TRAUMA

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hrisney
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248184
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TRAUMA
Updated:
2013-11-20 22:56:59
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CRITICAL CARE NURSING
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TRAUMA
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  1. deceleration force-body stops suddenly but tissues and organs continue moving forward=internal lacerations and crush injuries.  mvc, contact sports, blunt force, fall
    blunt trauma
  2. damage along path of penetration- knife, firearm, impalement injuries.
    penetrating trauma
  3. Primary survey-ABCDE
    • Airway
    • Breathing/ventilation
    • Circulation with hemorrhage control
    • Disability: neuro status
    • Exposure/environment control
  4. most common shock in trauma pts
    hypovolemic shock
  5. fluid replacement of choice in trauma pts
    Lactated Ringers
  6. Secondary Survey - AMPLE

    (when pt is hemodynamically stable)
    • Allergies
    • Medications currently used
    • Past medical hx
    • Last meal
    • Events/Environment related to injury
  7. One of most important nursing roles in critical care phase-
    Optimize 02 delivery to prevent further system damage (secondary injury)
  8. assessment findings in basilar skull fracture (not usually seen on films)
    • otorrhea
    • rhinorrhea
    • battle's sign- bruising behind ear
    • raccoon eyes-circles around eyes
  9. Confusion, Disorientation, Amnesia
    HA, dizziness, nausea, irritability, impaired memory, inability to concentrate, fatigue

    S&S of what?
    Concussion
  10. Brain injury accompanied by loss of neurologic fx; may last seconds to an hour
    concussion
  11. bruising of brain; usually r/t acceleration-deceleration injury

    results in hemorrhage into brain tissue
    contusion
  12. Coup injury
    affects tissue directly under point of impact
  13. Contrecoup injury
    affects tissue directly opposite point of impact
  14. S&S:  Brief loss of consciousness followed by a period of lucidity then rapid deterioration in LOC, dilated pupils on same side as impact; severe localized HA; sleepy
    Epidural hematoma
  15. Epidural hematomas are associated with-
    skull fractures and middle meningeal artery lacerations

    think arterial
  16. occurs after severe blow to head; change in loc, unconscious, unequal reaction

    usually venous
    Acute subdural hematoma
  17. develops 2 days to 2 weeks after injury
    Sub-acute subdural hematoma
  18. significant sx months after injury.  see in elderly especially those on anticoagulants

    s&s: lethargic, forgetful, HA
    Chronic subdural hematoma
  19. Intracerbral hematomas are different from cerebral and subdural hematomas in that -
    Intracerebral hematomas occur within cerebral tissue
  20. objects penetrate the skull and cause significant focal damage.  ex. bullet

    3 types-
    Missile injury

    depressed, penetrating, perforating
  21. accel/decal and rotational forces

    stretching and tearing of axons; causes microscopic lesions throughout; loss of consciousness.

    result of damage to axons or disruption of axonal transmission of neural impulses
    Diffuse axonal injury
  22. 3 classifications of Diffuse Axonal Injury:

    coma 24 hrs; periods of decorticate and decerebrate posturing
    Mild
  23. 3 classifications of Diffuse Axonal Injury:

    coma > 24 hrs; decorticate and decerebrate posturing
    Moderate
  24. 3 classifications of Diffuse Axonal Injury:

    prolonged coma w/ HTN, hyperthermia, sweating (sweat has an unusual smell)
    severe
  25. Most important assessment w/ TBI
    Nero assessment/ GCS
  26. 3 categories of TBI based on GCS:

    Mild-
    GCS 13-15; loss of consciousness up to 15 min; may be discharged home
  27. 3 categories of TBI based on GCS:

    Moderate
    GCS 9-12; loss of consciousness up to 6 hrs; admitted; high risk increased ICP; serial CT's.
  28. 3 categories of TBI based on GCS:

    Severe
    GCS 8 or less; intubated, ventilated, ICP and hemodynamic monitoring.
  29. Organ donation called when GCS is-
    less than 5
  30. Spinal Cord Injury

    cause-usually at c5-c6; sudden decal like in a head on collision/ cord gets compressed.
    Hyperflexion
  31. Spinal Cord Injury

    cause-cord is twisted backward and downward; whip-lash is mild form; from rear end accidents and diving accidents.
    Hyperextension
  32. Spinal Cord Injury

    cause-usually seen same time as flexion or extension injury; posterior ligaments are torn and spinal cord is misplaced.
    Rotation
  33. Spinal Cord Injury

    like a fall from a roof and landing on feet; burst fragments can penetrate spinal cord.
    axonal loading
  34. Spinal Cord Injury

    penetration of cord; bullet ect
    penetrating injuries
  35. full loss of sensory fx below level of damage
    complete injury
  36. some motor fx below level of injury
    incomplete injury
  37. C1-T1 level injury-loss of fx below level of injury
    quadriplegia
  38. T2-L1; loss of fx below level (may have full use of arms)
    paraplegia
  39. occurs shortly after traumatic injury and may last up to a month.  complete loss of all muscle tone and normal reflex activity below injury with bradycardia and hypotension
    spinal shock
  40. life threatening; caused by massive sympathetic response to noxious stimuli (full bladder, impaction, ect); pt can't sense problem; SNS is stimulated resulting in bradycardia, HTN, facial flushing, severe HA; can cause cerebral hemorrhage, seizures, acute pulmonary edema, and death.
    Autonomic dysreflexia
  41. Interventions for autonomic dysreflexia
    • Don't let pt lay down
    • Keep head up to decrease ICP
    • Frequent VS checks
    • System check starting w/ urinary catheter
    • Fecal impaction removal
    • Manage HTN
  42. 2 or more ribs fractured in 2 or more places
    paradoxical chest wall movements
    flail chest
  43. injury to 1st and 2nd ribs can cause
    intrathoracic vascular injuries
  44. injury to 7th-10th ribs can cause-
    liver and spleen injuries
  45. moist crackles, coughing, and blood tinged sputum after trauma could be-
    pulmonary contusion
  46. dyspnea, tachycardia, sudden chest pain, tracheal deviation
    tension pneumothorax
  47. tx tension pneumothorax
    large bore needle or chest tube into affected pleural space
  48. dyspnea, tachycardia, sudden chest pain, tracheal deviation, and subcutaneous emphysema around wound
    open pneumothorax
  49. tx open pneumothorax
    close at end expiration with occlusive dressing until chest tube is inserted
  50. decreased breath sounds, dullness to chest percussion, hypotension, hypovolemic shock, low CO, tissue ischemia, bleeding into pleural space.
    hemothorax
  51. Beck's triad
    • elevated CVP with neck vein distention
    • muffled heart sounds
    • severe hypotension
  52. beck's triad is indicative of
    cardiac tamponade
  53. beck's triad, pulsus paradoxus, pulseless electrical activity
    cardiac tamponade from cardiac injury
  54. tx of cardiac tamponade
    pericardiocentesis
  55. friction rub over liver or spleen =
    rupture
  56. immunization you have to have if spleen injury
    polyvalent pneumoccal vaccine (pneumovax)
  57. Most common finding for GU trauma
    hematuria
  58. dark tea colored urine indicates
    myoglobinuria from massive tissue breakdown
  59. area that's tight, swelling; can be unilateral or bilateral
    compartment syndrome

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