Concepts of Emergency and Trauma Nursing

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Martia
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256664
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Concepts of Emergency and Trauma Nursing
Updated:
2014-01-19 15:19:21
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nursing
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N303Critical Care,Test 1
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nursing school
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  1. emergency triage area
    • emergent - highest priority - trauma, major cardiac event
    • urgent - serious health issues - COPD
    • non urgent - episodic illness - recurrent UTI
    • fast track - minor acute with follow up in MD office - bone breaks, otitis media
  2. leading trauma injuries needing medical attention
    • #1 - falls
    • #2 - being struck by person or object
    • #3 - transportation related injury
  3. elderly and trauma
    • decreased reaction time, balance, coordination, sensory motor skills
    • pre existing conditions
    • limited physiological reserve - limited organ function
  4. trauma related injuries
    • identify mechanism of injury
    • types of kinetic injuries: blunt trauma and penetrating trauma
  5. blunt trauma
    • no skin interruption
    • tissue deformation and displacement
    • difficult to diagnose (covert injury)
    • degree of injury determined by velocity of the energy, surface area of injury, elasticity of tissues impacted
  6. shearing force in blunt trauma
    • sliding of body structures in the opposite direction upon impact from blunt force trauma
    • results in tearing or degloving
    • often causes aortic tears, splenic, renal, livr=er, brain, and heart injuries
    • coup-contrecoup: shearing injury at juncture C7 and T1
  7. acceleration force in blunt trauma
    • an increase in velocity of a moving body or structure
    • increased tissue and organ damage with greater velocity
    • being propelled foward
  8. deceleration force in blunt trauma
    decrease in velocity of a moving object
  9. tensile stress in blunt trauma
    • limited longitudinal stretch or stress upon a tissue or organ
    • results in tissue deformation
    • joint dislocation, sprains, strains
  10. compression force in blunt trauma
    • organ or tissue squeezed or pressed by force
    • high risk for rupture
    • in a car accident: heart and lung b/t chest walls; small bowel, liver, or spleen b/t vertebral column and seat belt
  11. common area of injury associated with blunt trauma
    • spinal cord injury
    • head injury
    • abd injury - #1:spleen; liver; small bowel
    • thorax injury - aorta
  12. penetrating trauma
    • disrupts skin integrity
    • if missile is impaled, LEAVE IT, removal can cause exsanguination
    • cavitation forms as a temporary cavity displacing tissue
    • blast effect - damage to surrounding vessels, nerves, and organs
  13. restrained driver with lap and shoulder harness injury patterns
    • pulmonary contusion
    • chest wall contusion
    • small bowel contusion

    pregnancy - high risk for blunt abd trauma and will show signs of hypovolemic shock late
  14. principle phases of trauma care
    • 1. primary survey and resuscitation
    • 2. secondary survey
  15. primary survey - airway management
    • head tilt is contraindicated for cervical spinal injuries b/c  that can hyperextend the cervical spine
    • chin lift and modified jaw lift are approved
    • after securing a definitive airway, place an oral or nasal tube to decompress the stomach

  16. airway management - nasopharyngeal airway
    • used in conscious patients
    • contraindicated for cribiform plate fracture and basal skull fractures
  17. airway management - oropharyngeal airway
    • used for unconscious patients with no gag reflex
    • contraindicated with conscious patients d/t vomting, gagging, and aspiration
  18. airway management - endotracheal intubation
    • used when:
    • patient needs more than an airway
    • pt. is struggling to breathe
    • pt. is apneic
  19. airway management - nasotracheal intubation
    • used when cervical spine cannot be hyperextended
    • contraindicated : cribiform plate fracture and basal skull fracture
  20. nursing actions for endotracheal intubation
    • auscultate all lung fields for breathe sounds
    • gurgling sounds over epigastrium means esophageal intubation
    • note placement (line at the lip)
    • confirm with CXR
    • obtain end tidal CO2 volume (EtCO2)
    • capnography - measures EtCO2 - normal 35 to 45mmHg
  21. airway management - surgical airways
    • needle, surgical, and emergency (laryngeal trauma) cricothyroidotomy
    • indications:
    • edema of the airway
    • laryngeal fracture or trauma (intolerant of the supine position)
    • hemorrhage of airway
  22. primary survey - breathing
    • look for resp excursion
    • listen for breath sounds
    • feel for breathing
    • all trauma patients should receive high flow oxygen during initial evaluation
    • provide positive pressure ventilation - mouth to mask, bag valve mouth, mechanical vent with PEEP
    • confirm adequacy of ventilation and oxygenation by ABGs, EtCO2, and pulse Ox
  23. primary survey - circulation
    • palpate pulses
    • eval skin temp, capillary refill, tissue perfusion by LOC
  24. compromised circulation
    • shock - clinical state of inadequate circulation, organ perfusion and tissue oxygenation 
    • hypovolemia - caused by acute blood loss from traumatic injury and/or shifting or loss of fluid from the intravascular space
    • exsanguination - most extreme form of hemorrhage; always leads to hypovolemic shock
    • s&s of exsanguination
    • 1. mild to marked tachycardia
    • 2. hypotension
    • 3. tachypnea and anxiety
  25. primary survey - disability
    • quick initial assessment to establish level of consciousness
    • LOC determined by AVPU scale
    • A - Alert
    • V - responds to verbal stimulation
    • P - responds to painful stimulation
    • U - unresponsive
  26. primary survey - exposure and evacuation
    • implement heat conservation methods
    • risk for hypothermia from:
    • 1. being disrobed
    • 2. cold blood products
    • 3. cold air from trauma rooms
    • 4. room temp IV fluids

    evacuate (transfer) to appropriate level trauma center if needed
  27. trimodal distribution of trauma deaths
    • first peak - death within minutes of injury; death  the at scene
    • second peak - death occurs within 2 hrs of injury (after arrival to ER); usually results rom brain injuries, ruptured organs, exsanguination, fractures
    • third peak - death within days to weeks to weeks after injury; usually occurs in the ICU
  28. resuscitation phase (simultaneously with primary survey)
    • most common cause of traumatic shock - hypovolemia from acute blood loss
    • most common areas of blood loss to produce shock state - abdomen, pelvis, retroperitoneum
  29. exsanguination resuscitation
    • large bore catheter (14 or 16 gauge)
    • rapid administration of warmed IV fluids - 2L Ringer's lactate or plasmolyte (both cystalloids)
    • Vasopressors are NEVER given to treat hypotension in shock
    • uncrossmatched O negative blood is given
    • autotransfusion - transfusing patient's own blood from their chest tube; done in massive hemorrhagic chest trauma
    • open resuscitative thoracotomy - used for great vessel exsanguinating thoracic injury (aorta)
  30. rib fractures
    • at risk for pneumonia and atelectasis
    • need adequate pain management
    • mortality increases with the # of rib fractures
    • ribs 4-9 are the most frequently fractured
  31. flail chest
    • lack of bony support d/t 2 or more rib fractures
    • clinical manifestations:
    • 1. uncoordinated paradoxical movement of flail section
    • 2. crepitus
    • 3. hypoxemia on ABGs

    • treatment (to prevent hypoxemia):
    • 1. high fowler's position
    • 2. pain management
    • 3. high flow O2 and positive pressure vent
    • 4. surgical stabilization of rib fractures

    • complications:
    • 1. hypoxemia
    • 2. pneumonia
  32. pulmonary contusions
    • blunt bruising to lung parenchyma
    • common with shoulder harness seat belt injuries
    • clinical manifestations:
    • 1. may not appear for several days
    • 2. xray shows pulmonary infiltrates
    • 3. crackles

    • treatment (improve gas exchange):
    • 1. coughing, deep breathing, spirometer
    • 2. ambulation
    • 3. removal of secretions
    • 4. intubate if necessary

    • complications:
    • 1. inflammation within the lung
    • 2. alveolar hemorrhage
    • 3. edema of lung tissue
    • 4. resp failure
  33. tension pneumothorax
    • cause by blunt force chest trauma and air enters into pleural space
    • clinical manifestations:
    • 1. pulsus paradoxus
    • 2. neck vein distention
    • 3. absent breath sounds on affected side (prevents lung from expanding)
    • 4. chest pain and tachycardia (from compression of the heart)
    • 5. hypotension and resp distress
    • 6. trachea displaced from midline toward unaffected side
    • 7. increased intrathoracic pressure
    • 8. decreased venous return

    • treatment:
    • 1. needle thoracotomy
    • 2. chest tube
  34. pulsus paradoxus
    • drop in systolic BP by 10mmHg or more upon inspiration d/t increased pericardial pressure
    • seen in tension pneumothorax and cardiac tamponade
    • causes decreased filling of the left ventricle and blood backing up into the right atrium
  35. open pneumothorax
    • penetrating chest wall injury
    • air escapes through the injury
    • same clinical manifestations as tension pneumothorax
    • goal is to normalize gas exchange and tissue oxygenation

    • treatment:
    • 1. sterile occlusive dressing taped on three side only until chest tube can be placed
    • 2. chest tube ASAP
    • 3. surgery to close penetrating wound
  36. massive hemothorax
    • accumulation of blood >1500mL in chest cavity
    • use autotransfusion
    • clinical manifestations:
    • 1. decrease breath sounds
    • 2. hypotension
    • 3. dullness to percussion
  37. cardiac tamponade
    • cause by blunt force or penetrating inury
    • pericardium fills with blood and tremendous pressure is placed around heart, preventing its ability to pump
    • clinical manifestations:
    • 1. beck's triad - elevated right atrial pressure with neck distention, hypotension, muffled heart sounds
    • 2. pulsus paradoxus
    • 3. PEA (pulseless electrical activity)

    • treatment:
    • 1. pericardiocentesis - fluid aspirated from pericardium
  38. blunt cardiac injury
    • cardiac contusion
    • bruising of myocardium (common from steering wheel)
    • clinical manifestations:
    • 1. chest discomfort
    • 2. EKG changes

    monitor with telemetry and echocardiogram
  39. spleen injuries
    • commonly injured organ in blunt trauma to abdomen
    • diagnosed by CAT scan
    • trend h&h levels to watch for hemorrhaging
    • monitor vital signs
    • vaccinations prior to discharge if splenectomy occurred
  40. liver injuries
    • majority of injuries are minor so no surgery is needed
    • diagnosed by CAT scan
    • graded on scale of 1-6 (6 is complete hepatic avulsion)
    • hemorrhage is most common complication
  41. best indicators of end points of resuscitation
    • 1. hemodynamic monitoring
    • 2. decreased lactic acid levels (means better perfusion)
    • 3. raised base level
  42. damage control surgery
    • three phases
    • 1. initial operation - control source of bleeding
    • 2. resuscitation - in the ICU for trauma resuscitation
    • 2. definitive restoration - back to OR usually within 72hrs of initial surgery for definitive repairs of injuries

    • complications:
    • 1. hypothermia
    • 2. coagulopathies (bleeding)
    • 3. systemic metabolic acidosis (caused by increased lactic acid)
    • 4. intraabdominal compartment syndrome (HTN of abd compartment)
  43. pelvic injuries
    • life threatening
    • usually from MVC or crushing injury to pelvis
    • high risk for hemorrhage
    • confirmed by CAT scan

    • interventions:
    • 1. monitor signs of continued hemorrhage
    • 2. fluid resuscitation
    • 3. physician order to log roll
    • 4. managed with internal or external fixation  or pelvic binder
  44. metabolic response to stress injury
    • ebb phase (survival) - initial state during acute resuscitation; lasts 24 to 36 hours
    • flow phase (recovery) - occurs after 36 hours from injury
  45. ebb phase
    • metabolic response to stress injury
    • metabolic rate unchanged
    • increased glucose production for injury healing
    • decreased oxygen consumption
    • decreased body temp
    • fat stores used - increased lactate levels

    • normal lactic acid <2.0
    • increases upon injury/illness and causes hypoperfusion
  46. flow phase
    • metabolic response to stress injury
    • hypermetabolic rate (increased energy usage)
    • increased oxygen demands
    • elevated body temp
    • protein breakdown - catabolic state
    • negative nitrogen balance

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