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CHAPTER 25 Trauma Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. OBJECTIVES Compare and contrast injuries associated with blunt and penetrating trauma. Discuss mechanism of injury, pathophysiology, assessment findings, medical management, and nursing management of traumatic injuries to the head, spinal cord, heart, lungs, and abdomen. Use assessment findings to identify potential complications and sequelae of traumatic injuries. PREVENTION OF TRAUMA Unintentional injury Motor vehicle accident vs. motor vehicle crash Prevention, recognition, and treatment of intimate partner violence Alcohol AUDIT alcohol screening questionnaire CAGE alcohol screening questionnaire MECHANISMS OF INJURY Blunt trauma Motor vehicle collisions Contact sports Blunt force injuries Falls Penetrating trauma Stabbings Firearm injuries Impalement PHASES OF TRAUMA CARE PREHOSPITAL RESUSCITATION Immediate stabilization and transportation Airway maintenance Control of external bleeding and shock Immobilization Immediate transport (ground or air) PHASES OF TRAUMA CARE ED RESUSCITATION Primary survey (A, B, C, D, E) Airway maintenance Breathing and ventilation Circulation and hemorrhage control Disability and neurological status Exposure/environmental control PHASES OF TRAUMA CARE RESUSCITATION PHASE Hypovolemic shock Blood Two large-bore peripheral intravenous lines Fluid loss resuscitation Placement of urinary and gastric catheters PHASES OF TRAUMA CARE SECONDARY SURVEY AMPLE Allergies Medications currently used Past medical history Last meal Events/environment related to injury QUESTION Which of the following pieces of information would be important when taking a history from a patient with a blunt chest injury? A. B. C. D. Caliber of weapon Restraint status Gender of assailant Weapon used ANSWER B. Restraint status Restraint status (lap belt, shoulder harness, or combination) is important information for the patient with blunt chest trauma. Caliber of weapon, gender of assailant, and weapon used are information that should be elicited in the case of a patient with penetrating trauma. PHASES OF TRAUMA CARE Definitive care/operative phase Trauma is a “surgical disease” Critical care phase Advanced trauma life-support guidelines Trauma complications Acute respiratory distress syndrome Sepsis Shock states Multiple organ dysfunction syndrome TRAUMATIC BRAIN INJURIES (TBI) Mechanism of Injury Penetrating Leading causes – falls, motor vehicle crashes, struck by or against events, and assaults Penetrating object – bullet Blunt trauma Deceleration Acceleration Rotational forces (continued) TRAUMATIC BRAIN INJURIES (TBI) (CONTINUED) Pathophysiology Primary injury Direct injury to the parenchyma Hemorrhage and compression of nearby structures Secondary injury Biochemical and cellular response to initial trauma Can exacerbate primary injury Consequences of increased intracranial pressure Risks of cerebral hypoperfusion Cerebral edema (continued) TRAUMATIC BRAIN INJURIES (TBI) (CONTINUED) Skull fracture Concussion Contusion Acceleration-deceleration injuries Coup-contrecoup mechanism of injury (continued) COUP-CONTRECOUP MECHANISM OF INJURY FIGURE 25-1 Coup and contrecoup head injury after blunt trauma. A, Coup injury: impact against object, showing the site of impact and direct trauma to brain (a), shearing of subdural veins (b), and trauma to the base of the brain (c). B, Contrecoup injury: impact within skull, showing the site of impact from brain hitting opposite side of skull (a) and shearing forces throughout brain (b). These injuries occur in one continuous motion; the head strikes the wall (coup) and then rebounds (contrecoup). TRAUMATIC BRAIN INJURIES (TBI) (CONTINUED) Cerebral Hematomas Epidural hematoma Subdural hematoma Intracerebral hematoma (continued) TYPES OF CEREBRAL HEMATOMAS FIGURE 25-2 Types of hematomas. A, Subdural hematoma. B, Epidural hematoma. C, Intracerebral hematoma. TRAUMATIC BRAIN INJURIES (TBI) (CONTINUED) Missile injuries Depressed, penetrating, or perforating Diffuse axonal injury (DAI) Prolonged posttraumatic coma Stretching and tearing of axons at time of injury Microscopic lesions throughout the brain (continued) MISSILE INJURIES FIGURE 25-3 Bullet wounds of the head. A bullet wound or other penetrating missile wounds cause an open (compound) skull fracture and damage to brain tissue. Shock wave effects are transmitted throughout the brain. A, Perforating injury. B, Penetrating injury. TRAUMATIC BRAIN INJURIES (TBI) (CONTINUED) Assessment in TBI Glasgow Coma Scale Degree of injury Mild injury Moderate injury Severe injury Nursing assessment Level of consciousness Motor movements Pupillary response Respiratory function Vital signs DIAGNOSTIC PROCEDURES IN TBI CT scan Electrophysiology studies in ongoing assessment MRI MEDICAL MANAGEMENT OF TBI Surgical management Nonsurgical management NURSING DIAGNOSIS PRIORITIES Ineffective breathing pattern related to neuromuscular impairment, perceptual or cognitive impairment Risk for aspiration Impaired gas exchange related to ventilation/perfusion mismatching Imbalanced nutrition: less than body requirements related to lack of exogenous nutrients and increased metabolic demand (continued) NURSING DIAGNOSIS PRIORITIES (CONTINUED) Powerlessness related to lack of control over current situation Decreased intracranial adaptive capacity related to failure of normal compensatory mechanisms Impaired physical mobility related to perceptual or cognitive impairment Ineffective cerebral tissue perfusion related to hemorrhage NURSING MANAGEMENT OF TBI Nursing priorities focus on: Stabilizing vital signs Preventing further injury Reducing increases in ICP and maintaining adequate cerebral perfusion pressure Hemodynamic management Fluid management Cerebral perfusion pressure more than 70 mm Hg Aggressive pulmonary care Reduce environmental stimuli SPINAL CORD INJURIES MECHANISM OF INJURY Hyperflexion Sudden deceleration Hyperextension Backward and downward motion Rotation Axial loading Vertical compression Penetrating injuries AXIAL LOADING FIGURE 25-4 Spinal cord compression burst fracture. Compression injuries cause burst fractures of the vertebral body that often send bony fragments into the spinal canal or directly into the spinal cord. PATHOPHYSIOLOGY OF SPINAL CORD INJURIES Primary injury Neurological damage occurs at moment of impact Secondary injury Complex biochemical processes affecting cellular functions Occur within minutes of injury and can last days to weeks (continued) PATHOPHYSIOLOGY OF SPINAL CORD INJURIES (CONTINUED) Functional injury of spinal cord Complete injury Quadriplegia Paraplegia Incomplete injury (continued) PATHOPHYSIOLOGY OF SPINAL CORD INJURIES (CONTINUED) Spinal shock Neurogenic shock Occurs shortly after traumatic injury to the spinal cord Complete loss of all muscle tone and normal reflex activity below the level of the injury Injury to the descending sympathetic pathways Autonomic dysreflexia Life-threatening complications Bradycardia, hypertension, facial flushing, and headache ASSESSMENT AFTER SPINAL CORD INJURY Airway Breathing Circulation Neurological assessment Diagnostic procedures Screening for spinal cord injury 15% of trauma patients with injury will have a cervical spine injury Eastern Association of Surgeons in Trauma guidelines (continued) ASSESSMENT AFTER SPINAL CORD INJURY (CONTINUED) Diagnostic procedures Diagnostic CT x-rays scan Tomograms Myelography MRI MEDICAL MANAGEMENT AFTER SPINAL CORD INJURY Pharmacological management Methylprednisolone Surgical management Provides spinal column stability Nonsurgical management Cervical Halo injury vest Thoracolumbar injury HALO VEST FIGURE 25-6 Halo vest. The halo traction brace immobilizes the cervical spine, which allows the patient to ambulate and participate in self-care. NURSING DIAGNOSIS PRIORITIES SPINAL CORD INJURY Decreased cardiac output related to lack of sympathetic innervation Risk for autonomic dysreflexia related to spinal cord injury above T6 Impaired gas exchange related to alveolar hypoventilation Ineffective breathing pattern related to impairment of innervation of diaphragm (lesion above C5), complete or mixed loss of intercostal muscle function (continued) NURSING DIAGNOSIS PRIORITIES SPINAL CORD INJURY (CONTINUED) Impaired physical mobility related to neuromuscular impairment, immobilization by traction, and paralysis Risk for impaired skin integrity related to immobility, traction, tissue pressure, altered peripheral circulation, and sensation Bowel incontinence related to disruption of innervation to bowel and rectum, perceptual impairment, and altered fluid and food intake (continued) NURSING DIAGNOSIS PRIORITIES SPINAL CORD INJURY (CONTINUED) Constipation related to disruption of innervation to bowel and rectum, perceptual impairment, and altered fluid and food intake Impaired urinary elimination related to disruption in bladder innervation, bladder atony (continued) NURSING DIAGNOSIS PRIORITIES SPINAL CORD INJURY (CONTINUED) Disturbed body image related to actual change in body structure, function, or appearance Ineffective coping related to situational crisis and personal vulnerability NURSING MANAGEMENT AFTER SPINAL CORD INJURY Nursing priorities are aimed at: Preventing secondary damage to the spinal cord Managing cardiovascular and pulmonary complications Coaching the patient to overcome the psychosocial challenges associated with severe neurological deficit THORACIC INJURIES Mechanism of injury Blunt thoracic trauma Penetrating thoracic injuries CHEST WALL INJURIES Rib fractures Flail chest Ruptured diaphragm FLAIL CHEST FIGURE 25-7 Flail chest. A, Normal inspiration. B, Normal expiration. C, The area of lung underlying the unstable chest wall sucks in on inspiration. D, The same area balloons out on expiration. Notice the movement of mediastinum toward opposite lung on inspiration. PULMONARY INJURIES Pulmonary contusion Tension pneumothorax Open pneumothorax Hemothorax QUESTION Which of the following positions should be used with a patient who has a left-sided pulmonary contusion with severe hypoxemia? A. B. C. D. Patient should be placed on the left side Patient should be positioned prone Patient should be placed in semi-Fowler’s position Patient should be placed on the right side ANSWER D. Patient should be placed on the right side Patients with unilateral contusions and significant hypoxia are placed with the injured side up and uninjured side down (“down with the good lung”). This positioning maximizes the match between pulmonary ventilation and perfusion. TENSION PNEUMOTHORAX FIGURE 25-8 A tension pneumothorax usually is caused by an injury that perforates the chest wall or pleural space. Air flows into the pleural space with inspiration and becomes trapped. As pressure in the pleural space increases, the lung on the injured side collapses and causes the mediastinum to shift to the opposite side. (From Marx J, et al: Rosen’s Emergency medicine: concepts and clinical practice, ed 5, St Louis, 2002, Mosby.) HEMOTHORAX FIGURE 25-9 Blunt or penetrating thoracic trauma can cause bleeding into the pleural space to form a hemothorax. CARDIAC AND VASCULAR INJURIES Penetrating cardiac injuries Cardiac tamponade Beck’s triad Pulsus paradoxus Blunt cardiac injuries (BCI) EAST guidelines CARDIAC TAMPONADE FIGURE 25-10 Cardiac tamponade is the progressive accumulation of blood in the pericardial sac. BLUNT CARDIAC INJURY FIGURE 25-11 Blunt cardiac trauma. Sudden acceleration (as from contact with the steering wheel) can cause the heart to be thrown against the sternum. NURSING DIAGNOSIS PRIORITIES THORACIC INJURIES Impaired gas exchange related to alveolar hypoventilation from lung contusion Ineffective breathing pattern related to pain from rib fractures Decreased cardiac output related to low preload from tension pneumothorax, hemothorax, or cardiac tamponade NURSING MANAGEMENT Nursing priorities emphasize delivery of adequate: Oxygen Ventilation Pain management Prevention of complications ABDOMINAL INJURIES Mechanism of injury Blunt trauma Penetrating trauma ASSESSMENT OF ABDOMINAL INJURIES Physical assessment Location of entry and exit sites associated with penetrating trauma assessed and documented Cullen’s sign Grey Turner’s sign Distended abdomen Rebound tenderness Kehr’s sign (continued) ASSESSMENT OF ABDOMINAL INJURIES (CONTINUED) Diagnostic assessment Diagnostic Bedside Chest CT peritoneal lavage (DPL) ultrasound x-ray scan of abdomen DIAGNOSTIC PERITONEAL LAVAGE FIGURE 25-12 Diagnostic peritoneal lavage (DPL) can exclude or confirm the presence of intraabdominal injury with a high accuracy rate. COMBINED ABDOMINAL ORGAN INJURIES Multivisceral injuries Damage control surgery Initial operation Intensive care unit resuscitation Definitive reoperation Abdominal compartment syndrome End-organ dysfunction caused by intraabdominal hypertension SPECIFIC ORGAN INJURIES Liver injuries Life-threatening hemorrhaging Hemodynamic instability Coagulopathies, acidosis, and hyperthermia Spleen injuries Life-threatening hemorrhaging Sepsis Intestinal injuries Sepsis and abscess or fistula formation GENITOURINARY INJURIES Mechanism of injury Blunt trauma Penetrating trauma Assessment Flank pain or colic pain Bluish discoloration of the flanks Perineal discoloration Urine/hematuria SPECIFIC GENITOURINARY INJURIES Renal trauma Flank ecchymosis Fracture of inferior ribs or spinous processes Gross hematuria CT scan Bladder trauma Caused by pelvic fractures Lower abdominal bruising, distention, and pain Difficulty in voiding Retrograde urethrogram COMPLICATIONS OF TRAUMA Hypermetabolism Initiate enteral feedings within 72 hours for patients with blunt and penetrating abdominal injuries and those with head injuries Infection Sepsis (continued) COMPLICATIONS OF TRAUMA (CONTINUED) Pulmonary Respiratory failure Fat embolism syndrome Pain Renal complications Renal failure Myoglobinuria (continued) COMPLICATIONS OF TRAUMA (CONTINUED) Vascular complications Compartment syndrome Venous thromboembolism Missed injury Commonly discovered in first 24 to 48 hours after presentation MODS SPECIAL CONSIDERATIONS IN TRAUMA CARE Meeting needs of family members and significant others Crisis situation for family and friends Trauma in older patients Risk of falls Risk of motor vehicle collisions Limited physiological reserve Age-related organ changes
