SHOCK, HEMMORRHAGE, TBI & cervical spine injury

Shock

It is a life-threatening condition that occurs when the body is not getting enough blood flow

Massive bleeding, infection, severe allergic reaction, severe dehydration, heart problems

Causes of shock

• Poor skin color that is pale, gray, or bluish

• Dizziness and lightheadedness

• Cold and clammy skin

• Low blood pressure

• Behaviour changes such as agitation, confusion, or unresponsiveness

Assessment of shock

 lie down; elevate

Help the person ____ and ___ their legs  

blankets; warm– thermoregulation

Cover the person with ____ to keep ____

Hypovolemic Shock

• Occurs when significant amounts of fluid are lost from intravascular space. 

• This fluid may be blood, plasma, or electrolyte solution.

• May result from hemorrhage, burns, GI losses, or fluid shifts.

Hemorrhage

Refers to rapid loss of circulating blood volume, usually 5 liters of blood volume is loss

Acute hemorrhage related to gunshot wound

• Penetrating trauma is one of the leading causes of hemorrhage, and GUNSHOT WOUNDS (GSW) are the leading source of high-velocity penetrating trauma

Ballistics

It is the science of the motion of projectiles.

Wound ballistics

The study of projectile penetration of the tissues

• caliber of the gun 

• type of bullet 

• proximity of the muzzle to the victim

The amount of destruction is directly related to:

gun's caliber, the presumed path and velocity, and the distance from the weapon to the victim's

The important indicators of determining the extent of injuries includes the ___________ entrance point

bullet; tissues; GSW victim

Kinetic Energy (KE) which is carried by the ___ and subsequently transferred into the ___, causes damage in a _____.

weight of the bullet, velocity, and gravitational acceleration

The wounding effect of a projectile is produced by the transfer of kinetic energy from the projectile of the tissues; In relation to physics, KE is computed based on __________

the greater the wounding potential 

The greater the kinetic energy of a projectile, _______

all its kinetic energy has been transferred to the tissues

If a projectile does not exit the body, then ____

Only some of its kinetic energy has been transferred to the tissues

If the projectile exits the body, then _________

V1 (inlet velocity)

Entrance wound is called _____ as the maximal point of energy

V2 (outlet velocity)

Exit wound is called

 zero or VO (no exit wound)

if the bullet does not exit the body, outlet velocity is ___

inward path; negative pressure'; debris and bacteria

The high V1 creates an ____ along which the bullet travels, but also _____ also exists behind the bullet, which pulls _____ to the wound

in greater damage

Tissue that is dense has a tendency to take up more energy, resulting ____

greater damage or greater tissue destruction 

Greater projectile/specific gravity =

Blood pressure

most important vital sign to be monitored in a patient who has a concussion

• Altered LOC

• narrowing pulse pressure

• hypotension (fall SBP)

• weak and thready pulse

• UO 25ml/hr

• pale and cold skin, diaphoresis

• subjective impeding doom

• excessive thirst

Signs and Symptoms of shock

to decrease blood loss and to increase intravascular volume

Goal of treatment in shock and hemorrhage

Altered Tissue Perfusion

Priority nursing diagnosis

3 mL of PLR for every 1 mL of blood loss

fluid of choice

supine position with legs elevated (modified Trendelenburg)

Position of patient in shock

• <700ml blood loss

• <100bpm

• normal BP

• slightly anxious

• crystalloids

Class 1 Hemorrhage

• 750-1500ml blood loss

• >100bpm

• normal BP

• mildly anxious

• crystalloids

Class II Hemorrhage

• 1500-2000ml blood loss;

• >120bpm,

• decreased BP

• anxious & confused

• crystalloids w/ BT

Class III Hemorrhage

• >2000ml blood loss

• >140bpm

• decreased BP

• confused & lethargic

• crystalloids w/ BT

Class IV Hemorrhage

Traumatic brain injury

It is a collective term describing a wide range of pathologic conditions and types of trauma involving the brain. It may occur when a substantial force strikes the skull, which can be blunt, penetrating, or combination of the two

Head trauma

Occurs when the generated force is greater than the cranial vault can absorb, transferring the kinetic injury to the delicate neural tissues beneath

Skull fracture

A distortion in the integrity of the bony skull

Linear fracture

results from a single blunt strike that creates a fissure line in the cranium

Basal skulls fracture

result from backward fall that damages occiput

Anterior basilar skull fracture

results from a forward fall that damages frontal area

Depressed skull fracture

result from a fall and may result laceration of bone tissues

Open skull fracture

a perforated scalp is observed

Concussion

direct brain injury involving neural tissue, a temporary loss of consciousness that results from a transient

Contusion

it is the bruising of the brain tissue that occurs when the head suffers a direct impact with a rigid object

Diffuse axonal injury

describes an extensive damage involving a wide area of neural tissues throughout the cerebrum and brainstem; the damage involves the innermost centroaxial areas of the neural white matter

Intracranial hemorrhage

significant bleeding into a space or potential space between the skull and the brain, It can be classified as epidural hematoma, subdural hematoma, or subarachnoid hemorrhage

• Always assume cervical spine fracture

• changes in LOC

• unequal or unresponsive pupils

• changes in respiration or apnea

• elevated temp

• seizure activity

• Battles sign, racoon’s eye, rhinorrhea, ortorrhea

Assessment of TBI

Battle’s signs

periauricular ecchymosis; a bluish discoloration behind the ears

• basal skulls/occiput fracture

Racoon’s eye

periorbital ecchymosis

• bleeding in brain

Rhinorrhea

CSF leak in the nose

Otorrhea

CSF leak in the ears

just-thrust maneuver

Open airway using

oral suction; gag reflex

standby ____ not stimulate ____ increase ICP

mannitol, anticonvulsants, antibiotics, antipyretic

meds for TBI:

NGT

if basilar facture or midface no ____

Cervical spine injury

These are injuries to the cervical spine due to crushing, stretching, and rotational shear forces exerted on the cord at the time of trauma that can produce severe neurologic deficits. Edema and cord swelling contribute further to the loss of spinal cord function.

• If at least one among C1 to C7 become injured, there will definitely be affectations.

• weakness/paralysis of diaphragm or lesions at/above C4

• hypotension, brady, warm, dry, skin-suggestive spine shock

• radicular pain in neck, occipital region & shoulder

• hx of unconsciousness

• quadriplegia

• loss of bowel & bladder control

• loss of sweating/ vasomotor tone,

• priaprism, hypothermia, hoffman’s sign

Assessment of CSI

Priapism

persistent erection of the penis

Hoffman’s sign

flicking of middle finger induces flexion of ipsilateral thumb or index finger

hypotension, hypothermia, bradycardia

monitor for these vital signs:

methylprednisolone 30 mg/kg IV as loading dose over 15 minutes; 5.4 mg/kg/hr infusion

high dose steroids: _________ followed by ____ to be initiated 45 minutes later, continue infusion for 23 hours