TRAUMAMary Corcoran RN, BSN, MICN

Trauma Overview

Epidemiology

Used to design public policy, legislation and injury prevention programs

Gathers Data such as› Incidence› Prevalence› Age› Sex› Race/Ethnicity› Geographic distribution› Morbidity and Mortality

Epidemiology

Trauma is a disease that remains the leading cause of death for all Americans Regardless of gender, race or economic status

Leading Cause of death for ages 1-45yrs› (see chart pg 234)

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Age

1-3 yrs= MVA› Due to unrestrained/ or improperly restrained

15-24= Accidents related to Drugs and Alcohol› Due to poor judgment and risk-taking behavior

16-19= MVA› Due to inexperience, lack of seatbelt usage,

etoh with driving 75+= “injuries”

› Due to frailer health, pre-existing conditions, Falls (most common cause in 65+ age group)

› Drivers 65+ have the highest death rate, per mile driven (except for teenagers)

› More likely to sustain a C-Spine injury

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Race

Males are 2.5 times more likely to be injured than females› Related to their participation in hazardous

activities, and greater risk taking The Auto vs Ped, and MVA death rate is

2x higher across the life span compared to women

African American- Homicide, MV (65+), and auto/ped

White/Native American- Suicide Hispanic- Pedestrian, Homicide

Factors Contributing to Death by Trauma

Fire Arms Alcohol Geography –Urban vs Rural Chronology- Weekends and Holidays

Patient Assessment

Beware of Adrenaline- pt may at first appear uninjured

MOI- What is the Mechanism Of Injury, and does the injury match?

Trauma Team Criteria?

Patient Assessment

A-Airway B-Breathing C-Circulation D-Disability E-Exposure/Environment F-Full Vitals, Family G-Give comfort measures H- Head to Toe/ History I-Inspect Posterior Surfaces

http://www.youtube.com/watch?v=LcdLqfdIkFc

Trauma Assessment

When to notify Trauma Team

Alert (minor)› Ejection› Death in same pass space› Extrication <20min› Falls <20ft› Rollover w/ injury› Auto Ped/Bike <5mph› Ped thrown or run over› MCA <20mph› Age >59 with blunt injury

to chest/abd› Children <5yrs› 2 long bone Fx› Pregnancy 23wks +

Activation (major)› GCS <13› Airway Compromise

Intubated PTA

› BP <90s Age specific in kids

› Penetrating injuries to head, neck, torso, and extremities prox to elbow and knee

› Traumatic Full Arrest› Paralysis› Amputation prox to wrist and

ankle› Bone Injury:

Pelvic FX, open skull

› Transferred receiving blood› MD discretion

Summary

Treatment of trauma patients depends on identifying all injuries and rapidly intervening to correct those that are “life threating”

Consideration of mechanisms of injury is essential to identifying patients with possible underlying injuries who require further evaluation and treatment

Head Trauma

Layers of the Brain

Traumatic Brain Injury (TBI) Leading Cause of Death and permanent

disability- considered a MAJOR public health problem

2 million people every year› 8x more than cancer, 34x more than HIV

50,000 deaths, 200,000 hospitalizations, 1million ER visits

$60 billion in costs in 2000› Average lifetime cost per survivor $111,578› Average cost per fatality $454,717

Head Trauma

Injuries can occur to the skull, brain, soft tissues, vascular structures, and cranial injuries

Mechanism are varied› Car crashes, sports, falls, penetrating

wounds› High risk behaviors include ETOH abuse,

drugs

Specific Injuries Classified by: Mechanism

› Blunt or Penetrating Severity

› Mild, Moderate or Severe Type

› Fracture, focal brain injury, diffuse brain injury

Minor Injuries

GCS is 14-15› Usually discharged after short observation

Normal pupils, may be asymptomatic, intact orientation/memory

Eg: Scalp Lacerations

Moderate Injury GCS 9-13

› High potential for increased ICP

Associated with Structural injury/damage

May require more frequent monitoring

Eg: Contusion

Severe Injury

GCS- 8 or less› Associated with Severe structural damage

High mortality rate Usually have long term or permanent

cognitive and physical disabilities› Aggressive initial management to ensure

adequate oxygenation and preventing HTN is essential

Increased Intracranial Pressure

A reaction to a change in any one of the 3 fixed brain volumes› Brain, CSF, or blood

If not immediately corrected will compromise cerebral blood flow

Normal ICP is 0-15, greater than 20=intracranial hypertension

Increased ICP Early S/S ~ HA, N/V, ALOC, pupils

sluggish Late S/S ~ Pupils fixed/dilated,

arousable only to deep stimuli (gcs <8), posturing, temperature changes› Cushings Triad (High blood pressure,

bradycardia, irregular resp rate)

Increased Intracranial Pressure

Treatment› Monitor ABC’s › Prepare for intubation (propofol)› Medicate with benzo’s › Mannitol?› Decrease stimulus› Consider insertion of ICP monitor› Decrease metabolic demands of the brain

Maintain normal temperature Maintain normal glucose Prevent seizures (Dilantin)

Skull Fractures

Linnear skull fracture

Non-displaced, most common type, usually benign

Skull Fractures

Depressed skull fracture› Damages underlying

brain tissue and vessels by compression or laceration. May precipitate seizures

Skull Fractures

Basilar skull fracture› May occur in anterior, posterior or middle

fossa. Leads to infection, hematoma, CSF leakage, SZ

› S/S ~ ALOC, pupil change, CSF leak, Battle sign, Raccoon eyes, change in mentation Change in mentation or combative

behavior, is hallmark› Avoid nasal intubation or NGT

BasilarSkull Fracture

Contusion

Bruise on the surface of the brain Occurs from movement of the brain

within the skull Coup and Contrcoup S/S are ALOC, N/V, vision changes,

weakness, and speech deficit

Epidural Hematoma Collection of blood between skull and dura Usually r/t laceration of the middle

meningeal artery assosciated with a temporal or parietal skull fracture

Mortality is 50% S/S ~ Initial period of unconsciousness,

lucid interval (5 min-6 hrs), rapid unconsciousness, unilateral fixed or dilated pupils, Cushing’s Triad

TX: prepare for evacuation/OR

Subdural Hematoma

Collection of blood between dura mater and subarachnoid layer

Usually caused by trauma Usually venous, therefore a slower

bleed S/S ~ HA, drowsiness, confusion,

steady decline in LOC, unilateral fixed and/or dilated pupils

TX: ABC’s, prep for OR (most successful if done within 4hrs of injury)

Subarachnoid Hemorrhage

Collection of blood between arachnoid mater and the pia mater

Caused by aneurysm rupture, AV malformation. › Aneurysm can be caused by valsalva,

sexual activity, heavy lifting, or excitement Usually 40-60 y/o. 12% die before

reaching hospital, 30% that survive have severe neurologic deficits

Subarachnoid Hemorrhage S/S ~

› “Worst headache of my life”› Accompanied by N/V or sudden seizure› Meningeal signs (fever, nuchal rigidity)

Subarachnoid Hemorrhage

Concussion

Traumatic, reversible neurological event when there is a temporary loss of consciousness and retrograde amnesia

S/S ~ dizziness, N/V, loss of memory of event

CT to r/o bleed Education to return if s/s

Diffuse Axonal Injury (DAI) Widespread disruption of neurologic

function without any focal lesions noted S/S

› immediate LOC lasting days-months› May see posturing› Loss of brain stem reflexes (no gag/cough)› HTN, hyperthermia, excessive sweating

TX: ABC’s prepare for intubation, mannitol

Spinal Trauma

Spinal Trauma

Damage of spinal cord tissue r/t penetrating trauma, fracture, or dislocation

Most often in males 15-35 y/o Costs: $218-741,000 for first year with

lifetime cost just under $3,000,000yr!

Sensory Dermatomes

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Observe for obvious signs of Spinal injury, including deformity of the vertebral column, cervical edema, and wounds

Ventilatory pattern may indicate spinal injury

Can they feel pain, or move arms and legs?

Priapism Spinal fluid leakage

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Palpation

Diaphoretic above level of injury› Indicates sympathetic injury

(above T4) Poikilothermic- assumes

temperature of surroundings› Hypothermia

Sensory status- sharp or dull Sacral and Perineal sensations Entire column should be

palpated for pain, tenderness and step-off deformity

*use log-roll technique*

Radiologic Intervention 3view XR- must see C7-T1 junction Swimmers View- Open Mouth view

› Used for C1,C2 views CT-“Recons”

› Done at same time as Chest/Abd CT MRI- used for suspected Cord injury

› Not good at bony injuries› SCIWORA (Spinal Cord Injury without

Radiologic Abnormality)

Management Methylprednisolone- reduces

biochemical responses when given within 8hrs of injury› Suspected to cause infection, PNA, decub

etc. Foley- for incont, or to monitor output NG/OG with intubation Warming blanket/fluids- pt can’t

thermoregulation Hypothermia???

Cervical Fixation

Halo/cervical tongs- provides c/s traction

Spinal Shock

When complete spinal cord injury occurs, all motor and sensory function below the level of injury is lost› Immediate onset

S/S: Flaccid paralysis, a-reflexia, bowel/bladder dysfunction, disruption in thermoregulation› Neurogenic shock (above T6) s/s include

sypathetic NS causes Bradycardia and Hpotension

Central cord syndrome

• Results from hyperextension• Bowel and

bladder fx intact

Anterior cord syndrome

• Results from disruption of the anterior spinal artery

• Can feel vibration, touch, and pressure• Posterior cord

syndrome light touch impaired by not lost

Brown-Sequard Syndrome Results from

Hemisection of the cord Most common from

penetrating injury Ipsilateral (same side)

paresis or hemiplegia and total loss of function

Contralateral (opposite side) has decreased sensation to pain and temperature changes

Autonomic Dysreflexia

Complication of injury at or above T6 Life Threating injury- occurs when

sympathetic stimulation leads to massive uncontrolled cardiovascular response

Common Causes: Full bowel or bladder at the time of injury

Autonomic Dysreflexia

S/S › sudden severe HA› HTN› sweating› flushing above level of injury› coolness below level of injury› Anxiety› Blurred vision

TX-ABC’s, raise HOB, identify cause, foley

Thoracic/Abdominal Trauma

Thoracic Trauma

Some of the most life threatening injuries

Have a lot of concurrent injuries

Anatomy

Pulmonary System Cardiovascular System

Patient Assessment

ABC’s Auscultation of lung sounds Inspect chest wall integrity Ultrasound (FAST Scan) of heart and

lungs

Chest Wall Injuries

Rib Fractures

Most common type of blunt chest injury S/S – SOB, localized pain with

movement, chest wall ecchymosis or contusion

Bony crepitus Usually does not require treatment

other than pain meds Elderly may need admission

Flail Chest

Defined as fractures in 2 or more adjacent ribs in 2 or more places, or bilateral detachment of the sternum from costal cartilage.

Usually associated with Massive crush injury, high speed MVC.

Will see paradoxical movement to affected area

Flail chest

YouTube - Flail Chest

Sternal Fracture Decreased incidence with increased

use of seatbelts, shoulder restraints and air bags› Usually caused by steering wheel impact,

sporting injury or falls Increased potential for cardiac or

pulmonary injury

Traumatic Asphyxia

Result of severe crush injury to the thorax › Long period of time, such as being pinned

Pathology:› Direct increase in thoracic and superior vena

cava pressure from the injury› Combined with closure of the glottis

S/S› Severe cyanosis of face and neck› Subconjunctival and retinal hemorrhages› Transient LOC, SZ, or blindness

Pulmonary Injuries

Laryngeal Injury

Rare and Life threating Caused by “clothesline” type injuries Females with long narrow necks are

predisposed s/s:

› Hoarseness, stridor, hematoma, ecchymosis, tenderness, sq emphysema, crepitus, or loss of landmarks

Tx:› NPO, HOB 30-45degrees, O2, ETT, Tracheostomy

Pneumothorax

Accumulation of air in the pleural space S/S – SOB, tachycardia, tachypnea,

decreased or absent breath sounds on the injured side, chest pain

Chest tube is indicated for PTX of usually greater than 10%

Needle decompression or chest tube insertion

Open Pneumotorax

“sucking chest wound”› May see bubbles or hear a “hissing” sound

Usually result of penetrating chest wound

Apply 3 sided dressing, allowing air out but not in

If penetrating object still in place *DO NOT REMOVE*

Tension PTX

Life threating Accumulation of air in one pleural

space forces thoracic contents to the opposite side of the chest› Air can get in but not out

Immediate needle decompression is required

Hemothorax An accumulation of

blood in the pleural space

S/S – SOB, Tachypnea, chest pain, decreased breath sounds

TX – chest tube with suction. May need to consider auto-transfusion or O.R.

Chest Tube insertion

YouTube - Chest Tube Insertion..!

Pulmonary Contusion

Potentially leathal 75% of pts with chest injury

› 40% mortality Contusions occur when underlying lung

parenchyma is damaged, causing edema and hamorrhage

Tx: › Semi-fowlers, suction, ETT (for severe

hypoxia)› Usually improve in 3-5 days

Ruptured Diaphragm

Potentially life threatening injury

S/S – SOB, difficulty swallowing, abd pain, bowel sounds heard in the lower to middle chest, decreased lung sounds on injured side

Cardiac and Great Vessel

Injury

Pericardial Tamponade Collection of blood

in pericardial sac S/S- Hypotension,

tachycardia or PEA, SOB, cyanosis› Beck’s Triad ~

Hypotension, JVD, muffled heart tones

Pericardiocentsis

http://www.youtube.com/watch?v=T1LbBxxwjak

Aortic Injury

Immediately fatal in most cases, usually die at the scene

Dx done by CXR

Aortic Injuries

Caused by penetrating or blunt trauma

S/S ~ hypotension, decreased LOC, chest pain, decreased quality of femoral pulses

Abdominal Trauma

Abdominal Trauma

Significant source of morbidity and mortality

Patients usually have a lot of pain and high risk for bleeding

Anatomy Peritoneum Solid Organs

› Liver, spleen, gallbladder Hollow organs

› Stomach, Bowels, Bladder

Reproductive Organs› Uterus, ovaries, penis,

testes Vascular Structures

› Abdominal Aorta

Assessment History Mechanism

› Blunt, Penetrating, MVA Auscultation

› Abdominal quadrants Palpation

› Start away from area of pain

Interventions

Foley› Check for bleeding first and do rectal for

prostate placement NG/OGT

› When to use NG vs OG tubes Wound Care Medications

› Pain, ABX Diagnostics

› XR, CT, FAST, MRI, ANGIO, DPL, Labs

Splenic Injuries

Associated with fractures to 11th and 12th ribs

S/S ~ LUQ abd pain, left shoulder pain, abd wall rigidity.

Severe injuries require surgery

Hepatic Injuries

Scaled 1-5 (p308)

RUQ abd pain, abd wall rigidity, rebound tenderness

Can have diffuse right shoulder pain

Large and small bowel injuries

Occur in less than 1% of trauma injuries

Assess for Seatbelt Sign S/S ~ peritoneal irritation manifested

by abd wall muscle rigidity, pain, hypovolemic shock, gross blood from rectum

Triple contrast CT

DPL

http://www.youtube.com/watch?v=FXtoTrLuFj8

Renal Injuries

Most common is blunt contusion S/S Gross or microscopic hematuria Flank or abd tenderness Ecchymosis over flank area 1-5 Levels (pg310)

› 1=Minor, 5=Major

Renal Injuries

Orthopedic and NeurovascularTrauma

Anatomy

Bones› Cancellous (spongy)

Skull, vertebrae, pelvis, ends of long bones› Cortical (dense)

Long Bones Ligaments & Tendons- connect bones

together Joints

› Nonsynovial (non-movable)› Synovial (freely movable)

Assessment

ABCs Stabilize and control bleeding Assess for edema, deformity, abrasion,

laceration, puncture Focused neurovascular

› Pain, pulses, paralysis, parasthesia, pallor (5p’s)

Immobilization

ASAP Soft splints (pillows), hard splints

(fiberglass), Traction splint (reduce angulation)

Neurovascular checks pre and post Elevate and Ice after splint

Orthopedic Trauma

Immediate treatment required for following-› Open Fracture› Pulseless extremity› Compartment syndrome› Hemorrhaging

Back Pain Affects 60-80% of population beginning

at ages 30-40 May be chronic or acute Concern is to R/O serious injury/disease Red Flags

› Trauma, age >50, fever, cancer, muscle weakness or inability to move, loss of sensation, weight loss

TX ~ Rest, Ice, NSAIDS, usually resolves

Dislocations Loss of anatomical position of

2 bone surfaces Medical emergency due to risk

for nerve and blood vessel damage

Usually requires conscious sedation

Affects shoulder, ankle, patellar, elbow

Shoulder dislocations

High incidence of recurrence Specific mechanisms or historical facts may

be suggestive of certain types of dislocations, such as lightning injuries, electrical injuries, and seizure with posterior dislocations

throwing a ball or a punch or forceful pulling of the arm with an anterior dislocation

axial loading of an extremely abducted arm with inferior dislocation.

Fractures

Fracture assessment

General trauma assessment must be completed to r/o other injury (distracting)

Extremity exam (PMSC)› Pulse, Motor, Sensation, Cap refill

S/S ~ pain, deformity, edema, spasm, numbness, tingling, crepitus

TX: Immobilze, splint, pain meds, ice, elevate

Open Fractures

Considered contaminated because of possibility of foreign materials

Graded from 1-3 Patient will require pain meds,

antibiotics, and tetanus prophylaxis Usually are in surgery for copious

irrigation within 24 hours

Amputations

Need to know history of injury Straight or guillotine cut has best

replantation potential Contraindications include: de-gloved,

mangled, crushed body part, or mishandling of body part

Consider transfer to re-implantation center

Amputations

For body part› Gently lift of contaminates (no soap, no

betadine, no peroxide)› Wrap in saline soaked gauze and place in

dry plastic bag and seal› Place bag on top of ice› Avoid submersion in ice water and avoid

dry ice

Crush Injuries

Caused by prolonged entrapment or crushing blow

Cellular destruction and damage to vessels and nerves make crush injuries difficult to treat

Compartment Syndrome 6 P’s

› Pain› Pallor› Paresthesias› Pulses› Pressure› Paralysis

Treatment Steinman Pin

› Provides temporary reduction of long bone fx’s, until open reeducation or internal fixation can be done

Treatment

Casts› Place splint if severe swelling expected

Clean skin well prior to placement Education pt to look for compartment

syndrome and not to scratch inside cast

Ambulation

Crutches› Proper fit is key

Cane› Minimal assistance

Walker Wheelchair

› May be used temporarily until ambulation therapy or training complete

Maxillofacial Trauma

Anatomy

Principle facial bones include frontal, nasal, maxilla, zygoma, and mandible

Assessment

ABCs› Mandibular fx may cause tongue to be

displaced blocking the airway› Remove dentures or other foreign bodies

Suction secretions Palpate facial structures Check vision and perception Obvious deformity or inury

Soft Tissue Trauma

Repair Lacerations within 8-12hrs› Unless combative- wait until more

cooperative Road Rash

› Debridement done asap Hematomas

› Should be drained and dressed to prevent scaring

Avulsions› May require plastic surgery followup

Mandibular fractures

Mainly R/T MVA, altercations S/S

› Pain, tenderness (often referred to ear)› Inability to open mouth (trismus)› Malocclusion› Ruptured TM or blood behind TM› Numbness to lower lip

Mandible Fracture

Mandible Fracture

TX: › Assure airway clearance› Prep for OR› Possibly wiring of the jaw in the ED

Orbital Fractures

“Blowout” fracture Usually caused by ball, baseball bat, or

other blunt blow High risk for nerve and tissue

damage/entrapment S/S

› Double vision, facial anesthesia, pain, limited vertical eye movement, enopthalmos

Orbital Fracture

Orbital Fracture

TX› Ice to area› ABC’s/CSP› Instruct not to blow nose› Pain meds, antibiotics› Prep for OR ~ usually a few days after

once swelling has gone down

Zygomatic Fracture

Mainly R/T MVA, altercations Sometimes presented with orbital fx S/S ~ pain, assymmetry of the face,

flattened cheek, epistaxis, double vision, numbness to cheek

TX: ABC’s, ice, eventual OR

Zygomatic Fracture

Maxillary Fractures

R/T MVA, assaults Classified into “LeFort” 1, 2, or 3

› LeFort 1 ~ transverse detachment of entire maxilla above teeth at level of nasal floor

› LeFort 2 ~ fracture of midface that involves a triangular segment of the mid face and nasal bones

› LeFort3 ~ complete separation of the cranial attachments from the facial bones

Maxillary Fracture

S/S› Facial edema› Nasal swelling› Malocclusion› Nasal swelling› CSF rhinorrhea (II, III)

LUNCH