Introduction

Introduction to
to
Emergency
Emergency Nursing
Nursing
Concepts
Concepts
Sandra 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/index.as
p
• 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!
 Transport
How is it decided?
• Travel time
• Terrain
• Availability of air or ground
transport
• Capability of personnel
• Weather
 Emergency Care Phase
Preparation
• 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 Embolism
Usually 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 Nutrition
Nutritional 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.