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Chapter 55:
Trauma
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Statistics on Trauma
• Second to heart disease as the leading cause of death
• Motor vehicle accidents are leading cause of injury in the
U.S.
• 1/3 of all patients are admitted, with a mean hospital
stay of 5 days.
• Intentional injuries (gunshot injuries, suicides, hangings)
• Unintentional injuries (MVA, falls, burns)
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Mechanism of Injury
• Involves a description of the events, persons, and
objects involved at the scene of the injury
• Provides the health care provider with an idea of the
extent of damage involved
• Also gives the health care provider of an idea of the time
between the injury and arrival of first responders
• Ask about environmental factors such as the
temperature, whether rain/snow/ice increased the
skidding (therefore the acceleration)
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Types of Injuries
BLUNT TRAUMA
• No break in the skin
• More life-threatening as not
as obvious and diagnosis is
more difficult
• Types include acceleration,
deceleration, shearing,
crushing, compressive
injuries
• Size of vehicle and
occupant as well as position
PENETRATING
TRAUMA
• Wounds caused by
impalement or an object
passing through tissue
• Severity is due to organ or
tissue damage
• High-velocity vs. lowvelocity weapons
– High velocity: highpowered rifle
– Low velocity: ski pole,
knife stab wound
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Blunt and Penetrating Traumas in MVA
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Prehospital Management
• Mechanism of injury (from patient or bystanders)
• Primary survey (ABCDs)
– Airway, Breathing, Circulation, Discover (bleeding)
– Head and neck stabilization
• Secondary survey
– Full body assessment from head to toe for any other
injuries
– SAMPLE (Signs/Symptoms, Allergies, Medications, Past
Medical History, Last Meal, Events leading up to accident)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which of the following is true regarding prehospital care of the
trauma victim?
A. Positive outcomes are ensured if the patient reaches a
level trauma I care hospital within 2 to 3 hours.
B. More interventions should be provided if the transport time
is short.
C. Transport of a patient to a trauma center is associated
with a lower mortality rate and better outcomes.
D. Transportation to a facility for stabilization initially is
imperative.
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Answer
C. Transport of a patient to a trauma center is associated with a
lower mortality rate and better outcomes.
Rationale: Trauma patients do have better outcomes if they are
admitted to a level I trauma center. Patients were initially
transported to a closer, but not necessarily a level I,
institution for stabilization, but this has proven not to be as
effective in decreasing the mortality rate. Positive outcomes
are ensured if the patient reaches a level trauma I center
within “the golden hour” after injury. More interventions
should be provided if the transport time is longer, not shorter.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Primary Survey: Initial Nursing Assessment
and Management
ASSESSMENT
NURSING INTERVENTIONS
Airway
Air flow to the lungs
maintained
Jaw thrust, chin lift; removal of
airway obstruction; suctioning;
insertion of oral or nasal airway; ETT
Breathing
Respiratory rate, SaO2,
breath sounds normal
range; trachea is midline.
Oxygen delivery systems; bag-valve
ventilation, then ventilator; treat
tension pneumothorax
Circulation
Apical pulse, BP; capillary
refill; peripheral pulses;
ECG; obvious external
bleeding
Hemorrhage control; IV therapy
and/or blood transfusions; treatment
of life-threatening conditions
(cardiac tamponade)
Disability
LOC and pupillary check
(direct/consensual
response)
Exposure
Look for bleeding
Stop any obvious bleeding with
pressure if not already done. Monitor
fractures, penetrating wounds.
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Primary Assessment
• After airway and breathing have been stabilized, monitor and
correct hypovolemia.
• Signs and symptoms of hypovolemia include pale skin,
diaphoresis, tachycardia, and hypotension. The patient may
also be confused and disoriented.
• A large-bore IV has been started by the first responders so
infusion of fluid should be run rapidly.
• A urinary catheter is inserted to measure hourly urine outputs.
• Take the patient’s temperature, especially if the accident
occurred outside. Use warm blankets and IV fluids to correct
temp.
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Intravenous Fluid Resuscitation Choices
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Question
According to research, which of the following is the best
fluid replacement in the early stages of hypovolemia in a
trauma patient?
A. NSS
B. D5W
C. Lactated Ringer’s (LR)
D. Hypertonic saline
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Answer
D. Hypertonic saline
Rationale: Although isotonic solutions such as NSS and
lactated Ringer’s have been used in the past, research
has shown that hypertonic saline restores cardiac
function more quickly with smaller volumes. The
recommended amount can be as little as 4 mL/kg.
Hypertonic saline recruits fluid from the interstitial space
and results in a rapid increase in intracellular pressure,
which improves hemodynamics.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Secondary and Tertiary Surveys
SECONDARY SURVEY
TERTIARY SURVEY
• More comprehensive
head-to-toe
assessment
• Assessment of ABCDEs
• Additional historical
information
• Review of lab data and
diagnostic studies
– Significant others
– Past medical records
• Diagnostic studies
• Another head-to-toe
assessment
• An injury found within
24 hours is not
counted as a “missed”
injury.
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Other Solutions That Could Be
Administered to Increase Volume
• Colloids
• Blood products
– Increase the
“pulling” power of
fluid. Makes fluid
stay in the vascular
tree.
– Types include
albumin, dextran,
and hetastarch.
– Increase volume
and oxygenation
– Risk of infection and
reactions
• Autotransfusions
• Blood substitutes
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Question
O+ blood that is not cross-matched can be administered to
a man or a postmenopausal woman.
A. True
B. False
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Answer
A. True
Rationale: In an emergency, O+ blood can be administered
to a man or postmenopausal woman without crossmatching, and O- blood can be used for a woman of
childbearing age.
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Types of Thoracic Injuries
• Tracheobronchial
trauma
• Bony thoracic rractures
– Fractured ribs
– Flail chest
• Pleural space injuries
– Pneumothorax
– Hemothorax
– Tension
Pneumothorax
• Pulmonary contusions
(most common)
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Signs/Symptoms of Thoracic Injuries
• Airway and
maintenance are first
priority
• Anxiety, restlessness
• Dyspnea
• Accessory muscle use
• Hemoptysis
• Stridor
• SQ emphysema
• Tachypnea
• Pain
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Nursing Care and Treatments for Thoracic
Injuries
• Oxygen
• Thoracentesis for
tension pneumothorax
• Pain control
• PEEP for flail chest
• Judicious fluid
management
• Chest tube insertion for
pneumothorax and
hemothorax
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Types of Cardiac Injuries
• Cardiac contusions
(most common)
• Penetrating cardiac
injury
• Cardiac tamponade
• Aortic injuries
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Signs/Symptoms of Cardiac Injuries
• Murmurs and extra
heart sounds (S3, S4)
• Chest pain
• Dyspnea
• Chest wall ecchymoses
• Cardiac dysrhythmias
• Nonspecific ST-T wave
changes
• Cardiac tamponade –
muffled heart sounds,
decreased BP,
distended neck veins
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Nursing Care and Treatments for Cardiac
Injuries
• Relief of symptoms
• Cardiac tamponade – pericardiocentesis; mediastinal
chest tube; pericardial window
• Treatment for hemorrhage/shock
• Exploratory medial sternotomy
• Aortic repairs - grafting
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Abdominal Trauma
• Usually blunt trauma
• Solid organs include liver, spleen, pancreas, and kidney
– Usually encapsulated and respond with bleeding
• Hollow organs include intestine, stomach, gallbladder,
and bladder
– They collapse and absorb force; release contents into
peritoneal cavity
• Generally more than one organ is involved
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Types of Abdominal Trauma and
Treatment
TYPE OF TRAUMA
DIAGNOSIS
TREATMENT
Esophagus
Diaphragm
Esophagoscopy
Ultrasound/CT
NPO, antibiotics; NGT
Surgical repair
Stomach
Small bowel
Blood in NGT; +DPL
Surgery; watch for sepsis
and peritonitis
Duodenum
Pancreas
CT; MRI; x-ray
Repair and drain lacerations;
splenectomy; cutaneous
fistula care; TPN or enteral
feedings
Colon
CT; MRI; x-ray
Exploratory lap; ostomy;
antibiotics
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Types of Abdominal Trauma and
Treatment (cont.)
TYPE OF TRAUMA DIAGNOSIS
TREATMENT
Liver
CT; MRI
Unstable; surgery; segmental
resection. Coagulopathies common.
Spleen
+Kehr’s sign;
+DPL or CT
Most common organ injured. NGT,
splenorrhaphy or splenectomy;
problems with infection, adrenal
insufficiency and DIC
Kidney
Helical CT;
Ultrasound;
IVP
Bed rest; catheterization if external
organs intact; low-dose dopamine
Bladder
Gross
If external injuries, cystography
hematuria; x- before catheter insertion.
ray; CT; MRI Suprapubic catheter.
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Question
A patient is admitted to the ICU after a MVA. He has
multiple fractures but no soft or hollow tissue organ
damage. Which of the following would change this
patient’s status to a more life-threatening prognosis?
A. An avulsion
B. Pelvic fracture
C. Femoral fracture
D. An open fracture
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Answer
B. Pelvic fracture
Rationale: Pelvic fractures and traumatic amputations are
more serious than other injuries. An avulsion is a skin
flap and not a complete fracture. A femoral fracture
(increased bleeding) and an open fracture (bleeding and
infection risk) increase complications but would not
necessarily increase the mortality rate.
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Musculoskeletal Injuries
• 20,000 per year with 8,000 fatalities
• Usually recognized and stabilized in the secondary survey
• Mechanism of injury is very important
• X-rays of cervical spine, chest, and pelvis done first, then
CT, MRI
• Pelvic fractures need to be stabilized with C-clamp, pelvic
binder, or external fixator
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Types of Fractures and Treatment
• Open
• External fixation
• Closed
• Surgery
• Dislocated
• Antibiotics
• Amputated
• Tetanus booster
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Complications of Musculoskeletal Trauma
• Compartment syndrome
– Fasciotomy if it impedes
circulation
• DVT
– Prevention;
anticoagulants and close
observation
• Pulmonary embolism
– From DVT; O2; can
cause arrest if large
enough
• Fat embolism
– 72 h after injury;
respiratory distress
• Maxillofacial trauma
– ABCDEs
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Early/Late Complications of Trauma
EARLY
LATE
• Severe head injury
• Hypovolemic shock
• Hemorrhage
• Infection/septic shock
• ARDS
• MODS
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