultimately result in tissue damage, cellular impairment, and fluid shifts. The burned tissues release mediators that cause an inflammatory response. The inflammatory response occurs both locally and systemically, and results in a shift of fluid from the intravascular fluid into the interstitial space (Oliver, 2012). This vascular response is typically limited to the burn area when the burn involves roughly less than 20% total body surface area. However, burns greater than 20% create a systemic-wide response of vasodilation and increased capillary permeability, which put the patient at risk for hypovolemia. This increased capillary permeability also causes colloid osmotic pressure to fall because of the shifts of large proteins out of the intravascular space into the interstitial fluid, which further aggravates edema in tissue. Insensible fluid loss, coupled with the fluid shift, causes hypovolemia. Almost half of the fluid infused during resuscitation can seep from the veins into the tissue. This can last from 6 to 12 hours after the burn injury, when the capillary membranes begin to repair and leakage begins to decrease (Oliver, 2012). During the time of increased capillary permeability, vascular fluid shifts into the interstitium (between cells or tissues), making the blood more viscous. This rise in the ratio of RBCs to plasma is reflected by the increase in hematocrit that is commonly seen after a major burn injury. The decreased intravascular fluid volume, increased blood viscosity, and increase in peripheral resistance all contribute to a decrease in cardiac output. The drop

57 Basic Trauma Nursing 69 in cardiac output and resulting sympathetic nervous system response of shunting blood to the heart and brain results in decreased perfusion to the skin, viscera, and kidneys. In addition, the destruction of RBCs in a deep burn results in free hemoglobin, which is normally excreted by the kidneys. However, in the presence of already inadequate perfusion to the kidneys, hemoglobinuria can be significantly toxic to the nephrons, resulting in renal failure. Therefore, aggressive early fluid resuscitation in burns is required. The vascular response to serious burn injury can affect all body organs. Cerebral perfusion abnormalities, impaired cardiac blood supply, renal insufficiency, and metabolic imbalance are likely consequences of large or deep burns. PULMONARY RESPONSE TO SMOKE INHALATION Smoke inhalation is the leading cause of death due to fires. It produces injury through several mechanisms, including thermal injury to the upper airway, irritation or chemical injury to the airways from soot, asphyxiation, and toxicity from carbon monoxide (CO) and other gases such as cyanide (Lafferty, Bonhomme, Martinez, & Wiener, 2014). Carbon Monoxide Intoxication Each year, more than 400 Americans die from unintentional CO poisoning not linked to fires, more than 20,000 visit emergency departments, and more than 4,000 are hospitalized (CDC, 2015). The most frequent cause of death in fire is victims being overcome by carbon monoxide before they are burned. Carbon monoxide is a colorless, odorless gas that is released during a fire. Toxicity primarily results from cellular hypoxia caused by impedance of oxygen delivery. CO reversibly binds hemoglobin, resulting in relative functional anemia (Shochat & Lucchesi, 2015). Carbon monoxide has an affinity for hemoglobin that is 200 times greater than that of oxygen. When carbon monoxide binds to hemoglobin, it interferes with adequate amounts of oxygen getting to the tissues. Additionally, carbon monoxide combines with myoglobin in the muscle cells, causing muscle weakness. The tissue hypoxia that results in muscle weakness and mental confusion is thought to be a primary contributor to fatalities. The signs and symptoms of poisoning depend on the level of carbon monoxide, the length of exposure, and the individual s overall health condition. Oxygen saturation (SaO 2 ) is usually measured as normal because an oximeter detects the color of the hemoglobin and does not measure carbon monoxide (ABA, 2011). Therefore, SaO 2 is unreliable in carbon monoxide victims. Early in carbon monoxide poisoning, while in the fire situation or just after, the patient feels few symptoms that he or she perceives as serious: some muscle weakness and mild dyspnea. The patient may become confused. Later signs of carbon monoxide poisoning are pink to cherry red skin, tachycardia, tachypnea, headache, dizziness, and nausea. Blood gas analysis should be performed to measure the level of carboxyhemoglobin, the compound formed by carbon monoxide and hemoglobin in carbon monoxide poisoning. Levels of carboxyhemoglobin below 15% rarely produce symptoms and are often seen in heavy smokers. Such symptoms as headache and confusion are seen in levels ranging from 15% to 40%. Blood levels of greater than 40% may result in coma. If the patient is thought to have carbon monoxide poisoning, 100% oxygen should be given. Occasionally, transfer to a center with a hyperbaric oxygen chamber may be indicated to provide high oxygen concentrations and pressures to help dislodge the carbon monoxide from the hemoglobin molecules. Upper Airway Obstruction Thermal injury to the upper airway is usually related to facial burns. Edema may occlude the airway at the level of the vocal cords or higher. Edema progresses rapidly, causing total occlusion within minutes to hours. Tissue damage in the posterior pharynx is usually from thermal causes. It is not likely that thermal damage occurs below the posterior pharynx because this area is an efficient system for heat exchange. When there is true thermal injury below the vocal cords, it is usually caused by superheated steam that is carried via water vapor into the lungs or by the inhalation of explosive gases. Immediate early intubation is required. If there is any doubt, prophylactic intubation is preferred. Chemical Injury Smoke inhalation often causes chemical injury to the lower airways and lung parenchyma. Carbon particles contained in smoke travel down to the bronchi and into the alveoli. Chemical injury causes hemorrhagic tracheobronchitis, increased edema, lowered levels of surfactant, and decreased function of pulmonary cells that are dust-phagocytic (macrophages). Clinical evidence of a pulmonary injury may not be immediately evident during the resuscitation phase (ACS, 2012). In the case of severe inhalation injury, the patient will have an increased need for fluids. MECHANISM OF INJURY Burns (the application of more energy than the body can absorb without damage) occur from several sources: 1. Thermal: Scald, flame, flash, contact 2. Chemical: Including contact with and inhalation of acids, bases, caustics 3. Electrical: Alternating current, direct current, lightning Cooking is the primary cause of residential fires, whereas smoking caused the most fire-related deaths (Aherns, 2013). For the most part, the longer the patient is in contact with the burning agent, the more severe the burn. Thermal Burns Scald Burns Scalds are the second most common of all burns. Water at 140 F (60 C) for 3 seconds will cause a deep partial or full-thickness burn. Hot beverages (coffee, tea, etc.) average 160 F to 180 F (71 C to 82 C) and can cause full-thickness burns on contact (ENA, 2014). Liquids of thick consistency stick to the skin longer and, therefore, burn longer. Cooking oil and grease can reach temperatures of up to 400 F (204 C). In the case of an immersion burn, such as in a bath, even though the water may be cooler than 140 F (60 C), the contact with the skin lasts longer. Flame Burns The most frequent cause of burns is flames. Although residential fires have decreased because of public education, smoke detectors, and improved fire codes, careless smoking, clothing ignited by stoves or space heaters, and motor vehicle crashes still contribute to a significant number of flame burns. Outdoor flame burns are often secondary to improper use of camping stoves, smoking in a sleeping bag, using lanterns in tents, and using gasoline or kerosene on a charcoal fire. Flash Burns Explosions of natural gas, propane, gasoline, or other flammable liquids cause flash burns. There is brief, intense heat. The burns are mostly partial thickness, but the depth of the burn is related to the amount and kind of fuel involved. Contact Burns Direct contact with a hot object can cause a deep burn. Common examples include burns caused by touching a hot stove, cooking appliance, or curling iron. Chemical Burns Chemicals cause the denaturing of the protein (protein loses some of its chemical and physical properties, just as cooking an egg white denatures the albumen) in tissues or a desiccation (drying) of the cells. In chemical burns, the type of chemical, concentration, and length of time of exposure all affect the extent of the burn. Acid Versus Alkali Burn Strong acids or alkalis that come in direct contact with the skin or pass through clothing cause most chemical burns. Alkali burns cause more damage than acids because the former are corrosive and are able to combine with water. With their ability to combine with water and act on fatty acids, alkali burns cause rapid, deep destruction of tissue. Tissue is gelatinized, turning grayish in color, and has a soapy, slippery feel. Whereas acids generally can be washed off the skin s surface, alkalis will be activated by water and continue burning until the chemical itself is totally removed from the patient. Therefore, all powders or particles should be removed prior to flushing any chemical burn with water. Electrical Burns Electric Shock Electrical burns are caused by low- or highvoltage contact, ranging from ordinary household current to utility power lines. Most electrical burns in the home are from the careless use of appliances or faulty equipment. Small children may stick their fingers into electrical outlets or bite into electrical cords. Downed power lines are another example of potential electrical contact. To cause a burn, electricity must enter the body at one point and exit at another point. As electricity passes through the body, it meets resistance from the body s tissues and is converted to heat. The heat generated is in direct proportion to the amperage of the current and the electrical resistance of the body parts.

58 70 Basic Trauma Nursing As electricity passes through the skin, it leaves a burn at the entry and exit sites. Extensive internal injury can occur between these sites. The amount of internal tissue injury is usually more extensive than indicated by the appearance of the skin wounds. Severe damage may be done to the deeper tissues. The heart, lungs, and brain can be damaged immediately after the body receives a shock. A burn may be followed by cardiac arrest due to a disruption in the normal electrical rhythm of the heart. Nerves, blood vessels, and muscles are less resistant and more likely to be damaged than bone or fat. The nervous system is particularly vulnerable to electrical burns. Acute and delayed spinal cord injuries have been described distal to the site of electric contact. Signs are variable and may include ascending paralysis, amyotrophic lateral sclerosis, or transverse myelitis. Motor deficits occur more frequently than sensory loss (Edlich, Drake, & Long, 2013). Electric current is AC (alternating current) and may cause violent muscle contractions, resulting in fractures or dislocations. This is referred to as tetany. The shock may also cause the patient to fall to the ground and incur additional injury. Highvoltage electricity can cause such severe destruction to muscles and skin that amputation is necessary. Cardiopulmonary resuscitation (CPR) may be the first intervention necessary with a patient who has sustained an electrical shock. If CPR is not necessary, further interventions can be initiated. Dry, sterile dressings should be placed on the burn wounds, and fractures should be immobilized. Further burn and trauma management is relative to the damage the patient has incurred. Lightning Lightning is a specific form of electrical burn. It has DC (direct current) and can be thousands of volts. The strike lasts for only a fraction of a second and is not always fatal. A high-voltage lightning strike involves the whole body. A superficial characteristic burn is usually on the skin at the site of the strike, but the burn itself is rarely deep. However, many body systems are affected, especially the nervous and cardiovascular systems. Most persons struck by lightning are immediately knocked unconscious and have no memory of being hit. Patients may experience numbness, tingling, partial or complete paralysis, blindness, loss of hearing from ruptured tympanic membranes, difficulty speaking, or an inability to speak. These problems usually resolve themselves. The greatest concern with a lightning strike is the electrical disturbance that causes a severely disrupted heart rhythm, which leads to full cardiac arrest. The absence of a heartbeat indicates that vigorous resuscitation attempts should begin; the condition may be reversible. Patients may be successfully resuscitated with immediate CPR and advanced cardiac life support measures. ASSESSMENT HISTORY Concomitant Injuries The history of how the injury occurred is important in managing the burn patient. A high index of suspicion is necessary to find associated injuries sustained during the trauma. Explosions can throw the patient into solid objects, resulting in internal injuries and fractures. Jumping or escaping from burning structures often results in concomitant injury. Burns not involving the airway can be deferred to the secondary survey and do not require immediate treatment. It is important that the time of burn injury be established to determine early fluid resuscitation requirements. Patients with burns sustained within an enclosed space are at high risk for inhalation injury. Preexisting Disease History should include assessment of any preexisting disease, such as diabetes; hypertension; or cardiac, pulmonary, or renal disease as well as any medications the patient is taking. Any patient with a compromised immune system will be vulnerable to disruption of the skin. Tetanus immunization is essential to establish. Extent The total body surface area (TBSA) burned can be estimated using the rule of nines (see Figure 11-2). Using this formula permits rapid, accurate assessment. The system divides the body into sections, each representing approximately 9% of the TBSA. Obviously, because of different body proportions, the rule is modified in infants and small children, pregnant women, and some other patients. The general formula for determining the TBSA in adults is as follows: Each upper extremity is counted as 9%. Each lower extremity is considered 18%. The front torso is 18%. The back torso is 18%. Genitals and perineum are 1%. Figure 11-2: Rule of Nines Note. From Cline, David; Ma, O. John; Cydulka, Rita; Meckler, Garth; Handel, Dan; Thomas, Stephen. Emergency medicine manual, 7th edition Reprinted with permission of McGraw-Hill Education. Circumferential burns are calculated by adding the percentages applicable to both the front and back of the area involved. Palmar surface assessment uses the palmar surface area (SA) of the patient s hand as an estimation guide. The SA of the patient s palm, including fingers, is assumed to be 1% of the total BSA (Scarisbrick & Morris, 2013). Remember that electrical injuries are deceptive and more difficult to evaluate because the burn surface area may be considerably less than the underlying damage. Depth Assess for the depth of burn, which is important in evaluating the severity of the burn, planning for wound care, and predicting functional and cosmetic results (see Figure 11-3). Assessment of burn depth at admission is only an estimate. The determination of burn depth may take up to 5 days because of the evolving status of zone 2, stasis of injury. First-degree: Only the superficial epidermis is injured, with minimal damage. The skin has mild erythema, no blistering, and there is no burning through the layers of skin. The epidermis may peel in small scales, without scarring. Discomfort resolves in a day or two. Sunburn is a good example of a first-degree burn. This burn generally does not require IV fluid replacement. Second-degree: Also known as a partialthickness burn, the entire epidermis and layers of the dermis are damaged. The skin is erythematous, Figure 11-3: Burn Depth Note. From American College of Surgeons. Advanced trauma life support, 9th edition. 2012, p Used with permission.

59 Basic Trauma Nursing 71 and it has blisters and a glistening or wet appearance. Second-degree burns are painful. The burn heals in 7 to 14 days as the epithelial layer regenerates. Third degree: The full thickness of the epidermis and dermis is destroyed in a third-degree burn, and damage may extend through or beyond the subcutaneous fat. The burned area may appear waxy, dry, leathery, or charred and may be discolored to brown or white. Clotted blood vessels may be seen under the burned skin. Subcutaneous fat may be exposed. The ability for this area to spontaneously reepithelialize is destroyed. The contact burn area (zone 1) is not painful because superficial nerve endings and blood vessels have been destroyed. However, the surrounding less severely burned area will be extremely painful. The affected area requires excision and skin grafting to heal. Location Any burn that is circumferential of (totally around) an extremity, the neck, or chest may contribute to compromised circulation or respiration. Burns of the face and neck with swelling may cause respiratory compromise as well as have emotional and psychological significance. Burns of the hands inhibit the ability to perform tasks and are of concern for long-term function. Burns of the feet impair ambulation. Burns of the perineum are at risk for infection from urinary/fecal contamination. Burns over any joint are at risk for contracture formation. PRIMARY SURVEY AND RESUSCITATION Airway History of being burned in an enclosed space or any signs of respiratory difficulties necessitates evaluation of the airway and definitive management. Inhalation injury may be subtle and signs frequently do not appear in the first 24 hours. Signs of inhalation injury include singed or absent facial hair, facial burns, difficulty speaking, hoarseness, or stridor. Soot in the oropharynx and oropharyngeal edema may also be noted. Early and aggressive airway management is required with a very low threshold to intubate with suspicion of inhalation injury. TABLE 11-2: CARBON MONOXIDE POISONING LEVELS AND SYMPTOMS CO Level Symptoms < 20% No symptoms 20% to 30% Headache and nausea 30% to 40% Confusion 40% to 60% Coma > 60 Death Note. Adapted from American College of Surgeons (ACS). (2012). ATLS: Advanced trauma life support for doctors (9th ed.). Chicago, IL: Author. Breathing Breathing can be impaired by the following injuries: inhalation of by-products of combustion, carbon monoxide poisoning, and restricted chest wall motion. Determine breathing effectiveness. Observe rate and depth of ventilations. Obtain a carboxyhemoglobin level with arterial blood gas analysis on admission. Carbon monoxide poisoning can result in coma or death (ACS, 2012; see Table 11-2). As previously discussed, carbon monoxide has increased affinity for hemoglobin, which displaces oxygen from the hemoglobin molecule. Promptly remove the patient from continued exposure and immediately institute oxygen therapy with a nonrebreather mask (Shochat & Lucchesi, 2015). Bronchoscopy is highly likely if the patient has inhalation injury; therefore, ensure that a large enough endotracheal tube is selected (generally size 7.0 and above) to accommodate later bronchoscopy. Full-thickness burns of the chest may also limit the ability of the chest wall to expand, and gas exchange will be inadequate. If the patient has full-thickness eschar that causes respiratory embarrassment, escharotomies are performed immediately at the bedside with an electrical cautery knife after the administration of IV narcotic analgesia. Improvement in chest wall expansion should occur immediately. After completion of the procedure, topical antibacterial agents are applied, along with wet-to-dry gauze dressings. Circulation Key point: In a burn involving less than 20% TBSA, burn response is usually limited to the burn area. Beyond 20%, the response goes from local to systemic. Therefore, it is recommended that any patient with a burn greater than 20% receive IV hydration, placement of a nasogastric tube for probable ileus, and a urinary catheter for fluid status monitoring. Hypovolemia that causes hypoperfusion of burned tissue and sometimes shock can result from fluid losses due to burns that are deep or that involve large parts of the body surface; whole-body edema from escape of intravascular volume into the interstitium and cells also develops (Wolf, 2013). Manual blood pressure measurements are difficult to obtain over burned skin; therefore, invasive arterial pressure monitoring can be helpful. Monitoring hourly urine output is necessary to judge the effectiveness of fluid resuscitation. A urinary catheter should be inserted in patients with burns greater than 20%. Insert a urinary catheter to monitor the effectiveness of fluid resuscitation (ENA, 2014). Normal urine output is: Adults: 0.5 ml/kg/hr Child: 1.0 ml/kg/hr Infant: 2.0 ml/kg/hr Two to four large-bore IV catheters should be placed, avoiding the legs because of the risk of thrombophlebitis. Peripheral IVs may be inserted into burn tissue if no other access is available, but only as a last resort. Suturing catheters in place may be considered because tape does not hold to burn tissue. Central lines are to be avoided but can be useful to measure central venous pressure. Begin fluid resuscitation with lactated Ringer s (ABA, 2011). It has the benefit of providing potassium, calcium, and lactate, in addition to sodium and chloride. It mimics the ions in plasma that are lost with increased capillary permeability. The goal of resuscitation is to support tissue perfusion and organ function while avoiding the complications of inadequate or excessive fluid therapy (ABA, 2011). Currently, burn patients require 2 ml of lactated Ringer s solution per kilogram of body weight per percentage of body burn in the first 24 hours (ABA, 2011). Of this amount, 50% should be infused in the first 8 hours postburn, and the remaining 50% should be given over the remaining 16 hours. The calculation should be made from the time of the actual burn, not arrival to the hospital. Research indicates that resuscitation based upon using 4 ml LR per kg per % TBSA burn commonly results in excessive edema formation and overresuscitation (ABA, 2011). In high-voltage electrical injuries where there is evidence of deep tissue injury (second or third degree) or hemochromogens (red pigments) in the urine, the recommendation is to use 4 ml of LR per kg of body weight per % TBSA (ABA, 2011). Caution should be taken with this formula because it is only an estimate of fluid need. The volume of IV fluid given should be carefully adjusted according to the individual patient s response as monitored by urinary output, vital signs, and general overall condition. A CASE STUDY 70 kg 40-year-old female sustains full-thickness burns to her entire circumferential right leg, her anterior torso, and her anterior right forearm and hand at 6:00 a.m. in a house fire. Questions 1. Use the rule of nines to estimate the extent of her burns. 2. Calculate the fluid requirements for: a. the first 24 hours postburn. b. the first 8 hours postburn. Answers 1. Burn extent using rule of nines: Entire right leg = 18.0% Anterior torso = 18.0% Anterior forearm = 4.5% 40.5% 2. Calculate the fluid requirements for: a. the first 24 hours postburn ( = 5,600 ml) b. the first 8 hours postburn (5,600/2 = 2,800 ml) Temperature Regulation Skin is the main organ for regulation of body temperature. A burn can disrupt or destroy this function. Further heat loss can occur from the flushing of burned tissue, administration of IV fluids, and the cool environment of the emergency department. Keep heat loss at a minimum by covering the patient with warm blankets, using warmed IV fluids and warmed humidified air for the ventilator circuit, covering the head, increasing the room temperature, and using an overhead warmer. Wound Care 1. Remove all of the patient s jewelry. 2. Assess the status of distal circulation. Use of a Doppler ultrasonic flow meter may be necessary to assess the peripheral pulses. 3. Apply clean dry white sheets and warm blankets over the wounds. The priority is not the wound, but the respiratory and hemodynamic stability of

60 72 Basic Trauma Nursing the patient. Superficial burns are painful but do not require any special wound care. Topical or oral analgesics may be used (Cameron, Ruzehaji, & Cowin, 2010). 4. Treatment of chemical burns: Brush off all powders or particles prior to flushing. Flushing of the area should begin as soon as possible, unless there is a specific antidote available per Material Safety Data information. Contain all water used for flushing; do not allow emptying into the general drainage system. The patient s clothing should be removed immediately, taking care not to get the chemical on the caregiver. Flushing should continue for at least 10 minutes to ensure that the entire chemical is removed. Periodically assess the ph with litmus paper until neutral. Following the flushing, cover the burned area with sterile, dry dressings. Irrigate eye injuries thoroughly with copious amounts of water or normal saline solution. Obtain an ophthalmology consultation immediately. 5. Apply mineral oil or petroleum jelly to tar or asphalt injuries. Immediately cool with ice, which will loosen the tar and allow you to remove the substance from the injured tissue. 6. Clean electrical wounds gently with water or normal saline solution. Electrical injuries may include muscle injury but little external tissue loss. However, electrical burns can be extremely deep and serious. The extremities can have considerable damage and tissue swelling, putting the patient at risk for compartment syndrome, which is indicated by pain, pallor, paresthesia, pulselessness, and paralysis. Use extreme care handling the limbs because the large vessels can tear, leading to massive hemorrhage. 7. For definitive care, a topical antimicrobial agent such as Silvadene, Sulfamylon, silver nitrate solution, gentamicin, or bacitracin may be applied, with eventual excision and primary closure or excision and grafting, depending on the burn. If, however, the patient is going to be transferred to a burn center, do not apply ointment and just keep the patient warm and covered. Gastric Tube Insertion Insert a nasogastric tube and attach it to suction. Patients with a greater than 20% burn often suffer from an ileus and can vomit and aspirate. Narcotics, Analgesics, and Sedatives Narcotics, analgesics, and sedatives should be administered in small frequent doses by IV routes only. Criteria for Transfer The American Burn Association has identified the following types of burns that require transfer to a burn center (ENA, 2014): 1. Partial-thickness and full-thickness burns greater than 10% of the TBSA in patients younger than 10 years of age or older than 50 years of age 2. Partial-thickness and full-thickness burns greater than 20% TBSA in other age groups 3. Partial-thickness and full-thickness burns involving the face, eyes, ears, hands, feet, genitalia, or perineum or those that involve skin overlying major joints 4. Full-thickness burns greater than 5% TBSA in any age group 5. Significant electrical burns, including lightning injury 6. Significant chemical burns 7. Inhalation injury 8. Burn injury in patients with preexisting illness that could complicate management, prolong recovery, or affect mortality COLD INJURY Cold injury depends on temperature, duration of exposure, environmental conditions, amount of protective clothing, and the patient s general state of health. Frostnip Frostnip is the mildest form of cold injury. Signs and symptoms include pain, pallor, and numbness of the body part. It is easily reversible with rewarming and does not result in any tissue loss. Frostbite Frostbite is due to freezing tissue. When rewarmed, there may be further injury. Frostbite can be classified as superficial or deep. Trench Foot, or Cold Immersion This painful injury is a nonfreezing of the hands or feet, typically seen in soldiers, sailors, or fishermen, that results from chronic exposure to wet conditions and temperatures just above freezing. Treatment of Cold Injuries Treatment should be immediate to decrease the time of tissue freezing. Ensure adequate ABCs of resuscitation. Remove constricting and damp clothing. Monitor the patient s core temperature. Cover with warm blankets. Administer hot fluids orally. Place the injured body part in circulating warm water. Avoid dry heat. Do not rub or massage the injured area. HYPOTHERMIA Hypothermia is defined as core temperature below 95 F (35 C). Hypothermia can be a solitary event due to environmental exposure, or it may be associated with trauma. Any degree of hypothermia in a trauma patient is considered detrimental. Treatment of Hypothermia Remove the patient from the cold environment. Remove wet, cold clothing and cover the patient with warm blankets or provide a convection air warmer. Administer warm oxygen. Administer IV fluids warmed to 76 F (42 C). Initiate cardiac monitoring. Consider a warmed saline lavage into the stomach or bladder. If the patient is in cardiac arrest, core temperature should be raised above hypothermic levels before the patient is pronounced dead. Remember the axiom: You are not dead until you are warm and dead. SUMMARY Burns are potentially the most painful and serious injuries that a person can sustain. Care of the burn patient is complex. Nursing management requires the nurse to explore many areas of nursing, continually evaluating signs and symptoms of physical dysfunction and addressing psychosocial impairment associated with injury. Chapter 12: Trauma in the Pregnant Woman CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe the principles of assessment and treatment of the pregnant trauma patient. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Describe normal changes in anatomy and physiology during pregnancy. 2. Identify common mechanisms of injury in trauma in pregnancy. 3. Identify frequent injuries seen in the pregnant trauma patient. 4. Describe appropriate nursing assessment of the pregnant trauma patient. 5. Discuss appropriate interventions for the pregnant trauma patient. INTRODUCTION Trauma is not only the leading cause of death among women of childbearing age; it is the leading nonobstetric cause of maternal death and disability during pregnancy (ENA, 2014). Trauma during pregnancy involves the safety and lives of both the mother and child. The number one cause of fetal death in trauma is maternal death. The fetal outcome is directly correlated to the maternal outcome. It is estimated that 7% of all pregnancies are complicated by trauma (Barraco et al., 2010). CHANGES IN ANATOMY AND PHYSIOLOGY DURING PREGNANCY Anatomic Differences The uterus remains an intrapelvic organ until approximately the 12th week of gestation, when it begins to rise out of the pelvis. During the last 2 weeks of gestation, the fundus descends as the fetal head engages the pelvis. As the uterus enlarges, the bowel is pushed cephalad so that the bowel lies mostly in the upper abdomen. Consequently, the bowel is more protected in blunt abdominal trauma, whereas the uterus and its contents become more vulnerable (see Figure 12-1). During the first trimester, the uterus is a thickwalled structure of limited size, mostly confined

61 Basic Trauma Nursing 73 Figure 12-1: Fetus in Normal Position Note. From Mistovich, Joseph J.; Karren, Keith J.; Hafen, Brent. Prehospital Emergency care, 10th edition Reprinted by permission of Pearson Education, Inc., New York, New York. within the bony pelvis. During the second trimester, it enlarges beyond its protected location, but the small fetus remains mobile and cushioned by amniotic fluid. By the third trimester, the uterus is large and thin-walled. In the typical vertex presentation, the fetal head is usually within the pelvis, with the remainder of the fetus exposed above the pelvis. Pelvic fractures in late gestation may result in skull fracture or serious intracranial injury to the fetus. The placenta has minimal elasticity, which can result in vulnerability to shear forces from the uterus. The placental vasculature is maximally dilated throughout gestation, yet it is very sensitive to catecholamine stimulation. A drop in maternal blood volume will result in uteroplacental vasoconstriction. Blood Volume and Hemodynamic Changes Plasma volume increases steadily throughout pregnancy (known as hypervolemia of pregnancy) and plateaus at 34 weeks gestation. A small increase in red blood cell volume occurs, resulting in decreased hematocrit, known as physiologic anemia of pregnancy. In late pregnancy, a hematrocrit of 31% to 35% is normal. In healthy individuals with normal oxygen-carrying capacity, the traditional signs of hemorrhage and adaptation do not become evident at rest until 15% to 20% (i.e., 1,200 ml) of total blood volume is lost (Schwaitzberg, Mahoney, & Newton, 2013). Fetal heart rate can act as a monitor of fetal well-being, adequacy of the pregnant woman s circulating blood volume, and her compensatory alpha-adrenergic response (Schwaitzberg, Mahoney, & Newton, 2013). Heart rate gradually increases during pregnancy until the second trimester and stays elevated by 10 to 20 bpm. This change in heart rate must be considered when interpreting the tachycardic response to hypovolemia. Peripheral resistance decreases, causing a small decrease in systolic blood pressure (Chang, 2011). After 20 weeks gestation, when the mother is supine, the fetus may compress the aorta and vena cava, decreasing cardiac output. Supine hypotension syndrome (autocaval compression) may occur after 20 weeks gestation as the aorta and inferior vena cava are compressed by the uterus when the patient is supine (ENA, 2014). Because the maternal perfusion pressure controls blood flow in the uterus, the changes can decrease perfusion in the uterus. At a time when uterine vasodilation is expanded to the maximum point, the vessels are unable to respond any further to the demand for increased blood flow. The patient can be tilted at least 15 in either direction to displace the gravid uterus off the aorta and inferior vena cava (ENA, 2014). In maternal shock with hypovolemia, a compensatory inhibition of vagal tone and release of catecholamines will occur. The effect of this response is to produce vasoconstriction and tachycardia. This vasoconstriction profoundly affects the uterus, causing fetal hypoxia and distress. Signs of hypovolemia (late decelerations or fetal tachycardia) may be present before overt changes in maternal vital signs (Zuccala & Alvero, 2013). Caution: The pregnant trauma patient can lose up to 1,500 ml of blood before any detectable change is noted in her blood pressure. Pregnant women in shock do not always have the physical indicators of cool, clammy skin because of vasodilation in the first two trimesters. The fetus is compromised with maternal blood loss of 15% to 30%. The fetus may be in distress, despite a stable mother. The fetus is often the first to show evidence of decreased uterine perfusion; therefore, assess the fetus for changes in fetal movement and fetal tachycardia or bradycardia (normal fetal heart rate is 120 to 160 bpm; ENA, 2014). Pulmonary Changes Significant changes in the pulmonary system occur during pregnancy. These include an increase in the amount of air moving in and out of lungs with each breath (tidal volume), an increase in the maximum amount of air exhaled from the point of maximum inspiration (vital capacity), an increase in respiratory rate with arterial blood gas levels reflecting hyperventilation and compensated respiratory alkalosis, and a decrease in the volume of air in the lungs at end expiration (functional residual capacity) due to an elevated diaphragm. Elevation of the diaphragm reduces the mother s pulmonary functional residual capacity. The capacity is also reduced because of increased maternal oxygen consumption. The diminished functional oxygen reserve in the mother makes the uterus susceptible to hypoxia, which affects fetal oxygenation. When fetal respiratory compromise occurs, the first sign is often a change in the fetal heart rate. In the case of maternal trauma, blood gas levels should be monitored to determine if hypoxia and acidosis have occurred. Supplemental oxygen at 100% is required. Neurologic Changes The nervous system does not normally change physiologically during gestation. Changes in the central nervous system during pregnancy may be indicative of pregnancy-induced hypertension, which may cause seizures and symptoms similar to a head injury. It should be considered if seizures occur with associated hypertension, hyperreflexia, proteinuria, and peripheral edema. Endocrine Changes The pituitary gland doubles in size and weight, and it needs an increased blood supply by the end of the pregnancy. Pituitary necrosis may be seen after severe postpartum hemorrhage and hypovolemia, and it may cause hypopituitarism immediately or several years later, depending on the degree of tissue destruction (Hao, Liu, & Mo, 2012). Gastrointestinal Changes Gastric emptying is prolonged during pregnancy. Early insertion of a nasogastric tube is necessary

62 74 Basic Trauma Nursing to minimize the risk of aspiration. The small bowel is pushed into the upper abdomen by the uterus. The large bowel moves posteriorly. Diminished bowel sounds may be a normal condition or may be a sign of intraperitoneal injury. Progesterone affects the gastrointestinal tract by reducing motility and tone, while relaxing the gastric sphincter. As the abdominal wall stretches, it becomes less sensitive to peritoneal irritation, causing muscle guarding, rigidity, or rebound tenderness to be dulled or absent and making abdominal physical examination difficult. Genitourinary Changes By the end of the first trimester, the bladder moves from a pelvic position to an intra-abdominal position, making it more vulnerable to injury. The uterus compresses the bladder by the third trimester, causing urinary frequency. Urinary stasis may occur from dilation of the ureters due to compression by the ovarian plexus. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values (Cheung & Lafayette, 2013). Musculoskeletal Changes As the pelvis prepares for pregnancy, it becomes more flexible. Hormonal changes loosen the ligaments of the symphysis pubis and sacroiliac joints. There is significant widening of the symphysis pubis by the seventh month. Because of these changes, the pelvis is less susceptible to fractures. MECHANISM OF INJURY Obviously, trauma can affect both the mother and child. Risks vary according to the stage of gestation and the changing vulnerability of the uterus. However, the stability of the mother most often predicts the outcome of the fetus. In the first trimester, the fetus has little chance of direct injury because the uterus is still small and protected by the pelvis. However, if the mother is injured, the fetus may suffer consequences from her injuries, such as hypoxia and decreased perfusion. By the last trimester, the uterus and fetus are more likely to be injured from direct trauma because of the expanded anatomic position. Blunt Trauma The most common causes of abdominal trauma are motor vehicle crashes, falls, and assaults. Other sources of injury are penetrating objects, domestic violence, burns, and smoke inhalation. As in any case of blunt trauma, the severity of injury ranges from minor to life threatening to the mother and fetus. Blunt abdominal trauma from rapid forward deceleration such as in motor vehicle crashes directs the energy through the abdomen, compressing the organs and structures against the spine. The fetus often takes the direct hit to the abdomen. In the third trimester, when the uterus is high in the abdomen and the fetus is exposed, the transferred energy can be a deadly force. The uterus may rupture, or the placenta may separate from the wall of the uterus. Massive hemorrhage and death of the mother and fetus can result. If the force is great enough to fracture the mother s pelvis, the fetal skull may also be fractured. Seat Belt Use If worn correctly, seat belts do not cause harm to the mother or baby. The American College of Obstetricians and Gynecologists (ACOG) suggests wearing the lap belt portion low on the hip bones and below the belly. The pregnant woman should put the shoulder belt portion to the side of her belly and across the center of her chest (ACOG, 2014; see Figure 12-2). Choosing not to wear a seat belt, based on the erroneous idea that it might injure the fetus, only contributes to the possibility of injury. Ejection from the vehicle is more likely to occur when a shoulder harness and lap restraint are not used. The mother is apt to have head trauma when ejected, and fetal fatality is more likely. Seat belts can cause serious injury if worn incorrectly, but the risks to mother and fetus are greater without them. Air bag use has also been shown to be safe for the mother and fetus. Falls The potential for a fall increases because hormonal changes soften joints and relax the pelvic ligaments. As a result, the mother has unstable balance and gait, has a protruding abdomen, and is easily tired. All of these factors make her more susceptible to a fall. Most falls happen during the third trimester. Penetrating Trauma Gunshots and stab wounds are the predominant cause of penetrating trauma. The probability of fetal injury is related to the point of contact of the penetrating mechanism, the stage of pregnancy, and fetal position. Uterine growth displacing the stomach and small intestine provides some protection for the mother against penetrating trauma. Although multiple organ injury to the mother is less likely to occur, the fetus is often wounded. Firearm injury to the maternal abdomen and uterus are frequently associated with fetal injury and death (ENA, 2014). Domestic Violence Physical abuse of women is increasing and is often exacerbated during pregnancy. It occurs Figure 12-2: Seat Belt Use During Pregnancy Note. From National Highway Traffic Safety Administration. regardless of ethnic background, cultural influences, or socioeconomic status (CDC, 2013). Factors that may suggest the presence of domestic violence include injuries inconsistent with stated history; diminished self-image, depression; self-abuse; frequent emergency department or physician office visits; and self-blame for injuries. SELECTED OBSTETRIC INJURIES Premature Labor The most frequent obstetric trauma complication is the onset of premature labor, which occurs in up to 25% of patients (ENA, 2014). Damaged cells release prostaglandin, a chemical that begins contractions. Basically, the degree of uterine damage, fetal age, and amount of prostaglandin released determine the progression of the contractions and labor. Premature labor usually can be detected in alert patients. However, in the unconscious or intubated patient, it easily can be missed. Generally, the contractions are self-limiting, and medical suppression is not necessary. If the contractions proceed, it may indicate other uterine complications such as abruptio placentae. Tocolysis, which is pharmacologic suppression of contractions, may effectively ablate the contractions. Place the patient suspected of having preterm labor on strict bed rest in the lateral decubitis position and administer an IV bolus of 500 to 1,000 ml lactated Ringer s (LR) over 30 to 60 minutes (Wilkins, Tirol, Peters, & Bearup, 2010). Signs and Symptoms Uterine contractions greater than 6 per hour Back pain Cervical dilation or effacement

63 Basic Trauma Nursing 75 Abruptio Placentae The most common cause of fetal death after blunt maternal injury is abruptio placentae, a separation of the placenta from the uterus that rarely occurs with a minor injury. Abruptio placentae is the leading cause of fetal death that is not related to maternal death. The maternal mortality rate is low; however, fetal mortality rates are as high as 30% to 68% (Chang, 2011). Because all gas exchange between the mother and the fetus is across the placenta, oxygen to the fetus decreases in abruptio placentae, and carbon dioxide increases in the fetal circulation. Fetal insult or death may occur and is related to the time between the separation of the placenta and delivery of the infant. Signs and Symptoms Vaginal bleeding (may be present or absent depending on the location of placental separation from the uterus) Uterine tenderness Abdominal pain Maternal shock Increasing fundal height Fetal distress (fetal monitoring should continue until the obstetrician states otherwise) Fetal distress requires immediate surgery. It is possible for the fetus to survive a small abruption. Uterine Rupture A direct blow to the abdomen or extreme compression injury can cause a rupture of the uterus. A previous cesarean section is a predisposing factor because it makes a woman vulnerable at the suture line. Although rare, a rupture of the uterus is highly lethal to the fetus and is usually associated with severe maternal injuries. Uterine rupture may be associated with pelvic fractures and bladder rupture. The clinical presentation is often dramatic, with severe abdominal pain and distention, palpable fetal parts, and shock. Maternal death generally is associated with additional injuries and occurs in less than 10% of cases, whereas fetal death is close to 100%. The uterus usually cannot be repaired, and a hysterectomy is indicated. Signs and Symptoms Abdominal pain Uterine tenderness Absent fetal heart tones Change in fundal height or abnormal contour of uterus Vaginal bleeding Maternal shock Perimortem Cesarean Section In rare circumstances, there have been successful emergency cesarean deliveries of viable fetuses in pregnant trauma victims in cardiopulmonary arrest. To optimize fetal outcomes, it is recommended that the cesarean section be initiated within 4 minutes of maternal arrest and the fetus delivered within 5 minutes of any successful maternal resuscitative attempts (the five minute rule adopted by the American Heart Association; Vanden Hoek et al., 2012). Immediately assess gestational age for viability (greater than or equal to 24 weeks). Promptly initiate CPR at the first signs of maternal arrest. Ensure availability of a neonatal resuscitation team. ASSESSMENT History Questions to ask: What was the mechanism of injury? Was the patient wearing a seat belt? When was the last menstrual period? When is the expected date of confinement? Have there been any complications during this pregnancy? Is there fetal activity? Does the mother feel the fetus moving? Are there any uterine contractions or abdominal pain? Initial Assessment Initial assessment priorities for an injured pregnant patient remain the same as for the nonpregnant patient. As with any trauma patient, the first priorities are the ABCs. Assure patent airway, adequate ventilation, and circulation. Auscultate fetal heart tones and rate. Initial fetal heart tones can be auscultated with a Doppler transducer (at 10 weeks or greater gestation). Normal fetal heart tones are 120 to 160 bpm. Bradycardia is a sustained fetal heart rate (FHR) less than 110 bpm. Tachycardia is a sustained FHR greater than 160 bpm. Inspect the perineum. Determine if there is any vaginal bleeding or the presence of amniotic fluid. A ph of 7 to 7.5 in the vagina suggests the presence of amniotic fluid, which indicates ruptured membranes. Palpate fundal height to estimate gestational age. The fundus is measured in centimeters from the symphysis pubis to the top of the fundus. The fundus can usually be palpated by 12 to 14 weeks gestation, and it reaches the umbilicus by 20 weeks. When the fundus is just below the xiphoid, the fetus is full term. Palpate the uterus for uterine tenderness or contractions. Shield the uterus for all necessary radiographs and avoid any duplication of films. Diagnostic Testing Indications for focused assessment sonography in trauma examination, diagnostic peritoneal lavage (DPL), or abdominal CT scan are the same as in the nonpregnant patient. If a DPL is performed, the catheter should be placed above the umbilicus, using an open technique. A fetal ultrasound is useful to detect fetal cardiac activity, movement, location, approximate age, and the amount of amniotic fluid. Fetal death also can be ascertained. The Kleihauer-Betke test determines whether fetal red blood cells are in the maternal circulation, which indicates hemorrhage of fetal blood through the placenta into the mother s circulation. This test is especially important for women who are Rh negative and have a fetus that is Rh positive. Treatment Logroll the patient toward her left side (tilt backboard 15 to 20 to the left) or manually displace the uterus to the left side with a roll under the right flank. Administer lactated Ringer s solution or normal saline solution IV via two large-bore catheters. Avoid the administration of vasopressors for the hypotensive pregnant trauma patient. Administer type-specific blood when at all possible. If type-specific blood is unavailable, for hemodynamically unstable bleeding patients, the use of emergency uncrossmatched type O Rh-negative blood is preferred. Insert a nasogastric tube early to prevent aspiration. Insert a urinary catheter to monitor urine output. Obtain an early obstetric consultation. Initiate FHR monitoring as soon as possible, but avoid interference with maternal resuscitation and stabilization. Continuous FHR monitoring is required for patients with a gestational age of greater than 20 weeks for a minimum of 4 to 6 hours. It is essential that a healthcare provider experienced in the interpretation of fetal monitoring be present to assist in the care of the patient (ENA, 2014). Consider all pregnant Rh-negative trauma patients for Rh immunoglobulin therapy unless the injury is very distant from the abdomen. Therapy should be instituted within 72 hours of injury and is determined by the obstetrician. SUMMARY Remember that the initial management of the pregnant trauma patient is directed at resuscitation and stabilization. The fetus is totally dependent on the mother s well-being. The number one cause of fetal demise is maternal demise. Therefore, goal-directed therapy should concentrate on maternal resuscitation to maximize fetal outcomes. Fetal monitoring should be maintained after satisfactory resuscitation and stabilization of the mother. It is important for the trauma surgeon to work together with the obstetrician for the best outcomes for the two patients. Chapter 13: Pediatric Trauma CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe assessment of and interventions for common pediatric trauma injuries. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Identify the unique characteristics of a child s anatomy and physiology. 2. Describe the common mechanisms of injury seen in pediatric trauma. 3. Identify common pediatric trauma injuries. 4. Discuss the appropriate assessment of a pediatric trauma patient. 5. Select appropriate nursing interventions for the pediatric trauma patient.

64 76 Basic Trauma Nursing INTRODUCTION It is often said in the field of pediatrics that children are not little adults. This true statement is echoed in the fact that children do have unique anatomic and physiologic characteristics. There are biophysical, psychosocial, and cognitive differences that distinguish them from adults. However, trauma resuscitation for a patient of any age requires immediate measures, which include assessing a patient s airway, breathing, and circulation, while simultaneously identifying life-threatening injuries (Dries, 2014). It is important to note that trauma is the primary cause of mortality and morbidity in the pediatric population (CDC, 2014a; Murphy, Xu, & Kochaneck, 2013). ANATOMY AND PHYSICAL CHARACTERISTICS OF CHILDREN Physical Growth The first year of life sees tremendous changes in growth and development. Average birth weight doubles in 6 months and triples by the end of the year. After that time, weight gain slows to about 2.5 kg (1 kg equals 2.2 lb) a year during the preschool and school years. Young children and infants have a higher center of gravity. The young child and infant s head is large in relation to his or her body, allowing a significant amount of heat to be lost through the scalp (see Figure 13-1). The combination of a large head and high center of gravity causes infants and young children to have poor balance control and be predisposed to falls. Metabolism and Fluid and Electrolyte Balance Fluid distribution in infants is different from that in adults. Seventy-five percent of the infant s weight is water, compared to 60% to 70% in the adult. Infants and young children have a metabolic rate 2 to 3 times greater than older children and adults. Therefore, their caloric, fluid, and oxygen needs are greater. Increased fluid needs and fluid turnover can bring about rapid deficits during periods of decreased fluid intake or increased fluid loss. Dehydration quickly follows. Thermoregulation Increased heat loss from the relatively large ratio of body surface area to weight and the limited ability to produce heat make it difficult for infants and small children to maintain their body temperatures. The large head size accounts for a high percentage of surface area and heat loss. Respiratory System Newborns normally have adequate pulmonary structures to support oxygenation and ventilation. However, the small airway size and an immature immune system increase the possibility of obstruction and respiratory disorders. Airway The child s neck is shorter, the tongue is larger, and the trachea is narrower than an adult s. It takes just a small amount of mucus, a small foreign object, or slight tissue edema to close off the airway (see Figure 13-2). Infants are nose breathers for the first few months of life, and nasal congestion can bring on signs of respiratory distress. Figure 13-1: Anatomic Considerations in the Infant and Child Note. From Mistovich, Joseph J.; Karren, Keith J.; Hafen, Brent. Prehospital emergency care, 10th edition Reprinted by permission of Pearson Education, Inc., New York, New York. A jaw thrust or chin lift will open the infant or young child s airway. In children younger than 8 years of age, the narrowest part of the airway is the cricoid cartilage. Historically, uncuffed endotracheal tubes were used in this age group; however, cuffed endotracheal tubes (CETTs) offer a large number of advantages in routine pediatric use. Their use requires selecting a correctly sized tracheal tube, placing it correctly, and monitoring cuff pressure during the conduct of anesthesia (Bhardwaj, 2013). Breathing Children younger than 7 or 8 years of age breathe with their diaphragms or abdomens. The diaphragm is the child s primary muscle of ventilation because the intercostal muscles are poorly developed and contribute little to chest wall movement. The weaker and less effective accessory muscles and the thin chest wall make it easier to see retractions in the supraclavicular, intercostal, and substernal areas (Gross, 2011). Crying children tend to swallow air, which causes gastric distention. Respiratory rates and oxygen consumption in children are higher because of their faster metabolic rates. Generally, the younger the child, the faster the respiratory rate (see Table 13-1). Infants and young children have fewer and smaller alveoli than adults; consequently, they have less pulmonary reserve. Children may become fatigued during the increased work of breathing. Due to diminished respiratory reserve and higher oxygen requirements, untreated respiratory distress can turn rapidly into respiratory failure. The chest wall in infants and young children is somewhat pliable, and blunt trauma to the chest usually results in rib contusions instead of fractures. When there are rib fractures, severe internal trauma is also likely. Cardiovascular System The child s normal cardiovascular system is anatomically and physiologically different from the adult s, which affects the child s response to stress. Blood volume, although actually low in the child, is relatively greater than the adult s. It does not take a great deal of blood loss in the child to impair perfusion and decrease circulating volume. However, even with serious blood loss, a large cardiac reserve and catecholamine response will maintain a normal blood pressure. Only when 30% of the circulating volume is lost does hypotension become evident. Hypotension is a late sign of hypovolemia and indicates impending cardiac arrest. The axiom in pediatric physiology and resuscitation is Adults roll downhill, while kids fall off cliffs. The inference is that adults demonstrate predictable physiologic signs during decompensation (yielding notable points at which one can intervene), whereas pediatric patients maintain normotension until the heart rate can no longer compensate, and then decompensation is rapid and profound (bradycardia and hypotension). Higher metabolic and oxygen demands in children require higher cardiac output per kilogram. When oxygen decreases, tachycardia is the response. If tachycardia does not increase oxygen delivery, tissue hypoxia and hypercapnia develop. Bradycardia follows, which is a late and ominous sign. As a rule, blood pressure increases with the age of the child (see Table 13-1). A neonate usually has a systolic pressure of 50 to 60 mm Hg. The same

65 Basic Trauma Nursing 77 Figure 13-2: Comparison of Adult and Pediatric Airways Pliable, smaller nares are prone to occlusion. Obligate nose breathers for up to a year. Softer palate(s) prone to trauma with intervention. Tongue is larger in proportion to the mouth. The epiglottis is large and floppy. The larynx is higher and more anterior. Flexible trachea inclined to collapse with hyperflexion. More elastic cartilaginous rings prone to collapse. Table 13-1: Pediatric Vital Signs Age Heart Rate (beats/min) Blood Pressure (mm Hg) Respiratory Rate (breaths/min) Premature / months / months / months / years / years / years /60/ years /65/ Note. From Mistovich, Joseph J.; Karren, Keith J.; Hafen, Brent. Prehospital emergency care, 10th edition Reprinted by permission of Pearson Education, Inc., New York, New York. pressure in a child indicates hypotension. A neonate s heart rate is usually 120 to 160 beats per minute (bpm) and decreases as the child grows older. Neurologic System Major neurologic structures are present but incompletely developed at birth. Temperature instability indicates incomplete development of the autonomic nervous system. Infants sensitivity to parasympathetic stimulation is shown by bradycardia with defecation or deep suctioning. The infant s head is proportionately larger than the adult s head. The bones of the cranium are soft and pliable, and they are held together by fibrous sutures to allow for brain growth. This structure allows the skull to cope with increased intracranial pressure (ICP), but it is also less able to protect the brain. A large head and high center of gravity make a child more prone to falls and head injuries. Infants (1 month to 1 year of age) are at risk for sustaining injury in the home environment. Falls and unintentional strikes are the leading mechanism of injury but rarely cause death (CDC, 2014b). Infants can have significant bleeding from a scalp laceration because of increased vascularity and large surface area. The cervical spine is vulnerable to injury. A large head, short neck, and more pliable ligaments increase the risk of hyperextension and flexion injuries. The vertebrae do not easily fracture, but the spinal cord is vulnerable. Musculoskeletal System Bones are pliable, so greenstick or incomplete fractures are common. Bone growth allows rapid callus formation, which permits bones to heal quickly. Although the bones are strong, fractures occur more frequently than muscle sprains or ligament tears because these structures are stronger than the bones. The growth (or epiphyseal) plate is unique to children. New longitudinal bone growth is dependent on this cartilaginous area, which does not ossify until puberty. This characteristic allows a fracture to be present without radiographic detection. Gastrointestinal and Genitourinary Systems Undeveloped abdominal muscles are weak and allow children s stomachs to protrude. The small size of a child s abdomen holds the organs close together. These two factors make the abdomen vulnerable to blunt trauma, especially multiple organ injury. Additionally, pliable ribs provide inadequate support for the lungs and do not adequately protect the abdominal organs, which is another factor that places children at risk for internal injuries. MECHANISM OF INJURY Motor vehicle crashes are the leading cause of injury and death among children in the United States (CDC, 2014b). Deaths due to firearms, other transportation (such as off-road, water, and snow vehicles), falls, and drowning follow in descending order of frequency. Child abuse accounts for the majority of homicides in infants. Penetrating trauma,

66 78 Basic Trauma Nursing most frequently from firearms, most often affects adolescents and carries a high mortality rate (CDC, 2014b). Falls are the second most frequent injury seen but are the least lethal. Blunt mechanisms of injury and the child s small body result in multisystem injury much more often than isolated injury. Motor Vehicle Crashes Child Safety Seats Buckling children in age- and size- appropriate car seats, booster seats, and seat belts reduces the risk of serious and fatal injuries. Car seat use reduces the risk for death to infants (aged < 1 year) by 71% and to toddlers (aged 1-4 years) by 54%. Booster seat use reduces the risk for serious injury by 45% for children aged 4 to 8 years when compared with seat belt use alone, and seat belt use in older children reduces the risk for death and serious injury by approximately half (CDC, 2014a). When young children are unrestrained and involved in a motor vehicle crash, they are thrown around inside the vehicle and may receive injuries to the head, abdomen, chest, and extremities. They are also at high risk for being thrown through a window. Head injuries are the leading cause of death among unrestrained children. When children are held on the lap of an adult, they can be crushed between the adult and the dashboard or steering column, or against the front seat if they are back seat lap passengers. Young children can sustain certain seat beltrelated injuries because of body size and proportion. A greater percentage of a child s body size is above the safety belt than an adult s, which allows forward motion and an increased chance of head and neck injury. Children can also jackknife over restraints, causing an airway or hanging injury. Air Bags Air bags have contributed to serious injuries and deaths of infants and young children because they are deployed when the unrestrained child is thrown against the dashboard during rapid deceleration before impact. Air bag deployment then propels the child against the structures inside the vehicle. Infants riding in rear-facing safety seats should never ride in the front seat of a car or truck with a passenger-side air bag. All children younger than 12 years of age should be restrained in the back seat with a shoulder and lap restraint. Riding Equipment All-terrain vehicles, snowmobiles, farm equipment, and riding lawn mowers can be dangerous and cause serious injuries and deaths. Whether a young child is riding as a passenger on or an older child is operating these vehicles, terrible injuries or death can occur from either carelessness or lack of skill. Sports Skateboarding and rollerblading contribute to multiple injuries. Children have a high center of gravity, which interferes with their ability to break a fall. Skateboarders should always wear proper protective equipment and stay out of traffic. Pedestrian Injuries Pedestrian injuries are the second greatest cause of mortality in 5- to 9-year-olds. Walking, running, crossing a street, and entering or leaving a school bus make up most of the injuries, which occur most often in the afternoon and early evening. When a vehicle strikes a child, a triad of injuries (known as Waddell s triad) occurs. Waddell s triad, first described in 1971 by Waddell and Drucker, involves a pattern of injuries to the head, chest/abdomen, and lower extremities (Vinson & Greenwell, 2012). The polytraumatized patients need multidisciplinary care. There is a high percentage of musculoskeletal and nonorthopedic injuries in Waddell s triad (Núñez-Fernández, Nava-Cruz, Sesma-Julian, & Herrera-Tenorio, 2010). Falls Falls are the most common cause of head injury and trauma-related hospitalization in young children and older adults. Young children sustain most fall-related injuries in the home because of clutter in the home, infants in walkers, open windows, stairs, climbing, bunk beds, and a myriad of other situations. Injuries from falls are the leading cause of visits to emergency departments and to deaths due to injuries (Kafadar & Kafadar, 2015). Child Abuse Child abuse is associated with head injuries, burns, abdominal injuries, and fractures. One characteristic is an inconsistent story, that is, the stated mechanism of injury often does not match the injury observed. A significant time lapse between the injury and presentation to the emergency department is common. In many states, child abuse or neglect is a mandatory reportable incident, and local authorities may need to be notified for the protection of the child. COMMON PEDIATRIC TRAUMA INJURIES Head Injury The pediatric population, particularly children 0 to 4 years of age and 15 to 19 years of age, is at greatest risk for traumatic brain injury (TBI). Motor vehicle crashes and falls cause most head injuries in the pediatric population. Attention to the ABCs is imperative because hypoxia and hypotension from associated injuries can significantly impact the outcome from head injury. Hypotension from hypovolemia is the most significant secondary injury to the brain and should be avoided at all costs. Key points regarding pediatric head injury include the following: In general, children have better outcomes from head injury than adults. Children tend to have fewer focal masses (epidurals and subdurals) than adults. Children tend to have more brain swelling than adults. Early neurosurgical consultation is imperative. Intracranial pressure monitoring is recommended in infants and children with a Glasgow Coma Scale (GCS) score of 8 or less (Daley, Lee, & Raju, 2013). Spinal Cord Injury Although spinal cord injury is relatively uncommon in the pediatric population, cervical spine injury must be presumed until proven otherwise (Daley & Raju, 2013). Motor vehicle crashes are by far the most common mechanism of injury to the spine in the pediatric patient population; however, children also sustain injuries related to acts of violence, falls, and sports-related activities (NSCISC, 2013). More common in children than adults is spinal cord injury without radiographic abnormality (SCIWORA). The pliability of the child s spine allows cord injury without bony abnormality. Transient displacement of the spinal column results from a flexion-extension or acceleration- deceleration force. The head is hyperflexed or hyperextended, and the cord stretches, causing injury or transection. Subsequently, the spinal cord returns to its normal length, and the vertebrae realign. The patient has signs of spinal cord damage, such as paralysis or deficits, without radiographic correlation. Thoracic Injury Most pediatric chest injuries are the result of blunt trauma. In children, energy from blunt force may be transmitted to the internal thoracic structures: the heart, lungs, and great vessels. Because the ribs are undeveloped and flexible, blunt trauma usually causes a contusion, rather than a fracture. When a fracture does occur, it is likely the result of considerable force, and there is a good chance of damage to the internal organs. Flail segments should raise suspicion of severe parenchymal injury. Mobility of the mediastinal structures makes the child more sensitive to tension pneumothorax and flail segments. Abdominal Injury As with thoracic trauma, blunt force is the most frequent cause of abdominal injury in children. The most common mechanism of injury is the result of motor vehicle crashes and falls. As described before, the abdomen is small, and the organs are close together, so blunt force is liable to cause damage to more than one organ. The ribs and overlying muscle and fat offer less protection to the liver, spleen, and kidneys. This lack of protection carries a higher risk of intra-abdominal and retroperitoneal organ injury with blunt trauma (ENA, 2012). Liver and spleen injuries are managed nonoperatively in hemodynamically stable pediatric trauma patients (Marwan, Harmon, Georgeson, Smith, & Muensterer, 2010). Word of Caution Any child with a potentially bleeding internal organ should be immediately transferred to a trauma center. This is especially true if there is no operating room or surgeon available at the first hospital. Even though most of these cases will be managed nonoperatively, the patient needs specialized and careful monitoring, and if the patient starts to bleed, surgery may be required immediately. The child needs to be in a place that has the resources to respond quickly. Children restrained only by a lap belt are at risk for a pairing of injuries caused by severe flexion of the spine and the gastrointestinal tract. As the lap belt-restrained child jackknifes forward in a frontal crash, there is a flexion disruption or (Chance) fracture of the lumbar spine. This is frequently seen with an associated small bowel injury. Ongoing assessment and evaluation of interventions include frequent serial reevaluation of the primary survey, monitoring for changes in vital signs, and continued reevaluation and management of pain and identified injuries (ENA, 2014).

67 Basic Trauma Nursing 79 Abused Child Any child who sustains an intentional injury that is inflicted by his or her caregivers is said to have abused child syndrome. The terms child abuse and child maltreatment are used interchangeably to describe neglect and physical, emotional, and sexual abuse. The manner of identifying and reporting maltreatment is directly related to the legal definitions and protocols of the city, state, and hospital. Hospital staff must be well versed in this information and these procedures. Indicators of Suspected Abuse The history and physical injury do not match. A significant time interval has passed between the time of injury and seeking help. The child has a history of repeated trauma and having been treated in different emergency departments. The parents respond inappropriately or do not follow medical advice. The injury story changes among caregivers. Clinical Signs Suggestive of Abuse Unexplained bruises or welts found on the face, torso, buttocks, back, or thighs, often reflecting the shape of the object used, such as a belt buckle, strap, or fly swatter Unexplained burns on palms, soles of feet, buttocks, or back; burns from a cigarette or electrical appliance; or a rope burn Unexplained fractures or dislocations involving the skull, ribs, and bones around joints, including multiple fractures or spiral fractures Other unexplained injuries, such as lacerations, abrasions, a human bite, pinch marks, clumps of lost hair, retinal hemorrhages, or abdominal injuries EVALUATION AND MANAGEMENT Initial Assessment Airway Assess the airway. A patent airway is the starting place in the initial assessment of pediatric trauma. The inability to establish or maintain a patent airway, with subsequent lack of oxygenation and ventilation, is the most common cause of cardiac arrest in children. Breathing Are respirations spontaneous? What is the respiratory rate? Respiratory rate decreases with age. An infant takes about 40 to 60 breaths per minute (bpm), whereas an older child takes 20 bpm. Normal tidal volume varies from 6 to 8 ml/kg for infants and children. Assess ventilation by watching the rise and fall of the chest. Remember, hypoxia is the most common cause of cardiac arrest in children. Hypoventilation causes respiratory acidosis, which can be corrected with adequate ventilation and perfusion. Circulation The signs of shock in children can be subtle and misleading (see Table 13-2). Children s increased physiologic reserves allow for maintenance of vital signs in normal ranges as blood loss occurs. Tachycardia and delayed capillary refill of more than 2 seconds are signs of poor tissue perfusion in pediatric trauma patients (AHA, 2011). Check apical pulse for rate, rhythm, and quality. Check peripheral pulses for quality. Check the patient s skin temperature and color. Children are often able to maintain normal vital signs, even with shock. Up to 30% blood loss is required before any change will be noted in a child s vital signs. Tachycardia and poor skin perfusion are early indicators of hypovolemia. Early subtle signs of hypovolemic shock include the following: Loss of distal peripheral pulses Narrowing of pulse pressure to less than 20 mm Hg Tachycardia Skin mottling Cool extremities (compared to trunk) with coolness ascending toward the trunk Decrease in level of consciousness (ask caregivers if this is usual behavior for the child) Dulled response to pain A late sign of hypovolemic shock is: decreased blood pressure; SBP = 70 mm Hg + (2 age) = hypotension > 1 year old (AHA, 2011). Be sure to refer to age-appropriate norms for reference. By the time hypotension is seen in a child, approximately 30% of the circulating blood volume has been lost, and tachycardia often changes to bradycardia at this point (AHA, 2011). Assess for adequate urine output, which is based on the patient s weight: Infant = 2 ml/kg/hr Toddler = 1.5 ml/kg/hr Child = 1 ml/kg/hr Adolescent = 0.5 ml/kg/hr Disability Perform a neurologic assessment. Check pupil size. Assess level of consciousness using AVPU (ENA, 2014). AVPU corresponds to the question: Is the patient Awake, responsive to Verbal stimuli, responsive to Painful stimuli, or Unresponsive? The clinician can then progress to the pediatric Glasgow Coma Scale score, which is adapted by changing the verbal section only (see Table 13-3). Expose Expose the patient for further assessment. Remove the patient s clothing and inspect the entire body. Monitor the patient s temperature. Children are more sensitive to heat loss because of the high ratio of body surface area to body mass, thin skin, and lack of substantial subcutaneous tissue. Initial Interventions Positioning To maintain optimal breathing, proper positioning of the child is necessary to avoid passive flexion of the cervical spine caused by a relatively large head. Place the child in neutral position to maintain alignment. Place a layer of padding under the infant or toddler s torso (shoulder to hips) to preserve neutral alignment of the spinal column. This also improves visualization of the vocal cords for intubation. Airway and Breathing Open the airway with the chin lift or jaw thrust maneuver, combined with inline spinal immobilization. Suction secretions and/or debris from the oral airway. Insert an oropharyngeal airway only in an unconscious child. Measure the airway from the corner of the mouth to the tip of the earlobe. Table 13-2: Systemic Responses to Blood Loss in Pediatric Patients System Cardiovascular Central nervous system Skin Mild Blood Volume Loss (< 30%) Increased heart rate; weak, thready peripheral pulses; normal systolic blood pressure ( [2 age in years]); normal pulse pressure Anxious; irritable; confused Cool, mottled; prolonged capillary refill Moderate Blood Volume Loss (30% to 45%) Markedly increased heart rate; weak, thready central pulses; absent peripheral pulses; low normal systolic blood pressure ( [2 age in years]); narrowed pulse pressure Lethargic; dulled response to pain 1 Cyanotic; markedly prolonged capillary refill Urine output 2 Low to very low Minimal None Severe Blood Volume Loss (> 45%) Tachycardia followed by bradycardia; very weak or absent central pulses; absent peripheral pulses; hypotension (< 70 + [2 age in years]); widened pulse pressure (or undetectable diastolic blood pressure) Comatose Pale and cold 1 The child s dulled response to pain with this degree of blood loss (30% to 45%) may be indicated by a decreased response to IV catheter insertion. 2 After initial decompression by urinary catheter. Low normal is 2 ml/kg/hr (infant), 1.5 ml/kg/hr (younger child), 1 ml/kg/hr (older child), and 0.5 ml/kg/hr (adolescent). IV contrast can falsely elevate urinary output. Note. From American College of Surgeons, Advanced trauma life support, 9th edition, 2012, p Used with permission.

68 80 Basic Trauma Nursing TABLE 13-3: PEDIATRIC GLASGOW COMA SCALE SCORE (VERBAL COMPONENT) Verbal Response Verbal Score Appropriate words or smile 5 Crying but consolable 5 Persistently irritable 3 Restless, agitated 2 No response 1 Use a tongue blade and the direct insertion technique with the oral airway curving down to avoid damage to the soft palate and to limit the potential for subsequent bleeding (Veyckemans, 2011). Place an orogastric tube to decompress the stomach prior to intubation. Crying children often swallow large amounts of air, which can lead to gastric distention, vomiting, and aspiration. Administer supplemental oxygen prior to any intubation attempts. Infants and children have a more pronounced vagal response to endotracheal intubation than adults do. Such responses may be caused by hypoxia or vagal stimulation during laryngoscopy, so be sure to watch for bradycardia. Initiate pulse oximetry monitoring. Consider a protocol for emergency intubation, referred to as rapid sequence intubation. This protocol, although often hospital-specific, generally consists of the following steps: preoxygenation, atropine to minimize vagal stimulation, sedation (short-acting and/or long-acting, e.g., etomidate, ketamine, or midazolam), and paralysis with short-acting paralytics such as succinylcholine prior to intubation. Oral intubation is preferred. Nasotracheal intubation is to be avoided. Cuffed endotracheal tubes are recommended for routine use with pediatric patients (Bhardwaj, 2013). Determine endotracheal tube size by using the following methods: Match tube size to the diameter of the child s little finger or external nares. Use an age-based formula such as the Morgan and Steward formula: (16 + age in years)/4. Use length-based resuscitation tape to properly size equipment. Confirm endotracheal tube placement by auscultating bilateral chest walls in the axilla for the presence of sounds, then over the epigastrum to note any absence of sounds. The infant s trachea is short; therefore, caution is necessary when intubating because the endotracheal tube tends to easily pass into the right mainstem bronchus instead of into the trachea. Monitor ETT cuff pressures to maintain them at or below 20 cm H 2 O (Bhardwaj, 2013). Obtain a chest X-ray to verify endotracheal tube placement. End tidal carbon dioxide monitoring and capnography are useful adjuncts to monitor airway patency, breathing effectiveness, and tissue perfusion. Recheck breath sounds and the tube s centimeter depth marking at the lip line periodically to ensure that the tube stays in position. Tube placement depth can be estimated by multiplying the diameter of the tube by 3. Example: endotracheal tube diameter size 4 3 = 12 cm (lip line). Any small movement of the head can dislodge the tube. When a surgical airway is required: Needle cricothyroidotomy is preferred in children younger than 12 years of age due to the potential of developing tracheomalacia. Surgical cricothyroidotomy can be performed when the cricothyroid membrane can be palpated, usually in children 12 years of age and older. When performing either bag-valve mask ventilation or bag to endotracheal tube ventilation, avoid overexertion of manual pressure, which may cause injury to the fragile upper airway tissues and lungs as well as push air into the stomach. Circulation Place the patient on a cardiac monitor. Obtain venous access. Peripheral IV sites are the preferred route for IV access. If there is anticipated difficulty with vascular access, proceed to intraosseous access as the first choice (Hockenberry, 2011). Perform an intraosseous insertion. Preferred sites are the proximal tibia and the distal femur. Avoid placing in a bone with a current fracture. Verify placement by aspiration of bone marrow. It can be used to infuse fluids, blood, and medications. Discontinue as soon as peripheral IV can be established. Depending on the skill level available, a femoral venous line may be inserted. Initiate fluid resuscitation. Administer a fluid bolus with warmed lactated Ringer s or normal saline solution, 20 ml/ kg up to three times to a total of 60 ml/kg. Consider a bolus of packed red blood cells next (10 ml/kg). Fluid resuscitation is based on body weight. Many hospitals use the Broselow Pediatric Emergency Tape, which allows quick estimates of weight, fluid volume, and drug dosages. Continuously monitor the child for improvements in response to fluid administration. Look for the following improvements: Return of peripheral pulses Improved skin color and warmth Pulse rate returning to normal range Improved level of consciousness Increased blood pressure Increased urine output If the child does not improve, other modalities to control blood loss should be anticipated, such as surgery. Ensure thermoregulation. Use blankets, warmed IV fluids, and ventilator circuits to preserve body temperature. Perform diagnostic assessment for bleeding internal injury. Rapid CT scanning allows for fast, precise identification of injuries. The use of focused assessment sonography in trauma (FAST) is relatively new in pediatric trauma but may be helpful to identify intra-abdominal blood. Diagnostic peritoneal lavage (DPL) is used with much less frequency because of the availability of FAST. However, DPL can be used in children when FAST or a CT scan is not available. Monitor glucose levels in pediatric patients. Physiologic stress may rapidly deplete glycogen stores, resulting in hypoglycemia and causing decreased cardiac contractility, alterations in level of consciousness, seizures, and acidosis (ENA, 2014). Consider nonoperative management. Most trauma centers today practice nonoperative management of pediatric abdominal injuries. Most bleeding from the spleen, liver, and kidney stops on its own and does not require surgery. Nonoperative management is carried out under the direction of a surgeon, in a hospital with 24-hour availability of an operating room. Secondary Survey History Information is gathered to determine who, what, where, when, and why the injury occurred. Detailed information is particularly important when the mechanism of injury is a passenger or pedestrian motor vehicle crash, bicycle crash, fall, gunshot, or stabbing wound, or when there is suspected neglect or abuse. Be sure to find out if the patient lost consciousness, for what duration, and if it was followed by vomiting and vision changes. Head, Eyes, Ears, and Nose Check the scalp for abrasions, lacerations, and open wounds. Palpate the scalp for step-off defects, depressions, hematomas, and pain. Palpate the forehead, orbits, maxilla, and mandible for crepitus, deformities, step-off defects, pain, and instability. Reassess the pupils, check for extraocular movements, and ask the child if he or she has any vision difficulties. Look for raccoon s eyes or Battle s sign. Note if the nose or ears have rhinorrhea or otorrhea. Evaluate for malocclusion by asking the child to open and close his or her mouth and ask whether the teeth feel like they line up normally. Note open wounds and loose, chipped, broken, or missing teeth. Check for orthodontic appliances and note if they are intact.

69 Basic Trauma Nursing 81 Evaluate facial symmetry by asking the child to smile, grimace, and open and close his or her mouth. Keep impaled or foreign objects in place, unless they are creating an airway obstruction or inability to functionally ventilate the patient. Neck While another person maintains neck stabilization, methodically open the cervical collar to reassess the anterior neck for jugular vein distention and tracheal deviation. Note bruising, open wounds, edema, crepitus, debris, or chemicals under the collar. If age appropriate, check for hoarseness or changes in the voice by asking the child to speak. Otherwise, listen to crying or sounds for normal phonation. Chest Note the respiratory rate and reassess breath sounds for quality. Palpate the chest wall and sternum for pain, tenderness, or crepitus. Observe inspiration and expiration for symmetry or paradoxical movement. Note the use of accessory muscles. Reassess apical heart rate, rhythm, and clarity. Abdomen, Pelvis, Genitourinary Look for bruising and distention of the abdomen, auscultate bowel sounds in all four quadrants, palpate the abdomen gently for tenderness, and assess the pelvis for tenderness and stability. Palpate the bladder for tenderness and distention, check the urinary meatus for injury or bleeding, and note priapism, genital trauma, lacerations, or any foreign bodies. Confirm rectal sphincter tone and look for lacerations. Musculoskeletal Assess extremities for deformities, swelling, lacerations, or other injuries. Palpate distal pulses for presence, quality, rate, and rhythm and compare them to central pulses. Ask the child to wiggle his or her toes and fingers and assess the strength of hand grips and foot flexion and extension. Back Logroll the patient, being careful to maintain spine and neck stabilization, to inspect the back. Look for bruising and open wounds; palpate all vertebrae for tenderness, pain, deformity, and stability; and assess the flank area for bruising and tenderness. TRANSFER The condition of a child with multisystem injuries can deteriorate rapidly and lead to serious complications. Therefore, such patients should be transferred early to a facility capable of managing children with multisystem injuries. The American College of Surgeons (ACS) suggests that specific centers that treat children should have capabilities above those of a general trauma center. Such centers are recognized by the ACS as trauma centers with a commitment to children. Pediatric patients have better outcomes and fewer unplanned events when transported by a specialized pediatric team (ENA, 2014). SUMMARY The pediatric patient has unique characteristics and problems for the trauma nurse to address. Potentially life-threatening injuries must be identified quickly and accurately. Children with multiple injuries, including head injury, must be aggressively resuscitated to avoid hypotension and secondary brain injury. Early involvement of the general surgeon is necessary to manage the injured child. Chapter 14: Geriatric Trauma CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to discuss common injuries seen in geriatric trauma patients, and their evaluation and management. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Identify anatomic and physiologic changes of aging. 2. Specify mechanisms of injury common to older adult patients. 3. Recognize hallmarks of abuse and neglect seen in older adult patients. 4. Identify the common types of injuries seen in older adult patients. 5. Choose the interventions appropriate to the management of critical injuries in geriatric patients. INTRODUCTION The fastest growing segment of the population is older adults. The percentage of the population over the age of 65 increases annually, and by 2040, 20% of the U.S. population will fall into this category (ENA, 2014). Older adults are living longer and with better health than ever before. Reasons vary from medical advances to personal awareness of nutrition, fitness, prevention, and care, along with societal support for improved quality of life. Numerous older adults continue to pursue many of the same activities that they did at a much younger age, but at an increased opportunity and risk for injury. Trauma is among the top 10 causes of death in the geriatric population (CDC, 2010). Trauma in the older patient is likely to be more serious than the same injury in the younger person. Older adults have increased morbidity and mortality and experience more severe injuries, most likely due to increased comorbidities (Cutugno, 2011). Despite advancing age, a number of older adults still participate in sports and continue to drive their own automobiles (Blumenthal, Plummer, & Gambert, 2010). For trauma patients over 80 years of age, a minor trauma can result in a major disability (ENA, 2014). Unrecognized states of hypoperfusion are thought to be the culprit, which is why early aggressive hemodynamic monitoring is necessary in the older adult trauma patient. Elder abuse and neglect is increasing for many reasons, including the growing aging population and complex problems related to caregivers. According to the American Psychological Association (APA), approximately 2.1 million older adults in the United States are victims of physical abuse, emotional abuse, neglect, or other forms of maltreatment (APA, 2012). EPIDEMIOLOGY AND MECHANISMS OF INJURY Although trauma remains a leading cause of morbidity and mortality across all ages, geriatric patients differ significantly from their younger counterparts in their greater number of comorbidities, as well as higher risk of severe disability and death (Colwell, 2015). The leading causes of death due to injury among older adult patients are falls, motor vehicle crashes, and burns (ENA, 2014). Falls In the older population, falls are the leading cause of injury-related death and the leading cause of hospital admissions for trauma (CDC, 2012). Many falls result in an isolated orthopedic injury, for example, tripping and fracturing a hip. When an older adult has a fall injury, the cause should be investigated thoroughly. Frequently, falls occur because the aging process causes postural instability, poor balance, alteration in gait, and decreased muscle strength and coordination. Associated acute or chronic conditions such as syncope, cardiac dysrhythmias, hypoglycemia, anemia, transient cerebral ischemia, and other gait-altering disorders must also be considered as precipitating factors for falls. For example, an episode of bradycardia may bring on syncope, resulting in a fall. Drugs, including alcohol, are a common cause or contributing factor to many falls. Motor Vehicle Crashes In 2012, there were 5,560 people age 65 and older killed and 214,000 injured in motor vehicle crashes. These older adults made up 17% of all traffic fatalities and 9% of all people injured in traffic collisions during the year (NHTSA, 2012). Additionally, many older adults are killed as pedestrians when they are struck by a motor vehicle. Auto versus pedestrian in this population is the third leading cause of death (ENA, 2014). Most motor vehicle crashes involving older adults occur during the day, in good weather, and close to home. Alcohol intoxication is much less frequent than in younger persons. Factors contributing to motor vehicle crashes involving older adult patients are decreased coordination and reaction time, vision impairment, alterations in sound processing, deficits in cognitive functioning, and antecedent medical conditions. Burns Burn injury to individuals older than 60 years occurs with a frequency that is disproportionate to that of all other victims except the very young. Burns continue to remain a major healthcare problem in the United States and globally. Fire and burn mortality rates of 1.29 per 100,000 are third only to falls and poisoning for adults aged 70 years and older (Grant, 2013). Factors involved in older adults sustaining burns are altered mobility that limits muscle strength and coordination,

70 82 Basic Trauma Nursing which causes spilling and scalding; neurosensory changes, including peripheral neuropathy and vascular disease, which cause alterations in sensation perception that allow prolonged contact with heat; forgetfulness and poor judgment regarding safety issues; and altered gait, which limits escape. Decreased dermal cell production causes thinner skin, which allows burns to be more severe and susceptible to infection. Preexisting disease often makes it impossible for the injured person to overcome serious but potentially survivable burns. Elder Abuse Abuse is a problem that is gaining more recognition, and older adult injuries must be carefully documented and investigated. Frequent visits for minor injuries, multiple bruises in various stages of coloration and healing, unkempt appearance, poor nutrition, and poor hygiene are all signals of possible abuse or neglect (see Table 14-1). If abuse is suspected, the nurse should systematically assess the patient from head to toe for signs and symptoms of abuse or neglect and document the findings. Elder abuse often is not recognized and is underreported. In many states, elder abuse or neglect is a mandatory reporting requirement; be prepared to alert local authorities if this concern arises. Table 14-1: ELDER ABUSE ASSESSMENT Unexplained dehydration Unexplained poor nutrition Unexplained bruises, wounds, or burns in various stages of healing Unexplained fractures Overmedication with sedatives Disinterest exhibited by caregivers Observed fear, withdrawal, or verbal confrontation between caregiver and patient CHANGES CAUSED BY AGING Many studies have demonstrated the physiologic differences between an older trauma patient and a younger trauma patient. These differences coupled with coexisting medical comorbidities makes caring for this population extremely challenging (Mangram et al., 2012; see Figure 14-1). Cardiovascular System Fibrosis causes progressive stiffening of the myocardium that results in diminished pump function and lower cardiac output. Blood pressure gradually increases. Blood vessels tend to harden. Decreasing sensitivity to catecholamines, such as epinephrine and norepinephrine, causes an inability to develop appropriate tachycardia. Therefore, there is a decreased ability to increase cardiac output in response to hypovolemia, pain, and stress (Martin, Alkhoury, O Connor, Kyriakides, & Bonadies, 2010). Older adult patients who have preexisting anemia and then sustain trauma may have decreased oxygen transport, which can precipitate angina or a myocardial infarction. Respiratory System Diminished pulmonary compliance and reduced ability to cough effectively are the result of decreased Figure 14-1: Changes Caused By Aging Note. From American College of Surgeons, Advanced Trauma Life Support, 9th Edition, 2012, p Used with permission. lung elasticity and progressive stiffening of the chest wall. Vital capacity of the lungs decreases. Coalescence of alveoli and reduced small airways support lead to decreased surface area for gas exchange. The reduced efficiency in gas exchange decreases arterial oxygenation. Nervous System Starting in the 40s, the brain begins to atrophy. By the 70s, there is a 10% reduction in the size of the brain. As a result, the space between the surface of the brain and the skull increases and stretches the dural bridging veins. This stretch can contribute to bleeding. One retrospective study reported that 56% of cases of subdural hematoma were in patients in their fifth and sixth decades; another study noted that more than half of all cases were in patients older than 60 years. The highest incidence, 7.35 cases per 100,000 population, occurs in adults aged 70 to 79 years (Meagher & Young, 2015). Functional deterioration of the following increases the potential for accidental injury: Cognition Poor memory, impaired judgment, and deficient data acquisition Hearing Decreased auditory acuity, particularly with high-frequency sounds; lack of or inadequate hearing devices because of financial limitations or limited access to health care Eyesight Decreased visual acuity and peripheral vision; intolerance to glare; and outdated, inadequate, or inappropriate eyeglasses Musculoskeletal System Loss of bone density from osteoporosis brings about a predisposition to fractures, even with minor traumatic energy transfer. Osteoporosis is more pronounced in older women, leaving them prone to fractures (especially of the hip and femur). Pelvic fractures can be life threatening, and all fractures are slow to heal. Complications are not uncommon. Osteoarthritis and diminution in vertebral body height contribute to significant spinal changes. Examples are kyphoscoliosis and spinal stenosis due to osteoarthritis. Fibrosis and decrease in muscle mass diminishes agility and strength. Renal System Renal mass and function decline with age. By 65 years of age, a 30% to 40% loss is not uncommon. Remaining nephrons show aging and deterioration of the tubules and glomeruli. Sodium tends to be lost, and potassium tends to be retained. Physiologic changes related to aging make elderly patients more susceptible to acute kidney injury when exposed to other risk factors such as trauma, sepsis, or nephrotoxins (Jayaraman & Cooper, 2014).

71 Basic Trauma Nursing 83 Metabolic and Hepatic Changes The basal metabolic rate slows, along with the liver s ability to clear toxins. The caloric needs of men and women decline with age as lean body mass and metabolic rate gradually decrease. There is often chronic inadequate nutrition among older adults, which contributes to a significantly increased complication rate in geriatric trauma. Older adults also have a blunted immune response (with resultant impaired ability to respond to infection) and are more prone to develop multiple organ system failure. Thermoregulation The skin and connective tissues of older adults undergo extensive changes, including cell number decrease, loss of strength, and impaired function. Older adults, therefore, are more prone to heat loss, chilling, and dehydration than younger persons. COMORBID CONDITIONS Older patients average six or more preexisting conditions, and these comorbidities may result in a cascade of effects in which one system impacts another, resulting in increased morbidity and mortality (Kaplan & Porter, 2011). It is essential for the nurse to find out concurrent diseases and medications so that appropriate interventions and treatment can be administered. The information is important and affects patient management, from resuscitation strategies to continuing care. The more common conditions include cardiac disease, hypertension, neurologic disorders, liver disease, pulmonary disease, renal disease, diabetes, malignancy, and obesity. COMMON INJURIES IN OLDER ADULTS Hip and Femur Fractures The most common area for fracture in geriatric trauma is the hip. Osteoporosis contributes to the increase in long-bone fractures seen in older adults. A large proportion of fall deaths are due to complications following hip fracture. One out of five hip fracture patients dies within a year of the injury (CDC, 2014). Hip fractures lead to prolonged bed rest, decreased mobility, and thus predisposition to coagulopathies (blood clots), decubitus formation, and nutritional deficiencies that magnify preexisting comorbid factors. Early operative stabilization, with aggressive management of hemodynamic status, has been shown to decrease morbidity and mortality. Brain Injuries This age group has a higher incidence of subdural hematomas (Meagher & Young, 2015). This may be due to older adult patients higher use of anticoagulants and to the physiologic effects of aging on the brain. With atrophy of the brain, there is a corresponding increased stretching of the parasagittal bridging veins, which makes them more prone to rupture on impact, causing a subdural hematoma. This can happen with even minor jarring of the body, such as simply brushing up against a doorframe while walking through the house. The patient and family often report no history of trauma, which further confuses the clinical picture. This may lead to a common presentation of chronic or acute-on-chronic subdural hematoma. Burns Burns are the third leading cause of traumatic death in older adults. Factors associated with degenerative disease and physical impairment appear to contribute significantly to the overrepresentation of burns in older adults. A small burn in an older adult with comorbid conditions may be a life-threatening event, whereas a large burn in a young person is often survivable. Rib Fractures The mortality rate for chest injuries in older adult patients is higher than in younger adult patients. Chest wall injury and rib fractures or pulmonary contusions are common and not well tolerated. Simple pneumothorax and hemothorax are of major concern, and admission to the hospital is required. Pain control and vigorous pulmonary toilet are essential for a satisfactory outcome. EVALUATION AND MANAGEMENT OF THE OLDER ADULT TRAUMA PATIENT As in all trauma cases, the ABCs are the initial approach for the older adult trauma patient. However, the following differences for the workup of the older adult trauma patient should be emphasized: Administer supplemental oxygen to all older adult trauma patients, even those with a history of chronic obstructive pulmonary disease (COPD). Continue to carefully monitor patients because those with COPD retain carbon dioxide and lose the normal respiratory drive produced by an elevated partial pressure of arterial carbon dioxide. Anticipate intubation if necessary. Early aggressive intubation is warranted in older adult patients because of the limitation often present in their cardiopulmonary reserves. The presence of decreased level of consciousness and chest injury also warrant early aggressive intubation. However, a sometimes unfortunate consequence of aggressive early respiratory support is a potentially difficult or prolonged ventilatory wean. Remove broken dentures but leave intact wellfitting dentures because they can help achieve a good seal when using the bag-valve mask. Use caution when inserting nasogastric tubes because of fragile tissues. Early aggressive monitoring of the cardiovascular system is required. Evaluate blood pressure and heart rate in the context of the older adult (see Table 14-2). Expected vital sign changes that occur with shock may not be present because of medications that the patient is taking, such as a beta-blocker or calcium channel blocker (see Table 14-3). All other principles of airway management remain the same. Pitfalls Early and aggressive hemodynamic monitoring is required to identify older adult patients at TABLE 14-2: PITFALLS IN THE INTERPRETATION OF VITAL SIGNS IN OLDER ADULT PATIENTS Normal blood pressure Normal heart rate A typical mistake with older adult patients is to believe that normal blood pressure and heart rate indicate normovolemia. Early and aggressive monitoring of the cardiovascular system is necessary. Blood pressure increases with age. Therefore, 120 mm Hg may represent hypotension in the older adult patient whose normal preinjury blood pressure was 170 mm Hg. Absence of tachycardia. The older adult patient cannot generate an increased heart rate in response to blood loss. Therefore, ongoing blood loss may be masked by the absence of tachycardia, resulting in delayed diagnosis and a poor outcome. TABLE 14-3: MEDICATIONS AND OLDER ADULT PATIENTS Effect on Traumatic Drug Injury Beta-blockers Limit the ability of the heart to generate a tachycardia, which will mask shock Calcium channel blockers Nonsteroidal anti-inflammatory agents Chronic anticoagulants Chronic diuretics Prevent peripheral vasoconstriction and contribute to hypotension Affect platelet function, which contributes to blood loss Increase blood loss Possibly cause dehydration, which contributes to shock risk for deterioration. Older adults have limited physiologic reserves, which makes it difficult to generate an adequate response to injury. Central venous pressure monitoring and pulmonary artery catheter insertion and monitoring may be helpful, along with traditional resuscitation endpoints such as urine output and base deficit. Fluid resuscitation, although often necessary, should be done with care, especially with patients who have cardiac conditions. Lactated Ringer s solution is the initial fluid of choice. Careful monitoring of blood urea nitrogen and electrolyte, blood sugar, and creatinine levels is warranted. There is increased potential for medication toxicity due to altered absorption of medications, secondary to decreased lean body mass and decreased liver and kidney function. Increased length of stay in the emergency department has been associated with poorer outcomes and increased mortality across all patient populations (Mowrey et al., 2011). There is dispute over optimal hemoglobin levels for older adult patients. Age older than

72 84 Basic Trauma Nursing 65 years and the presence of cardiac disease indicate maintaining a hemoglobin level over 10 gm/dl to maximize oxygen-carrying capacity. However, indiscriminate administration of blood is also to be avoided. If a bleeding abdominal injury is suspected, an early aggressive operation is warranted. Although nonoperative management of spleen and liver injuries is aggressively pursued in all other age groups, it is not the standard of care for older adult patients. Older adult patients have reduced tolerance for blood loss and mask it to a degree that can make the employment of nonoperative management difficult. Elderly patients have diminishing biologic reserves, and structural alterations concordant with age make spontaneous hemostasis unlikely. Due to changes in vascular integrity, there is increased splenic frailty, where even minor blunt trauma can lead to significant injury (Beuran, Gheju, Venter, Marian, & Smarandache, 2012). History The initial assessment is divided into two phases: primary and secondary. The primary assessment includes a systematic search for serious injuries. The secondary assessment involves special attention to health history before the injury. This assessment is crucial to appropriate management of the patient, as it can help avoid inappropriate treatment or a potentially preventable event. Did a motor vehicle crash occur under normal conditions, or was there an antecedent episode, such as a cerebrovascular accident, a transient ischemic attack, a myocardial infarction, or a cardiac rhythm disturbance that caused the accident? Have more than one of these incidents or similar incidents occurred in the recent past? If so, there may be an untreated medical condition contributing to the incidents. Has the patient recently begun a new medication or had a change in the dosage of a regular medication? Obtain a list of all the patient s medications, dosages, and times of administration as soon as possible. If a list is not available, try to obtain all of the patient s medication containers or call his or her pharmacy for a list. A high level of expertise is necessary to generate good outcomes for older adults who have experienced trauma. Prompt transfer to a trauma center can save lives. SUMMARY Older adults are living longer and are in better health than ever before. By the year 2020, the number of people in this country older than 65 years of age will be at least 52 million. Anatomic, physiologic, and mental changes occur with aging. These changes make identifying injury and the recovery process more complicated and a longer-term endeavor. Trauma in older adults is likely to be more serious, lead to more complications, be more costly, and have more psychosocial ramifications than trauma in younger persons. Improved outcomes for the injured geriatric patient require early aggressive resuscitation and monitoring. Chapter 15: The Bariatric Trauma Patient CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe the unique challenges and augmentations needed to assess and treat the bariatric trauma patient. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Identify anatomic and physiologic changes in the bariatric patient. 2. Specify mechanisms of injury common to bariatric patients. 3. Identify challenges encountered when treating bariatric patients. 4. Understand how to use different techniques when assessing and managing bariatric trauma patients. INTRODUCTION Obesity in the United States has increased steadily over the past decades. This in turn has caused the healthcare system to emphasize how to assess, diagnostically work up, and care for the bariatric patient. The focus is not just on the trauma patient; all bariatric patients throughout the continuum of health care must be considered. The challenges faced in caring for this population are multifold and have forced healthcare professionals to reassess the traditional approach to patient treatment. EPIDEMIOLOGY AND MECHANISM OF INJURY In the United States alone, adult obesity affects 78.6 million people (or more than one-third of the population; CDC, 2014). Obesity is defined as a body mass index (BMI) of 30 kg/m 2 ; and morbid obesity is a BMI of 40 kg/m 2 (WHO, 2012). Non- Hispanic blacks have the highest age-adjusted rates of obesity (47.8%), followed by Hispanics (42.5%), non-hispanic whites (32.6%), and non-hispanic Asians (10.8%; Ogden, Carroll, Kit, & Flegal, 2012). Many comorbid conditions, which are also some of the leading causes of preventable death, are associated with obesity, including heart disease, stroke, type 2 diabetes, and certain types of cancer (CDC, 2014). The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008; medical costs for people who are obese were $1,429 higher than those of normal weight (CDC, 2014). Bariatric patients with sprains, strains, and dislocations have higher rates of hospitalization than patients of normal weight (ENA, 2014). Recent studies have shown that, once injured, the bariatric patient has an increased incidence of complications (Mica, Keel, & Trentz, 2012). It has long been theorized that obese patients experience trauma differently, and we now know that several risk factors contribute to their higher mortality rate. These risk factors include the comorbidities of patients with increased BMI along with a higher incidence of specific injuries and an inability to use or properly fit into safety equipment (ENA, 2014). Obese people have higher mortality in frontend motor vehicle crashes (ENA, 2014). Other injuries that are more common in this population are rib fractures, chest injuries, and pulmonary contusions; pelvic injuries; and extremity injuries. Injuries that are less likely in this population are head injuries and liver and other significant abdominal injuries. (Nickson, 2014) Emerging theories suggest that trauma and obesity-induced inflammatory stress play a pivotal role in increased morbidity and mortality in severe trauma combined with weight disorders. In general, trauma induces an immunologic response with a complex acute-phase protein and cytokine release that result in damaged endothelial cells, dysfunctional vascular permeability, microcirculatory disturbances, and necrotic parenchymal cells. An altered posttraumatic inflammatory response in obese patients seems to determine the risk for multiple organ failure after severe trauma (Andruszkow, Veh, Mommsen, Zecky, Hildebrand, & Frink, 2013). This pathophysiologic cascade demonstrates that in addition to current therapies for a specific traumatic injury, nutrition status seems to play a pivotal role in the posttraumatic clinical course and therefore should be considered in therapeutic strategies for patients suffering from major trauma (Andruszkow et al., 2013). Anatomic and pathophysiologic variances in the Bariatric patient Anatomic and physiologic changes related to obesity can influence the assessment and care of this patient group. As with any disease process, obesity affects many body systems in various ways. When assessing obese trauma patients, keep the following changes in mind: Neurologic: Associations between obesity and various neurological disorders have been reported, including sleep apnea, anxiety, manic- depressive disorders, and increased risk of developing cerebrovascular accidents (CVA) (Awada, Parimisetty, & Lefebvre, 2013). Obesity has also been linked to narcolepsy (Akinnusi, Saliba, Porhomayon, & El-Solh, 2012). Airway: There is increased cervical fat with larger neck circumference, increased soft tissue distribution in the oropharynx, increased tongue size, and risk of airway collapse with compromise (Ogden et al., 2012). Respiratory: Obese patients may suffer from obstructive sleep apnea (OSA). The classic presentation is characterized by episodes of apnea (usually about 10 seconds in length). The apnea causes chronic hypoxemia that can lead to a myriad of pathophysiologic conditions (secondary polycythemia, hypercapnia, pulmonary and systemic vasoconstriction) and an increased risk of cardiac and cerebral ischemia and intrapulmonary shunting (Padoto, 2012). The airway of a patient of normal weight is often best maintained in the supine position; for the bariatric patient, the opposite may be true (ENA, 2014).

73 Basic Trauma Nursing 85 Obesity is associated with restrictive lung disease caused by increased intra-abdominal pressure and decreased chest wall compliance, which result in decreased static and dynamic lung volumes (Padoto, 2012). Respiratory rate and work of breathing can be up to 40% higher in obese patients to compensate for the aforementioned changes (ENA, 2014). Cardiac: Morbid obesity creates higher metabolic demand on the body. The resultant cardio vascular augmentation, hypervolemia, and excessive catecholamine tone can to lead to systemic and organ-specific dysfunction, including pulmonary hypertension, ischemic heart disease, left ventricular hypertrophy and dysfunction, and an increased risk of atrial fibrillation and ventricular dysrhythmias (Padoto, 2012). Gastrointestinal: Gastroesophageal reflux disorder (GERD), gastroparesis, biliary tract disease, pancreatitis, and hernias are common in bariatric patients (Apovian, Bays, & Ryan, 2013). Musculoskeletal: Obesity can lead to degenerative joint disease and chronic back pain (Apovian, Bays, & Ryan, 2013). Endocrine: The obese patient is at higher risk for type 2 diabetes, dyslipidemia, liver and gallbladder disease, some cancers (endometrial, breast, and colon; CDC, 2014), metabolic syndrome, polycystic ovarian syndrome, hypothyroidism, infertility, and male hypogonadism (Apovian, Bays, & Ryan, 2013). Hematologic: Obesity can lead to hematologic conditions such as deep vein thrombosis, hypercoagulable state, and chronic venous stasis (Apovian, Bays, & Ryan, 2013). Challenges encountered with bariatric trauma patients Bariatric trauma patients present unique challenges when encountered by healthcare workers of all disciplines. Specialized training becomes necessary in the enhanced approaches needed for assessment, transport, interventions, resuscitation, stabilization, and long-term care of the bariatric trauma patient. Bariatric medicine is becoming a true discipline of its own; however, emergency clinicians need to be particularly versed in the augmentations needed to maximize care. Assessment To gather accurate information while assessing the bariatric trauma patient, it is necessary to prepare the patient and properly fit equipment because improperly fitting diagnostic tools may yield false data (Collopy, Kivlehan, & Snyder, 2012). If not contraindicated, keep the patient upright as much as possible. To maximize pulmonary auscultation, listen to lung sounds in areas with less adipose tissue, such as the posterior medial scapular region. Pulse oximetry may be challenging in areas with more adipose tissue, such as the first through fourth digits. It may be necessary to use more unorthodox placement sites such as fifth digit, earlobe, nose, or temporal artery region. Cyanosis may be more pronounced in the oral mucosa and conjunctiva. Heart tones may be difficult to hear with usual patient positioning. Left lateral positioning forces the heart to shift closer to the chest wall, yielding more prominent tones as auscultated through the stethoscope. Blood pressure cuffs need to be properly sized to ensure a correct reflection of the patient s hemodynamic state. Cuffs that are too small artificially inflate the blood pressure. It may be necessary to use unorthodox sites such as the forearm or larger thigh cuffs for the upper arm. Lateral placement of electrodes does not transmit signals well when placed on the obese anterior abdomen. Use lateral placement for better signal quality. (Collopy, Kivlehan, & Snyder, 2012) Airway Airway control and maintenance is always paramount and sometimes challenging in trauma patients. Obese patients can create additional hurdles for the clinician to overcome when trying to establish and maintain airway patency. Increased body mass coupled with excess soft tissue in the upper airway increases airway resistance. During bag-mask ventilation, overcoming this increased resistance requires the clinician to squeeze the bag with more force. This can easily result in loss of mask seal and ineffective ventilation (Navarro, 2014). The ability to ventilate obese patients with a bag-mask is extremely important because they have decreased oxygen reserves and will not tolerate apnea for any period of time (Collopy, Kivlehan, & Snyder, 2012). To facilitate ventilation with a bagmask, rescuers should use a two-person technique. Oropharyngeal or nasopharyngeal tube insertion may help provide a patent airway and assist rescuers as they work to maintain an effective mask seal (Navarro, 2014). During intubation, the ramped position has been proven to improve the laryngeal view and intubation conditions compared to the standard sniffing position. In the ramped position, the external auditory meatus and the sternal notch are horizontally aligned to reproduce the same alignment of the intubation axis that the sniffing position produces in nonobese patients (Jones, 2012). While the use of laryngeal mask airways (LMA) increases the risk of aspiration in obese patients, the use of supraglottic airway devices in general can help reduce hypoxic periods (Collopy, Kivlehan, & Snyder, 2012). The use of video-assisted devices has been shown to improve visualization of the larynx and require a lower dose of propofol when compared to the traditional Macintosh laryngoscope (Jones, 2012). Awake videolaryngo s copy may be useful for the tracheal intubation of the morbidly obese (Moore, Schricker, & Court, 2012). With the advent of more affordable portable video laryngoscopy devices, their use has become prevalent in nonsurgical hospital departments and prehospital settings. Transportation and Movement Transportation and movement of the bariatric patient can pose both logistical and clinician hazard issues. Healthcare providers must know the weight capacity of all equipment, including beds, bedside chairs, scales, wheelchairs, toilets, bedside commodes, carts, OR tables, and radiology equipment (Blythe & Powers, 2011). Appropriate patient movement/transfer systems must also be located wherever metabolic and bariatric surgery patients receive care. Personnel must be trained to use the equipment and be capable of moving patients without injuring the patient or themselves (MBSAQIP, 2014). Patient as well as staff safety is paramount when dealing with any patient, and bariatric patients are no exception. In fact, in most cases safety is a higher priority. Vascular Access Vascular access in any critical patient may be challenging at best. Bariatric patients offer additional obstacles, with excessive tissue and adipose distribution making the ability to palpate, visualize, and identify veins very difficult. As a result, multiple IV attempts are common and increase the risk of infection, phlebitis, and thrombosis. To help lessen the risk, consider intravenous catheters longer than the standard 1.5-inch needle and avoid butterfly needles, as they are much shorter and even less likely to provide proper access (Collopy, Kivlehan, & Snyder, 2012). Choosing the most appropriate device in conjunction with practicing the most effective technique will improve vascular access outcomes for obese patients (Houston, 2013). To increase venous cannulation success rates in patients with difficult access, several techniques have emerged that use specialized equipment and training. The following are becoming more popular vascular access options in prehospital and hospital settings: Ultrasound-guided peripheral and central access. Ultrasound-guided IV access requires training sessions, and physicians, nurses, and ED technicians can perform it using the singleoperator or dual-operator method. For patients with known or suspected difficult IV access, ultrasound-guided techniques improve success rates in a timely manner, with improved patient satisfaction (Crowley et al., 2011). Intraosseous access (IO). IO access provides vascular access in a timely manner when healthcare providers are faced with difficult IV access. IO access has significantly higher first-pass success rates and faster placement compared with central venous catheters. IO operators report high satisfaction with and confidence in its use (Lee et al., 2015). IO access offers very desirable flow rates depending on the insertion site. A recent study compared the rate of flow at the three most clinically used adult IO infusion sites: the sternal site provided the most consistent and highest flow rate compared with the humeral and tibial insertion sites. The average flow rate in the sternum was 1.6 times greater than in the humerus and 3.1 times greater than in the tibia (Pasley et al., 2015). The IO route is clearly a valuable alternative to consider with problematic intravascular access, and achieving insertion competence is relatively uncomplicated following minimal preparation (Garside, Prescott, & Shaw, 2015). Illumination-guided vascular access. Vein illumination works by shining two lights onto an area of the patient s skin. One is an infrared (or near-infrared) light that detects hemoglobin, and the other light is used to project the vein pattern back onto the patient s skin. This technology

74 86 Basic Trauma Nursing facilitates peripheral venous access for patients with difficult veins, thus enhancing first-attempt success rates (Kim et al., 2012). Spinal Immobilization When managing a traumatically injured obese patient, it may be unrealistic to completely immobilize the spine without jeopardizing the safety of both the patient and the healthcare providers (Collopy, Kivlehan, & Snyder, 2012). Strategies employed to help minimize cervical movement may include the following: Regardless of methods, providers must remember to avoid excessive tightness with a c-collar. If none of the cervical collars fit properly, towels may be used to minimize cervical movement. Towels may need to be placed under the patient s neck to prevent hyperextension from excessive adipose tissue on the back. Many obese patients suffer from sleep apnea whereby excessive soft tissue obstructs the airway when the patient is supine; in such situations, a reverse Trendelenburg position may facilitate lung expansion. (Long, McGary, & Jaunch, 2011) It is important for the healthcare professional to know the capabilities and limitations of all equipment when treating bariatric trauma patients. This will help ensure safety for the patient as well as the caregiver. Resuscitation While acknowledging that approaches will vary, resuscitation in the bariatric population starts with the basic principles of the ABCs of resuscitation, and standard Advanced Cardiac Life Support (ACLS) protocols need not stray from the published algorithms (Vanden Hoak et al., 2010). Airway is still the utmost priority, with modifications made for size and anatomic variances. Resuscitation of the bariatric patient also requires the facility and caregivers to modify the team and equipment to maximize safe ergonomics as well as the efficient work of the resuscitation team. In burn care, the obese patient poses many clinical challenges related to accurate measurement of burn size, resuscitation, mechanical ventilation, wound infections, mobilization, effective deep vein thrombosis prophylaxis, and nutritional goals (Rae et al., 2013). Obesity appears to be associated with a higher risk of complications and deaths after major burns (Ghanem et al., 2011). Morbidly obese patients with severe burns tend to receive closer to predicted fluid resuscitation volumes for their actual weight. However, this patient group has persistent metabolic acidosis during the resuscitation phase and is at risk of developing more severe multiple organ failure. These factors may contribute to higher mortality risk for the morbidly obese burn patient (Rae et al., 2013). Rehabilitation of the bariatric patient Approximately one third of the American population is obese. This number is rising, and the number of obese individuals involved in highenergy accidents with multiple injuries has proportionately increased as well (Licht et al., 2014). With more traumatic events, more patients are involved in the resuscitation phase and ultimately the post-event and rehabilitation phases as well. While several studies have suggested that trauma in general has seen an increased rate of complications and costs, a recent study has definitively concluded that higher levels of obesity are associated with higher total hospital charges, longer hospital stays, higher level of care discharge dispositions, and higher rates of surgical orthopedic intervention (American Academy of Orthopaedic Surgeons, 2014). Special equipment is necessary to care for this patient population. The equipment must be appropriately sized, and it must accommodate the patient s weight (Blythe & Powers, 2011). Emphasis must be placed on proper preplanning in relation to staff, room accommodations, emergent needs of the patient should the scenario present itself, and daily diagnostics. With longer hospital stays, multiple comorbid factors to manage, and specialized training, the rehabilitation of the bariatric patient can be taxing on both the patient and staff. Proper preplanning is essential to ensure a consistent continuum of care for this patient group. Summary The proliferation of obesity in the United States has forced the medical community not only to identify this population but to manage their care safely, competently, and compassionately. Retention of patient dignity is essential with any patient population, and the bariatric patient is no exception. In addition to the expanding roles of the trauma nurse, empathy and patient advocacy are still at the core. Knowledge of changing anatomy and physiology will help steer the trauma nurse on how to successfully care for the bariatric trauma patient. Chapter 15: The Bariatric Trauma Patient CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe the unique challenges and augmentations needed to assess and treat the bariatric trauma patient. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Identify anatomic and physiologic changes in the bariatric patient. 2. Specify mechanisms of injury common to bariatric patients. 3. Identify challenges encountered when treating bariatric patients. 4. Understand how to use different techniques when assessing and managing bariatric trauma patients. INTRODUCTION Obesity in the United States has increased steadily over the past decades. This in turn has caused the healthcare system to emphasize how to assess, diagnostically work up, and care for the bariatric patient. The focus is not just on the trauma patient; all bariatric patients throughout the continuum of health care must be considered. The challenges faced in caring for this population are multifold and have forced healthcare professionals to reassess the traditional approach to patient treatment. EPIDEMIOLOGY AND MECHANISM OF INJURY In the United States alone, adult obesity affects 78.6 million people (or more than one-third of the population; CDC, 2014). Obesity is defined as a body mass index (BMI) of 30 kg/m 2 ; and morbid obesity is a BMI of 40 kg/m 2 (WHO, 2012). Non-Hispanic blacks have the highest age-adjusted rates of obesity (47.8%), followed by Hispanics (42.5%), non-hispanic whites (32.6%), and non-hispanic Asians (10.8%; Ogden, Carroll, Kit, & Flegal, 2012). Many comorbid conditions, which are also some of the leading causes of preventable death, are associated with obesity, including heart disease, stroke, type 2 diabetes, and certain types of cancer (CDC, 2014). The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008; medical costs for people who are obese were $1,429 higher than those of normal weight (CDC, 2014). Bariatric patients with sprains, strains, and dislocations have higher rates of hospitalization than patients of normal weight (ENA, 2014). Recent studies have shown that, once injured, the bariatric patient has an increased incidence of complications (Mica, Keel, & Trentz, 2012). It has long been theorized that obese patients experience trauma differently, and we now know that several risk factors contribute to their higher mortality rate. These risk factors include the comorbidities of patients with increased BMI along with a higher incidence of specific injuries and an inability to use or properly fit into safety equipment (ENA, 2014). Obese people have higher mortality in frontend motor vehicle crashes (ENA, 2014). Other injuries that are more common in this population are rib fractures, chest injuries, and pulmonary contusions; pelvic injuries; and extremity injuries. Injuries that are less likely in this population are head injuries and liver and other significant abdominal injuries. (Nickson, 2014) Emerging theories suggest that trauma and obesity-induced inflammatory stress play a pivotal role in increased morbidity and mortality in severe trauma combined with weight disorders. In general, trauma induces an immunologic response with a complex acute-phase protein and cytokine release that result in damaged endothelial cells, dysfunctional vascular permeability, microcirculatory disturbances, and necrotic parenchymal cells. An altered posttraumatic inflammatory response in obese patients seems to determine the risk for multiple organ failure after severe trauma (Andruszkow, Veh, Mommsen, Zecky, Hildebrand, & Frink, 2013). This pathophysiologic cascade demonstrates that in addition to current therapies for a specific traumatic injury, nutrition status seems to play a pivotal role in the posttraumatic clinical course and therefore should be considered in therapeutic strategies for patients suffering from major trauma (Andruszkow et al., 2013).

75 Basic Trauma Nursing 87 Anatomic and pathophysiologic variances in the Bariatric patient Anatomic and physiologic changes related to obesity can influence the assessment and care of this patient group. As with any disease process, obesity affects many body systems in various ways. When assessing obese trauma patients, keep the following changes in mind: Neurologic: Associations between obesity and various neurological disorders have been reported, including sleep apnea, anxiety, manic- depressive disorders, and increased risk of developing cerebrovascular accidents (CVA) (Awada, Parimisetty, & Lefebvre, 2013). Obesity has also been linked to narcolepsy (Akinnusi, Saliba, Porhomayon, & El-Solh, 2012). Airway: There is increased cervical fat with larger neck circumference, increased soft tissue distribution in the oropharynx, increased tongue size, and risk of airway collapse with compromise (Ogden et al., 2012). Respiratory: Obese patients may suffer from obstructive sleep apnea (OSA). The classic presentation is characterized by episodes of apnea (usually about 10 seconds in length). The apnea causes chronic hypoxemia that can lead to a myriad of pathophysiologic conditions (secondary polycythemia, hypercapnia, pulmonary and systemic vasoconstriction) and an increased risk of cardiac and cerebral ischemia and intrapulmonary shunting (Padoto, 2012). The airway of a patient of normal weight is often best maintained in the supine position; for the bariatric patient, the opposite may be true (ENA, 2014). Obesity is associated with restrictive lung disease caused by increased intra-abdominal pressure and decreased chest wall compliance, which result in decreased static and dynamic lung volumes (Padoto, 2012). Respiratory rate and work of breathing can be up to 40% higher in obese patients to compensate for the aforementioned changes (ENA, 2014). Cardiac: Morbid obesity creates higher metabolic demand on the body. The resultant cardiovascular augmentation, hypervolemia, and excessive catecholamine tone can to lead to systemic and organ-specific dysfunction, including pulmonary hypertension, ischemic heart disease, left ventricular hypertrophy and dysfunction, and an increased risk of atrial fibrillation and ventricular dysrhythmias (Padoto, 2012). Gastrointestinal: Gastroesophageal reflux disorder (GERD), gastroparesis, biliary tract disease, pancreatitis, and hernias are common in bariatric patients (Apovian, Bays, & Ryan, 2013). Musculoskeletal: Obesity can lead to degenerative joint disease and chronic back pain (Apovian, Bays, & Ryan, 2013). Endocrine: The obese patient is at higher risk for type 2 diabetes, dyslipidemia, liver and gallbladder disease, some cancers (endometrial, breast, and colon; CDC, 2014), metabolic syndrome, polycystic ovarian syndrome, hypothyroidism, infertility, and male hypogonadism (Apovian, Bays, & Ryan, 2013). Hematologic: Obesity can lead to hematologic conditions such as deep vein thrombosis, hypercoagulable state, and chronic venous stasis (Apovian, Bays, & Ryan, 2013). Challenges encountered with bariatric trauma patients Bariatric trauma patients present unique challenges when encountered by healthcare workers of all disciplines. Specialized training becomes necessary in the enhanced approaches needed for assessment, transport, interventions, resuscitation, stabilization, and long-term care of the bariatric trauma patient. Bariatric medicine is becoming a true discipline of its own; however, emergency clinicians need to be particularly versed in the augmentations needed to maximize care. Assessment To gather accurate information while assessing the bariatric trauma patient, it is necessary to prepare the patient and properly fit equipment because improperly fitting diagnostic tools may yield false data (Collopy, Kivlehan, & Snyder, 2012). If not contraindicated, keep the patient upright as much as possible. To maximize pulmonary auscultation, listen to lung sounds in areas with less adipose tissue, such as the posterior medial scapular region. Pulse oximetry may be challenging in areas with more adipose tissue, such as the first through fourth digits. It may be necessary to use more unorthodox placement sites such as fifth digit, earlobe, nose, or temporal artery region. Cyanosis may be more pronounced in the oral mucosa and conjunctiva. Heart tones may be difficult to hear with usual patient positioning. Left lateral positioning forces the heart to shift closer to the chest wall, yielding more prominent tones as auscultated through the stethoscope. Blood pressure cuffs need to be properly sized to ensure a correct reflection of the patient s hemodynamic state. Cuffs that are too small artificially inflate the blood pressure. It may be necessary to use unorthodox sites such as the forearm or larger thigh cuffs for the upper arm. Lateral placement of electrodes does not transmit signals well when placed on the obese anterior abdomen. Use lateral placement for better signal quality. (Collopy, Kivlehan, & Snyder, 2012) Airway Airway control and maintenance is always paramount and sometimes challenging in trauma patients. Obese patients can create additional hurdles for the clinician to overcome when trying to establish and maintain airway patency. Increased body mass coupled with excess soft tissue in the upper airway increases airway resistance. During bag-mask ventilation, overcoming this increased resistance requires the clinician to squeeze the bag with more force. This can easily result in loss of mask seal and ineffective ventilation (Navarro, 2014). The ability to ventilate obese patients with a bag-mask is extremely important because they have decreased oxygen reserves and will not tolerate apnea for any period of time (Collopy, Kivlehan, & Snyder, 2012). To facilitate ventilation with a bagmask, rescuers should use a two-person technique. Oropharyngeal or nasopharyngeal tube insertion may help provide a patent airway and assist rescuers as they work to maintain an effective mask seal (Navarro, 2014). During intubation, the ramped position has been proven to improve the laryngeal view and intubation conditions compared to the standard sniffing position. In the ramped position, the external auditory meatus and the sternal notch are horizontally aligned to reproduce the same alignment of the intubation axis that the sniffing position produces in nonobese patients (Jones, 2012). While the use of laryngeal mask airways (LMA) increases the risk of aspiration in obese patients, the use of supraglottic airway devices in general can help reduce hypoxic periods (Collopy, Kivlehan, & Snyder, 2012). The use of video-assisted devices has been shown to improve visualization of the larynx and require a lower dose of propofol when compared to the traditional Macintosh laryngoscope (Jones, 2012). Awake videolaryngo s copy may be useful for the tracheal intubation of the morbidly obese (Moore, Schricker, & Court, 2012). With the advent of more affordable portable video laryngoscopy devices, their use has become prevalent in nonsurgical hospital departments and prehospital settings. Transportation and Movement Transportation and movement of the bariatric patient can pose both logistical and clinician hazard issues. Healthcare providers must know the weight capacity of all equipment, including beds, bedside chairs, scales, wheelchairs, toilets, bedside commodes, carts, OR tables, and radiology equipment (Blythe & Powers, 2011). Appropriate patient movement/transfer systems must also be located wherever metabolic and bariatric surgery patients receive care. Personnel must be trained to use the equipment and be capable of moving patients without injuring the patient or themselves (MBSAQIP, 2014). Patient as well as staff safety is paramount when dealing with any patient, and bariatric patients are no exception. In fact, in most cases safety is a higher priority. Vascular Access Vascular access in any critical patient may be challenging at best. Bariatric patients offer additional obstacles, with excessive tissue and adipose distribution making the ability to palpate, visualize, and identify veins very difficult. As a result, multiple IV attempts are common and increase the risk of infection, phlebitis, and thrombosis. To help lessen the risk, consider intravenous catheters longer than the standard 1.5-inch needle and avoid butterfly needles, as they are much shorter and even less likely to provide proper access (Collopy, Kivlehan, & Snyder, 2012). Choosing the most appropriate device in conjunction with practicing the most effective technique will improve vascular access outcomes for obese patients (Houston, 2013). To increase venous cannulation success rates in patients with difficult access, several techniques have emerged that use specialized equipment and training. The following are becoming more

76 88 Basic Trauma Nursing popular vascular access options in prehospital and hospital settings: Ultrasound-guided peripheral and central access. Ultrasound-guided IV access requires training sessions, and physicians, nurses, and ED technicians can perform it using the singleoperator or dual-operator method. For patients with known or suspected difficult IV access, ultrasound-guided techniques improve success rates in a timely manner, with improved patient satisfaction (Crowley et al., 2011). Intraosseous access (IO). IO access provides vascular access in a timely manner when healthcare providers are faced with difficult IV access. IO access has significantly higher first-pass success rates and faster placement compared with central venous catheters. IO operators report high satisfaction with and confidence in its use (Lee et al., 2015). IO access offers very desirable flow rates depending on the insertion site. A recent study compared the rate of flow at the three most clinically used adult IO infusion sites: the sternal site provided the most consistent and highest flow rate compared with the humeral and tibial insertion sites. The average flow rate in the sternum was 1.6 times greater than in the humerus and 3.1 times greater than in the tibia (Pasley et al., 2015). The IO route is clearly a valuable alternative to consider with problematic intravascular access, and achieving insertion competence is relatively uncomplicated following minimal preparation (Garside, Prescott, & Shaw, 2015). Illumination-guided vascular access. Vein illumination works by shining two lights onto an area of the patient s skin. One is an infrared (or near-infrared) light that detects hemoglobin, and the other light is used to project the vein pattern back onto the patient s skin. This technology facilitates peripheral venous access for patients with difficult veins, thus enhancing first-attempt success rates (Kim et al., 2012). Spinal Immobilization When managing a traumatically injured obese patient, it may be unrealistic to completely immobilize the spine without jeopardizing the safety of both the patient and the healthcare providers (Collopy, Kivlehan, & Snyder, 2012). Strategies employed to help minimize cervical movement may include the following: Regardless of methods, providers must remember to avoid excessive tightness with a c-collar. If none of the cervical collars fit properly, towels may be used to minimize cervical movement. Towels may need to be placed under the patient s neck to prevent hyperextension from excessive adipose tissue on the back. Many obese patients suffer from sleep apnea whereby excessive soft tissue obstructs the airway when the patient is supine; in such situations, a reverse Trendelenburg position may facilitate lung expansion. (Long, McGary, & Jaunch, 2011) It is important for the healthcare professional to know the capabilities and limitations of all equipment when treating bariatric trauma patients. This will help ensure safety for the patient as well as the caregiver. Resuscitation While acknowledging that approaches will vary, resuscitation in the bariatric population starts with the basic principles of the ABCs of resuscitation, and standard Advanced Cardiac Life Support (ACLS) protocols need not stray from the published algorithms (Vanden Hoak et al., 2010). Airway is still the utmost priority, with modifications made for size and anatomic variances. Resuscitation of the bariatric patient also requires the facility and caregivers to modify the team and equipment to maximize safe ergonomics as well as the efficient work of the resuscitation team. In burn care, the obese patient poses many clinical challenges related to accurate measurement of burn size, resuscitation, mechanical ventilation, wound infections, mobilization, effective deep vein thrombosis prophylaxis, and nutritional goals (Rae et al., 2013). Obesity appears to be associated with a higher risk of complications and deaths after major burns (Ghanem et al., 2011). Morbidly obese patients with severe burns tend to receive closer to predicted fluid resuscitation volumes for their actual weight. However, this patient group has persistent metabolic acidosis during the resuscitation phase and is at risk of developing more severe multiple organ failure. These factors may contribute to higher mortality risk for the morbidly obese burn patient (Rae et al., 2013). Rehabilitation of the bariatric patient Approximately one third of the American population is obese. This number is rising, and the number of obese individuals involved in high-energy accidents with multiple injuries has proportionately increased as well (Licht et al., 2014). With more traumatic events, more patients are involved in the resuscitation phase and ultimately the post-event and rehabilitation phases as well. While several studies have suggested that trauma in general has seen an increased rate of complications and costs, a recent study has definitively concluded that higher levels of obesity are associated with higher total hospital charges, longer hospital stays, higher level of care discharge dispositions, and higher rates of surgical orthopedic intervention (American Academy of Orthopaedic Surgeons, 2014). Special equipment is necessary to care for this patient population. The equipment must be appropriately sized, and it must accommodate the patient s weight (Blythe & Powers, 2011). Emphasis must be placed on proper preplanning in relation to staff, room accommodations, emergent needs of the patient should the scenario present itself, and daily diagnostics. With longer hospital stays, multiple comorbid factors to manage, and specialized training, the rehabilitation of the bariatric patient can be taxing on both the patient and staff. Proper preplanning is essential to ensure a consistent continuum of care for this patient group. Summary The proliferation of obesity in the United States has forced the medical community not only to identify this population but to manage their care safely, competently, and compassionately. Retention of patient dignity is essential with any patient population, and the bariatric patient is no exception. In addition to the expanding roles of the trauma nurse, empathy and patient advocacy are still at the core. Knowledge of changing anatomy and physiology will help steer the trauma nurse on how to successfully care for the bariatric trauma patient. Chapter 16: Psychosocial Considerations CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to identify the psychosocial issues affecting the staff taking care of trauma patients as well as patients and families who have experienced a traumatic injury. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Describe three critical factors in crisis intervention for the trauma patient. 2. Identify common psychosocial needs of the trauma patient. 3. Recognize characteristics of posttraumatic stress disorder. 4. Identify interventions for successful family presence during resuscitation. 5. Specify interventions to optimize organ donation after trauma. 6. Identify the principles of critical incident stress debriefing. A INTRODUCTION traumatic injury is a devastating event that produces both physical and psychological injury. Caring for the trauma patient requires a basic understanding of the psycho social responses and needs of the patient and his or her significant others. Focusing on the psychologic aspects of trauma patient care, completing a thoughtful assessment, and planning and implementing psychosocial interventions can significantly affect recovery (ENA, 2014). Specific strategies can be used to support the patient and his or her family. POTENTIAL FOR GROWTH OUT OF CRISIS Trauma often occurs rapidly and is unanticipated. Both the patient and family are affected, and they often feel vulnerable and ill prepared to deal with the event. As a result of the stress, patients must adapt by calling upon their coping mechanisms. If these coping mechanisms are inadequate, there will be ongoing crisis. A number of positive and negative coping styles, resilience factors, and trauma interpretation methods determine recovery from trauma (De Sousa, 2010). Understanding the human response to injury and disability can provide the nurse with tools to enhance patient care and increase self-awareness of how repeated exposure to these events may negatively affect one s wellbeing (ENA, 2014). Nurses can assist with appropriate interventions to achieve this higher growth. P CRISIS INTERVENTION eople in crisis find their equilibrium is significantly affected by their perception of an event, their support system, and their coping mechanisms (APA,

77 Basic Trauma Nursing ). These factors often determine if an event will produce a crisis for the individuals involved. PSYCHOSOCIAL NEEDS Several common psychosocial needs have been identified in patients and families experiencing trauma (Clark, 2010). These include the need for (a) information, (b) compassionate care, and (c) hope (see Table 16-1). POSTTRAUMATIC STRESS DISORDER Posttraumatic stress disorder (PTSD) is recognized as a major health concern after trauma. Historically, military phrases such as battle fatigue and shell-shocked preceded the now more common term posttraumatic stress disorder. Symptoms of PTSD can begin at any time and may include: flashbacks; physical symptoms, such as a racing heart or sweating; bad dreams; frightening thoughts; staying away from places, events, or objects that are reminders of the experience; feeling emotionally numb; feeling strong guilt, depression, or worry; losing interest in activities that were enjoyable in the past; having trouble remembering the dangerous event; being easily startled; feeling tense or on edge ; and having difficulty sleeping, and/or experiencing angry outbursts. (NIMH, 2014) PTSD is also associated with a range of medical conditions, with a preponderance of cardiovascular, respiratory, musculoskeletal, neurologic, and gastrointestinal disorders; diabetes; chronic pain; sleep disorders; and other immune-mediated disorders (Gupta, 2013). The main treatments for people with PTSD are psychotherapy ( talk therapy), medications, or both. Everyone is different, so a treatment that works for one person may not work for another. It is important for anyone with PTSD to be treated by a mental health specialist who is experienced with PTSD (NIMH, 2014). FAMILY PRESENCE DURING RESUSCITATION Family presence during resuscitation has become an accepted practice in many institutions throughout the United States. A study showed that family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the healthcare team, or result in medicolegal conflicts (Jabre et al., 2013). Offering family members of patients undergoing CPR the option of witnessing the resuscitation efforts was associated with a significantly lower incidence of PTSD-related symptoms (Jabre et al., 2013). Families who witness resuscitation have fewer symptoms of grief and distress during the first 6 months of their bereavement. The idea of having family members present during resuscitation often stimulates trepidation in nurses and physicians; however, there is no evidence to suggest that this practice increases lawsuits. A recent look at family presence during trauma resuscitation showed that family members present during trauma resuscitation suffered no ill psychological effects, and their scores on measures of anxiety, satisfaction, and well-being were equivalent to those of family members who were not present (Pasquale, Pasquale, Baga, Eid, & Leske, 2010). The concept of family presence during trauma resuscitation (FPTR) remains controversial, however. Pasquale and colleagues (2010) reported that all family members they studied who were present during resuscitation would repeat the experience again, which supports the idea that FPTR was not too traumatic for those who chose to be present. Tips to Incorporate Family Presence During Resuscitation Ensure that your healthcare facility has written policies and procedures that support family presence during resuscitation and invasive procedures. Offer the family the choice of being present. Avoid passing judgment and causing feelings of guilt, whatever their choice. Establish ground rules. The family will always be accompanied by a nurse who is dedicated to the family members and not part of the resuscitation. The family can leave and return to the room at any time. TABLE 16-1: PSYCHOSOCIAL NEEDS OF TRAUMA PATIENTS AND FAMILIES Need Nursing Interventions For Information Continually ask if they have questions. Ask them to repeat what the doctor has told them. Provide clear, consistent, repeated explanations. Ask them to repeat back to confirm understanding. Encourage them to write down questions for the doctor in advance of rounds. Schedule regular patient/family/physician meetings. For Compassionate Care Use compassionate touch and tone of voice. Refer to the patient by name. Work to keep the patient s pain under control. Encourage the family to touch and talk to the patient. Involve family in care as appropriate. For Hope No matter how critical the situation, allow the patient/family to hope. For the good of the patient, the family must not interfere with care. The family will be allowed to touch the patient as soon as it is practical. Assign a nurse who is specifically prepared to provide explanations and enforce ground rules during the resuscitation. This nurse should be experienced in handling distressed and grieving persons. Provide clear and honest explanations of all events. Tell the family if/when the patient is dead. In case of death, inform the family that they will be escorted from the room briefly while equipment is removed, after which they can return to grieve in private. Provide the family the gift of time. Allow the family time to reflect on the events. Allow the family to ask further questions. (AACN, 2010) ORGAN DONATION When death is inevitable, some families may receive comfort from the ability to donate their loved one s organs or tissues (ENA, 2014). The following points outline the status of organ donation in the United States: More than 120,000 men, women, and children currently need life-saving organ transplants. Every 11 minutes, another name is added to the national organ transplant waiting list. An average of 18 people die each day because of the lack of available organs for transplantation. In 2014, there were 29,533 transplants performed and a total of 14,412 donors (U.S. Department of Health & Human Services, 2015). 98% of all adults have heard about organ donation, and 86% have heard of tissue donation. Although 90% of Americans say they support donation, only 30% know the essential steps to take to be a donor. (Donate Life America, 2015) General Facts About Organ Donation Organ and tissue recovery takes place only after all efforts to save the patient s life have been exhausted and death has been legally declared. The donor family and/or the donor s estate is never billed for any costs related to donation. The body is treated with the utmost respect and dignity during the procurement process. Donated organs are removed surgically, in a routine operation similar to gallbladder or appendix removal. After the tissues and organs are recovered, the ventilator is turned off, wounds are closed, and the body is released to the morgue and then to the funeral home. Donation does not disfigure the body or rule out an open casket funeral. (Center for Donation & Transplant, 2015) Suggested Strategies to Increase Organ Donation 1. Work to dispel myths surrounding organ donation with continued and repeated credible information.

78 90 Basic Trauma Nursing 2. Establish a go-to person in your hospital who is knowledgeable about donation and with whom staff can easily consult when they are unsure about making a referral for organ donation. This person is usually from an organ procurement organization (OPO) that is part of the United Network for Organ Sharing (UNOS). 3. Establish a strong relationship with the donor family early on and earn their trust. To be successful, organ donation processes and protocols need to be implemented, both within and outside of the hospital setting, by champions from among organ procurement staff, hospital staff, and others such as medical examiners, EMS staff, and donor families. These processes and protocols span hospital development activities, family support and bereavement care, clinical support of potential donors, and follow-up. CRITICAL INCIDENT STRESS DEBRIEFING At times, staff members are involved with the treatment of trauma patients that causes them to react with unusually strong emotions. These critical incidents put staff at risk for continued dysfunction unless intervention is offered. Critical incidents in trauma include the following: Death or homicide of a child Events associated with significant media presence Victims who are relatives or friends of a trauma team member Events that threaten the safety or lives of trauma team members Mass casualty situations Critical incident stress management includes the use of debriefing techniques. These techniques include gathering staff after a stressful situation to share emotions and information. This allows for a safe, supportive environment where feelings can be expressed and performance can be analyzed without criticism. This promotes a return to a productive level of functioning. Critical Incident Stress Debriefing Measures Provide the opportunity to debrief with relevant team members. Have trained personnel (usually mental health professionals and peer support personnel) lead the session. Give individuals the opportunity to discuss their roles in the event and share how they felt during and after the incident. Participation in this discussion should be voluntary, not mandatory. Discuss stress management strategies and identify methods to support one another. Make referrals as appropriate. END-OF-LIFE DECISIONS Many older adults survive illnesses and injury and return to their previous levels of function and independence. However, many struggle to rebound from traumatic events. Long hospital stays with ventilator dependency and multiple complications are not infrequent. Sometimes the healthcare team, in conjunction with the patient and family, may choose to forego lifesaving measures, perhaps in cases of extensive burns in elderly patients that they are unlikely to survive. The trauma team should attempt to check for the existence of a living will, advance directives, or similar legal documents. Decisions should always be made in the best interest of the patient. SUMMARY Injury is physically and emotionally disrupting for the patient and family. Care of the injured patient includes psychosocial considerations. The psychological impact of the injury must be addressed throughout the trauma cycle. Appropriate application of crisis intervention methodology assists the patient, family, and healthcare providers as they deal with the stresses of the injury. The trauma nurse should be mindful of these considerations while providing trauma care. It is also important to include the family in support strategies. Often, community agencies and other resources are necessary to support the patient from the point of injury through the rehabilitation process. Chapter 17: Disaster Management CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to describe the principles of disaster management. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Differentiate among internal, external, manmade, and natural disasters. 2. Distinguish between a multiple casualty incident and a mass casualty event. 3. Describe nursing responsibilities during a disaster. INTRODUCTION Society has been confronted with an increasing frequency of catastrophic events in recent years that have resulted in large numbers of injuries, casualties, and property damage. Characteristics of such disasters include a sudden and unpredictable occurrence, a disruption of societal infrastructure that gives rise to chaos, and existing resources being overwhelmed. The approach used to manage mass casualties is different from that used when providing routine care to several emergency patients at the same time. Types of Disasters Events that cause disasters are often classified as internal or external and natural or manmade (see Table 17-1). In an internal or institutional disaster, the hospital suffers an event that disrupts routine hospital function. Examples include a disrupted water supply, major power outage, and fire. These circumstances result in the hospital being unable to receive patients and having to go offline, thus requiring patients to be diverted to other facilities. Additionally, when the site of the disaster is the hospital itself, patients may have to be evacuated to other facilities. An external disaster is any situation, natural or manmade, that overwhelms a community s ability to respond with existing resources. The majority of large-scale disasters involve high numbers of casualties. Disaster Terminology Various terms are used to refer to large-scale injury incidents. The definitions in Table 17-2 provide the reader with a basic primer of helpful disaster terminology. Simply put, a disaster can be characterized as any event that results in destruction, damage, injuries, or death and that overwhelms local resources. Multiple casualty incidents are defined as incidents in which patient care resources are overextended but are not overwhelmed, such as a motor vehicle crash that involves five or more patients. Mass casualties following disasters and major incidents are often characterized by a quantity, severity, and diversity of injuries and number of patients that can rapidly overwhelm the ability of local medical resources to deliver comprehensive and definitive medical care (ENA, 2014). Of course, numbers of casualties are relative and determined by the size of and resources available at the receiving facility. Incident Command System Disasters follow no rules. No one can predict the time, location, or type of the next disaster. However, a standardized and well-rehearsed incident management system together with standard operating procedures are paramount for linking site operations to health facility based care during an actual disaster (WHO, 2011). The key principle of disaster care is to do the greatest good for the greatest number of patients. An effective way to organize multiple resources responding to a disaster is the use of the Incident Command System (ICS). In 2008, U.S. Homeland Security Presidential Directive 5, Management of Domestic Incidents, led to the development of the National Incident Management System (NIMS). Under NIMS, the ICS was standardized across the country (ENA, 2014). Medical command can be further broken down into triage, treatment, transport, and staging. Following this organizational template ensures that all needs are addressed and coordinated in the event of a disaster. The structured flexibility of an ICS allows it to be adapted to all types of emergency incidents. Scene Response The first step is activation of the emergency medical services (EMS) response system. This is typically performed by the witness to the event who calls the local 911 emergency dispatch center. Security and personnel safety is a high priority and requires coordination with local law enforcement leaders to protect the response teams from a second strike or potentially becoming contaminated (resulting in further casualties), as well as to provide for entrance and exit of rescue workers and victims. As the first medical responders arrive, the initial priority is safety for all involved, including the responders. The best way to achieve this is to perform an overall scene assessment. The goal is to estimate the potential number of casualties, determine what medical resources will be required, and evaluate whether any specialized equipment or personnel, such as search and rescue teams, can be utilized. Disasters and mass casualty incidents, by their nature, create a chaotic scene and environment. In addition to numerous first responders, there is often a mass gathering of media, bystanders, and volunteers.

79 Basic Trauma Nursing 91 TABLE 17-1: TYPES OF DISASTERS Internal Any internal event that disrupts routine hospital function Major power outage Water disruption Elevator disruption Fire Bomb threat Inability of staff to reach hospital Although most are well intentioned, unsupervised or uncontrolled volunteers and bystanders can often add to the confusion and complicate the response. Local hospitals should be notified early to activate their disaster plans and prepare for arriving patients. Depending on the type of disaster, communication between all elements of a disaster response can be challenging. Telephone lines and cellular phones are vulnerable to failure in most disasters within minutes because of overload or destruction of their infrastructure. Back-up methods of communication are encouraged, such as handheld radios on a dedicated network, satellite phones, or even ham radio operators. Preincident planning should include contingencies for power outages, with backup generators and supplies of batteries for these back-up methods to work. Scene Triage Typically, the local population nearest the disaster site provides the first immediate search and rescue effort, which is quickly transferred to police, fire, and EMS personnel. Finally, specialized search and rescue teams are mobilized from around the country, often with members who are knowledgeable in hazardous materials, structural engineering, and canine search and rescue. Scene workers should always wear personal protective equipment. Experience from previous disasters has shown that about 60% of fatalities in confined spaces are would-be rescuers (SCM, 2013). Patients are initially assessed at the scene, and a triage category is assigned. The term triage means to sort. Patients are often divided into groups by severity of injury and assigned a color. There are several types of triage systems in use, but the most common and encouraged system is the Simple Triage and Rapid Transport (START) system. The U.S. Department of Health and Human Services describes the system as consisting of four color-coded groups of patients sorted according External Any event, natural or manmade, that overwhelms a community s ability to respond with existing resources Natural Manmade Tornado Terrorism Earthquake Airplane crash Wildfires Train derailment Hurricane Ice or snow storm Floods TABLE 17-2: DISASTER TERMINOLOGY Term Definition Disaster An incident in which the needs of patients overextend or overwhelm the resources needed to care for them Incident command system An organizational structure that provides overall direction for the management of the disaster response Mass casualty event A disaster in which patient care resources are overwhelmed and cannot immediately be supplemented Multiple casualty incident A disaster in which patient care resources are overextended but not overwhelmed to the level of care required: red (immediate care required), yellow (urgent care required), green (minimal care required), and black (end-of-life care required; ENA, 2014; see Figure 17-1). Emergency medical personnel must avoid the temptation to stop and treat patients as they go. As mentioned earlier, the primary principle in disaster care is to do the most good for the most people. Care should also be taken to match the right patient with the right hospital. Avoid overtriage of minor casualties to the trauma center. Conversely, avoid undertriage, which occurs when the sickest patients are taken to the closest hospital rather than transported farther to a trauma center. Hospital Response The hospital closest to the event should anticipate the greatest influx of patients. Generally, 50% of all casualties arrive in the first hour and 75% within 2 hours; of the 75% of patients sent to the nearest hospital, most of those who arrive first are not the most severely injured. So it may be necessary to wait for critically injured patients; coordination of patient intake care requires effective prehospital triage and the ability to lock down the hospital and retriage patients upon arrival (Eckstein, Cryer, & Diebel, 2014). Frequently, the patients who are the least injured will leave the scene of their own accord and make their way to the closest hospital. This results in large numbers of walking wounded arriving at the hospital (potentially overwhelming its resources) before the first critical patient ever arrives via ambulance. Dispersion of casualties to multiple hospitals, when possible, will help prevent this. Therefore, it is imperative to have mechanisms in place to lock down the closest hospital to screen out low-level casualties, bystanders, and untrained volunteers to preserve its resources for the 10% to 20% of survivors who will need immediate care. Hospitals should immediately implement their disaster plans when notified. Time should be spent clearing large spaces to accommodate anticipated casualties. This is known as surge capacity. The emergency department, intensive care units, and inpatient units should move out or discharge existing patients. Physicians and staff should be called in to expand OR capacity; capability of the blood bank should be expanded; retriage should be performed in the ED (with patients who do not require immediate care set up outside the hospital); an incident command structure should be established; resources should be reorganized according to a preconceived plan; delayed-category patients should be kept in the ED awaiting their turn in the OR; and the most critical patients should be treated in the resuscitation suite and transported to the OR, the ICU, or interventional radiology (Eckstein et al., 2014). Extra nurses should be mobilized to the emergency department. Decontamination Victims who have been exposed to radiologic, biologic, or chemical contaminants require specific decontamination procedures. Whether a natural disaster, industrial incident, or manmade event, recognizing the need for adequate decontamination is crucial to ensuring the safety of emergency personnel and minimizing any cross-contamination to other people (ENA, 2014). Most decontamination procedures have been copied from military concepts of hot, warm, and cold zones. Ideally, decontamination should occur before patients are brought to the hospital. This should be done by the local fire department, which has the expertise and equipment to conduct decontamination procedures at a remote site. Decontamination at the hospital would be for those who get through field triage and are not processed by the fire department. Decontamination at the hospital is very labor and resource intensive and degrades the hospital disaster response, while putting clinical personnel at increased risk. The decontamination area is broken into three zones. The hot zone is the area with actual or potential contamination and the highest potential for exposure to hazardous substances. The warm zone is the transition area between the exclusion and support zones. This area is where responders enter and exit the exclusion zone and where decontamination activities take place. The cold zone is the area of the site that is free from contamination and that may be safely used as a planning and staging area (EPA, 2014). Only basic life support is provided in these zones. Nurses working in the hot zone should concern themselves with patient care and supervision of decontamination procedures performed by others. Patients should not be sent into the emergency department until they are considered clean and decontaminated. Decontamination typically follows screening/triage, stripping of clothes, shower/rinse, dry, provide clean clothing, decon banding, progression to clean holding, then released to appropriate area (hospital, release, or morgue; ENA, 2014). Treatment Interestingly, the consistent pattern of injury seen following most disasters is that most survivors are not severely injured and do not require urgent medical care (Eckstein et al., 2014). The 10% to 20% of casualties who require immediate care do require the services of a trauma center if one is available. Injury patterns include burns, blunt trauma, and penetrating injuries, which are treated

80 92 Basic Trauma Nursing Figure 17-1: Triage of Mass Casualty Patients Using the START Method the same way as usual trauma injuries. Blast injury and explosions are being seen with more frequency because high-energy explosives are relatively easy to access, are inexpensive, and require little education and training to create. This mechanism is the most likely threat for which American medical personnel should prepare. Recovery and Psychological Response Psychological trauma is a frequent side effect of disasters. With terrorism events, the psychologic pain is intensified. Disasters that intensify mental distress occur with little or no warning, present serious threats to personal safety or have unknown health effects, and are often manmade with malicious intent. Long after patients have been treated for injuries related to a disaster, the psychological effects may continue, both for patients and for healthcare providers (ENA, 2014). Psychological responses can range from mild stress responses to full-blown posttraumatic stress disorder. Some people are at greater risk for posttraumatic stress disorder than others. Common post-disaster responses include intense or unpredictable feelings, changes in thoughts and behavior patterns, sensitivity to environmental factors, strained interpersonal relationships, and stress-related physical symptoms (APA, 2013). Brief crisis counseling should be provided at the hospital, followed by referral when treatment is indicated. Disaster workers can also exhibit stress during disasters. Nurses may report feelings of anxiety, irritability, and being overwhelmed. Complaints of memory loss, reduced attention span, insomnia, inappropriate humor, and crying easily are also reported. Efforts to reduce worker stress on site include reassigning the nurse to another area of the hospital (limiting his or her exposure to traumatic stimuli), reducing work hours, encouraging adequate sleep and rest, providing adequate amounts of private time, and, finally, debriefing (providing opportunities for counseling). Summary The study of past large-scale disasters yields insights into disaster commonalities. Learning from our past is pivotal to our ability to anticipate the future. There is value in a well-developed and

81 Basic Trauma Nursing 93 rehearsed disaster plan. Understand that communication problems frequently occur. Keep the hospital facility secure from external threats, be able to lock it down quickly, and have a plan ready for evacuation. Ensure that everyone knows who is in charge. Utilize effective triage upon patient arrival. Focus on those patients with survivable injuries. Expect to encounter blast injuries frequently. Avoid overtriage of those with minor injuries to trauma centers and undertriage of those with severe injuries to the closest hospital. Finally, develop strategies to deal with stressed workers, patients, and family members. Chapter 18: Nursing Care of the Recovering Trauma Patient CHAPTER OBJECTIVE Upon completion of this chapter, the learner will be able to discuss nursing management of problems commonly experienced by trauma patients during hospitalization. LEARNING OBJECTIVES Upon completion of this chapter, the learner will be able to: 1. Select nursing strategies appropriate for the recovering trauma patient. 2. Describe appropriate pain management for the recovering trauma patient. 3. Describe nursing interventions to optimize the nutrition and mobility of the trauma patient. INTRODUCTION After the initial resuscitation and stabilization of the trauma patient has been performed, the patient has different and unique challenges on the road to recovery. Excellent nursing care involves the totality of the patient. For trauma patients, it specifically involves optimizing ventilation and airway clearance, pain control, nutrition and fluid status, wound care, mobility, and psychological support. Quality nursing care during this phase can make a substantial difference in patient recovery. Most patients remember nurses as being the most important people in their recovery. Therefore, the important role that nurses play in trauma recovery should not be underestimated. OPTIMIZING AIRWAY CLEARANCE AND VENTILATION Procedures that effectively clear the airways at all anatomic levels and remove retained secretions are imperative for the recumbent immobilized trauma patient. Meticulous pulmonary care can often be difficult and time consuming for the nurse but is necessary for a trauma patient s recovery without complications. Coughing and Deep Breathing Patients who are immobile, in pain, or sedated are at risk for inadequate ventilation and airway clearance. Prophylactic maneuvers for reducing the incidence and magnitude of postoperative atelectasis in high-risk patients should be encouraged. These techniques are deep-breathing exercises, coughing exercises, and incentive spirometry (Madappa & Sharma, 2014). However, caution should be used in patients recovering from neurosurgery or facial surgery because coughing is typically contraindicated. Otherwise, a typical trauma patient s schedule includes deep breathing and coughing five to ten times every hour while awake. Use of incentive spirometry is encouraged and helps nurses quantify the patient s efforts, which can then be documented. An incentive spirometer helps the patient achieve maximal ventilation by encouraging deep breaths held for several seconds. This device measures inspiratory effort (flow rate) in cubic centimeters per second. Flow Incentive Spirometers Contain plastic balls that rise according to the volume of air the patient pulls through the device. Are commonly used for patients at low risk for atelectasis. Volume Incentive Spirometers Are activated when the patient inhales a certain volume of air. Estimate the volume of air inhaled. Measure lung inflation more precisely. Are commonly used with patients at high risk for atelectasis. Chest Physiotherapy When necessary, a physical therapy consultation may be required for postural drainage, percussion, and vibration (which are used to mobilize intrapulmonary secretions), accompanied by suction or coughing to clear the larger airways. However, based on current limited evidence, chest physiotherapy might not be recommended as routine additional treatment for pneumonia in adults (Yang et al., 2013). Suctioning Optimal methods of endotracheal suctioning have been the subject of nursing research and clinical review. Endotracheal suctioning frequently induces adverse effects. Problems with technique, suctioning frequency, and higher positive end-expiratory pressure (PEEP) are risk factors for complications; their incidence can be reduced with the implementation of suctioning guidelines (Maggiore et al., 2013). Ironically, the problems continue in many hospitals. Nonintubated trauma patients who are unable to effectively cough and breathe deeply may require nasotracheal suctioning. Prophylactic placement of a nasopharyngeal airway, also known as a nasal trumpet, can help prevent injury and reduce discomfort associated with frequent nasotracheal suctioning. A closed endotracheal suctioning system, which minimizes the chance of bacterial contamination of the respiratory systerm, is currently used for intubated patients. Positioning Another aspect of superior pulmonary therapy is therapeutic positioning, that is, the use of specific body positions to maximize oxygenation and ventilation. Turning the patient has long been accepted as treatment for the complications of immobility. Perfusion is greatest in the dependent lung or dependent portions of the lung; therefore, it is possible to position the patient so that specific lung areas receive a greater or lesser proportion of blood flow. Patients with compromised lung areas from injury and poor ventilation should ideally be positioned so that the injured lung is uppermost, thus receiving a gravity-dependent reduction in blood flow. The result is increased blood flow to areas of best ventilation, decreased flow to poorly ventilated areas, and overall improved ventilation perfusion matching. Kinetic Therapy Other measures that decrease ventilator-associated pneumonia (VAP) risk include extubating the patient as quickly as possible, performing range-ofmotion exercises, turning and positioning the patient to prevent the effects of muscle disuse, having the patient sit up when possible to improve gas exchange, and providing appropriate nutrition to prevent a catabolic state (Parker, 2012). Although the idea of turning immobile patients to prevent pulmonary complications seems self-evident, manually turning a patient has not been shown to alter pulmonary function. Physical therapies have been developed to help treat acutely injured lungs and avoid pulmonary complications such as VAP. These therapies involve turning patients at various angles to improve gas exchange, mobilization of secretions, and lymphatic drainage. Kinetic therapy (systematic mechanical rotation of patients with 40 to 60 turns) is an option for badly injured patients with severe chest trauma (Zeckey et al., 2015; see Figure 18-1). Kinetic therapy appears to be effective in preventing VAP and lobar atelectasis in critically ill patients. More importantly, kinetic therapy has not been shown to be an independent risk factor for mortality (Zeckey et al., 2015). Proning The most aggressive turning approach is prone therapy. Technically difficult to do, placing patients in a prone position improves gas exchange but has not generally been shown to change patient outcomes. However, use of the prone position is increasing in popularity for trauma patients who have had pulmonary collapse of the posterior lung fields (see Figure 18-2). The bulk of data indicates that in severe acute respiratory distress syndrome, carefully performed prone positioning offers an absolute survival advantage of 10% to 17%, making this intervention highly recommended in this specific population subset (Gattinoni, Taccone, Carlesso, & Marini, 2013). The improvement noted with the use of the prone position may be attributed to the redistribution of ventilation (recruitment of previously collapsed dorsal regions) and more uniform distribution of perfusion. Although this approach is cumbersome and resource intensive, many intensive care units have instituted proning protocols for intubated patients when necessary. Different methods utilized to prone the patient include a Stryker frame, two hospital beds pushed together, a single hospital bed with a special proning device, and a kinetic therapy turning bed. Supporting the head and maintaining the endotracheal tube s position are of paramount importance. PAIN MANAGEMENT IN TRAUMA Physiology of Pain Acute pain is the normal, predicted physiologic response to an adverse chemical, thermal, or mechanical stimulus. It is also associated with surgery, trauma, and acute illness (Wuhrman &

82 94 Basic Trauma Nursing FIGURE 18-1: KINETIC THERAPY Note. Image courtesy of ArjoHuntleigh, Inc. Disclaimer: The RotoRest Delta Advanced Kinetic Therapy System allows clinicians to offer Kinetic Therapy systematic mechanical rotation of critically ill patients up to 62 degrees. This product is not specifically indicated for the treatment of ARDS or VAP. Cooney, 2011). The injury initiates a cellular cascade that can produce allodynia and ultimately result in severe pain. Early analgesia can prevent or reverse this cascade. Therefore, early pain management for patients with multiple injuries is particularly critical. Physiologic Effects of Pain Effective management of pain in trauma patients is a high priority. Unrelieved pain produces multiple adverse effects (see Table 18-1). Inadequately controlled acute pain can be a factor in the development of chronic pain, extended hospital stays, readmission, and patient dissatisfaction (Wuhrman & Cooney, 2011). Many hospitals have instituted pain as the fifth vital sign, so that pain is assessed along with temperature, pulse, oxygen saturation, and blood pressure. Because acute pain is dynamic, frequent assessment of its intensity and quality over time is necessary to make adjustments in analgesic doses and multimodal pharmacotherapy treatment strategies. Some clinicians recommend acute pain evaluation as frequently as every 2 hours, though this is not standard or practical in all settings (Radnovich et al., 2014). Pain Assessment The most reliable and valid tool for pain assessment is self-report (ENA, 2014). The difficulty of assessing pain in a trauma patient can be compounded by the patient s altered level of consciousness. The numerical rating scale (NRS) measures pain intensity on a numerical scale ranging from 0 to 10, with corresponding verbal anchors (e.g., no pain and worst possible pain ) on both ends. The NRS is the most frequently used scale for measuring pain, but results show poor reproducibility in repeated tests of the same subjects (Radnovich et al., 2014). Faces scales are frequently used with children as self-report measures of pain intensity in research FIGURE 18-2: PRONE POSITIONING Supine Prone Oxygenation improvement

83 Basic Trauma Nursing 95 TABLE 18-1: Physiologic Effects of Pain Body System Effect Neurologic Anxiety, fear, anger, depression, confusion Respiratory Atelectasis, pneumonia, hypoxemia Cardiovascular Angina, deep vein thrombosis Gastrointestinal Ileus, nausea and vomiting, constipation Genitourinary Urinary retention Musculoskeletal Weakness, muscle spasm, fatigue Metabolic Weight loss, fever, tachycardia and clinical practice (Savino et al., 2013; see Figure 18-3). Lastly, for trauma patients who are unable to self-report, behavioral assessment tools may be used (ENA, 2014; see Table 18-2). The key point is that the use of an objective pain rating scale means that the patient s pain is believed to be measurable, therefore allowing for quantitative assessment and evaluation in response to intervention. Acute Pain Pain can be functionally divided into acute and chronic types. Acute pain and chronic pain are the result of different physiologic mechanisms and require different treatments. Acute pain serves a purpose by providing a warning that illness or injury has occurred. Pain stimulates the sympathetic nervous system, which in turn increases heart rate (HR) and causes peripheral vasoconstriction (Hamunen et al., 2012). Types of acute pain include somatic, visceral, and referred. Somatic Pain Superficial, coming from the skin or subcutaneous tissues Sharp or burning pain Visceral Pain Originates in the internal organs and the linings of the body cavities Poorly localized, diffuse Deep cramping or stabbing pain FIGURE 18-3: WONG-BAKER FACES PAIN RATING SCALE Referred Pain Felt in an area away from the site of the stimulus Occurs when activation of nociceptors in the viscera results in a perception of pain that is localized to the body surface (Fitzakerley, 2014) Often occurs with visceral pain; examples include the following: Shoulder pain from myocardial infarction Back pain from pancreatitis Right shoulder pain from gallbladder disease Left shoulder pain from splenic injury Chronic Pain Chronic pain is prolonged pain that persists beyond the expected normal healing time. Chronic pain is poorly understood and is more difficult to manage than acute pain. Patients with chronic pain may not have the behaviors associated with acute pain. Patients with chronic pain demonstrate lowered resting heart rate variability relative to their healthy counterparts. In addition, their autonomic nervous system response has been shown to be blunted following laboratory pain induction (Evans et al., 2013). Because other symptoms may not be present, assessing chronic pain requires listening to the person s description of it. Adequacy of Pain Management in Trauma Undertreated pain continues to plague emergency and trauma care despite efforts to correct this problem. The term oligoanalgesia is defined as the undermedication of patients who report pain as their chief complaint. In the recent past, nurses were requested to withhold analgesics to prevent the masking of clinical findings (despite the report of pain) so that the physician could continually assess the patient. This practice is no longer considered an appropriate standard of care. Comparisons of nurse and patient estimates of pain, however, reveal that nurses routinely underestimate patients musculoskeletal pain. It has been known for decades that the initial treatment of acute pain is all too often followed by substantial delay in reassessment and repeat therapy in the emergency department (Thomas, 2015). Barriers to Analgesia Administration in Trauma Unfortunately, inadequate analgesia in the emergency department often still occurs because of focused attention on acute injuries, failure to adequately assess pain, concerns over masking the underlying diagnosis, and fear of inducing respiratory depression or hemodynamic compromise. Studies that have attempted to identify barriers to adequate analgesia in emergency departments found that ethnicity, health insurance status, and extremes of age were associated with inadequate analgesia. However, these results have not always been reproduced in other studies, leaving this a hotly debated topic. A 2013 study that addressed the issue supported the need for increased opioid analgesic usage and protocol-based management of pain in peripheral limb injuries and other less severe forms of trauma (Balakrishnan, Jhaj, & Raj, 2013). Evidence of inadequate analgesia also exists in the prehospital setting, although only a handful of studies have attempted to identify the associated barriers. Patients gender contributes to bias in pain management. Implementing standardized analgesic protocols has been shown to minimize bias in analgesic care. Findings suggest that a standardized pain management protocol based on patients subjective pain rating may reduce gender-related bias in acute musculoskeletal pain management (Uri, Elias, Behrbalk, & Halpern, 2015). Prevention of Bias in Analgesic Administration Clearly, because behavioral cues may be used to validate patient self-reports of pain severity, to minimize observer bias that may adversely affect treatment decisions, observational measures of pain require the observer to be cognizant of the effects that cultural, social, contextual, and interpersonal influences have on the expression of pain. Suggested strategies to improve pain management in the emergency department include the following: Place educational emphasis on pain management practices in nursing and medical schools. Promote clinical quality improvement activities for evaluating pain management in the emergency department. Investigate studies of patients with special needs to identify ways to improve pain management for elderly and very young patients in the emergency department. Identify strategies to help clinicians change attitudes about addiction, which currently result in inappropriate diagnoses of drug-seeking behavior, fear of addiction, and fear of prescribing opioids (opiophobia). 0 NO HURT 1 HURTS LITTLE BIT 2 HURTS LITTLE MORE 3 HURTS EVEN MORE 4 HURTS WHOLE LOT 5 HURTS WORST Note. Wong-Baker FACES Foundation (2015). Wong-Baker FACES Pain Rating Scale. Retrieved 7/22/15 with permission from WongBakerFACES.org.

84 96 Basic Trauma Nursing TABLE 18-2: FLACC BEHAVIORAL PAIN ASSESSMENT SCALE Scoring Categories F Face L Legs A Activity C Cry C Consolability No particular expression or smile Normal position or relaxed Lying quietly, normal position, moves easily No cry (awake or asleep) Content, relaxed Promote strategies to help clinicians change their attitudes and remove bias in terms of ethnic and racial stereotyping. Provide educational programs to help clinicians realize the safety of opioids compared with nonsteroidal anti-inflammatory drugs (NSAIDs) so that providers feel comfortable prescribing opioids appropriately. (Danis, Blansfield, & Gervasini, 2007) Pharmacologic Pain Management Strategies Pain management strategies are traditionally divided into pharmacologic (nonopioid and opioid) and nonpharmacologic strategies. In the chaotic emergency department, the foundation of pain management is pharmacologic. Most of the clinical pharmacology for analgesia has been published in the cancer literature. The World Health Organization (WHO) has developed guidelines that provide a logical strategy for managing acute pain. For acute, severe, traumatic pain, a variation of the WHO guidelines was introduced by the World Federation of Societies of Anaesthesiologists (Roth, Frost, & Gevirtz, 2015). Each organization s guidelines follow the concepts of starting with nonopioid analgesia and progressing to more aggressive opioid options as warranted by the patient s condition. The concept of progressing through steps or stages of pain intensity can easily be applied to severely injured patients. Nonopioids Nonopioids with or without adjuvants (such as anxiolytics or antidepressants) have proven useful in managing slight to mild pain. NSAIDs are the drug of choice for musculoskeletal injuries because they are anti-inflammatory and antipyretic. As a Occasional grimace or frown, withdrawn, disinterested, appears sad or worried Uneasy, restless, tense, occasional tremors Squirming, shifting back and forth, tense, mildly agitated (e.g., head back and forth, aggression), shallow, splinting respirations, intermittent sighs Moans or whimpers, occasional complaint, occasional verbal outburst or grunt Reassured by occasional touching, hugging, or being talked to; distractible Frequent to constant frown, clenched jaw, quivering chin, distressed-looking face: expression of fright or panic Kicking or legs drawn up, marked increase in spasticity, constant tremors or jerking Arched, rigid, or jerking, severe agitation, head banging, shivering (not rigors), breath-holding, gasping or sharp intake of breath, severe splinting Crying steadily, screams or sobs; frequent complaints, repeated outbursts, constant grunting Difficult to console or comfort, pushing away caregiver, resisting care or comfort measures Note. From The Revised FLACC Observational Pain Tool: Improved Reliability and Validity for Pain Assessment in Children with Cognitive Impairment, by S. Malviya, T. Voepel-Lewis, C. N. Burke, S. Merkel, & A. R. Tait, 2006, Pediatric Anesthesia, 16, Retrieved from publication/ _the_flacc_a_behavioral_scale_for_scoring_postoperative_pain_in_young_children/ links/00b7d533ab604ce pdf. Printed with permission The Regents of the University of Michigan. class, NSAIDs cause gastrointestinal distress, ulceration, bleeding, renal dysfunction, and renal failure. Topical Anesthetic Options for Trauma-Related Procedures Pain experienced during the stages of trauma recovery can vary from acute to intermittent, procedural, persistent, and, eventually, chronic if not resolved. Direct tissue trauma results in acute pain. The perception of discomfort declines as tissue inflammation diminishes and healing occurs over time. Intermittent or procedural pain can be the result of routine nursing interventions such as venipuncture, dressing changes, positioning, or suctioning. Painless placement of IV lines and tubes can be augmented by application of topical anesthetic agents for both adult and pediatric patients. Vapocoolants are a group of skin refrigerants used to reduce pain with a fast-acting spray under pressure that provides a short duration of analgesia (5 to 10 seconds), allowing for insertion of catheters without pain. Four percent lidocaine jelly is useful to reduce discomfort caused by nasogastric tube and urinary catheter insertions. Caution should be used with application in infants because of its absorption risks. Adjuvant Medications Other medications used to augment analgesics for traumatic pain relief include benzodiazepines to reduce anxiety and pain related to muscle injury and spasms. Anticonvulsants can help relieve chronic neuropathic pain. Muscle relaxants can help reduce muscle spasms in patients with back pain that is exacerbated by muscle spasms. Finally, corticosteroids are used to decrease bone, visceral, and neuropathic pain. Opioids Opioids produce analgesia by binding to specific receptors in the peripheral and central nervous systems. Opioids produce their major effects on the central nervous and gastrointestinal systems. Shortterm effects of opioids and morphine derivatives include drowsiness, slowed breathing, constipation, unconsciousness, nausea, and respiratory depression (National Institutes of Health, 2013). Opioids produce a dose-dependent reduction in the responsiveness of the brainstem s respiratory center. Opioids have no anxiolytic or amnestic properties; therefore, coadministration of a benzodiazepine is recommended to achieve controlled levels of sedation and amnesia when patients require moderate sedation or prolonged mechanical ventilation. The most common IV opioids studied in the emergency department and prehospital settings are morphine, hydromorphone, fentanyl, and meperidine. At equianalgesic doses, these opioids are expected to produce a similar analgesic effect (Patanwala, Keim, & Erstad, 2010). Adverse effects of opioids are transient and tend to be dose dependent. Respiratory depression is the most serious adverse event. Diligent nursing assessment and monitoring of respiratory status is essential. Nausea and vomiting are also common after opioid administration. Antiemetic therapy can be supportive. Opioids slow gastric emptying time by reducing peristalsis and decreasing intestinal secretions. Constipation is the most frequent side effect associated with long-term opioid therapy, and the standard prophylactic regimen includes a stool softener and a stimulant laxative (University of Wisconsin Pain Care Services, 2011). Opioids are also known to increase smooth muscle tone, which causes increased sphincter tone that can lead to urinary retention. Closely monitoring spontaneous voiding and bladder emptying is essential. Opioid Routes Routes for opioid administration in trauma depend upon the patient s phase of recovery and include oral, intravenous, patient-controlled analgesia, and peripheral nerve blocks. Oral route. The oral route usually is chosen because it is the easiest and most convenient route of administration. However, the rate of absorption in the gastrointestinal tract is variable. This route is typically used in the intermediate and rehabilitation phases of trauma care. Intravenous route: Preferred to intramuscular administration for speed of onset. In addition, the IV route allows for steady blood levels and, therefore, the ability to rapidly titrate analgesics as needed. It is the preferred route for moderate to severe pain. Patient-controlled analgesia: Allows the patient to self-administer analgesics by way of the IV route. This route has been reported to provide consistent drug concentrations, less sedation, less opioid consumption, and, potentially, fewer adverse effects compared with alternative means of opioid administration. Peripheral nerve blocks: Used for selected trauma patients with crush injuries, fractures, and burns. These blocks prevent or relieve pain by interrupting nerve conduction, and they specifically aim to block the nociceptive impulses transmitted along peripheral nerves. This long-lasting

85 Basic Trauma Nursing 97 analgesia allows early mobilization and physiotherapy, both postoperatively and posttraumatically, in patients with rib fractures and abdominal pain. Intercostal blocks significantly reduce opioid demand following thoracotomy and are an effective way to manage postoperative pain. Nonpharmacologic Pain Management Strategies A classic nonpharmacologic strategy used in immediate trauma care to reduce pain is the early placement of splints for any suspected fracture. Splinting provides fast pain relief, and it prevents excessive movement, which can cause further bleeding and muscle spasms. In addition to splinting, rest, ice, immobilization, and elevation all help prevent further injury and also reduce or limit edema formation and bone movement. Ice is used to limit injury-induced damage by reducing the temperature of the tissues at the site of injury and consequently reducing metabolic demand, inducing vasoconstriction, and limiting bleeding. It also can reduce pain by increasing threshold levels in the free nerve endings and at synapses and by increasing nerve conduction latency to promote analgesia (Van den Bekerom et al., 2012). Application of heat, on the other hand, is more effective during later phases of care such as rehabilitation (see Table 18-3). Nursing comfort measures also include providing padding and repositioning with extra pillows, back rubs, skin care, use of a calm and reassuring voice, and distraction techniques such as music therapy and television to promote comfort and enhance analgesic drug effectiveness, when at all possible. Many nurses have found success teaching relaxation, breathing techniques, and guided imagery. Specific techniques for reducing incisional pain include encouraging the patient to use the bedside rails for support when moving, to move slowly and smoothly, and to time movement in conjunction with pain medication administration. Splinting abdominal or chest incisions by holding pillows against the incision when coughing and breathing deeply can also help reduce pain. Patient teaching is important in pain management. Patients should be taught how to use a pain assessment tool and anticipate the timing of analgesic doses related to their activity. Preventing pain is much easier than treating pain that is out of control. Upon discharge, patient teaching shifts to the potential side effects of analgesics and the need to avoid alcohol. Hazardous activities should be avoided until patients know how the drug affects them. Finally, patients should be reminded that many analgesics cause constipation, so care should be taken to increase fiber and fluid intake in the patient s home diet. NUTRITION AND FLUID BALANCE Adequate intake of nutrients and fluid is necessary to promote healing, ensure hydration, and provide energy for the increased basal metabolic rate associated with trauma and surgery. The hypermetabolism of trauma is the result of the acceleration of catabolic processes to remove damaged tissue. Portions of healthy tissue also are broken down to supply nutrients to tissues undergoing repair. After insults such as shock, trauma, burns, and sepsis, the resulting hypermetabolism and catabolism can cause malnutrition (Beretta, Rochetti, & Braga, 2010). After trauma, there is an increased energy and nutrient demand, coupled with an inability to ingest food, which set patients up for nutrient deficiencies and can further decrease resistance to infection and hinder wound healing. Stress Ulcer Prophylaxis Stress-induced gastritis also referred to as stress-related erosive syndrome, stress ulcer syndrome, and stress-related mucosal disease can cause mucosal erosions and superficial hemorrhages in patients who are critically ill or in those who are under extreme physiologic stress. This condition results in minimal to severe gastrointestinal (GI) blood loss and a blood transfusion if the problem is not addressed (Clarke, Ferraro, Gbadehan, & Dim, 2014). Histamine-2 receptor antagonists are the most common medications administered to decrease the risk of gastric ulcer in trauma patients who are on NPO (nothing by mouth) status and to those with postpyloric feeding tubes. Sucralfate, antacids, and proton pump inhibitors are also used. Timing of Feeding After the initial resuscitation and stabilization of the trauma, the patient s nutritional support should be considered as early as possible. Patients who are in shock, or are recovering from it, have poor perfusion of the gastrointestinal tract. Feeding increases the demand for oxygen, so feeding into a poorly perfused gut can exacerbate gastrointestinal ischemia and even lead to bowel necrosis. Patients with mild injuries who were previously well nourished might be provided with 5% dextrose in water intravenously if they are expected to resume oral intake within 5 to 7 days. It is important to initiate early enteral nutrition in trauma patients to TABLE 18-3: COLD VERSUS HEAT APPLICATION IN TRAUMA Cold Application Heat Application Reduces swelling and pain because of its vasoconstriction effects Effective after muscle twisting and strain For use during the early acute injury phase Caution regarding use in patients with compromised vascular perfusion Increases blood flow to the area and elasticity of joint connective tissues, relaxes tight muscles and muscle spasms Effective for chronic injuries or injuries that have no inflammation or swelling, such as sore, stiff, nagging muscle or joint pain For use during post-acute phases of injury such as the rehabilitation phase Effective after physical therapy Caution regarding potential for damage to skin integrity and risk of burns blunt their hypermetabolic response and improve their nitrogen balance (Jivnani, Iyer, Umakumar, & Gore, 2010). Early consideration of feeding is important because trauma patients often require multiple frequent surgeries (e.g., incision and drainage procedures) and may have oral intake restricted each time, which prevents optimal nutrition. Route of Feeding The type of feeding route depends largely on the severity and location of the patient s injuries, as well as the expected recovery period. The best route is the one that minimizes risk to the patient. Enteral nutrition is the physiologically normal route. Typically, the ranking of feeding is that oral is better than tube feeding, which is better then parenteral nutrition. Parenteral nutrition can contribute to higher infection rates and longer hospital stays, so it is considered only when other options are not possible, such as when patients have bowel obstruction, bowel ischemia, or fistulas. Enteral Support and Monitoring Nurses play key roles in enteral nutrition administration by inserting feeding tubes, maintaining patency, administering feeds, documenting accurate intake and output, preventing complications, and assessing the patient s response and tolerance to feeding. Patients are administered the recommended feeds enterally by one of the following four routes: nasogastric tube feeding, feeding gastrostomy, feeding jejunostomy, and oral feeding (Jivnani et al., 2010). Nasogastric, nasoduodenal, and nasojejunal routes provide short-term (less than 4 weeks) access for enteral support. For trauma patients needing long-term support (4 weeks or greater), gastrostomy or gastrojejunostomy routes are preferred. Trauma patients are at risk for posttraumatic paralytic ileus, which resolves sometime during the first 72 hours after injury, after which gastric feeding is well tolerated. Trauma patients tolerate nasogastric tube feedings if elevating the head of the bed is not medically restricted. The nasal route is typically contraindicated for trauma patients who have sustained basilar skull or nasal fractures. The orogastric route is preferred for patients with facial trauma. Despite injury and surgery, small bowel motility and absorption remain intact. Therefore, feeding into the jejunum is encouraged even if gastric motility is impaired. Tube Placement and Care Feeding tubes can be placed at the time of laparotomy or inserted by blind passage at the bedside or by fluoroscopic or endoscopic placement. Soft, small-bore tubes are commonly used. Inadvertent placement of the feeding tube into the respiratory tract occurs in fewer than 5% of new tube insertions. Radiographic confirmation of placement before initiating feedings is the gold standard for confirmation. Other supportive nursing actions include checking the ph of aspirate, stabilizing tube placement, auscultating to determine correct placement, monitoring the patient frequently, checking for tube clogging, and maintaining tube patency (Singapore Ministry of Health, 2010). Gastrostomy and jejunostomy tubes should be dressed daily with dry gauze and the skin inspected for breakdown or redness (see Figure 18-4). Verifying tube placement and patency is a basic, but important, nursing procedure. Tube occlusion is often caused by the interaction of protein-based formulas

86 98 Basic Trauma Nursing FIGURE 18-4: Tube Feeding Routes Note. Copyright 2010 Amy Speech & Language Therapy, Inc. Retrieved from amyspeechlanguagetherapy.com/tube-feeding.html with an acidic environment and medications. If not flushed properly, tubes of smaller diameter such as jejunostomy tubes often clog (Itkin et al., 2011). Water is the best irrigant, and ports should be flushed routinely per hospital protocol. Prevention of Aspiration Aspiration of tube feeding is a serious complication that can be avoided. Signs and symptoms include cough, tachypnea, and respiratory distress. Although aspiration is common, diagnosis in the early phase of injury is challenging because most aspiration events are unwitnessed or silent. Knowledge of actual and potential risk factors is essential. Risk factors include the following: pathology of the upper gastrointestinal tract, including gastroesophageal reflux disease (GERD), and conditions that cause slowed peristalsis such as postoperative analgesia, vagus nerve injury during surgery (prevents stomach emptying), and ileus; geriatric patients with a predisposition to comorbid factors (gastrointestinal, mechanical solid food consumption, and poor oral hygiene); secondary mastication and mechanical movement of solid food from stroke, seizures, and head/spinal cord injuries; decreased level of consciousness from any etiology; nasogastric tube placement and feeding that can cause passive regurgitation; endotracheal tube intubation; and obesity (Smit & Guo, 2015) Strategies for prevention of aspiration include: increasing head of bed elevation to 30 to 45 ; maintaining the minimal occlusive volume for endotracheal or tracheostomy cuffs of ventilated patients; administering promotility agents such as metroclopramide for gastric feedings; administering continuous feedings, which are associated with a reduced risk of aspiration compared with large volume, intermittent bolus feedings; checking gastric residual volumes: 200 to 500 ml indicates that the patient should be monitored closely, greater than 500 ml indicates the need to withhold tube feedings and reassess tolerance; and avoiding glucose strips and methylene blue dye in the tube feeding to detect aspiration because they are no longer standard-of-care and are discouraged. Feeding Method and Rates Continuous feeding is typically administered via an automatic pump and is preferred over intermittent feeding to minimize gastric complications such as nausea, cramping, and diarrhea. Patients should be sitting upright at 30 to 45 during tube feeding and for 1 to 2 hours afterward to minimize the incidence of nosocomial aspiration pneumonia and to allow gravity to help propel the food (Thomas, 2015). Typically, the rate is increased by 20 to 25 ml every 4 to 8 hours, and the residual is checked every 2 to 4 hours, as needed. Nursing assessment includes checking for nausea, vomiting, bowel sounds, residual volume, flatus, amount and consistency of stools, abdominal discomfort, and abdominal girth. Large-volume residuals continue to be the primary reason tube feedings are interrupted. WOUND CARE Traumatic wounds differ from controlled wounds that result from elective surgery. Traumatic wounds are often multiple, induce extensive stress with catecholamine release, are often concomitant with shock and hypoxemia, and have the potential for bacterial contamination. Factors that affect wound healing include age, impaired tissue oxygenation and perfusion, contamination, anemia, nutritional status, stress, and presence of preexisting comorbidities. Wound Assessment Assessment of traumatic wounds includes pertinent history and evaluation of the wound. Wound irrigation and exploration in a well- lighted area may help identify the site of bleeding, allow for immediate intervention, and identify any emergency surgical concerns (Nicks, Ayello, Woo, Nitzki- George, & Sibbald, 2010). A complete patient history is essential to assess all factors that may contribute to the outcome of maximal wound healing. Comorbidities, circumstances surrounding the etiology, and contributing elements in the wound formation need to be identified to foresee potential complications in wound healing. Wound assessment is performed for location, length, width, depth, type of tissue in the wound bed, neurovascular and functional status of surrounding structures, and associated contaminants. Specialty consultation may be necessary when neurovascular compromise is present or if deep structures such as tendons, muscles, or bones are involved (Nicks et al., 2010). Wound Closure Options Options for wound closure include primary, secondary, and tertiary intention, as well as skin grafts and tissue flaps (see Table 18-4). The decision to close a wound primarily depends on the degree of contamination and the timing of the injury. Generally, wounds that are treated within 6 to 8 hours of injury are considered for primary closure. Wounds that have occurred more than 8 hours earlier are considered for secondary intention or delayed primary closure. Wounds on the face and scalp may be an exception to this rule because a better vascular supply to these areas reduces infection risk and because of cosmetic considerations. Wounds that exhibit extensive soft tissue loss and cannot be closed primarily require skin grafting or flap closure. Sutures should be removed within 1 to 2 weeks of their placement, depending on the anatomic location (Mackay-Wiggan, 2014). Wound Dressings Multiple wound dressings are available for use in trauma. The purpose of the dressing is to decrease contamination and dehydration of the wound, provide support to the wound during granulation, and stabilize the reapproximated wound edges. The major groupings of wound dressings include nonsynthetic and synthetic dressings. Nonsynthetic dressings include gauze (fluffs, 4 by 4 pads), which

87 Basic Trauma Nursing 99 TABLE 18-4: WOUND CLOSURE OPTIONS Type of Closure Alternate Name Definition Primary intention Primary closure Closure using sutures, tape, tissue adhesives, or staples. Secondary intention Secondary closure Leaving the wound open to granulate and close on its own. Tertiary intention Delayed primary closure Initially leaving the wound open, followed in a few days by primary closure. Skin graft Transplantation of skin. Tissue flap A flap of tissue is surgically removed from one area and attached to another. are adherent, absorbent, occlusive, and can be painful to remove. Synthetic wound dressings expand into the following groups of products: vapor-permeable adhesive films; hydrogels; hydrocolloids; alginates; synthetic foam dressings; silicone meshes; tissue adhesives; barrier films; and silver- or collagen-containing dressings. (Ngan, 2013) Sterile, occlusive, and normal saline-moistened wet-to-dry gauze dressings are the traditional dressings applied to open wounds. Dry, sterile dressings are applied to sutured or stapled wounds. The alginates and hydrocolloid dressings are gaining popularity for use with primary-closure and secondaryintention wounds. This is because they require less frequent changes and increase ease of management. Mobility Prolonged immobility, sedation, and mechanical ventilation during a critical illness have been associated with joint mobility restrictions, muscle weakness, critical illness neuromyopathies, pressure ulcers, deep vein thrombosis, prolonged mechanical ventilation, and psychological disturbances (Clark et al., 2013). To promote circulation and reduce the risk of skin breakdown, frequent patient repositioning is advocated. Pillows and foam wedges are effective to maintain position and support dependent limbs. The skin should be assessed every shift. Be aware that after some specific surgeries, turning and repositioning may be contraindicated and should be cleared by the surgeon first. Videotaped sleep studies have found that adults might change their position between 3 and 36 times a night, with the average person switching about a dozen times (Reddy, 2013). The current standard of care is to reposition patients every 2 hours, yet many nurses fail to incorporate this into their routine practice. Lack of time and staff are frequently cited as reasons, and coordination of the timing of pain medicine prior to repositioning adds to the complexity. It is reported that turning was rated by patients as the most painful routine procedure (Vazquez et al., 2011). Head-of-bed elevation is another important component of patient positioning and is advocated for patients who are receiving enteral nutrition to prevent aspiration of gastric contents. Maintain the head of the bed at or below 30 or at the lowest degree of elevation consistent with the patient s medical condition (National Pressure Ulcer Advisory Panel, 2015). There are also contraindications to head-ofbed elevation; therefore, appropriate nursing judgment must be used on a case-by-case basis. Prolonged bed rest leads to loss of muscle mass and strength. In young, healthy adults subjected to bed rest, the loss of lower body lean mass appears to be on the order of 100 to 200 grams per week (English & Paddon-Jones, 2010). Avoiding muscle wasting is essential to recovery. Early passive range of motion is advocated as soon as possible in the patient s stay. Mobility progression ranges from sitting up in bed, to dangling on the side of the bed, to standing and pivoting, and finally taking steps (see Table 18-5). Close patient assessment during each phase is required to see how the patient tolerates the procedure and to evaluate his or her progress. Patient-specific parameters should be monitored to help the patient progress to the next level of mobility. Document the patient s progress in the medical record. Set new goals with the patient and family every day, and communicate these goals to all staff. Psychological Support Trauma patients suffer from a variety of psychological stressors that are unique to trauma. Patients and families who sustain a sudden and severe trauma may experience a myriad of emotions and physical manifestations from fear, grief, and anxiety, to aches and pains, changes in sleep patterns, and diarrhea (Levin, 2011). Normal reactions to a traumatic event include anger, shock, guilt, nightmares, headaches, and the inability to concentrate. In most cases, these reactions can adversely affect normal coping strategies. Mobilizing family and friends to provide support, if available, will often help the patient cope. Other common reactions include fatigue, insomnia, confusion, difficulty feeling happy, irritability, emotional numbness, and feelings of vulnerability, self-blame, alienation, and distrust. Posttraumatic stress disorder (PTSD) is a response to a violent or life-threatening experience and is common among trauma patients. The three main symptoms are reliving the event, social avoidance, and a heightened sense of threat when in a repeat situation related to the event (Smith & Segal, 2015). Within the first month after a traumatic event, many people relive the event. Flashbacks, nightmares, or obsessive thoughts are not uncommon. Many patients go to great lengths to avoid places and activities related to the event. If the original trauma was a motor vehicle crash, there is a deepened sense of threat when first having to travel in a car again. Symptoms must last for at least 1 month to be considered symptoms of PTSD. While the symptoms of PTSD most commonly develop in the hours or days following the traumatic event, it can sometimes be weeks, months, or even years before they appear (Smith & Segal, 2015). If PTSD symptoms interfere with the patient resuming usual activities, mental health treatment should be encouraged. Coping strategies vary from patient to patient. Talking with friends, family, or other trauma survivors does provide support. However, some patients choose never to talk and should not be pushed. An important goal of talking is to validate the patient s feelings and to provide help with day-today functioning and moving on with life. Long-term counseling may be necessary and should be readily offered. Medications for depression are also used as part of PTSD treatment. A SUMMARY traumatic injury is a devastating event that produces both physical and psychological injury. The family as well as the patient is affected by the injury and the crisis that often ensues. The nurse, along with the other members of the healthcare team, plays a significant role in assisting the patient through the recovery process. Each aspect of patient care is interrelated. For example, managing the patient s pain optimizes mobility; proper nutrition affects mobility and wound healing. The nurse plays an essential role in the success of returning the patient to the highest level of functioning possible. TABLE 18-5: MOBILITY PROGRESSION Level of Mobility Characteristic Head of Elevate to 30 to 45. bed elevation Dangle the patient with assistance. Position the patient on the bed with legs over the edge and touching the floor if possible. Support the torso until the patient can sit independently. Stand Stand the patient at the bedside with support. Begin weight-bearing on one or two legs. Transfer Transfer the patient to a chair by pivot or taking one or two small steps. Walks with The patient may benefit from use of a walker or physical support of an individual. assistance Always have a wheelchair following behind in case the patient becomes exhausted or breathless and needs to suspend activity. Walks The patient walks independently. independently

88 100 Basic Trauma Nursing Resources TRAUMA-RELATED WEB SITES American Association for the Surgery of Trauma American Burn Association American College of Emergency Physicians American College of Surgeons American Spinal Injury Association American Trauma Society Association for the Advancement of Automotive Medicine Bike Helmet Safety Institute Brain Injury Association of America Center for the Study and Prevention of Violence Centers for Disease Control and Prevention Eastern Association for the Surgery of Trauma Insurance Institute for Highway Safety National Center for Health Statistics: Injury Data and Resources National Highway Traffic Safety Administration National Trauma Data Bank SafetyLit: Injury Prevention Literature Update & Archive Database Society of Critical Care Medicine Society of Trauma Nurses Trauma.Org Western Trauma Association World Health Organization Glossary abruptio placentae: Premature separation or detachment of a normally situated placenta from the wall of the uterus; can be a partial or complete separation. acceleration injury: Any injury resulting from an acceleration or increased forward speed of the body. allodynia: Means other pain. It refers to pain from stimuli that are not normally painful. anxiolytic: A drug used for the treatment of symptoms of anxiety. Battle s sign: Ecchymosis over the mastoid area that may indicate a fracture at the base of the skull. Beck s triad: Classic symptoms of cardiac tamponade that include distended neck veins, hypotension, and muffled heart tones. blunt trauma: Damage to the body without penetration of the skin, caused by rapid deceleration and sudden impact with an object. brain death: Cessation of all functions of the entire brain, including the brainstem. Cerebral and brainstem functions are absent. The heart is kept beating by mechanical support, but the patient is not alive and not actually functioning. burn: Tissue injury resulting from excessive exposure to thermal, chemical, electrical, or light mechanisms; smoke inhalation; or radiation. Effects vary according to the type of burn, duration of exposure, intensity of the agent, and the part of the body involved. cardiopulmonary resuscitation (CPR): An emergency technique used in the attempt to save the patient s life when he or she is in cardiac or respiratory arrest. The goal is to provide oxygen quickly to the brain, heart, and other vital organs until definitive medical treatment is able to restore cardiac and pulmonary functions. cardiovascular system: A system made up of the heart and blood vessels, including the aorta, arteries, arterioles, capillaries, venules, veins, and vena cava. The system keeps the body running by delivering oxygen and nutrients and disposing of cellular waste and carbon dioxide through a complex arrangement of systemic circulation and pulmonary circulation. central nervous system (CNS): The portion of the nervous system made up of the brain and spinal cord. The brain is the controlling organ of the body, and the spinal cord transmits messages back and forth between the brain and the body. cerebrospinal fluid (CSF): A watery fluid, continuously produced and absorbed, that flows in the ventricles (cavities) within the brain and around the surface of the brain and spinal cord. child maltreatment: Although different states definitions vary to an extent, the terms child abuse and maltreatment are used interchangeably to describe neglect or physical, emotional, and sexual abuse of the child. chondrolysis: A process characterized by progressive destruction of articular cartilage resulting in secondary joint space, narrowing, and stiffness. choroid: The dark brown vascular coat of the eye between the sclera and retina. The choroid is made up of blood vessels united by connective tissue containing pigmented cells and five layers. It is a part of the uvea or vascular tunic of the eye. comorbid conditions in elderly people: Diseases that commonly develop, along with the anatomic and physiologic changes occurring in aging, that seriously affect the older person s response to injury. compartment syndrome: Increased pressure in a fascial compartment arising from either an internal source, such as hemorrhage or edema, or an external source, such as a cast. Nerves, blood vessels, and/or muscle can be compressed as pressure rises inside the compartment. contrecoup injury: Injury occurring on the opposite side from the impact to the head. coup injury: Injury on the same side as the impact to the head. cranial nerves: Twelve pairs of nerves originating in the brainstem, each having a separate name, Roman numeral identifier, and anatomical and physiological function. The nerves exert unconscious control over sensory, motor, or both types of activities. Cushing s triad: Increased systolic blood pressure, widened pulse pressure, and reflex bradycardia as a response to cerebral and brainstem ischemia. death: Irreversible cessation of circulatory and respiratory function, evidenced by persistent cessation of these functions. The time and date of death must be documented on the patient s medical record, which is signed by the physician. deceleration injury: An injury resulting from a force that stops or decreases the velocity of a moving victim. decerebrate posturing: Extension and internal rotation of the upper extremities, wrist flexion, internal rotation and plantar flexion of the lower extremities; usually bilateral; may represent significant injury to the midbrain or pons. decorticate posturing: Adduction of the shoulders and pronation and flexion of the elbows and wrists along with the extremities; bilateral; may represent significant injury to the cerebrum or corticospinal motor tracts. diffuse head injury: A head injury that involves the entire brain. displaced fracture: A fractured bone that has been pushed out of alignment, causing deformity and requiring reduction before immobilization. dyskinesia: Difficulty or distortion in performing voluntary movements. embryo: The stage in prenatal development between being an ovum and becoming a fetus, lasting from the second to eighth weeks of gestation. epidemiology: The distribution and determinants of disease frequency in humans. Epidemiology is relative to trauma in the collection of such data as age, gender, race/ethnicity, and geographic characteristics that form frequency and distribution patterns of injury, morbidity, and mortality due to trauma. exsanguination: Extensive loss of blood due to internal or external hemorrhage. extremis: At the point of death; near death. failure to thrive: A condition seen in children younger than 5 years of age when growth continues to significantly fail to meet the norms for age and sex based on national growth charts. fasciotomy: The surgical treatment for compartment syndrome, in which the fascia is cut to relieve the pressure or tension within the compartment. fetus: The developing child in utero from the third month of pregnancy to birth.

89 Basic Trauma Nursing 101 flail chest: Abnormal chest wall movement when two or more consecutive ribs are broken in two or more places, resulting in a portion of the rib cage becoming unstable and moving in a direction opposite to the rest of the rib cage during inspiration and expiration. focal head injury: A head injury having a specific area of involvement. foot pound: Work expended when 1 lb is moved a distance of 1 ft in the direction of the force. gestation: The period of time from conception to birth, usually from 38 to 40 weeks. Glasgow Coma Scale: A scoring system to measure the patient s level of consciousness; scores range from 3 to 15; points correspond to responses in three areas: eye opening, verbal response, and motor response. The patient s best responses in each of three areas are added for a total score. golden hour: Refers to the occurrence of death following injury as a function of time. There are three peaks of the occurrence of death after injury: immediate, early, and late. It is early deaths, occurring within the first few hours, that the golden hour refers to. Modern trauma centers are often able to save these patients during this time. Survival of seriously injured or ill patients is the highest when intervention takes place within the first hour after the injury occurs. heterotopic ossification: The abnormal formation of true bone within extraskeletal soft tissues. hypervolemia: An abnormal increase in the amount of intravascular fluid or volume of blood plasma; often called fluid overload. hypovolemia: An abnormal decrease in blood volume or volume of blood plasma. inhalation injury: Damage to the air passages caused by the inhalation of toxic fumes, hot air, and/or carbon monoxide. Kehr s sign: Referred left shoulder pain that is associated with splenic rupture because of blood irritating the phrenic nerve. kinematics: Branch of mechanics that deals with the study of motion. Le Fort classification: System for classifying maxillary fractures using Roman numerals. malocclusion: A misaligned bite caused by facial trauma to the jaw. manual techniques to clear the airway: Techniques used to open the patient s airway, which include jaw thrust, head tilt-chin lift, and chinlift maneuvers. mechanical methods for airway control: Used in the semiconscious or unconscious patient when basic manual techniques do not clear the airway. Use of these mechanisms requires special training for professionals. Devices include oropharyngeal airways, nasopharyngeal airways, esophageal obturator airways, pharyngotracheal lumen airways, endotracheal tubes, and laryngeal mask airways. meninges: Three vascular layers of membrane that surround and protect the brain and spinal cord. Monro-Kellie hypothesis: States that a slight increase in any one of three volumes of the cranial cavity (brain, blood, cerebrospinal fluid) causes a decrease in another volume, without a significant change in intracranial pressure. neglect: Intentional or unintentional omission of needed care and support, or the caregiver being either unable or unwilling to provide the most basic needs for the person in his or her care. nociception: The neural processes of encoding and processing noxious stimuli. Synonyms include nocioception and nociperception. nociceptive: Caused by or responding to a painful stimulus. nursing diagnosis: A clinical nursing judgment about individual, family, or community reactions or responses to illness or injury, problems, or life processes. The diagnoses serve as a basis for nursing interventions that have outcomes for which the nurse is accountable. The physician does not have to give an order for these interventions. oligoanalgesia: Underuse of analgesics in the face of valid indications. opiophobia: Physicians fear of prescribing pain medications that are needed. orbital complex: A bony pyramid-shaped cavity in the skull that contains and protects the eyes; composed of the frontal bone, zygoma, and maxilla. organ donor: After death has been pronounced, a patient who the organ procurement agency has determined, according to specified criteria, is suitable for the donation of organs (and/or tissues) to be used in transplantation. orthopedic injuries: Musculoskeletal injuries, including soft-tissue strains and sprains; damage to the skin, tendons, ligaments, cartilage, and associated vessels and nerves; and dislocations, subluxations, and fractures that are a significant cause of short- and long-term disabilities. paraplegia: Injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris, resulting in paralysis to the lower half of the body. pathologic fracture: A fracture in a diseased or weak bone that can occur with minimal force. Pathologic fractures frequently occur in the spine without the patient being aware of the fracture. penetrating trauma: Injury caused by an object hitting the body with such force that it pierces the skin and may leave tissue and organ injury or destruction along its path. peripheral nervous system: Linking cables of nerve fibers reaching outside the central nervous system. The system includes the nerves that enter and leave the spinal cord and those that connect the brain and organs without passing through the spinal cord. There are 31 pairs of peripheral nerves called spinal nerves and 12 pairs of cranial nerves. peritoneal space: A cavity that is really a potential space between the layers of the parietal and visceral peritoneum. It contains a small amount of fluid so that the viscera can glide easily on each other or against the wall of the abdominal cavity. physical abuse: Intentional infliction of physical injury, torture, maiming, or unreasonable force or omission/failure to protect an individual from danger and injury. prehospital care: The part of the emergency medical services system that begins at the point of discovery of a person s illness or injury, access to the system, or professional medical care until the patient reaches the emergency department. There are two levels of care provided by prehospital personnel: basic life support (BLS) and advanced life support (ALS). priapism: Abnormal, painful, and continued erection of the penis due to disease or lesions of the spinal cord above the lumbar region. primary assessment: Rapid initial assessment of the patient s condition that is conducted on every patient. Primary assessment includes determination of the status of the ABCs: airway, breathing, and circulation. Included are providing resuscitation and stabilization on a priority basis and determining critical injuries and the level of care the patient needs. psychosocial: The internal/psychological and interpersonal/social factors that determine a person s emotional state. Psychosocial conditions should not be confused with psychiatric or altered mental conditions. pulse pressure: The difference between the systolic and diastolic blood pressures. It roughly reflects the degree of vasoconstriction or vasodilation of the blood vessels. raccoon s eyes: Black eyes or discoloration under the eyes that may indicate a basilar skull fracture. respiratory system: A system consisting of air passages and organs, including the nasal cavities, oral cavity, pharynx, larynx, trachea, lungs, bronchi, bronchioles, alveolar ducts, and alveoli. The system functions to bring in and distribute oxygen to nourish the body and to rid it of the waste products of respiration. response to trauma: Response to trauma going beyond the physical injury and including the mind and spirit s reactions; a complex, integrated system of reactions. retinal detachment: Occurs when the pigment layer of the retina remains attached to the choroid and the rest of the retina detaches from it. Can occur with or without a tear. retroperitoneum: Located behind the peritoneum and outside the peritoneal cavity; contains the kidneys, bladder, ureters, reproductive organs, inferior vena cava, and abdominal aorta. saddle nose: A nose with a depressed bridge usually congenital due to the absence of bone or cartilage support; also may be due to disease or a deformity secondary to trauma, causing a septal hematoma. secondary assessment: Conducted after the primary assessment, or survey, is completed and the ABCs are stabilized. The purpose is to thoroughly evaluate and document additional injuries and illnesses, including stopping any bleeding and administering supplemental oxygen. The patient is reassessed frequently, and a history is obtained. In addition, the patient s current medications and allergies are recorded. shock: A clinical syndrome that is a series of reactions to mental or physical upset of the body s internal balance. splanchnic: Refers to the visceral organs of the intestines. tetraplegia: Also called quadriplegia. Paralysis of the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord. This disorder is usually caused by spinal cord injury, especially in the area of the fifth to the

90 102 Basic Trauma Nursing seventh vertebrae. Generally refers to paralysis in all four extremities. thermoregulation: The regulation of temperature, and physiologically, body temperature. tocolysis: Delaying or inhibiting labor during the birth process. trauma: Physical injury caused by an external action, such as an assaulting force or thermal or chemical agent that is strong enough to potentially threaten a patient s limbs or life. trauma center: A hospital facility designated according to the level of trauma care it provides. Determination is made according to established criteria regarding the numbers and qualifications of the surgeons who staff it 24 hours a day and specialty services provided. Levels of trauma centers are I, II, III, and IV. Trauma centers have a team activation system that operates according to triage criteria, with its members having defined roles and responsibilities to provide systematic and coordinated care. triage: Injury assessment using defined criteria. Triage means sorting. In emergency medical services, it means assessment to sort patients by severity of illness or injury. The process is used in a prehospital situation in which the patient is assessed and directed to the most appropriate level of hospital emergency services. In the emergency department, triage is used to sort the severity of illness or injury to determine the priority of care the patient receives. Triage is also used during mass casualties and military operations. UNOS: United Network for Organ Sharing is a private, nonprofit agency that operates the Organ Procurement and Transplantation Network by serving as a clearinghouse and carrying out the objectives of the Secretary of the Department of Health and Human Services in accordance with the National Organ Transplantation Act of urinary system: Controls the elimination of specific toxic waste products filtered from the blood. Also manages the body s water and electrolyte balance. Other functions include stimulating red blood cell production, activating vitamin D, and degrading insulin. vapocoolants: Topical spray anesthetics that provide transient anesthesia within seconds of application via evaporation-induced skin cooling. Used prior to needlestick procedures to reduce pain. viscus: Internal organ (plural, viscera).

91 Self-assessment questions The following self-assessment questions are based on the learning objectives and are designed to evaluate your comprehension of the material and how well the content meets the educational objectives. Receive immediate feedback by comparing your answers to the Study Guide on page 109. This self-assessment is provided as a learning tool only. You are not required to submit your answers to receive credit for the course. Chapter 1 1. Which act authorized $224 million in federal funding for trauma and medical services programs? a. Trauma Care Center Grants Act b. National Trauma Center Stabilization Act c. Patient Protection and Affordable Care Act d. Emergency Care Program Act 2. The most common cause (mechanism of injury) of trauma in the United States is a. poisonings b. suicides. c. falls. d. firearms. 3. The highest percentage of trauma deaths occur a. immediately at the scene of the injury (first phase). b. within the first 4 hours following the injury (second phase). c. later during hospitalization due to multisystem organ failure (third phase). d. within 4 weeks following discharge from the hospital (late phase). 4. Which of the following is correct regarding motor vehicle crashes? a. Trauma results from a transfer of kinetic energy to the body. b. Car mass is more significant than velocity in determining injury. c. Injuries cannot be predicted reliably based on type of impact. d. The majority of injuries are the result of side-impact collisions. 5. The use of seat belts is known to a. prevent injuries in side-impact crashes. b. increase survival in rollover crashes. c. cause abdominal injury if worn appropriately. d. prevent neck injuries in rearimpact crashes. Item #N Contact Hours Chapter 2 7. Inclusive trauma care is best characterized by a. all components of the trauma system being involved in patient care. b. only the sickest patients receiving treatment. c. only one trauma center being allowed in the system. d. patient transfer agreements not being allowed. 8. The 3 E s of injury prevention refer to a. extrication, environment, and encompassing areas. b. enforcement, emergency care, and established protocols. c. environment, emergency protocols, and education. d. education, engineering, and enforcement. 9. Which of the following actions is recommended for bystanders at the scene of a car crash? a. Avoid stopping for fear of lawsuits. b. Stop and call for help. c. Alert the local radio station. d. Stop traffic by stepping in the road and waving arms. 10. Emergency medical services provide critical services to the trauma patient. Which of the following is an appropriate function of EMS when called to the scene of a trauma patient? a. Insert an IV and then check for breathing. b. Check in with police before approaching the patient. c. Transport the patient slowly and carefully. d. Assess mechanism of injury and injury status. 11. Thirty-two patients are seriously injured in a bus collision on the local highway. You are a nurse working for a local trauma center and are part of a helicopter crew dispatched to the scene. Which of the following is a basic principle of triage? a. Treat the least severely injured patients first. b. Produce the greatest number of survivors based on available resources. c. Rapidly transport all patients to the nearest hospital. d. Treat the greatest number of patients in 12. Which of the following characteristics are matched to the appropriate level of trauma center? a. Level I trauma centers treat high volume and severe injuries. b. Level II trauma centers are found in rural areas. c. Level III trauma centers perform research and education. d. Level IV trauma centers stabilize and provide rehabilitation. 13. How does rural trauma care differ from urban trauma care? a. The risk of death is much lower in rural trauma settings. b. Outcomes from rural and urban trauma care are the same. c. Rural trauma care often lacks professionally trained EMS personnel. d. Prehospital response times are shorter in rural areas than in urban locations. Chapter The use of a nasopharyngeal airway adjunct is most appropriate in a. a partially responsive patient with an intact gag reflex. b. a patient totally unresponsive to stimuli with no gag reflex. c. a patient with facial trauma or deviated septum. d. a patient with basilar skull fracture with otorrhea. 15. Which of the following findings in an adult trauma patient should prompt immediate return to the primary survey for assessment and intervention? a. Heart rate of 100 beats per minute b. Glasgow Coma Score of 14 c. Temperature of 36.5 C (97.7 F) d. Respiratory rate of 40 breaths per minute 16. Which element confirms placement of the oral endotracheal tube? a. Gastric fluids in the tube b. Normal end-tidal CO 2 capnography c. Ability of the patient to talk d. Unilateral chest wall expansion 6. Secondary blast injury is associated with a. bomb fragments. b. blast wave. c. victim as a missile. d. burns. the shortest period of time page 103 CE Express

92 104 Basic Trauma Nursing 17. Which of the following procedures is performed in the primary assessment? a. Bowel sound assessment b. Pulse check c. Neurovascular extremity checks d. Rectal examination 18. Pulse oximetry in trauma patients is best utilized as a a. measure of the patient s PaO 2. b. measure of SaO 2 in severely hypothermic patients. c. noninvasive continuous measure of O 2 saturation. d. means for alarm when it stays above 93%. 19. Nasogastric tube placement in trauma can a. increase the risk of aspiration. b. decrease gastric distention. c. provide nasal packing for nasal fractures. d. prevent drainage into the oropharyngeal airway. 20. During the initial assessment, the patient injured by a fall from 20 ft should be completely immobilized until a. the patient is able to indicate that he has no neck pain. b. the patient complains of potential pressure sores due to the board. c. the patient is logrolled to inspect the posterior surface. d. the full neurologic examination has been completed. Chapter Which of the following best characterizes a diagnosis of shock? a. Evidence of inadequate perfusion b. Systolic blood pressure below 90 mm Hg c. Pulse pressure less than 20 mm Hg d. Arterial blood gas analysis showing metabolic alkalosis 22. An anticipated compensatory finding when assessing vital signs during early shock is a a. wide pulse pressure. b. tachycardia, tachypnea, and diaphoresis. c. shallow and slow respiratory rate. d. unresponsive and unarousable state. 23. Compensatory mechanisms in shock include a. increased peripheral vasoconstriction. b. decreased sympathetic tone. c. decreased heart rate. d. increased blood flow to the gut. 24. In which class of hemorrhagic shock does a drop in systolic blood pressure first occur? a. Class I b. Class II c. Class III d. Class IV 25. A confounding factor the nurse must consider in the assessment of a patient for hemorrhagic shock is that a. tachycardia is a normal finding in the elderly. b. athletes already have a low blood volume and will exhibit signs of shock sooner. c. the normal hypervolemia of pregnancy may mask signs of blood loss. d. persons who take beta-blockers may bleed more easily. 26. A 16-year-old male is brought into the emergency department after crashing his car into a cement wall at high speed. He is unconscious and in obvious shock with a blood pressure of 60/40 and a pulse rate of 150. He has no open wounds or obvious fractures. The cause of his shock is most likely a. epidural hematoma. b. subdural hematoma. c. transected spinal cord. d. hemorrhage into the chest or abdomen. 27. A classic sign of neurogenic shock includes a. a slow increase in blood pressure. b. significantly narrowed pulse pressure. c. hypotension without tachycardia. d. hives and airway constriction. 28. A 20-year-old male arrives at a trauma center with a gunshot wound to the abdomen. He is in Class IV shock with a tachycardia of 156 and blood pressure of 78/40. He is immediately prepped and leaves for the operating room. Which blood administration is preferred for this patient? a. Emergency uncrossmatched type O positive b. Emergency uncrossmatched type O negative c. Type-specific blood d. Crossmatched blood 29. Which of the following interventions is considered to be an aggressive warming treatment for the hypothermic trauma patient? a. Gastric lavage with room temperature saline b. Increased room temperature c. Cloth blankets d. Warmed IV fluids Chapter Late signs of increasing ICP can be characterized best by a. increased respiration. b. increased pulse rate. c. increased blood pressure. d. narrowed pulse pressure. 31. An unhelmeted 20-year-old female is thrown from a horse and arrives at the emergency department (ED). She responds to verbal stimuli with eye opening and confused speech. She has purposeful movement and can follow commands. What is her GCS score? a. 9 b. 13 c. 14 d A characteristic of focal head injuries is that they a. involve widespread damage throughout the brain. b. involve damage to a localized area of the brain. c. rarely result in a fatal outcome. d. usually penetrate the skull. 33. A construction worker arrives at the ED after being hit in the head with a large steel pipe at a construction site. His GCS score is 6, he has a palpable depressed skull fracture, and he has gurgling respirations. There is vomitus on his face and clothing. The most appropriate initial treatment strategy is a. suction to clear the airway. b. administer oxygen via bag-valve mask. c. administer oxygen via nonrebreather mask. d. insert an oropharyngeal airway. 34. Nursing intervention(s) aimed at preventing secondary brain injury include a. administering an osmotic diuretic. b. raising the head of the bed. c. adequate oxygenation and IV fluids. d. reducing the brain s metabolic requirements. Chapter Fluorescein staining of the eye is used to a. decrease eye pain. b. make corneal abrasions visible. c. treat eye infections. d. increase visual acuity. 36. An indication of a mandibular fracture is a. Battle s sign. b. malocclusion. c. carotid artery involvement. d. Le Fort s syndrome.

93 Basic Trauma Nursing Which of the following is characteristic of an orbital blowout fracture? a. It is the most common fracture of the face. b. The muscles of the eye are not involved. c. It is caused by a direct blow to the eye. d. Symptoms result from ocular hemorrhage. 38. Four-vessel cerebral angiography is indicated in penetrating neck trauma when there is a. clinical evidence of significant vascular injury in Zones I and III. b. accompanying facial trauma. c. a history of thyroid disease. d. a palpable carotid pulse. 39. A patient is brought into the emergency department with maxillofacial trauma after being accidentally shot in the face. Your initial assessment reveals a large cheek wound; there is blood in his airway, and his radial pulse is weak and rapid. What is your first priority? a. Suction to clear the airway. b. Apply oxygen with a nonrebreather mask. c. Insert a nasopharyngeal airway. d. Ventilate with a bag-valve mask. Chapter Which of the following is indicated for the immediate management of an open pneumothorax? a. Cricothyroidotomy b. Occlusive dressing taped on three sides c. Dry, sterile gauze dressing d. Positive-pressure ventilation 41. Absent breath sounds and asymmetry of chest wall motion could result from a. abnormal anatomy. b. cardiac tamponade. c. cardiac contusion. d. tension pneumothorax. 42. Which thoracic injury is characterized by Beck s triad of hypotension, muffled heart sounds, and distended neck veins? a. Sucking wound b. Cardiac tamponade c. Hemopneumothorax d. Tension pneumothorax 43. A diagnostic technique used to quickly identify cardiac tamponade is the a. electrocardiogram. b. CT scan. c. chest X-ray. d. FAST examination. 44. Emergency department thoracotomy performed in the emergency department may be indicated for a. cold water drowning. b. a penetrating stab wound to the heart. c. multiple fractured ribs. d. a high cervical spinal cord injury. Chapter Which of the following is true about blunt genitourinary trauma? a. The genitourinary organs are unprotected. b. Genitourinary injuries occur in isolation. c. Both kidneys are usually injured together. d. The urinary bladder is more likely to rupture when it is full. 46. The organ injuries that can be expected to bleed the most are a. kidney, spleen, and liver. b. ureter, urethra, and bladder. c. stomach, duodenum, and colon. d. gallbladder, cecum, and rectum. 47. The abdominal organ most commonly injured from blunt trauma is the a. stomach. b. pancreas. c. liver. d. small bowel. 48. A passenger in a motor vehicle crash has fractured ribs on the left and is complaining of left shoulder pain, but there is no obvious left shoulder injury. Her vital signs are blood pressure 86/68, pulse 136, respirations 32 and shallow. As her nurse, you notify the physician because you think that her signs and symptoms are related to a. anxiety. b. substance withdrawal. c. injury to the spleen. d. fracture of the left humerus. 49. When a patient with reported abdominal injuries arrives in the emergency department, the sequence of physical examination of the abdomen is a. auscultate, inspect, percuss, and palpate. b. percuss, auscultate, inspect, and palpate. c. inspect, auscultate, percuss, and palpate. d. palpate, inspect, auscultate, and percuss. 50. A 19-year-old male was struck by a truck traveling 50 mph. He was subsequently transported to a trauma center. He has obvious fractures of the right tibia and fibula and complains of abdominal pain. His heart rate is 170 beats/min, respiratory rate is 36 breaths/min, and blood pressure is 84/50 mm Hg. Intravenous access is established. To identify the presence of abdominal trauma, the nurse anticipates that the next action taken will be to a. collect a clean-catch urine specimen. b. send the patient to the radiology department for an abdominal X-ray. c. schedule a stat intravenous pyelogram. d. perform a focused abdominal ultrasound. Chapter All messages that the brain sends for the body to function are transmitted through the a. vertebral ganglia. b. sensory and functional nervous systems. c. spinal cord. d. sympathetic and parasympathetic nervous systems. 52. The most common mechanisms of injury to the spine in adults are a. penetrating injuries from gunshot wounds and stabbings. b. sports-related injuries and pedestrian accidents. c. deceleration injuries from falls and motor vehicle crashes. d. strain from lifting heavy objects and hereditary predisposition. 53. A patient with a C6 spinal injury would most likely have which of the following symptoms? a. Tetraplegia b. Paraplegia c. Hemiparesis d. Aphasia 54. Patients with anterior cord syndrome experience the loss of a. vibratory sense. b. proprioception. c. movement on one side. d. pain sensation. 55. A 30-year-old man presents to the emergency department after sustaining a 20-ft fall from scaffolding. He is unable to move his legs and has some limited movement of his arms. The lateral cervical spine X-ray shows a subluxation of C5 on C6. Vital signs are: BP 110/60, P 100, RR 8. The nurse should anticipate which of the following management priorities? a. Immediate MRI b. Assistance with ventilation c. Preparation for surgery d. Insertion of an indwelling catheter

94 106 Basic Trauma Nursing Chapter What do tendons connect? a. Muscle to bone b. Bone to bone c. Muscle to muscle d. Cartilage to cartilage 57. A 56-year-old farmer is found trapped from the waist down beneath his overturned tractor. He has been pinned for 4 hours prior to being found. He is hemodynamically unstable with vital signs of BP 82/50, P 144, RR 36. He was awake and alert until just before arriving at the emergency department. He is now becoming difficult to rouse. His pupils are 3 mm in diameter, symmetrical, and reactive to light. EMS reports that he would not move his legs, even with painful stimuli. The most likely cause of his deterioration is a. intracerebral hemorrhage. b. hip fracture. c. pelvic fracture-associated hemorrhage. d. bilateral leg compartment syndrome. 58. Which of the following is a consistent sign in compartment syndrome? a. The distal pulse will be absent. b. It commonly occurs in the upper arm. c. It can be identified easily in patients with head injuries or in severely injured patients. d. Deep throbbing pain is far greater than the pain caused by the original injury. 59. Which of the following dislocations is considered a true orthopedic emergency? a. Hip dislocation b. Compound fracture of the leg c. Shoulder dislocation d. Elbow dislocation 60. Initial nursing management of musculoskeletal injuries includes a. splinting the extremity first, prior to assessing for injury. b. assessing the integrity of the skin over the point of injury and surrounding tissues to determine if the injury is a closed or open fracture. c. pulling off the patient s clothing as fast as possible if a fracture with hemorrhage is suspected. d. straightening the limb prior to splint application. 61. A 50-year-old man sustains a closed femur fracture in a motor vehicle crash, and his left thigh is angulated. A traction splint is applied to the injured leg and, shortly thereafter, the patient complains of severe pain in his foot and lower leg. Assessment reveals absent pedal pulses. The appropriate nursing intervention is to a. elevate the extremity. b. administer pain medication. c. release the traction. d. tighten the traction. Chapter The skin regulates the body temperature through sweat-producing glands and a. the production of vitamin D. b. creating a barrier against outside organisms. c. shielding the body from ultraviolet rays. d. evaporation of sweat and water. 63. Possible injuries related to smoke inhalation include a. bronchial asthma. b. upper airway obstruction. c. spontaneous pneumothorax. d. premature development of emphysema. 64. An adult patient who has been in an industrial explosion is brought into the emergency department. He is burned on his entire front torso and genitals and has circumferential burns on both of his legs. According to the rule of nines, what percentage of TBSA has been burned? a. 37% b. 45% c. 55% d. 60% 65. A 13-year-old girl is involved in a garage explosion. She arrives at the emergency department with singed eyebrows and 25% partial-thickness burns to her face, arms, chest, and hands. She is hoarse and tachypneic. The first management priority is to a. apply sterile dressings. b. administer morphine. c. intubate the patient. d. debride the wound. 66. The initial treatment for frostbite includes a. warm water bath. b. vasodilators. c. topical application of silvadene. d. padding and elevation. Chapter Which of the following changes best characterizes the normal response to pregnancy by the seventh month? a. Decrease in plasma volume b. Lowering of the diaphragm c. Decrease in tidal volume d. Widening of the symphysis pubis 68. Which of the following best characterizes mechanisms and patterns of injury among pregnant trauma patients? a. The uterus is more vulnerable to injury in the first trimester. b. Rapid deceleration in a motor vehicle crash results in a stalled delivery process. c. Maternal pelvic fractures from blunt trauma may be associated with fetal skull fractures. d. Assault is the most frequent mechanism of injury in pregnant females. 69. The most common cause of fetal death after blunt injury to a pregnant woman is a. ruptured uterus. b. prolapsed cord. c. abruptio placentae. d. premature labor. 70. In your assessment of a pregnant patient who has sustained blunt abdominal trauma, you find that her vital signs indicate shock and she has severe abdominal pain and distension. You alert the physician immediately because you are concerned that a. the pregnancy may involve twins. b. the patient s uterus has ruptured. c. delivery is imminent. d. she should be transferred to another facility as soon as possible. 71. In assessing a pregnant trauma patient, a most important question to ask is a. Do you smoke? b. How many other pregnancies have you had? c. When was your last prenatal visit with your doctor? d. Do you have any contractions or abdominal pain? 72. A pregnant trauma patient should be placed in which position? a. Back with head elevated b. Back with feet elevated c. Right side d. Left side

95 Basic Trauma Nursing 107 Chapter Until about 8 years of age, the narrowest part of the airway is the a. bronchi. b. cricoid cartilage. c. epiglottis. d. larynx. 74. Which of the following statements regarding children and trauma is true? a. Children can suffer spinal cord injury that may not be detected on X-ray. b. Children have more focal mass lesions than adults. c. Children suffer more spinal cord injuries than adults. d. An infant with a closed-head injury may become hypotensive from increased cerebral edema. 75. The number one mechanism of injury resulting in pediatric death is a. falls. b. sports injuries. c. gunshot wounds. d. motor vehicle crashes. 76. Which of the following best characterizes pediatric trauma injuries? a. Most pediatric spleen injuries require prompt surgery. b. Most pediatric chest injuries result in rib fractures. c. Small bowel injuries may occur in children with lap belt injuries. d. The most frequent cause of head injury in pediatrics is child abuse. 77. Early indicators of hypovolemic shock in a pediatric trauma patient are poor skin perfusion and a. decreased blood pressure. b. widened pulse pressure. c. bradycardia. d. tachycardia. 78. A 4-year-old boy was a pedestrian struck by a car and brought to the emergency department. His blood pressure is 90 mm Hg systolic, heart rate is 140 beats/min, and respiratory rate is 36 breaths/min. The preferred route of venous access in this patient is a. intraosseous. b. femoral vein. c. subclavian central line. d. peripheral veins in upper extremity. 79. A 9-year-old female falls 20 feet from a tree house and is brought into the emergency department of a small rural hospital at 9:00 p.m. Diagnostic tests reveal multisystem injuries, including a severe laceration of the spleen. The hospital does not have 24-hour operating room capabilities or a surgeon on call. The most appropriate management of this patient would be to a. transfer her to a hospital with 24-hour operating room capability. b. obtain a type and cross-match for blood. c. admit the patient to the pediatric intensive care unit for careful observation. d. prepare the patient for surgery as a first case for the next day. Chapter Trauma in the older patient is likely to be a. less complicated than in younger persons. b. from abuse. c. the result of carelessness. d. more serious than the same injury seen in a younger person. 81. The most common cause of injury and death among older adults is a. motor vehicle crashes. b. falls. c. gunshot wounds. d. ingestion of a foreign body. 82. An older adult patient presents with multiple bruises in various stages of healing. They are located on his upper arms. He also complains of neck pain. There are what appear to be round burn marks on his hands. His caregiver says he fell out of his wheelchair. The priority action for the nurse is to a. systematically assess the patient from head to toe for signs and symptoms of abuse. b. immediately report the caregiver to the authorities. c. evict the family from the hospital. d. have social services put a seat belt on the patient s wheelchair for his safety. 83. In the older person, cardiovascular system changes include a. progressive stiffening of the myocardium. b. decreased blood pressure. c. increased sensitivity to catecholamines. d. increased heart rate. 84. The most common area for fracture in geriatric trauma is the a. hip. b. wrist. c. forearm. d. ankle. 85. Which statement is correct regarding brain injury in older adults? a. Hormonal blood changes result in increased clotting. b. Minor forms of trauma can result in significant brain injury. c. Brain atrophy contributes to susceptibility to infections. d. Epidural hematomas are the most common brain injury seen. 86. In the older adult patient, the response to ongoing blood loss can be masked by a. increased cerebral blood flow. b. absence of tachycardia. c. peripheral vasodilation. d. increased lung vital capacity. 87. An effect of beta-blockers is that they a. may diminish the tachycardic response to trauma. b. cause peripheral vascular dilation. c. elevate blood pressure. d. constrict cranial blood vessels. 88. Which of the following is an important part of the secondary assessment of an elderly trauma patient? a. Ask about contacting nearby relatives or friends. b. Determine the patient s socioeconomic and insurance status. c. Assess the patient s preinjury health history. d. Ascertain the date of the last visit with the primary care provider. Chapter Which of the following is not an anatomic/physiologic change seen in the bariatric patient? a. Increased tongue size b. Chronic hypoxemia c. Chronic venous stasis d. Hypocapnia 90. The best position in which to place a bariatric patient to perform orotracheal intubation is a. supine. b. Trendelenburg. c. reverse Trendelenburg. d. ramped. 91. Which is not a typical vascular access option in the bariatric patient? a. Hypodermoclysis b. Intraosseous c. Ultrasound guided d. Illumination guided

96 108 Basic Trauma Nursing Chapter Which of the following patient characteristics is a critical factor in crisis intervention? a. Level of education b. Sex c. Age d. Support systems 93. Mr. Jones is 80 years old and has just suffered a stroke. He is admitted to your intensive care unit and placed on a ventilator. Mr. Jones s son, Tom, arrives from out of state and is anxiously pacing outside of the waiting room. Which of the following statements regarding Tom s psychosocial needs is true? a. The need for acceptance from the staff is paramount. b. The need to ventilate emotions is a priority. c. The need for information, while maintaining hope, is important. d. The need to be with the patient is more important than the need for information. 94. In posttraumatic stress disorder, a. the imprint of the traumatic moment can cause flashbacks. b. initial presenting symptoms usually do not occur until years after the event. c. treatment is more effective if held until the patient moves to rehabilitation. d. the patient often draws closer to his family and friends as a means to cope. 95. A 34-year-old male motorcyclist who was hit by a car arrives at the trauma center in full arrest. After 35 minutes of failed resuscitation, he dies. His wife is hovering in the hallway outside of the resuscitation room. Which of the following would have the greatest impact on meeting the wife s needs? a. Call pastoral care or a social worker to come and provide counseling. b. Tell the wife that her husband is in a better place now. c. Suggest that she may not want to view the patient because of obvious injuries. d. Assign a nurse to meet the wife, explain the situation, and offer the opportunity to see the patient. Chapter An example of an internal type of disaster is a(n) a. category 2 storm. b. major power failure. c. train derailment. d. earthquake. 98. An example of a mass casualty event is a(n) a. three-car collision involving six severely injured patients. b. lightning strike at a golf course involving four severely injured patients. c. tornado touchdown at an unoccupied school. d. airplane crash resulting in 120 deaths and 85 survivors with multiple injuries. Chapter A nursing strategy to improve inadequate ventilation includes which of the following? a. Incentive spirometry b. Oral suctioning c. Mouth care d. Encouraging the patient to perform the Valsalva maneuver 100. When teaching patients about pain management, the nurse should instruct the patient to a. take pain medication only when the pain is severe. b. discontinue all opioids once discharged from the hospital. c. take as little pain medication as possible at one time to avoid addiction. d. avoid alcohol while taking pain medication. 96. During critical incident stress debriefing, a. discussion should be mandatory. b. individuals are able to share their feelings. c. a member of the clergy must be present. d. the entire department must be present to support those affected.

97 STUDY GUIDE Evaluate your comprehension of the course content by comparing your answers to the self-assessment questions below. We encourage you to apply what you have learned to your clinical practice. Chapter 1 1. Which act authorized $224 million in federal funding for trauma and medical services programs? c. Patient Protection and Affordable Care Act 2. The most common cause (mechanism of injury) of trauma in the United States is c. falls. 3. The highest percentage of trauma deaths occur a. immediately at the scene of the injury (first phase). 4. Which of the following is correct regarding motor vehicle crashes? a. Trauma results from a transfer of kinetic energy to the body. 5. The use of seat belts is known to b. increase survival in rollover crashes. 6. Secondary blast injury is associated with a. bomb fragments. Chapter 2 7. Inclusive trauma care is best characterized by a. all components of the trauma system being involved in patient care. 8. The 3 E s of injury prevention refer to d. education, engineering, and enforcement. 9. Which of the following actions is recommended for bystanders at the scene of a car crash? b. Stop and call for help. 10. Emergency medical services provide critical services to the trauma patient. Which of the following is an appropriate function of EMS when called to the scene of a trauma patient? d. Assess mechanism of injury and injury status. 11. Thirty-two patients are seriously injured in a bus collision on the local highway. You are a nurse working for a local trauma center and are part of a helicopter crew dispatched to the scene. Which of the following is a basic principle of triage? b. Produce the greatest number of survivors based on available resources. Item #N Contact Hours 12. Which of the following characteristics are matched to the appropriate level of trauma center? a. Level I trauma centers treat high volume and severe injuries. 13. How does rural trauma care differ from urban trauma care? c. Rural trauma care often lacks professionally trained EMS personnel. Chapter The use of a nasopharyngeal airway adjunct is most appropriate in a. a partially responsive patient with an intact gag reflex. 15. Which of the following findings in an adult trauma patient should prompt immediate return to the primary survey for assessment and intervention? d. Respiratory rate of 40 breaths per minute 16. Which element confirms placement of the oral endotracheal tube? b. Normal end-tidal CO 2 capnography 17. Which of the following procedures is performed in the primary assessment? b. Pulse check 18. Pulse oximetry in trauma patients is best utilized as a c. noninvasive continuous measure of O 2 saturation. 19. Nasogastric tube placement in trauma can b. decrease gastric distention. 20. During the initial assessment, the patient injured by a fall from 20 ft should be completely immobilized until c. the patient is logrolled to inspect the posterior surface. Chapter Which of the following best characterizes a diagnosis of shock? a. Evidence of inadequate perfusion 22. An anticipated compensatory finding when assessing vital signs during early shock is a b. tachycardia, tachypnea, and diaphoresis. 23. Compensatory mechanisms in shock include a. increased peripheral vasoconstriction. 24. In which class of hemorrhagic shock does a drop in systolic blood pressure first occur? c. Class III 25. A confounding factor the nurse must consider in the assessment of a patient for hemorrhagic shock is that c. the normal hypervolemia of pregnancy may mask signs of blood loss. 26. A 16-year-old male is brought into the emergency department after crashing his car into a cement wall at high speed. He is unconscious and in obvious shock with a blood pressure of 60/40 and a pulse rate of 150. He has no open wounds or obvious fractures. The cause of his shock is most likely d. hemorrhage into the chest or abdomen. 27. A classic sign of neurogenic shock includes c. hypotension without tachycardia. 28. A 20-year-old male arrives at a trauma center with a gunshot wound to the abdomen. He is in Class IV shock with a tachycardia of 156 and blood pressure of 78/40. He is immediately prepped and leaves for the operating room. Which blood administration is preferred for this patient? a. Emergency uncrossmatched type O positive 29. Which of the following interventions is considered to be an aggressive warming treatment for the hypothermic trauma patient? d. Warmed IV fluids Chapter Late signs of increasing ICP can be characterized best by c. increased blood pressure. 31. An unhelmeted 20-year-old female is thrown from a horse and arrives at the emergency department (ED). She responds to verbal stimuli with eye opening and confused speech. She has purposeful movement and can follow commands. What is her GCS score? b A characteristic of focal head injuries is that they b. involve damage to a localized area of the brain page 109 CE Express

98 110 Basic Trauma Nursing 33. A construction worker arrives at the ED after being hit in the head with a large steel pipe at a construction site. His GCS score is 6, he has a palpable depressed skull fracture, and he has gurgling respirations. There is vomitus on his face and clothing. The most appropriate initial treatment strategy is a. suction to clear the airway. 34. Nursing intervention(s) aimed at preventing secondary brain injury include c. adequate oxygenation and IV fluids. Chapter Fluorescein staining of the eye is used to b. make corneal abrasions visible. 36. An indication of a mandibular fracture is b. malocclusion. 37. Which of the following is characteristic of an orbital blowout fracture? c. It is caused by a direct blow to the eye. 38. Four-vessel cerebral angiography is indicated in penetrating neck trauma when there is a. clinical evidence of significant vascular injury in Zones I and III. 39. A patient is brought into the emergency department with maxillofacial trauma after being accidentally shot in the face. Your initial assessment reveals a large cheek wound; there is blood in his airway, and his radial pulse is weak and rapid. What is your first priority? a. Suction to clear the airway. Chapter Which of the following is indicated for the immediate management of an open pneumothorax? b. Occlusive dressing taped on three sides 41. Absent breath sounds and asymmetry of chest wall motion could result from d. tension pneumothorax. 42. Which thoracic injury is characterized by Beck s triad of hypotension, muffled heart sounds, and distended neck veins? b. Cardiac tamponade 43. A diagnostic technique used to quickly identify cardiac tamponade is the d. FAST examination. 44. Emergency department thoracotomy performed in the emergency department may be indicated for b. a penetrating stab wound to the heart. Chapter Which of the following is true about blunt genitourinary trauma? d. The urinary bladder is more likely to rupture when it is full. 46. The organ injuries that can be expected to bleed the most are a. kidney, spleen, and liver. 47. The abdominal organ most commonly injured from blunt trauma is the c. liver. 48. A passenger in a motor vehicle crash has fractured ribs on the left and is complaining of left shoulder pain, but there is no obvious left shoulder injury. Her vital signs are blood pressure 86/68, pulse 136, respirations 32 and shallow. As her nurse, you notify the physician because you think that her signs and symptoms are related to c. injury to the spleen. 49. When a patient with reported abdominal injuries arrives in the emergency department, the sequence of physical examination of the abdomen is c. inspect, auscultate, percuss, and palpate. 50. A 19-year-old male was struck by a truck traveling 50 mph. He was subsequently transported to a trauma center. He has obvious fractures of the right tibia and fibula and complains of abdominal pain. His heart rate is 170 beats/min, respiratory rate is 36 breaths/min, and blood pressure is 84/50 mm Hg. Intravenous access is established. To identify the presence of abdominal trauma, the nurse anticipates that the next action taken will be to d. perform a focused abdominal ultrasound. Chapter All messages that the brain sends for the body to function are transmitted through the c. spinal cord. 52. The most common mechanisms of injury to the spine in adults are c. deceleration injuries from falls and motor vehicle crashes. 53. A patient with a C6 spinal injury would most likely have which of the following symptoms? a. Tetraplegia 54. Patients with anterior cord syndrome experience the loss of d. pain sensation. 55. A 30-year-old man presents to the emergency department after sustaining a 20-ft fall from scaffolding. He is unable to move his legs and has some limited movement of his arms. The lateral cervical spine X-ray shows a subluxation of C5 on C6. Vital signs are: BP 110/60, P 100, RR 8. The nurse should anticipate which of the following management priorities? b. Assistance with ventilation Chapter What do tendons connect? a. Muscle to bone 57. A 56-year-old farmer is found trapped from the waist down beneath his overturned tractor. He has been pinned for 4 hours prior to being found. He is hemodynamically unstable with vital signs of BP 82/50, P 144, RR 36. He was awake and alert until just before arriving at the emergency department. He is now becoming difficult to rouse. His pupils are 3 mm in diameter, symmetrical, and reactive to light. EMS reports that he would not move his legs, even with painful stimuli. The most likely cause of his deterioration is c. pelvic fracture-associated hemorrhage. 58. Which of the following is a consistent sign in compartment syndrome? d. Deep throbbing pain is far greater than the pain caused by the original injury. 59. Which of the following dislocations is considered a true orthopedic emergency? a. Hip dislocation 60. Initial nursing management of musculoskeletal injuries includes b. assessing the integrity of the skin over the point of injury and surrounding tissues to determine if the injury is a closed or open fracture. 61. A 50-year-old man sustains a closed femur fracture in a motor vehicle crash, and his left thigh is angulated. A traction splint is applied to the injured leg and, shortly thereafter, the patient complains of severe pain in his foot and lower leg. Assessment reveals absent pedal pulses. The appropriate nursing intervention is to c. release the traction. Chapter The skin regulates the body temperature through sweat-producing glands and d. evaporation of sweat and water. 63. Possible injuries related to smoke inhalation include b. upper airway obstruction.

99 Basic Trauma Nursing An adult patient who has been in an industrial explosion is brought into the emergency department. He is burned on his entire front torso and genitals and has circumferential burns on both of his legs. According to the rule of nines, what percentage of TBSA has been burned? c. 55% 65. A 13-year-old girl is involved in a garage explosion. She arrives at the emergency department with singed eyebrows and 25% partial-thickness burns to her face, arms, chest, and hands. She is hoarse and tachypneic. The first management priority is to c. intubate the patient. 66. The initial treatment for frostbite includes a. warm water bath. Chapter Which of the following changes best characterizes the normal response to pregnancy by the seventh month? d. Widening of the symphysis pubis 68. Which of the following best characterizes mechanisms and patterns of injury among pregnant trauma patients? c. Maternal pelvic fractures from blunt trauma may be associated with fetal skull fractures. 69. The most common cause of fetal death after blunt injury to a pregnant woman is c. abruptio placentae. 70. In your assessment of a pregnant patient who has sustained blunt abdominal trauma, you find that her vital signs indicate shock and she has severe abdominal pain and distension. You alert the physician immediately because you are concerned that b. the patient s uterus has ruptured. 71. In assessing a pregnant trauma patient, a most important question to ask is d. Do you have any contractions or abdominal pain? 72. A pregnant trauma patient should be placed in which position? d. Left side Chapter Until about 8 years of age, the narrowest part of the airway is the b. cricoid cartilage. 74. Which of the following statements regarding children and trauma is true? a. Children can suffer spinal cord injury that may not be detected on X-ray. 75. The number one mechanism of injury resulting in pediatric death is d. motor vehicle crashes. 76. Which of the following best characterizes pediatric trauma injuries? c. Small bowel injuries may occur in children with lap belt injuries. 77. Early indicators of hypovolemic shock in a pediatric trauma patient are poor skin perfusion and d. tachycardia. 78. A 4-year-old boy was a pedestrian struck by a car and brought to the emergency department. His blood pressure is 90 mm Hg systolic, heart rate is 140 beats/min, and respiratory rate is 36 breaths/min. The preferred route of venous access in this patient is d. peripheral veins in upper extremity. 79. A 9-year-old female falls 20 feet from a tree house and is brought into the emergency department of a small rural hospital at 9:00 p.m. Diagnostic tests reveal multisystem injuries, including a severe laceration of the spleen. The hospital does not have 24-hour operating room capabilities or a surgeon on call. The most appropriate management of this patient would be to a. transfer her to a hospital with 24-hour operating room capability. Chapter Trauma in the older patient is likely to be d. more serious than the same injury seen in a younger person. 81. The most common cause of injury and death among older adults is b. falls. 82. An older adult patient presents with multiple bruises in various stages of healing. They are located on his upper arms. He also complains of neck pain. There are what appear to be round burn marks on his hands. His caregiver says he fell out of his wheelchair. The priority action for the nurse is to a. systematically assess the patient from head to toe for signs and symptoms of abuse. 83. In the older person, cardiovascular system changes include a. progressive stiffening of the myocardium. 84. The most common area for fracture in geriatric trauma is the a. hip. 85. Which statement is correct regarding brain injury in older adults? b. Minor forms of trauma can result in significant brain injury. 86. In the older adult patient, the response to ongoing blood loss can be masked by b. absence of tachycardia. 87. An effect of beta-blockers is that they a. may diminish the tachycardic response to trauma. 88. Which of the following is an important part of the secondary assessment of an elderly trauma patient? c. Assess the patient s preinjury health history. Chapter Which of the following is not an anatomic/physiologic change seen in the bariatric patient? d. Hypocapnia 90. The best position in which to place a bariatric patient to perform orotracheal intubation is d. ramped. 91. Which is not a typical vascular access option in the bariatric patient? a. Hypodermoclysis Chapter Which of the following patient characteristics is a critical factor in crisis intervention? d. Support systems 93. Mr. Jones is 80 years old and has just suffered a stroke. He is admitted to your intensive care unit and placed on a ventilator. Mr. Jones s son, Tom, arrives from out of state and is anxiously pacing outside of the waiting room. Which of the following statements regarding Tom s psychosocial needs is true? c. The need for information, while maintaining hope, is important. 94. In posttraumatic stress disorder, a. the imprint of the traumatic moment can cause flashbacks. 95. A 34-year-old male motorcyclist who was hit by a car arrives at the trauma center in full arrest. After 35 minutes of failed resuscitation, he dies. His wife is hovering in the hallway outside of the resuscitation room. Which of the following would have the greatest impact on meeting the wife s needs? d. Assign a nurse to meet the wife, explain the situation, and offer the opportunity to see the patient. 96. During critical incident stress debriefing, d. the entire department must be present to support those affected.

100 112 Basic Trauma Nursing Chapter An example of an internal type of disaster is a(n) b. major power failure. 98. An example of a mass casualty event is a(n) d. airplane crash resulting in 120 deaths and 85 survivors with multiple injuries. Chapter A nursing strategy to improve inadequate ventilation includes which of the following? a. Incentive spirometry 100. When teaching patients about pain management, the nurse should instruct the patient to d. avoid alcohol while taking pain medication. Course Completion Code: PATCC2 You must enter this code to receive your certificate of completion.