EMERGENCY NURSING (TRAUMA)

• Blunt acceleration forces

• Deceleration forces

• Penetrating forces

Most common forces involved in head trauma are:

Blunt acceleration forces

when the head is struck with an object

Deceleration forces

when the head is moving and strikes a stationary object

Penetrating forces

when an object enters the head

• Missed injuries

• secondary neurologic injuries (i.e. injuries to the brain and brainstem)

— are common in emergency care settings.

• to identify any obvious signs of head trauma and underlying neurological injury

• to provide baseline data which can be used to identify a developing neurological injury

Two fundamental goals for neurological assessment:

• intracranial hemorrhage

• edema of the soft tissues of the brain

Problems with PERRLA are often the first signs of increased ICP due to, for example, an — or —, etc

• disconjugate gaze (deviation of one eye)

• ptosis (drooping of the eyelid/s)

— are common signs of neurologic injury:

Decorticate / flexion (where the patient's arms are drawn rigidly up against their chest)

-– affects vision, hearing, eye movement, motor control and consciousness

Decerebrate / extension (where the patient's arms turn rigidly outwards against the sides of their body)

– affects coordination, sensation, facial expression, swallowing, breathing

• hypertension (a compensatory mechanism to maintain cerebral blood flow)

• cardiac dysrhythmia (due to brainstem dysfunction)

• hyperthermia (as cerebral dysfunction and metabolism increases)

Signs of a serious brain injury include:

• Hypertension

• Widening pulse pressure (i.e. increasing distance between systolic and diastolic BPs)

• Bradycardia

A patient with a severe late brain injury, where there is significant pressure on the brainstem, will often demonstrate signs known as 'Cushing's triad':

• a CT scan be undertaken if a patient has a GCS of 13 on initial presentation or a GCS of <15 2 hours after the injury

• a suspected skull fracture

• a post-traumatic seizure

• any focal neurological deficit

• more than 1 episode of vomiting

The National Institute of Health and Clinical Excellence's Head Injury: Assessment and Early Management (CG176) guideline recommends that:

Scalp lacerations

• — is highly vascularised and — often bleed profusely

• typically managed by direct pressure to control initial hemorrhage, and subsequent wound repair using sutures, staples or clips

• linear

• depressed

Skull fractures:

linear skull fracture

• the fracture is non-displaced, and there is no or minor neurological damage

• usually only require supportive care (e.g. rest, pain management, etc.)

depressed skull fracture

• one side of the fracture displaces below the other, and there is moderate to severe neurological damage

• often require surgical repair, including plating.

• hemotympanum (leakage of blood from the ears)

• 'panda' or 'raccoon' eyes (circular bruising around the eyes)

• leakage of cerebrospinal fluid from the ear/nose

• Battle's sign (bruising behind the ears)

Signs of a suspected skull fracture:

Contusion

a bruise on the scalp or on the surface of the brain

• Coup

• Contrecoup

When acceleration-deceleration forces are involved in the injury, two contusions on the surface of the brain may result:

Coup

the initial site of impact

Contrecoup

the opposite side of the brain, as it rebounds inside the skull

• an altered LOC

• nausea and or vomiting

• visual disturbances

• weakness

• difficulties with their speech.

Patients with contusion typically present with:

Subdural or epidural hematoma

bleeding beneath or between the skull and one of the layers of the dura mater or arachnoid mater

• severe headache

• pupillary dilatation on the same side of the body to that which they sustained the traumatic injury

• hemiparesis (i.e. one-sided weakness) on the opposite side

Patients with haematoma often present with:

Concussion

mild traumatic brain injury that involves a loss of consciousness with associated disruptions to neurological functioning

• nausea/vomiting

• temporary amnesia

• minor confusion and disorientation

• Headache

• Dizziness

• Drowsiness

• Irritability

• visual disturbances

People with concussion will display mild, transient neurological symptoms such as:

• non-narcotic analgesia

• anti-emetics

• fluid therapy

Care for a patient who has experienced a concussion involves regular observation to identify more serious brain injury, and symptomatic management —

Diffuse axonal injury (DAI)

a severe traumatic brain injury that results in shearing of axons, key structures within the white matter of the brain

• extended loss of consciousness

• flexion or extension posturing

• dysfunction of the autonomic nervous system

Patients with DAI typically present with:

• cerebral edema

• increase in cerebral blood flow (e.g. hemorrhage, acute hypertension, etc.)

Increased ICP Causes:

• decreased LOC

• changes in vital signs (including Cushing's triad)

• pupillary dilatation

• decrease in motor function

• severe headache

• nausea/vomiting

Patients with increased ICP will present with:

brain death

Where ICP is very high, pressure on the brainstem may result in — where brain function completely and irreversibly ceases.

• treating the greatest threat to life first (management of airway, breathing and circulation)

• effectively managing patient’s pain (contributes to an increase in ICP)

• use small but frequent doses of intravenous opioid

Providing care to a person with injuries resulting from head and/or neurologic trauma

Focus treatment on:

Orthopedic Trauma

bones, surrounding soft tissue, and associated neurovascular structures including the nerves and blood vessels

• road traffic accidents

• falls from height

• assaults

• sports and recreation accidents

• general accidents at work or in the home

Most common mechanisms that cause orthopedic injuries are:

• the long bones

• hemorrhage

• shock and severe pain

Orthopaedic injuries typically require urgent (rather than immediate) care; however, some orthopaedic injuries - including those involving — which may result in — - may require immediate care.

• obvious deformity

• lacerations

• contusions

• edema

• abrasions

• pain

Examine trauma site/s for obvious signs of orthopedic injury:

• Colour

• Temperature

• Pulses

• Sensation

• motor function in the affected limb/s

Do a focused neurovascular assessment, where any of these signs are identified: (orthopedic injury)

Strains and sprains

• involve minor damage to a muscle, usually at its point of attachment to a tendon

• although painful, strains and sprains do not require urgent care

• support

• ice

• elevate the affected limb

• manage pain using oral analgesia (e.g. paracetamol, ibuprofen)

• avoid weight-bearing for 24 to 72 hours

Patients should be encouraged to: (strains and sprains)

Fractures

any disruption or break in the bone

• closed

• open compound

Fractures may be described as:

closed

where the bone is broken but the skin is intact

open compound

where the bone is open and protrudes through the skin

• obvious deformity (confirmed by X-ray)

• pain (which may be severe)

• swelling

• ecchymosis in the affected region

Patients with fractures usually present with:

• Immobilization of the fracture

• traction splint or an adjacent leg splint for fractures of the femur

• vacuum splint for all other long bone fractures

• temporary casts may also be used

• Minor fractures may be reduced (i.e. realigned) and fixed in the emergency care setting

• More severe fractures require surgical intervention

Fracture Management:

• broken bones may lacerate vital organs/arteries/nerves

• fractures of the large bones may result in hemorrhage, etc.

Fracture Complications:

Dislocations

occurs when a joint exceeds its normal range of motion, and the joint surfaces become disconnected

• shoulder

• elbow

• finger

• hip

• knee/patella

• ankle and toe

Common points of dislocation:

• obvious deformity (confirmed by X-ray)

• pain (which may be severe)

• swelling

• ecchymosis in the affected region

Patients with dislocation usually present with:

Subluxation

– term used to describe a dislocation if there is only partial or incomplete displacement of the joint surfaces

Traumatic Amputation

involves the removal of all or part of a digit, limb or other body structure such as foot, hand, ear, nose, etc.

• Resuscitation is usually required for larger amputations involving hemorrhage

• Preservation of the stump (focus of care in the emergency setting)

• irrigating with normal saline to remove gross contamination

• moist dressing

• elevation and prophylactic antibiotic administration

Traumatic Amputation Management

Limb Replantation

• a complex microsurgical procedure that allows patients to have severed limbs reattached or “replanted” to their body

• Most patients need — within hours of experiencing traumatic injuries

• It is important to highlight that this is not successful in all cases.

Muscle injuries

including injuries to the rotator cuff (muscles in the shoulder) and meniscus (fibrocartilage in the knee)

rotator cuff

muscles in the shoulder

meniscus

fibrocartilage in the knee

Crush Injury

occurs when part of the body, typically a digit or limb, is crushed for a prolonged period

• necrosis of the crushed body part

• symptoms of 'systemic crush syndrome’

• myoglobinuria [myoglobin is a muscle breakdown product]

• acidosis – release of lactic acid

• renal failure – free myoglobin are too big to cross the glomerulus, resulting to plugging of holes

• cardiac disruption – release of potassium systemically

A patient with crush injury may present with:

myoglobinuria

myoglobin is a muscle breakdown product

acidosis

release of lactic acid

renal failure

free myoglobin are too big to cross the glomerulus, resulting to plugging of holes

cardiac disruption

release of potassium systemically

Compartment Syndrome

occurs when excessive pressure builds up inside an enclosed muscle space or compartment in the body

Compartment Syndrome

causes a decrease in perfusion and function of the tissues within that space

Compartment Syndrome

usually develops between 6 and 8 hours after the primary injury, when the compartment pressure exceeds capillary pressure and becomes clinically evident when the compartment pressure exceeds venous pressure

Compartment Syndrome

results in lack of outflow, which worsens the compartment pressure as blood and edema back up in the space.

• Pain

• disproportionate to the injury

• worse with passive stretching of the muscles in the compartment (e.g., dorsiflexion of the foot for a compartment syndrome of the calf)

• Paresthesia

Compartment Syndrome (5 P’s) Early signs:

• Pallor

• Paralysis

Compartment Syndrome (5 P’s) Late signs:

Pulselessness – occurs when the pressure finally exceeds arterial pressure (results in the need for amputation because the nerves and muscles are dead)

Compartment Syndrome (5 P’s) Last sign:

Fasciotomy

• a surgery to relieve swelling and pressure in a compartment of the body

• tissue that surrounds the area is cut open to relieve pressure

• partial or complete paralysis

• loss of motor ability

• loss of conscious function of body processes

• life-threatening CNS dysfunction (problems with A,B,C)

Spinal Trauma
Damage to the spinal cord, depending on the location of the injury, may result in:

• road traffic accidents

• falls from height

• assaults

• sports and recreation accidents

• general accidents at work or in the home

Mechanisms of spinal injury:

Neurogenic shock

• occurs when a spinal cord injury is complete, and all sensation and motor function below the level of the injury immediately ceases

• is generally irreversible

• patients must be carefully managed using spinal immobilization techniques to prevent further injury to the unstable cord in the immediate post-injury period

Autonomic Dysreflexia

a complication of spinal cord injury which occurs above the level of the T6 vertebrae

Autonomic Dysreflexia

occurs when impairments in the functioning of the sympathetic nervous system lead to a massive, uncontrolled cardiovascular response

Autonomic Dysreflexia

often triggered by simple causes such as a full bladder or bowel, and it can occur any time after the onset of a spinal injury

• a sudden severe headache

• hypertension

• bradycardia

• anxiety

• nausea/vomiting

• a combination of profuse sweating above and coolness below the level of the injury

Patients with Autonomic Dysreflexia will present with:

• hemorrhage

• edema

• hypoperfusion of the spinal cord

• endogenous biochemical responses

Secondary injuries to the spinal cord

Manifestations:

• cervical spine immobilization

• Spinal board

Management of Spinal Injuries:

cervical spine immobilization

– routinely done by paramedics for suspected or actual head injury

Spinal board

– used for those who complain of altered sensation in their peripheries

Thoracic Trauma

any traumatic injury affecting the chest area

• blunt forces (e.g. the sudden deceleration, compression and or direct blows sustained in road traffic accidents)

• penetrating injuries (e.g. stabbings, gunshot wounds, etc.)

Thoracic Trauma Causes:

• hypoxemia (a lack of oxygen in the blood)

• hypoventilation (a low respiratory rate)

Two main problems associated with actual or potential thoracic injuries:

Rib fractures

may involve a single rib or multiple ribs, and most often occur in the fourth to the tenth rib

flail injury

• a section of the ribcage moves independently from the main ribcage during breathing

• caused by severe rib fractures, those involving eight or more ribs

• Splinting

• rest

• pain management

— are all key interventions in the management of rib fracture.

Pneumothorax

involves an accumulation of air in the pleural space around the lung/s, and the resultant 'collapse' of the lung/s

• chest pain

• dyspnea

• tachycardia

• decreased or absent chest sounds on the side/s of the collapsed lung/s

• tracheal deviation away from the side of the pneumothorax

Patients with pneumothorax typically present with:

Hemothorax

is a similar condition where blood fills the pleural space

Cardiac tamponade

occurs when there is a rapid accumulation of the blood in the pericardial sac, which surrounds the heart

• hypotension

• muffled or indistinct heart sounds

• distended neck veins

'Beck's triad’:

• increasing dyspnea

• decreased level of consciousness (LOC)

• eventual death

If Cardiac Tamponade is left untreated, the condition results in —

acute circulatory dysfunction including cerebral hypoxia

As the pericardial sac is a closed space with a definite volume, blood in this space places pressure on the ventricles and prevents them from filling to capacity. This results in —

• blunt force trauma

• penetrating forces may also be seen

• road traffic accidents (including pedestrian-versus-vehicle accidents)

• falls from height

• assaults

Abdominal and Genitourinary Trauma

• injuries to the solid organs (kidneys, pancreas, spleen, liver)

• injuries to the hollow organs (stomach, urinary bladder, intestines)

Abdominal and Genitourinary Trauma Two types:

Lacerations to the solid organs

• liver and spleen

The — are common sites of traumatic abdominal injuries. Because the liver holds up to 25% of the body's circulating blood at any given time, injuries to the liver are particularly significant, often resulting in major hemorrhage.

Renal injuries

• kidneys

The — are another solid organ which are commonly affected by traumatic abdominal injury.