GMED3009 Trauma - Applied Bioscience for Health Complexity 2 - Curtin University - PDF

Applied Bioscience for Health Complexity 2 (GMED3009) Trauma Learning outcomes Explain the mechanism of injury Describe the basics of trauma management Primary survey Resuscitation Secondary survey Discuss common conditions associated with trauma (pneu...

Applied Bioscience for Health Complexity 2 (GMED3009) Trauma Learning outcomes Explain the mechanism of injury Describe the basics of trauma management Primary survey Resuscitation Secondary survey Discuss common conditions associated with trauma (pneumothorax, haemothorax, flail chest etc. ) and their management Discuss haemorrhagic shock and its management Mechanisms of Injury The extent of a patient’s injuries depends on the Mechanisms of Injury. Mechanisms of Injury are the exchange of forces between environment and person that result in injury. The transfer of kinetic energy, or energy of motion (shock wave) to tissues results in injury. There are many different types of energy agents, including: Mechanical or kinetic energy- blunt or penetrating injury Thermal energy- injury due to heat or cold Chemical energy- acid or alkaline exposure Radiant energy- exposure to radiation Electrical energy- electrocution Oxygen deprivation- smoke inhalation or drowning Mechanism of injury details provide clues to the patients' injuries and extent. Types of Traumatic Injury 1. Blunt Trauma Compression Shear Overpressure 2. Vehicle collusion Frontal impact collisions Lateral impact collisions Rear impact collisions Off-center or rotational collisions Rollover 3. Open Vehicles Initial Assessment and Management of the Trauma Patient Basics of Trauma Assessment Preparation Team assembly Equipment check Triage Sort patients by level of acuity Primary survey Designed to identify injuries that are immediately life threatening and to treat them as they are identified Resuscitation Rapid procedures and treatment to treat injuries found in primary survey before completing the secondary survey Secondary survey Full history and physical exam to evaluate for other traumatic injuries Monitoring and evaluation Transfer to definitive care ICU, ward, operating theatre, another facility  Preparation Organize Trauma Response Team http://www.trauma.org/archive/resus/ traumateam.html Primary Survey Airway and protection of spinal cord Breathing and ventilation Circulation Disability Exposure and control of the environment Airway and Protection of Spinal Cord Why first in the algorithm? Loss of airway can result in death in < 3 minutes Prolonged hypoxia = Inadequate perfusion, end-organ damage Airway assessment Vital signs = RR, O2 sat Mental status = Agitation, somnolent, coma Airway patency = Secretions, stridor, obstruction Traumatic injury above the clavicles Ventilation status = Accessory muscle use, retractions, wheezing Clinical signs and symptoms Patients who are speaking normally generally do not have a need for immediate airway management Hoarse or weak voice may indicate a subtle tracheal or laryngeal injury Noisy Respirations frequently indicates an obstructed respiratory pattern Airway interventions Maintenance of Airway Patency Suction of secretions Chin lift/Jaw thrust Nasopharyngeal airway Definitive airway Source undetermined Airway support Oxygen (NRBM, Bag valve mask) Definitive airway Definitive Airway Endotracheal intubation Source undetermined In-line cervical stabilization Surgical cricothyroidotomy Source undetermined Airway/Interventions Difference between a cricothyrotomy and a tracheostomy The difference is placement, and circumstances under which they're done. A cricothyrotomy is usually done in an emergent situation when you are unable to intubate someone and need to get access to someone's airway in a hurry. It's done through the cricothyroid membrane (through the Adam's apple). Landmarks are easy to identify, and the vocal cords and the person's thyroid gland & associated vessels are avoided. A tracheostomy is placed lower down in the trachea, between the tracheal rings. It can be placed in an operating room or at the bedside in an ICU setting. It is usually placed if someone is going to need the support of a ventilator for a long time This allows the patient to talk and not have the extreme discomfort of a tube going down his mouth into his trachea. Tracheostomy Cricothyrotomy Protection of Spinal Cord General Principle: Protect the entire spinal cord until injury has been excluded by radiography or clinical physical exam in patients with potential spinal cord injury. Spinal protection Rigid Cervical Spinal Collar = Cervical Spine Long rigid spinal board or immobilization on flat surface such as stretcher = T/L Spine Etiology of spinal cord injury (AUS) Road traffic accidents High energy falls Clinical treatment Treatment (Immobilization) before diagnosis Return head to neutral position Do not apply traction Diagnosis of spinal cord injury should not precede resuscitation Motor vehicle crashes and falls are most commonly associated with spinal cord injuries Main focus = Prevention of further injury C-spine Immobilization Return head to neutral position Maintain in-line stabilization Correct size collar application Blocks/tape Rolled Towels Source: www.ossur.com/ bracesandsupports/ neckandspine/ prehospit...oncollars /phillyblockhead Accessed 9/20/09 Yahoo Images Breathing and Ventilation General Principle: Adequate gas exchange is required to maximize patient oxygenation and carbon dioxide elimination Breathing/Ventilation assessment: Exposure of chest General inspection Tracheal deviation Accessory muscle use Retractions Absence of spontaneous breathing Paradoxical chest wall movement Auscultation to assess for gas exchange Equal bilaterally Diminished or absent breath sounds Palpation Deviated trachea Broken ribs Injuries to chest wall  Breathing and Ventilation Identify Life Threatening Injuries Tension pneumothorax Air trapping in the pleural space between the lung and chest wall Sufficient pressure builds up and pressure to compress the lungs and shift the mediastinum Physical exam Delldot ( Absent breath sounds wikimedia) Air hunger Distended neck veins Tracheal shift Treatment Needle decompression 2nd Intercostal space, midclavicular line Tube thoracostomy 5th Intercostal space, anterior axillary Source: www.meddean.luc.edu lumenMedEd/medicine/pulmona line r/cxr/pneumo1.htm Accessed 9/20/09 – Yahoo Images  Breathing and Ventilation Haemothorax Blood collecting in the pleural space and is common after penetrating and blunt chest trauma Source of bleeding = Lung, chest wall (intercostal arteries), heart, great vessels (aorta), diaphragm Physical exam Absent or diminished breath sounds Dullness to percussion over chest Hemodynamic instability Treatment = Chest tube Thoracostomy 10-20% of cases will require thoracotomy for http://www.trauma.org/index.php/main/i mages/C11/ control of bleeding  Breathing and Ventilation Flail Chest Direct injury to the chest resulting in an unstable segment of the chest wall that moves separately from remainder of thoracic cage Typically results from two or more fractures on 2 or more ribs Typically accompanied by a pulmonary contusion Physical exam = Paradoxical movement of chest segment Treatment = Improve abnormalities in gas exchange Early intubation for patients with respiratory distress Avoidance of overaggressive fluid resuscitation http://images1.clinicaltools.com/ images/trauma/ flail_chest_wounded.gif Flail Chest http://you.tu.be/mJ_FYwUqzsM  Breathing and Ventilation Open pneumothorax Sucking chest wound Large defect of chest wall Leads to rapid equilibration of atmospheric and intrathoracic pressure Impairs oxygenation and ventilation Initial treatment Three-sided occlusive dressing Provides a flutter valve effect Chest tube placement remote to site of wound Avoid complete dressing, will create a tension pneumothorax http://www.brooksidepress.org/Products/ OperationalMedicine/DATA/ operationalmed/Procedures/ TreataSuckingChestWound.htm http://www.trauma.org/index.php/main/image/ Pneumothorax Haemothorax 24 Tension Pneumothorax  Tube Thoracostomy www.simulab.com/TraumaMa n...tesis.htm/ http://www.trauma.org/i mages/image_library/ch est0051a.jpg Circulation Shock Impaired tissue perfusion Tissue oxygenation is inadequate to meet metabolic demand Prolonged shock state leads to multiorgan system failure and cell death Clinical signs of shock Altered mental status Tachycardia (HR > 100) = Most common sign Arterial hypotension (SBP < 120) Inadequate tissue perfusion Pale skin color Cool clammy skin Delayed cap refill (> 3 seconds) Altered LOC Decreased urine output (< 0.5 mL/kg/hr) Circulation Types of shock in trauma Hemorrhagic Assume hemorrhagic shock in all trauma patients until proven otherwise Results from internal or external bleeding Obstructive Cardiac tamponade Tension pneumothorax Neurogenic Spinal cord injury Sources of bleeding Chest Abdomen Pelvis Bilateral femur fractures Circulation Emergency nursing treatment Two large IV lines Cardiac monitor Blood pressure monitoring General treatment principles Stop the bleeding Apply direct pressure Temporarily close scalp lacerations Close open-book pelvic fractures Abdominal pelvic binder/bedsheet Restore circulating volume Normal saline Administer blood products Immobilize fractures Circulation Pericardial Tamponade Pericardium or sac around heart fills with blood due to penetrating or blunt injury to chest Beck’s Triad Distended jugular veins Hypotension Muffled Heart Sounds Treatment Rapid evacuation of pericardial space Performed through a Pericardiocentesis (temporizing measure) Open Thoracotomy Pericardial Tamponade 31  Pericardiocentesis www.brooksidepress.org/ProductsTrau ma_Surgery?M=A Disability Baseline neurologic exam (GCS) Pupillary xam Dilated pupil – suggests herniation on ipsilateral side. AVPU Scale Alert Responds to verbal stimulation Responds to pain Unresponsive Gross neurological exam – Extremity movement Equal and symmetric Normal gross sensation Glasgow coma Scale: 3-15 Rectal exam Normal rectal tone Note: If intubation prior to neuro assessment, consider quick neuro assessment to determine degree of injury  Disability GCS ≤ 8 Glasgow Coma Scale Intubate Eye Spontaneously opens 4 To verbal command 3 To pain 2 No response 1 Best Motor Response Obeys verbal commands 6 Localizes to pain 5 Withdraws from pain 4 Flexion to pain (Decorticate Posturing) 3 Extension to pain (Decerebrate Posturing) 2 No response 1 Verbal Response Oriented/Conversant 5 Disoriented/Confused 4 Inappropriate words 3 Incomprehensible words 2 No response 1  Disability Cervical Spinal Clearance Patients must be alert and oriented to person, place and time Not clinically intoxicated with alcohol or drugs Non-tender at all spinous processes No focal neurological deficits No distracting injuries Painless range of motion of neck Exposure Remove all clothing Examine for other signs of injury Injuries cannot be diagnosed until seen by provider Logroll the patient to examine patient’s back Maintain cervical spinal immobilization Palpate along thoracic and lumbar spine Minimum of 3 people, often more providers required Avoid hypothermia Apply warm blankets after removing clothes Hypothermia = Coagulopathy Increases risk of hemorrhage  Exposure http://www.trauma.org/index.php/main/image/98/C11 Accessed 9/20/09 – Yahoo Images  Physical Exam Seatbelt sign http://www.itim.nsw.gov.au/images/seat_belt_mark_2.jpg  Physical Exam Battle Sign Raccoon's Eyes http://health-pictures.com/eye/ Periorbital-Ecchymosis.htm Cullen’s Sign http://sfghed.ucsf.edu/ Education/ClinicImages/Battle's %20sign.jpg Grey-Turner Sign H. L. Fred and H.A. van H. L. Fred and H.A. van Dijk Dijk (Wikimedia) (Wikimedia) Trauma in Special Populations Pregnancy Supine Hypotensive Syndrome After 20 weeks, enlarged uterus with fetus and amniotic fluid compresses inferior vena cava Decreases venous return and decrease cardiac output Keep pregnant patients in left lateral decubitus position to avoid excessive hypotension Optimal maternal and fetal outcome is determined by adequate resuscitation of mother Fetal monitoring  Classic Radiographical Findings Pelvic Fracture http://www.itim.nsw.gov.au/images/Open_book_pelvic_fracture_xray.jp g  Classic Radiographic Findings Femur Fracture Source: www.flickr.com/photos/40939239@N08/3771820 024/ Paediatric Focus Background Trauma/serious injury is a leading cause of death in children in Australia EarlyABC interventions improve morbidity and mortality secondary to major trauma A trauma team approach should be used to manage seriously injured children Activate a ‘Trauma Call’ for all major trauma patients – see PMH Trauma Call Pathway Primary Survey The primary survey involves a rapid structured assessment of Airway, Breathing, Circulation, Disability and Exposure. Treat life threatening issues immediately as they are discovered during the primary survey before moving on. Paediatric focus Fluid resuscitation – 20ml/kg of 0.9% saline and repeat if necessary Treat raised intracranial pressure – 20% mannitol or 3% saline Correct hypoglycaemia – 2ml/kg of 10% glucose IV Conclusion Assessment of the trauma patient is a standard algorithm designed to ensure life threatening injuries do not get missed Primary Survey + Resuscitation Airway Breathing Circulation Disability Exposure References Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2019). Lewis's Medical-surgical Nursing ANZ: Assessment and Management of Clinical Problems (5th ed.). Chatswood, NSW: Mosby, Elsevier. Craft, J., Gordon, C., Huether, S., McCance, K., Brashers, V., & Rote, N. (2019). Understanding pathophysiology (3rd ed). Elsevier Australia. Kolecki, P. (2016). Hypovolaemic Shock. Medscape e-medicine. Retrieved from https://emedicine.medscape.com/article/760145-overview#:~:text=Hypovolemic% 20shock%20refers%20to%20a,%2C%20pathophysiological%2C%20and%20reparativ e%20processes. LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., Reid-Searl, K., et al. (2020). Medical-surgical nursing: Critical thinking in client care (4th Aus. ed.). Pearson Australia; Relevant Chapters