Introduction to Introduction to Emergency Nursing Emergency Nursing

ConceptsConcepts

Introduction to Introduction to Emergency Nursing Emergency Nursing

ConceptsConcepts

Sandra H. Lewis, ARNP-BC-ADMSandra H. Lewis, ARNP-BC-ADM

Prehospital Care and Transport

• The time from injury to definitive care is a determinant of survival, particularly those with major internal hemorrhage.

• Careful attention must be given to the airway with cervical spine immobilization, breathing and circulation. (ABC’s)

Continued…• Full spinal mobilization is being

challenged and reexamined:• Asking: Is full spinal mobilization

necessary in all trauma patients?• How appropriate is the assessment of

prehospital assessment?• Concerns over the high false positive

rate that occurs with prolonged spinal immobilization.

Current Guidelines

Objectives• 1. Explain emergency care as a

collaborative, holistic approach that includes patient, family and significant others.

• Discuss priority emergency measures for any patient with an emergency situation.

• 3. Discuss pre-hospital, emergency care and resuscitation of the trauma patient.

Objectives• Discuss disaster triage concepts

and contrast with traditional triage concepts.

Trauma• The fourth leading cause of death for

ALL ages.• Nearly ½ of all traumatic incidents

involve the use of alcohol, drugs or other substance abuse.

• Is predominantly a disease of the young and carries potential for permanent disability.

Systems Approach to Trauma

• An organized approach to trauma care that includes:

• Prevention, access, acute hospital care, rehabilitation, and research.

Trimodal Distribution of Death

• First peak- seconds to minutes from time of injury to death—severe injuries: lacerations of the brain, brainstem, high spinal cord, heart aorta, large blood vessels.

• Second peak- minutes to several hours: subdural, epidurdal hematomas, hemopneumothorax, ruptured spleen, lacerated liver, pelvic fractures, other injuries associated with major blood loss.

• Third peak-occurs several days to weeks after the initial injury: most often the result of sepsis and multiple organ failure. At this stage, outcomes are affected by care previously provided.

Levels of Trauma Care• American college of Surgeons

Committee on Trauma• Level’s I-IV, Level ones are the

most sophisticated and care for all aspects from prevention to rehabilitation.

Trauma Triage• Minor trauma: single system injury

that does not pose threat to life or limb and can be appropriately treated at a basic emergency facility.

• Major trauma: serious multi system injuries that require immediate intervention to prevent disability.

Mechanism of Injury

• Is vital to the initial assessment and may raise suspicions about the patients injury pattern.

• Blunt vs. penetrating injury

Blunt Trauma• Most often results from vehicular

accidents, but may occur in assaults, falls from heights, and sports related injuries.

• May be caused by accelerating, decelerating, shearing, crushing, and compressing forces.

Blunt Trauma, cont.• Coup-contra coup injury• Body tissues respond differently to

kinetic energy…low density porous tissues and structures, such as lungs, often experience little damage because of their elasticity.

Blunt Trauma cont.• The heart , spleen and liver are less

resilient often rupturing or fragmenting.• Often, overt external signs are not

apparent…making the mechanism of injury most important to the practitioner performing the physical examination.

Penetrating Trauma• Results from the impalement of foreign

objects into the body.• More easily diagnosed because of

obvious injury signs.• Stab wounds are usually low velocity…

the direct path, the depth and width determine injury.

• Women tend to have trajectories in a downward motion, men in an upward force.

Penetrating Trauma cont.

• Ballistic trauma may be either low or high velocity injuries.

• Missiles or bullets that come into contact with internal structures that produce a change in in pathway release more energy and result in more injury than a direct pathway.

Penetrating Trauma, cont.

• Injuries sustained from penetrating objects must be assessed for the potential for infection from the debris carried by the penetrating object.

Disaster / Mass Casualty Triage

Concepts• Most severe injuries in mass

trauma events are fractures, burns, lacerations, and crush injuries.

• Most common injuries are eye injuries, sprains, strains, minor wounds and ear damage. (CDC Website)

Mass Casualty: Who is at risk?

• Anyone in surrounding area.• Rescue workers and volunteers.

Bioterrorism Agents/Diseases, Threats• CDC Website ( see handout)

Disaster Triage• www.bt.cdc.gov/masstrauma/inde

x.asp• www.nyerrn.com/simulators

Pre-Hospital Care and Transport

• The time from injury to definitive care is a determinant of survival.

• Careful attention is given to C-spine immobilization, breathing and circulation…(ABC’s)

Current Guidelines on C-Spine Immobilization• Although it has been challenged,

C-spine immobilization is still the protocol for trauma patients until diagnostically cleared (X-Ray)

Additional Pre-Hospital Measures

• Occlusive dressings to open chest wounds

• Needle thoracotomy to relieve tension pneumothorax

• Endotracheal intubation• Cricothyrtomy

Caveat!!!• Research has indicated

INCREASED mortality with IV fluids BEFORE hemorrhage control.

• Transport is not delayed to start IV access!

TransportHow is it decided?

• Travel time• Terrain• Availability of air or ground

transport• Capability of personnel• Weather

Emergency Care PhasePreparation

• Trauma team at receiving hospital responds before arrival of patient

• Report has been transmitted• Preparations are initiated based on

report.

Initial Patient Assessment

• Clinical presentation• Physical assessment• History of traumatic event• Pre-existing illness

Primary Survey• Most crucial assessment tool in trauma

care• 1-2 minutes MAX!• Designed to identify life threatening

injuries ACCURATELY• Establish priorities• Provide simultaneous therapeutic

interventions.

Resuscitation Phase• Secondary Survey:

• Table18:2 page 647/648• 32

EFGHI =• E- Expose the patient• F- *Full set of vital signs, *five interventions

(cardiac monitor, pulse oximetry, urinary catheter, NG if not contraindicated, lab studies)

• G- giving comfort measures…pain control, reassurance to patient and family

• H- history/ head to toe assessment• I- inspect for hidden injuries-log roll patient to

inspect posterior aspect.

Sequence of Diagnostic Procedures

• Influenced by:

• Level of consciousness• Stability of patient’s condition• Mechanism of injury• Identified injuries

Maintain Airway Patency

• Essential to trauma management• EVERY trauma patient has potential for

airway obstruction• Most common obstruction: Tounge• Other common causes: blood or

vomitus, secretions, structural impairment, depressed sensorium, absent gag reflex

How to open the airway?

• Jaw thrust or chin lift!!!• These maneuvers do not

hyperextend the neck or compromise the integrity of the C-spine

Maintaining the airway• Simple, simple!!

• Nasopharyngeal airway• Oropharyngeal airways

Definitive Nonsurgical Airway

• Endotracheal intubation-Complete control of the airway

• Nasotracheal intubation—INDICATED for the spontaneously breathing patient..CONTRAINDICATED in the patient with facial, frontal sinus, basilar skull or cribriform plate fractures.

Choice of Airway management

• Familiarity of procedure• Clinical condition of the patient• Degree of hemodynamic stability

• A PATENT AIRWAY IS THE CORNERSTONE OF SUCCESSFUL TRAUMA RESUSCITATION

A LIFE THREATENING CONDITION EXISTS

• Altered mental status (agitation)• Cyanosis( nail beds and mucous membranes)• Asymmetrical chest expansion• Use of accessory muscles/abdominal muscles• Sucking chest wounds• Paradoxical movements of the chest wall• Tracheal shift• Distended neck veins• Diminished or absent breath sounds

Impaired Gas Exchange• Follows airway obstruction as the nest

most crucial problem for the trauma patient.

• Reasons: decreased inspired air, retained secretions, lung collapse or compression, atelectasis, accumulation of blood in the thoracic space.

Decreased Cardiac Output/Hypovolemia

• Acute Blood loss—MOST common cause in acute trauma

• May be external or internal

Treatment• PASG- anti-shock garment (pneumatic anti-

shock garment)• When inflated, PASG compresses the legs and

abdomen, resulting in increased venous return and SVR(systemic vascular resistance) preventing further blood loss into the abdomen and legs.

• Elevates systemic pressure by shunting a small amount of blood into central circulation.

• CAN be a detriment, elevates BP, and in the event of hemorrhage without DEFINITIVE control can be fatal.

Additional Causes of Decreased Cardiac

Output• (impaired venous return to the

heart)• Tension Pneumothorax• Pericardial Tamponade (from

decreased filling and ventricular ejection fraction)

Table 18-4• Pay attention to Class I through IV

*EBL (estimated blood loss)• *Changes in pulse, BP, RR, UOP,

mental status.• Note the fluid/blood needed to

replace: 3:1 rule

Priority Interventions• Patent airway• Maintaining adequate ventilation• Adequate gas exchange• Then:• Control hemorrhage, replace

circulating volume, restore tissue perfusion

Control of External Hemorrhage

• Direct Pressure• Elevation• Compression of pressure points

(arteries, veins)• AVOID tourniquets…can

compromise loss of circulation and loss of limb

Control of Internal Hemorrhage

• Identification and correction of underlying problem.

Fluid Resuscitation• Venous Access and Volume infused are

key.• Two large bore IV’s 14-16 gauge.

(never less that 18, that is the smallest to give blood through rapidly and not have hemolysis)

• Forearm and anti-cubital veins are preferred

• Central lines are more beneficial as resuscitation MONITORING tools

Fluid Resuscitation Cont…

• A pulmonary artery catheter may be inserted in the critical care unit to monitor volume.

• RULE: Venous access with largest bore catheter possible.

• Isotonic fluids are used INITIALLY• Ringer’s Lactate is first choice followed

by Normal Saline

Fluid Resuscitation Cont…

• Large bore catheters, short tubing, rapid infuser devise that warms fluids and blood.

• An initial bolus of 2 liters of fluid is used unless there is contraindication…

• 3:1 rule= 3mls of crystalloid for each 1ml of blood loss.

• INITIAL response to fluid challenge is urine output..should =50 ml in adult, LOC, heart rate, BP and capillary refill.

Three Response Patterns

• Rapid Response- respond quickly to fluid challenge and remains stable at completion of bolus.

• Transient Response- responds quickly but declines when fluids are slowed

(indicates continued blood loss)**Non Response- fail to hemodynamically

respond to crystalloid and blood…require immediate surgical intervention.

See table 18-5 on page 652

Decision to give Blood• Based on patients response to initial

fluid. • ** if unresponsive to fluid, type

specific blood is given, IF LIFE THREATENING…may give O positive.

• ***Crossmatched, type specific should be given as soon as possible.

Auto-transfusion• Collection of blood from the

patients intra-thoracic injuries is anti-coagulated and filtered and administered to the patient.

• SAFE, carries no compatibility problems, no risk of transmitted disease.

During resuscitative phase

• Imperative to locate etiology of hemorrhage:

• Chest and pelvis, extremity X-rays• Abdominal ultrasound• Abdominal CT can be used but in the

case of hemodynamic instability Peritoneal lavage is the quick, invasive test of choice

Peritoneal Lavage• Insertion of lavage catheter directly into

the abdomen• Aspiration of greater than 10 mls blood

and patient goes directly for surgery.• If less than 10 mls of blood, 1 liter of

warmed NS is infused into peritoneal cavity, then drained and sent for cell counts, amylase, bile, food particles, bacteria, fecal matter.

Hypothermia

• Defined as a core temp of 35 degrees Centigrade• Can occur year round• More susceptible person: older, using alcohol or

sedatives, severe injury, massive transfusions. • In presence of cooler atmospheric temps• Submersion in water• Rapid infusion of room temp. IV fluids• Effects the myocardium and the coagulation system.• Can result in bradycardia, atrial and ventricular

fibrillation.

Treatment• Warm fluids• Warming blankets• Overhead warmers

Ongoing Signs and Symptoms of Shock

• Decreased H&H• Deterioration of PaO2 and pH• Rising base deficits• Diminished UOP (less than

>.5ml/kg/hr)• Increasing Lactate levels

Unreliability of H&H• Can take up to 4 HOURS!! To re-

equilibrate, therefore cannot gauge degree of shock.

On-going Metabolic acidosis

• Result of hypovolemia and hypoxia• Indicates inadequate tissue

perfusion• Indicates anaerobic metabolism—

very inefficient cellular metabolism.• Must be interrupted or cellular

dysfunction results in cellular swelling, rupture and death.

Massive Fluid Resuscitation

• Greater than 10 units of PRBC’s over 24 hours or the replacement of the patient’s total blood volume in less than 24 hours.

• It is associated with VERY poor outcomes.

Continued..• Purpose is to restore oxygen

transport to the tissues, stop the progression of shock, prevent complications.

Potential Complications of Massive Fluid Resuscitation

• Acid base imbalances• Electrolyte imbalances• Hypothermia• Dilutional coagulopathies• Volume overload• SIRS (systemic inflammatory response syndrome)• ARDS (acute respiratory distress syndrome)• MODS (multi-organ dysfunction syndrome)

Oxygen Debt• Result of metabolic acidosis—shift

from aerobic to anaerobic metabolism resulting in accumulation of lactic acid…hence…lactic acidosis.

• MUST REVERSE to prevent cellular death

Electrolyte Imbalances• Hypocalcemia• Hypomagnesemia• Hyperkalemia

• May lead to changes in myocardial function, laryngeal spasm, neuromuscular and central nervous system hyperirritability

Third Spacing

• Vessels become more permeable to fluids and molecules, leading a change in movement from the intravascular space to the interstitial space.

• Patients become more hypovolemic requiring more fluid replacement.

Dilutional Coagulopathy

• Dilutional thrombocytopenia• Reduced fibrinogen• Reduced factor V, FactorVIII and other clotting

components• High levels of citrate in blood products reduce

calcium…leading to an ineffective clotting cascade (calcium is a necessary co-factor for this process).

• Platelet dysfunction can occur secondary to hypothermia or metabolic acidosis

Treatment of Dilutional Coagulopathy

• Improve tissue perfusion• Resolve hypothermia• Administer clotting factors (FFP,

cryoprecipitate, platelets)• Monitor labs (H&H, PLT count,

fibrinogen, PT, PTT

Changes in the Coagulation Cascade

• Initially helpful…release of inflammatory mediators…over time (can be a fairly short time) can result in SIRS, ARDS, MODS

Assessment and Management of specific

Organ Injuries• Chest Injuries• Spinal Cord Injuries• Head Injuries• Musculoskeletal Injuries• Abdominal Injuries

Chest Injuries• Tension Pneumothorax- is rapidly fatal• Easily resolved with early recognition and

intervention• Air enters the pleural cavity without a route of

escape, with each inspiration, additional air enters the pleural space, INCREASING intrathoracic pressure causing collapse of the lung.

• The increased pressure causes pressure on the heart and great vessels compressing them TOWARD the unaffected side.

Tension Pneumo cont..• Physical evidence: • Mediastinal Shift & distended neck veins.• RESULTS in: decreased Cardiac Output

and alterations in gas exchange• Manifested by: severe resp. distress,

chest pain, hypotension, tachycardia, absence of breath sound son affected side, and tracheal deviation

• Cyanosis is a LATE manifestation.

Tension Pneumo cont…• Diagnosis based on CLINICAL presentation not

Chest x-ray• Treatment is never delayed to confirm by X-ray• Immediate decompression with a 14 gauge

needle (thoracostomy)..inserted at the 2nd intercostal space at the midclavicular line on the INJURED side.

• This converts a tension pneumo to a simple pneumo.

• Definitive treatment then requires placement of a chest tube.

Hemothorax• Collection of blood in the pleural space• From injuries to the heart, great

vessels, or pulmonary parenchyma• Signs and symptoms: decreased breath

sounds, dullness to percussion on affected side, hypotension, respiratory distress.

• Treatment: Placement of chest tube.

Open Pneumothorax• Results from penetrating trauma that allows

air to pass IN AND OUT of the pleural space.• Patient presents with hypoxia and

hemodynamic instability• Management: Three sided occlusive

dressing…fourth side is LEFT OPEN to allow for exhalation of air from the pleural cavity.

• IF the dressing is occluded on all four sides the patient may develop a tension pneumothorax.

• Treatment: Chest tube placement

Cardiac Tamponade• Life threatening condition caused by RAPID accumulation

of fluid (usually blood) in the pericardial sac.

• As intra-pericardial pressure increases, cardiac output is impaired because of decreased venous return.

• Classic signs are: BECK’s Triad: muffled or distant heart sounds, hypotension, elevated venous pressure…and may not present until the patient is hypovolemic and hypotensive.

• Pulsus paradoxus= a decrease in systolic blood pressure during spontaneous respiration.

Cardiac Tamponade• Causes: penetrating trauma to chest,

blunt trauma to chest.• Diagnosed with FAST ( focused abdominal

sonography or pericardiocentesis—don’t with 16 or 18 gauge cath over needle and 35 ml syringe and 3 way stopcock)

• Aspirated pericardial blood usually will not clot unless the heart has been penetrated.

Cardiac Tamponade cont..

• Arterial BP can dramatically improve with as little as 15-20 ml of blood removed.

• Nurses should anticipate and prepare for pericardiocentesis in the event of cardiac arrest.

Pulmonary Contusion• Results from blunt or penetrating

trauma to the chest• One of the most common causes

of death after trauma• Predisposes the patient to

pneumonia and ARDS.• Can be difficult to detect.

Pulmonary Contusion cont..

• May not be seen on initial X-ray• Infiltrates and hypoxemia may not occur

for hours of days.• Clinical presentation includes: chest

abrasions, ecchymosis, bloody secretions, PaO2 of 60mmHG or less on room air.

• Often associated with flail chest and rib fractures

Pulmonary Contusion cont..

• The bruised lung becomes edematous, resulting in hypoxia and respiratory distress

• Treatment is ventilatory support, careful fluid administration, pain management.

Rib Fractures• Most common injury after chest trauma• Rib fractures usually dx’d by xray, but

can be clinically dx’d• HIGH IMPACT force is needed to

fracture the 1st and 2nd ribs. Clinically look for major vessel injury..

• Injury to the liver spleen and kidneys should be considered with fracture of ribs 10-12

Rib Fractures cont…• Treatment: Depends on ribs Fx’d

and age of patient. Elderly with multiple rib fx may require hospitalization.

Patient Teaching is very important:DO NOT restrict chest movement,

pain control, ambulation.

Flail Chest• Usually caused by blunt force trauma, EX:

Chest hits steering wheel.• Three or more adjacent ribs are fractured.• Flail section floats freely resulting in

paradoxical chest movement.• Flail section contracts INWARD with inspiration

and expands OUTWARD with expiration.• Treatment: Intubation/mechanical ventilation,

frequent pulmonary care, aggressive pain management.

Aortic Disruption• Produced by blunt trauma to the chest• Ex: rapid deceleration from head-on

MVA, ejection, or falls.• Four common sites of dissection: the

left subclavian artery at the level of the ligamentum arteriosum, the ascending aorta, the lower thoracic aorta above the diaphragm, and avulsion of the innominate artery at the aortic arch.

Aortic disruption cont..• Signs: weak femoral pulses, dysphagia,

dyspnea,hoarsness, pain.• Chest x-ray shows wide

mediastinum(greater or equal to 8mm), tracheal deviation to the right, depressed mainstem bronchus, first and second rib fractures, left hemothorax.

• CONFIRMATION is done with aortogram• Treatment is SURGICAL

Spinal Cord Injury• Mechanism of injury can be:

hyperflexion, hyperextension, axial loading, rotation, penetrating trauma

• Initially: ABC’s, immobilization• Triage to appropriate facility• Complete sensory &motor neuro

exam

Spinal Cord Injury• Lateral C-Spine films, possible Spinal

CT to rule out occult fracture.• Dislocations of the spine are reduced

ASAP• Postural reduction with tongs, halo

traction or surgical fusion.• IV methylprednisolone within 8 hours

Spinal Cord Injury• Spinal Shock= loss of sympathetic

output=Neurogenic shock results are bradycardia, hypotension.

• Need vasopressors to compensate for loss of sympathetic innervation and resultant vasodilatation.

Spinal Cord Injury cont.• Potential Complications: GI

dysfunction, autonomic dysreflexia, DVT, orthostatic hypotension, loss of bowel and bladder function, immobility, spasticity, and contractures.

• THINK EARLY PREVENTION AND INTERVENTION!!!!

Head Injury• Can be caused by blunt or

penetrating trauma.• Lacerations to the scalp produce

profuse bleeding.• Fractures of the skull may have

underlying brain injury

Heady Injury cont…

• Basilar skull fractures are located at the base of the cranium and potentially involve 5 bones that form the base of the skull.

• Are diagnosed based on the presence of CSF in the nose (rhinorrhea) or ears (otorrhea)

Heady Injury cont..• Basilar Skull Fracture cont…• Ecchymosis over the mastoid

(Battle’s sign)• Hemotympanium (blood in the

middle ear)• Raccoon eyes or periorbital

eccymoses =cribiform plate fracture

Head Injury cont.• Potential complications of Basilar

Skull Fractures: Infection and cranial nerve injury.

Secondary Head Injury• Refers to the systemic

(hypotension, hypoxia, anemia, hypocapnia, hyperthermia) or intracranial ( edema, intracranial hypertension, seizures, vasospasm) changes that result in alteration in the nervous system..page 657..read this!!! Very important.

Secondary Head Injury• Prehospital MOST important• Supplemental oxygen, often intubation• Aggressive and careful volume

replacement• ICP monitoring/ Goal is 20mm Hg• Cerebral Perfusion Pressure=MAP(mean

arterial pressure) Minus Mean ICP and keep at 70mm Hg to decrease neurological disability.

Secondary Head Injury cont..

• Osmotic and loop diuretics, CSF drainage, hyperventilation (results in vasoconstriction of cerebral vessels allowing more space for swelling brain tissue), paralysis WITH sedation, pentobarbital induced coma is final intervention when all else fails.

Nursing Care for Traumatic Head Injury

• Airway, adequate ventilation and gas exchange, clearance of pulmonary secretions, proper head alignment, close neurological function monitoring.

• Pulmonary complications are common, aggressive pulmonary hygiene

• HOB at 30 degrees• Assess for intracranial hemodynamics(ICP and

perfusion pressure) and patient tolerance

Musculoskeletal Injuries

• See Types of Fractures Table 18-7 on page 658

• Extremity Assessment= the 5 P’s• Pallor pain, pulses, parethesia, paralysis

(describes the neurovascular status of the injured extremity.

• When possible the injured extremity if compared with the non-injured extremity

Musculoskeletal Injury cont..

• Fracture wounds should be debrided and the fracture reduced within 18 hours to prevent infection and nonunion.

• If hemodynamically unstable, skeletal traction to realign the extremity may be used .

MS Cont..• Unstable Pelvis fractures can be

life threatening secondary to potential for severe hemorrhage, exsanguination, damage to genitourinary system and sepsis.

Traumatic Soft Tissue Injury

• Categorized as: contusions, abrasions, lacerations, punctures, hematomas, amputations, and avulsions.

• All wounds are considered contaminated.

• Tetanus Toxoid and antibiotics are always CONSIDERED.

Complications of Musculoskeletal

Injuries• Rhabdomolysis-a complication of

crush injuries—marked vasoconstriction and hypotension followed by ARF

Results from muscle destruction.Myogolobin and potassium are

released from the damage muscles

Cont.Can result in life threatening hyperkaemia.Myoglobin excreted through the urine,

combined with hypovolemia, produces ARF and ATN if not aggressively treated.

Treatment= Aggressive saline replacement, alkalinization of urine, osmotic diuresis.

Compartment Syndrome

• Places the patient at risk for limb loss.

• More common in the legs and forearms but can occur other places.

• The closed muscle compartment contains neurovascular bundles tightly covered by fascia.

Cont…• An increase in pressure within that compartment

produces the syndrome.• Internal sources= hemorrhages, edema, open or closed

fractures, crush injuries• External sources=PASG’s, casts, skeletal traction, air

splints.• The pain is described as throbbing appearing

DISPROPORTIONATE TO THE INJURY. Increases with muscle stretching. The affected area is firm to touch. Paresthesia distal to the compartment, pulselessness, and paralysis are LATE signs.

• Treatment s immediate surgical fasciotomy.

Fat EmbolismUsually associated with long bone, pelvis, and

multiple fractures.Usually develops within 24 to 48 hours after

injury.Hallmark clinical signs: low grade fever, new

onset tachycardia, dyspnea, increased resp rate and effort, abnormal ABG’s, thrombocytopenia and petechiae.

Development of lipuria (fat in the urine) indicates severe fat embolism syndrome.

Fat embolism cont..• Prevention is the best treatment.• Treatment is directed at preserving

pulmonary function and maintenance of cardiovascular function.

• Careful attention to EKG changes.• See Box 18-2 on page 660

IMPORTANT!!!

Abdominal Injuries• The Classic sign is PAIN.• But may be obscured by AMS, drug

or alcohol intoxication, Spinal cord Injury with impaired sensation

• The liver is the most commonly injured organ from blunt or penetrating trauma

Cont…• Liver injuries are graded I through VI. • Splenic injury most commonly occurs

from blunt trauma but can be caused by penetrating trauma.

• Presentation: LUQ tenderness, peritoneal irritation, referred pain to the left shoulder (Kerr’s sign)

Cont…• Graded I to V.• Diagnosed with FAST, Abd. CT or

peritoneal lavage.• Patients more at risk for

pneumococcal disease and should have immunization with in first few post op days after splenectomy

Cont…Kidney Injury• Usually attributed to blunt trauma• Presentation may include CVA

tenderness, microscopic or gross hematuria, bruising, ecchymosis over the 11th and 12th ribs, hemorrhage or shock.

Cont…• Diagnostic testing= IVP, CT scan,

angiography, cystoscopy.

Critical Care Phase• ABC’c• Post OP standard VS= q5min x3,

q15minx3, q30min X2, q1 hour forward.

• Shivering is to be avoided=increase in metabolic rate and increase in oxygen demands.

Cont..• Physical Assessment =FULL BODY• Level of Consciousness• Invasive Line assessment• Pain Assessment• Ongoing Assessments revolve around the

patient’s diagnosis and/or surgical procedure.• Anticipation and prevention of untoward

complications.• READ PAGES 661-668 CAREFULLY

Damage Control Surgery

• = Staged laporaotmy• Trying to avoid hypothermia,

acidosis, coagulopathy• Shown to improve outcomes of

critically ill patients with sever intra-abdominal injuries.

ARDS• Chapter 13 fully covers• May occur 2 to 48 hours after

traumatic injury, however sometimes up to 5 days or more before RECOGNIZABLE clinical signs.

• There are direct and indirect causes.

Cont…• Clinical Manifestations: hypoxemia, rising

CO2 levels, tachypnea, dyspnea, pulmonary hypertension, decreased lung compliance, new diffuse bilateral lung infiltrates.

• Treatment: correction of underlying cause---maximize O2 to the tissues, decrease pulmonary congestion, prevent further lung damage, support cardiovascular system.

DVT• Increased incidence of DVT= patients

with obesity, age, malignancy, pregnancy, heart failure, SCI, recent surgery, extremity fractures, pelvic fractures, history of DVT, prolonged immobilization, resp. failure, # of transfusions,central venous catheterization, vascular injury.

Cont..• Clinical Manifestations= pain and

tenderness, swelling fever, venous distention, palpable cord, discoloration, + Homan’s sign

• Treatment= prevention, prophylaxis, early ambulation, sequential compression devices, filter placement in the inferior vena cava.

Cont.• Pulmonary embolism is an often fatal

complication of DVT• Clinical manifestations of PE= sudden

onset dyspnea, sudden onset chest pain, rapid shallow resps, SOB, Auscultation of bronchial breath sounds, pale, dusky or cyanotic skin, Anxiety, decreased LOC, signs of hypovolemic shock (decreased BP, narrowing pulse pressure, tachycardia)

Infection• Pulmonary • Catheter Sepsis• Sinusitis

Acute Renal Failure• From systemic effects of trauma • OR from actual injury to the renal

system• There is a reduction in renal blood

flow in the trauma patient associated with shock or low cardiac output.

Altered NutritionNutritional demands are increased in the

trauma patient by alterations in metabolism

Metabolism is increased by activation of the sympathetic response.

Ebb (1st 24-48 hours after injury) and Flow Phase (peaks 5-10 days after injury)

Cont.• Because of this increased need the

patient may demonstrated: decreased body mass, increased O2 consumption, increased CO2 production, delayed wound healing, and a weakened immune system

Cont..• Anthropometric measurements• Nutrition replacement in 24 to 48

hours.• Route based on individual status

of patient…can be enteral, or parenteral

Multiple Organ Dysfunction Syndrome

• Immune, inflammatory, and hormonal responses are underlying causes.

• Defined as presence of altered organ function in the acutely ill.

• There is incomplete understanding of its pathophysiology.

• Management focuses on prevention, early identification, elimination of sources of infection, maint. Of tissue oxygenation and nutritional support.