Download Trauma Resource Guide - Michigan State University

Trauma Resource Guide for the PICU RN
By: Marci Mechtel RN, BSN
Michigan State University MSN Ed student
March 2004
Trauma History

.
The Johns Hopkins Children's Center serves
as the Trauma center for children < 15 yo in
the state of Maryland. US statistics show
that the Central Nervous System is a factor
in 60-70% of all trauma-related injuries in
children. This accounts for approximately
200,000 hospital admissions annually. Of
that number, 4000 will die with 50% of the
deaths occur in the first few hours after
injury; and 15,000 will go on to require
prolonged care. The most common head
injury in all ages in seen with blunt trauma.
The result, in infants and children is diffuse
brain swelling and in adolescents the result,
is a focal mass or lesion. Primary injury
occurs at the time of the insult involving
destruction of brain tissue, the goal is the
prevention or limitation of secondary injury
which involves the destruction of viable
brain tissue due to hypoxia, hypotension
and cerebral edema.
Trauma Resource Guide on
Quickplace
2
Trauma History

The presents of severe neurological
injury in a child < 1 yo without a
consistent significant history of trauma
should be consider child abuse until
proven otherwise. Shaken Baby
Syndrome is the leading form of child
abuse as a cause of death in children < 1
yo accounting for about 50,000 cases
annually with 1 in 4 children will die. The
finding is the presence of a subdural
hematoma (caused by the whip-like
motion that tears the bridging veins from
the accelerant forces) or parenchymal
hemorrhage. Frequently bilateral retinal
hemorrhages are present. Skull fractures
or only present if the child's head struck
a surface during the incident.
Trauma Resource Guide on
Quickplace
3
General Principles
The head is the largest portion of body mass and is more malleable, making it easily
deformed in infants and children. The neck muscles aren’t well developed and the
mylenation of nerve fibers isn’t complete until 10 years of age.
1° injury: occurs at the time of incident and severity depends on amount of brain tissue
involved. Types include:


1.
2.
3.

Concussion-there is a transient LOC, with occasional amnesia to event, HA, N/V dizziness but no
long term sequale.
Diffuse Axonal Injury (DAI) it is a non focal injury where there is no obvious tissue damage but
the shearing force causes an physiological or anatomical disruption of the axon (portion of the
nerve cell). It results in prolonged coma with cerebral edema. DIA
Focal injuries include: laceration or contusion that is an area of bruising or microscopic
hemorrhage caused by coup (direct trauma) or contrecoup (indirect trauma-impact of the brain
on the opposite side of the brain) injury.
2°injury: occurs as the result of the damage of the 1° injury such as  in size of
hematoma or  blood supply to the injured area  compression  development of
cerebral edema or ischemia  ICP   brain compliance
Trauma Resource Guide on
Quickplace
4
General Guide




General Head Injury Information Link
Great Ormand Street Hospital Information Sheet
Parent/Family Guide Link
Virtual Hospital: Acute Brain Injury - A Guide for Family and Friends
Basic Concepts Neurological System
Basic concepts of the nervous system anatomy and physiology
JHH policy and procedure manual
Trauma Resource Guide on
Quickplace
5
Skull Fractures
Types of Skull Fractures:
1.
Linear Non-Depressed- Look for underlying
brain injury otherwise no treatment
required
2.
Depressed- Management is directed at any
underlying brain injury. Consult NUS if
fracture depressed more than the thickness
may need to be surgically elevated.
3.
Compound-There is a communication with
the underlying brain. NUS involved as pt
needs to go to the OR for elevation,
debridement of the brain and closure of the
dura. Pt placed on post-op oxacillin.
4.
Basilar S/S: raccoon eyes (cause by orbital
roof fx causes interorbital bleed), battle
sign (bruise behind ear), presence of blood
or CSF in ears or nose. NO NGT for this
population.
5.
Link: eMedicine - Skull Fracture : Article by
Nazer H Qureshi, MD
Trauma Resource Guide on
Quickplace
6
Epidural Hematoma



Occurs most often from a tear in the middlle
meningeal artery. In 60-80% of the cases it is
associated with a skull fracture over the
parietal or temporal bones. Up to 20% can
be a venous bleed that may arise from a tear
in the dural sinus or posterior fossa.
Bleeding occurs in the potential space
between the skull and the dura. This creates
a mass effect, resulting in shifting and
compression of brain tissue. It is a true
neurosurgical emergency because it can be
fatal because 2° injury can occur rapidly.
Small bleeds may require PICU observation
with follow-up CT and the blood will reabsorb
on its own in 2-4 weeks
S/S: Early- initial LOC noted by a lucid
interval followed by a rapid  in LOC.
Headache, seizures. Pt is never symptom
free. With 2nd LOC there may be hemiparesis
of the opposite side. Late-Hallmark sign in
50% of the patients is a fixed or dilated pupil
on the same side as the bleed. Signs of
herniation.
Trauma Resource Guide on
Quickplace
7
Subdural Hematoma


Bleeding occurs between the dura and
arachnoid membranes due to the tearing
of the bridging veins, small cerebral
arteries or from lacerations of the brain.
A skull fracture may be present, if so the
underlying brain injury is severe, the
prognosis is dismal even with early
evacuation, mortality is high. The bleed
will not be reabsorbed. It can be acute,
subacute or chronic (classification
depends on when symptoms progress). It
will create a mass effect that results in
shifting any compressed brain tissue.
S/S may be slow to develop include: HA,
fluctuations in LOC, hemiparesis, seizures
(chronic), chocked optic disc (chronic),
signs of herniation.
Trauma Resource Guide on
Quickplace
8
Intracerebral Hematoma


Bleeding occurs in the cerebral tissue, it
is usually small and multifocal. Any
significant bleeding is the result of
penetrating injury and occurs most
often in the temporal and frontal lobes.
It can create a mass effect.
S/S early HA and decreased LOC and
late signs of herniation. Late
complications depend on size and
location and is usually seizures and
learning disabilities.
Trauma Resource Guide on
Quickplace
9
Hematomas







UNC Case #2 Epidural
CNS Pathology Epidural
Head Trauma Epidural
CNS Pathology Subdural
UNC Case#1 Subdural
Sudural Hematoma
Picture –Can you identify the bleeds?
Trauma Resource Guide on
Quickplace
10
 ICP/ICP waveforms


1.
2.
3.

Link to general information Increased Intracranial Pressure
3 types of Cerebral Edema:
Cytoxic: affects the gray matter and there is an increase in intracellular space
associated with hypoxia, anoxia, hypo-osmolar solutions, electrolyte imbalance (SIADH),
bacterial menegitis.
Vasogenic: affects the white matter and is the most common. It is caused by the
increase in the capillary permeability which lead to a breakdown of the Blood Brain
Barrier (BBB). It causes the fluid to leak extracellular and is seen in trauma, cerebral
ischemia and hemorrhage.
Intersititial: Increase in intersititial fluid due to movement of CSF out of the
ventricules associated with hydrocephalus (communicating/noncommunicating)
ICP waveforms Intracranial pressure / waveforms
Trauma Resource Guide on
Quickplace
11
Camino Catheter for ICP monitoring





The neurosurgeon will decide between the ICP
monitor catheter and the ICP monitor with
drain. They are located in the supply room with
the cranial access kit . The Codman
Subarachnoid bolt is in the 1st big room top
shelf. The procedures are done sterilely, need
hats, masks, gowns and gloves.
Pt has to have PT/PTT documented. Be
prepared to give FFP if bleeding times
prolonged.
REMEMBER THE CATHETER NEEDS TO BE
ZEROED WITH THE SMALL SCREW INCLUDED
IN THE KIT BEFORE THE SURGEON INSURTS
INTO THE PT.
To zero to the Marquette monitor, Press cal step
on the front of the camino, cal step
0.20,40,100,200 then simultaneously press the
zero button on the Marquette monitor as you cal
step to 0 again.
See Camino Resource Guide for further details.
Trauma Resource Guide on
Quickplace
12
Treatment of  ICP










Hyperventilation  PaCO CBF(cerebral blood flow) ICP . Goal CO= 35. This works in the 1st 72
hours after that you see a rebound effect, once you stop bagging ICP. Works best with PaO > 100.
Use of thiopental 1-5 mg/kg/dose IV as needed last for ~ 5 min/pentobarbital IV bolus (1-5 mg/kg) or gtt
at 1-4 mg/kg/hr for sedation. SE: Use with caution as may cause hypotension.
Use of 3% NS or mix of NS and acetate (avoids hyperchoridemia) to  Serum Na/serum osmolarity. Dose 6
cc/kg given IV over 20-30 min.
No dextrose unless hypoglycemia-hyperglycemia can cause further injury
Lasix- loop diuretic used to increase urine output also inhibits CSF formation. Dose 0.5-1 mg/kg IV q 4-6
hr. side effects (SE): electrolyte imbalance, prerenal azotemia and ototoxicity.
Mannitol-osmotic diuretic helps to move fluid from extracellular to intravascular space excreted by the
kidneys overall dehydration. Dose 0.25-1 gm/kg/dose SE hypovolemia, hypotension,use with caution if
serum osm > 310 can lead to a breakdown in BBB and deposit mannitol into brain parenchyma may lead
to accumulation of H2O in the effected area. Need to draw up via filter needle and don’t inject air into
bottle leads to crystalization.
Phenytoin/Fospheytoin- Given prophalatically to prevent seizures Dose: Load 15-20 mg/kg and
maintenance 4-7 mg/kg/day. SE: may cause profound hypotension with rapid administration, can cause
tissue damage if infiltrates. Give fospheytoin (same dose) if pt only has PIV or having issue with BP.
Lidocaine-used as an anesthetic to suppress cough reflex during suctioning. Dose is 1 mg/kg need to
follow lidocaine level to prevent toxicity
Hypothermia- decrease pt temperature to 36.0° C rectally as a way to control ICP last attempt measure
watch for shivering as it can cause  ICP.
Operative craniotomy has shown no true benefit.
Trauma Resource Guide on
Quickplace
13
Herniation Syndrome

1.
2.
3.
Supratentorial-displacement of tissue normally
located above the tentorium cerebelli can be:
Central-downward displacement of
cerebral hemisphere,basal
ganglia,diencephalon and mid brain
through the tentorial notch. S/S  LOC,
altered resp. pattern, small pupils,
babinski present  loss of oculocephalic
reflex (Doll’s eyes), Cheyne-Stokes resp.
and decoticate posturing.
Uncal-downward displacement of inner
edge of temporal lobe-most common.
Causes compression of diencephalon &
midbrain S/S in dilation of same side
pupil, hemiparesis,
decorticate/decerebrate posturing altered
resp. pattern, untreated  fixed, dilated
pupils, flaccid extremities and respiratory
arrest.
Cingulate-a unilateral lesion in the
supratentorial space forces tissue laterally
causes compression of the local blood
supply. It is hard to identify


Infratentorial-downward displacement
through tentorial notch or downward
displacement through foramen magnum
 brain stem compression  damage to
the cardiac and respiratory center. This
causes a rapid deterioration in status 
death
Link Herniation Syndrome
Trauma Resource Guide on
Quickplace
14
Systemic Effects of Neurological System Failure




Respiratory- Can lead to an altered respiratory pattern, Neurogenic pulmonary edema due
to autonomic effects on the pulmonary vasculature, potential for aspiration pneumonia due
to loss of protective mechanisms (cough/gag), V-Q mismatch due to sympathetic nervous
stimulation.
Cardiovascular-  Cardiac output 2° to bradycardia, arrhythmias with brain stem injury,
potential inhibition of autonomic nervous system leads to an inability to vary HR.
GI: potential for GI ulceration/hemorrhage. Pt on Zantac or protonix to prevent.
Metabolic DI-Diabetes insipidus results from damage to the hypothalamus leads to
impaired production/release of ADH, so kidney is unable to concentrate urine and conserve
H2O. S/S: U/O > 5 cc/kg/hr, specific gravity < 1.005, Na > 145, Serum Osm > 295 leads
to dehydration and pot hypovolemic shock. Remember Pt is high (Na) and dry (due to high
urine output). Tx: Urine replacement as ordered and Vasopressin gtt to titrate urine to 1-2
cc/kg/hr. SIADH-Syndrome of inappropriate Anti-diuretic hormone. Results from the
damage to the feedback loop regulating ADH release causes dilutional hyponatremia and
H2O toxicity S/S: minimal U/O specific gravity> 1.030 N/V, change in LOC,seizures ( w/ Na
< 120), twitching, Na< 130, Serum osm < 275 (can calculate by 2* Na + (glucose/18) +
(BUN/2.8). Tx: restrict fluid, replace Na with hypertonic solutions, and lasix. Goal U/O= 2
cc/kg/hr.
Trauma Resource Guide on
Quickplace
15
Non accidental trauma/Shaken Baby Syndrome



Links for Shaken Baby Syndrome
(SBS)
inflicted head injury – intro
Virtual Children's Hospital:
Intentional Head Trauma in Infants
NursingCenter –SBS
Hallmark is + retinal hemorrhage
(pictured)
Part of work-up is skeletal survey
(child < 2), ophthalmology consult,
child protection team notification.
Trauma Resource Guide on
Quickplace
16
Management of the Patient with Acute Spinal Cord Trauma
Injury is caused by fracture of the vertebral
bodies, subluxation of the vertebra that
results in cord compression, and direct cord
injury or compromise of spinal cord
perfusion.
HIGH CORD INJURY PRESENTS AS A
RESPIRATORY ARREST.
Traumas need C-spine immobilization until
there is documented evidence that no cord
trauma exists.
S/S Complete injury is loss of movement
and/or sensation and loss of sphincter tone.
S/S Partial Injury:





1.
2.
3.
4.
Brown-Sequard-hemisection (North/South)
results in ipsilateral loss motor function/non
painful sensation and contralateral loss of
pain/temperature
Central Cord-usually cervical motor
deficits/sensory loss UE>LE.
Anterior Cord-pain/temp/motor function is lost
below level of lesion-vibration, position,&
sensation intact.
Posterior Cord-rare results in loss of position,
vibration and sensation
Trauma Resource Guide on
Quickplace
17
Management of the Patient with Acute Spinal Cord Trauma






Tractions system in place with 5# weight until pt can be placed in a Halo jacket or cervical spinal fusion
done.
May require long term ventilation
Infections common particularly pulmonary and UTI
Spinal Shock may occur in cervical and high thoracic injuries loss of sympathetic tone distal to the level
of the injury may last from hrs to weeks. S/S hypotension(due to vasodilation of vascular beds),
bradycardia,hypothermia (neurogenic shock), flaccidity, bowel/bladder disfunction. Change positions with
care because normal compensation for postural changes is lost. Tx: Phenylephrine gtt to start at 0.5
mcg/kg/min titrate to effect. It is used as a vasoconstrictor as an adrenergic antagonist needed for the
hypotension.
Autonomic dysreflexia-it is seen in patients with injuries T6 and above. It is cause by nerve impulses from
noxious stimuli below the lesion. Some causes can be: bladder distention, constipation, pressure sore or
infection. hypertension, bradycardia, diaphoresis, chills. If untreated it can lead to CVA. Tx-is to identify
and treat the cause and treat the hypertension.
Methylpredisolone-most beneficial if started within 8 hours after injury-decrease the edema around the
cord. Dose is 30 mg/kg load IV over 15 min. After 45 min begin gtt at 5.4 mg/kg/hr x 23 hr. SE:
hyperglycemia, hypokalemia, alkalosis, N/V, and peptic ulcer
Trauma Resource Guide on
Quickplace
18
Management of the Patient with Thoracic Trauma-Lung

1.
2.
Lung injury-caused by massive blunt trauma
Pulmonary Contusion-is a laceration of lung
tissue with interstital hemorrhage. It is the most
common parenchymal injury after trauma. V-Q
mismatch leads to hypoxia leads to a R to L shunt
through the contused, underventilated pulmonary
parenchyma may lead to ARDS. Complicated by
presents of aspirated gastric contents, flail chest
or pneumothorax. S/S Bloody ETT secretions,
Resp distress, persistent air leak after CT
placement. SQ emphysema present. Tx. ABC’s,
O2 to maintain O2 sats if hypoxic on > 50%
intubate/ventilate. CPT to atelectatic area and
avoid over hydration.
Flail Chest-seen in multiple rib fractures with
underlying parenchymal injury. Segment of chest
wall has no continuity with main thoracic cage. VQ mismatch occurs leads to hypoxia. S/S
paradoxical breathing noted on affect side due to
the change in intrathoracic pressure. Palpable
crepitus and rib fractures. Tx. Is intubation with
use of PEEP, positive pressure stabilizes the
chest wall, narcotics for the pain and avoid
over hydration-will worsen contusion.
Trauma Resource Guide on
Quickplace
19
Management of the Patient with Thoracic Trauma-Cardiac


Cardiac Tamponade- Rarely seen in blunt trauma. It
is commonly seen when a rib fracture or another
object penetrates the heart. The heart is compressed
due to the accumulation of blood in the pericardial
sac. This pressure then exceeds the intracardiac
pressure with leas to decreased filling of heart and
cardiac output. S/S narrow pulse pressure, muffled
heart sounds, neck vein distension, pulses paradoxes
with a > 10 mmHg gradient.Intubate, ventilate, IVFs
including PRBC’s. Pericardialcentesis to drain blood
may see PVC’s if needle is to far into myocardium.
Watch also for ST changes and widening QRS. Pt
need to go to OR after to repair site and drain
pericardium.
Myocardial Contusion-blunt trauma causing cardiac
musc le injury. There is a disruption in myocardial
blood flow leads to ischemia. S/S Elevation of CPKMB, risk for dysrhthmias esp. PAC/PVC. Rarely will
hear new murmur. Tx: EKG monitoring, adequate
oxygenation. Serial CPK’s and ECHO if you see
ischemic changes on EKG.
Trauma Resource Guide on
Quickplace
20
Management of the Patient with Abdominal Trauma





Liver/Spleen lacerations, Intestinal Tears, and
renal hematomas- 90% of abdominal injury is
due to blunt trauma. Liver and splenic
lacerations are due to the rapid deceleration
forces and intestinal tears are due to seat belt
injury. They are graded I-IV. It is diagnosed by
CT or by the presence of free air on an
abdominal x-ray.
S/S bruising abrasions, lacerations or seat belt
marks on the abdomen. Abdominal distension or
mass palpated. Presence or absence of bowel
sounds and pt c/o pain anteriorly and flank pain
for renal injury.
Tx. ABC’s. good IV access for fluid resuscitation,
OG Tube for gastric decompression, Foley if no
uretheral injury to monitor U/O. Serial
hemogloblins may need Surgical intervention if
pt has sudden drop in hemoglobin or becomes
hemodynamically unstable.
Links Peds Trauma
Virtual Children's Hospital: Pediatric Case 17
Trauma Resource Guide on
Quickplace
21
End of Resource Guide


Please fill out the evaluation rubric, so that this site
may be as useful as possible. Thank You.
Home
Trauma Resource Guide on
Quickplace
22