NCM 0118: LECTURE
MODULE 7: TRAUMATIC EMERGENCIES
1ST SEMESTER | S.Y. 2021-2022
QUESTIONS
1. You witnessed a patient’s arrival. At far, you
noted the presence of a metallic rod
perforating his left leg. With your knowledge
regarding the different types of energy
transfer in trauma. Most likely, this injury was
brought by what form of energy?
A. Chemical energy
B. Mechanical energy
C. Electrical energy
D. Nuclear energy
E. Thermal energy
Specifically, what type of kinetic force trauma
are you thinking of? Penetrating trauma.
2. Which statement/s regarding the “Trimodal”
death distribution of trauma victims is/are
the most appropriate?
A. Deaths during the first hours are usually
secondary to major blood vessel
disruption or massive spinal cord/CNS
injury.
B. Around 50 % of deaths are usually
secondary to major blood vessel
disruption or massive spinal cord/CNS
injury. These usually occur on the first few
days.
C. Multi-organ failure and sepsis usually
occur at the third peak of deaths
secondary to trauma which is usually
days after the incident.
3. Which phase of the Nursing practice
through the cycles of trauma will usually
require nurses to assist on surgical
procedures and perform secondary
assessment/surveys?
A. Phase 1
B. Phase 2
C. Phase 3
D. Phase 4
E. Phase 5
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This phase is also known as Hospital resuscitation
and operative phase.
4. A 45-year-old arrives at the emergency
department who suffered multiple injuries
from a motor vehicular accident. Which of
the following assessment should take the
highest priority to take in your primary
survey?
A. Full vital signs
B. Assess pain level
C. Neurological assessment
D. Check for burns in the airway
E. Check for contusion on the extremities.
5. During your duty, you were asked to assess a
5-year-old girl. You noted presence of a
wound with jagged edges on her arm. Most
likely, this soft tissue injury is a:
A. Abrasion
B. Laceration
C. Puncture
D. Burn
E. Swelling
6. Which interventions is/are appropriate to
avoid the most common cause of traumatic
death?
A. Provide rewarming measures
B. Direct pressure on the bleeding site
C. Place the bleeding are below the heart
level.
D. Check for burns in the airway
E. Insert two large bore needles.
7. The driver of a sport utility vehicle lost control
and struck a utility pole head-on. The driver
was killed instantly. The passenger, a young
female, is conscious and alert and with
abrasions to her left forearm. Initial
Treatment for the passenger should
A. A focused exam of her forearm.
B. Transport to a community hospital.
C. Performing a rapid trauma assessment.
D. Allowing a friend to drive her to a hospital
Rationale: Do not allow the friend to drive the
patient to a hospital. Remember, you have to
provide psychological safety and security. If you
are in a traumatic scenario, hindi lang physical
yung concern mo. You are also concern with
the psychological.
8. Which of the following statements regarding
the mechanism of injury (MOI) is the most
correct?
A. A significant MOI always results in patient
death or permanent disability.
B. The exact location of a patient's injuries
can be always determined by the MOI.
C. MOI may allow you to predict the
severity of a patient's injuries.
D. A non-significant MOI rules out the
possibility of serious trauma.
9. Select-all-that-apply: What are the typical
signs and symptoms of cardiac
tamponade?
A. Hypotension
B. Increase in the SBP during inspiration
C. Changes on sensorium
D. Rasping sound, synchronous with the
heartbeat
10. The nurse is evaluating the condition of a
client after pericardiocentesis performed to
treat cardiac tamponade. Which
observation would indicate that the
procedure was effective?
A. Muffled heart sounds
B. Distended neck veins.
C. A rise in the BP. If treatment is effective,
there is an increase in BP.
D. Verbalization of dyspnea
11. A client with an injury to his chest has
developed cardiac tamponade. The
client’s blood pressure has dropped from
110/70 mmHg to 75/56 mmHg. The provider
is preparing to perform a pericardiocentesis
to remove the excess fluid around the
client’s heart. Which action best describes
the appropriate role of the nurse?
A. Withdraw fluid from the pericardial sac.
B. Position patient in sitting position with
head leaning forward.
C. Prepare ECG machine for monitoring.
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D. Prepare 1 large bore needle IV site.
12. A nurse is working with a 47-year-old client
with poor pulses, and mental status changes
due to cardiac tamponade. Which of the
following conditions is this client most likely
experiencing?
A. Disturbed sleep pattern
B. Risk for deficient fluid volume
C. Ineffective breathing pattern
D. Decreased cardiac output
13. During your reporting, your clinical instructor
asked you about the explanation of
hypotension in a cardiac tamponade. You
are trying to remember the formula for blood
pressure. What are the 2 factors that
determine the blood pressure?
 SVR
 CO
 What would happen to the BP of clients
with cardiac tamponade? Decrease BP.
14. Which is the most significant concern with
cardiac contusion?
A. Hypertension
B. Dysrhythmias
C. Restlessness
D. Hypoxia
Note: Always prepare ECG machine at the
bed side. Initially, monitor for 24 to 72 hours.
15. Which should alarm the nurse in monitoring
a patient with penetrating chest injury?
A. Low BP
B. Low oxygenation
C. Altered mental status
D. Thready pulse
E. New set of dysrhythmia
If there is low BP, altered mental status and
thready pulse, decreased cardiac output
will be the nursing problem.
Nursing implication: refer to physician and
the primary nursing problem would be a
decrease in CO.
16. Which of the following signs and symptoms
usually signifies rapid expansion an aortic
disruption?
A. Absent pedal pulses
 B. Chest pain  The said injuries are caused by some form of
C. Bradycardia energy that is said to be beyond the body’s
D. Lower back pain tolerance. It may be classified as intentional
or unintentional.
Rationale: this would mean that the
o Intentional: there is a purpose or intent
bleeding has expanded which already
on harming the patient. An example is,
caused pain not only on the chest, but also
assault or murder.
referred pain on the low back or abdominal
o Unintentional: no purpose of hurting
area.
somebody. This type of trauma is usually
17. What is the definitive test used to diagnose seen on falls, accidents, or work-related
an abdominal aortic dissection? accidents.
A. Ultrasound  It may also be divided into minor or major
B. Abnormal x-ray trauma.
C. Aortogram o Major trauma: any injury that could
D. CT scan potentially lead to death, prolonged
18. Which of the following groups of symptoms disability or permanently diminished
indicated an aortic dissection? quality of life.
A. Intermittent lower back pain, decreased o Example: trauma that could lead to loss
BP, decreased RBC, increased WBC of vision or amputation.
B. Severe lower back pain, decreased BP,
EPIDEMIOLOGY
decreased RBC, decreased WBC
According to the American Association for
C. Severe lower back pain, decreased BP,
the Surgery, Trauma Injury is a major public
decreased RBC, increased WBC health problem. In the United States, injury
D. Lower back pain, increased BP, accounts for over 150,000 deaths and over 3
decreased RBC, increased WBC million non-fatal injuries per year. Around the
19. The clinical manifestations for dissection world, injury is responsible for more than 5
include: million deaths per year.
A. Abdominal pain
B. Increase urine output “TRIMODAL” DEATH DISTRIBUTION OF TRAUMA
C. Bradycardia VICTIMS (TRUNKEY, 1983)
D. BP higher in lower extremities than in
Upper extremities
E. Lower back pain.
F. Strong pulses (No. it should be decreased
pulse on the lower extremities)
20. When the patient arrives in the Recovery
Room (RR) after a surgery for aortic
dissection. The nurse's interventions should
include?
A. Placing her in a Trendelenburg position
B. Monitoring Blood pressure.
C. Monitoring urine output q shift According to Trunkey (1983), for patients
D. Assess for sensorium. who had trauma, there are 3 peaks when a
person could experience death.
TRAUMA
 T1: 50% of deaths within seconds or minutes
 Trauma is an injury to human tissues and
due to major blood vessel disruption or
organs as a result from the transfer of energy
massive spinal cord/CNS injury.
from the environment.
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 o According to the diagram, 50% of the
deaths from trauma can occur
TRIVIA
immediately.
Trauma nursing as a specialty was initiated in
o Immediate deaths are deaths which
the United States at the Shock Trauma Center
can occur from minutes to seconds after
of the University of Maryland at Baltimore and
the trauma. at Cook County Hospital in Chicago. The first
o 50% of deaths do occur in this period. known shock trauma nurses were Elizabeth
o The common cause of death would be Scanlan, RN and Jane Tarrant, RN who
major blood disruption which causes pioneered the role in a two-bed
hemorrhage or a massive spinal cord or shock/trauma research center with Dr. R
CNS injury, Adams Cowley in Baltimore, the first of its kind
 T2: 30% of deaths within 1st hour due to to support the study of trauma.
truncal injury causing respiratory &
circulatory compromise. TRAUMA NURSING
o The Second peak which comprises 30%
 Nursing specialty which makes use of
of cause of deaths for patients with
evidence-based treatment to guide
trauma would occur 4 hours, an hour or
decisions and interventions in managing the
a few after the injury.
trauma patient.
o This is secondary to presence of
 Nurses, in collaboration with other members
respiratory or circulatory compromise.
of the health care team, identify and
o Hypotension, shock etc.: these will be
incorporate best practice guidelines in
the cause of death after a few hours.
patient care for better outcomes
 T3: 20% of deaths much later from ARDS,
o The nurse actively participates in the
sepsis and diffuse brain injury, multi-organ
interdisciplinary approach to care
failures or complications of the primary
which facilitates the coordination of
injury.
resuscitation efforts, evaluation and
o Third peak
definitive management plans for
o 20% would occur days or weeks after the
patients with trauma.
trauma.
o For traumatic nursing, it would involve
 Golden Hour: 80% of trauma deaths in first
giving timely interventions for the
hour after injury.
trauma, monitoring patients and
o Gold hour compromise the first few
managing the possible complications of
hours or the first hour after the trauma.
the initial trauma. The cause of death for
o For trauma patients, we would like to
trauma would not only occur at the first
recognize immediate assessment and
hour or immediately, but some would
proper interventions because 80% of the
die days or weeks after the trauma.
possible deaths would occur on the first
o Remember: trauma nursing is involved
hour of trauma.
from the acute phase to the
 Implication: Immediate recognition and
rehabilitation phase.
appropriate timely interventions in order to
o Your actions must be based on
decrease the probability of death and
evidence.
increase the likelihood of patient’s survival.
 Trauma nursing centers on meeting the
needs of the injured patient which can be
encompassed in FIVE SPHERES
FIVE SPHERES
Support of Support for Promotion of Support for Support of
vital life + physiologic + safety and + psychosocial + spirituality = Better Patient
functions adaptation security adaptation Care

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1. Support of vital life functions
 ABC and ventilation
2. Support for psychosocial adaptation
 As a nurse, it is very important for us to
practice therapeutic communication
and provide support to the patient.
3. Support for physiologic adaptation
 Monitor patient’s response in the trauma
itself, response on the medications and
response on the possible complications
for trauma.
4. Support of spirituality
 Remember: as much as we support the
patient’s need, in terms of the physical
aspect, we need to support his
spirituality.
 We have to look at the patient holistically
(43:00)
5. Promotion of safety and security
Note: All of these 5 spheres would lead to better
patient care.
REMEMBER
Several factors can influence body’s
response and outcome to trauma:
 Severity of injury. Is the injury minor or
major? This would affect possible
outcomes.
 Mechanism. How did he have the
trauma? What were the factors that
contributed to trauma? The mechanism of
injury would help the healthcare
practitioners to somehow predict the
severity and outcome of the injury. It
would help us identify who are at risks for
major injury or minor injury.
 Patient’s profile: age, co-morbidities,
medications, protective factors. Example,
an elderly who has osteoporosis, even just
a minor injury or fall could lead to a major
trauma. Always consider the overall
picture and the patient’s characteristics;
even the medication that he is taking. Get
a good history of your patient.
 Quality and timing of interventions would
affect the body’s response and outcome
to trauma. Timely interventions would lead
to likelihood of better survival. Proper
assessment and timely interventions
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should be a priority in taking care of
patients with traumatic injury.
Implication: Quality assessment and history
taking are essential
RESPONSE TO TRAUMA
Major Patient Problems
1. Hypovolemia/ Hypoperfusion
 Hypovolemia: a decrease in circulating
volume
 Hypoperfusion: a decrease in
oxygenation.
2. Respiratory dysfunction
3. Cerebral dysfunction
4. Acidosis
 Metabolic or acidosis
5. Hypothermia
6. Bleeding or hemorrhage
KINEMATICS OF TRAUMA
 Kinematics is a field of physics which
describes the motion of objects.
 The goal of studying kinematics in trauma is
to help us understand how injuries occur.
Understanding the biomechanics of injury
may help us prevent and treat these injuries
in order to optimize outcomes.
o Helps in making priority decisions
regarding assessment, management
and transport of patient.
o It would also help us understand the
possible mechanism of injury.
o The mechanism of injury helps us predict
which patient might have occurred a
major injury.
 Remember: Trauma results from the transfer
of energy in a quantity sufficient to cause
damage at the cellular level. The transfer of
energy is beyond the cellular tolerance.
Hence, Injury is sustained whenever the
energy delivered to a tissue exceeds the
injury threshold or tolerance of that tissue.
The energy can be delivered in any of its
forms:
o Kinetic (mechanical) energy. One of
the most common types of energy
encountered causing trauma. Examples
 are moving objects, falls, vehicular
accidents.
o Thermal energy. This includes heat
transfer. Examples are burns (most
common type of injury secondary to
thermal injury).
o Electrical energy. An example is
electrocution
o Chemical energy. Ingestion
chemicals or poisoning.
o Nuclear energy. Type of injury such as
radiation.
 Any type of this energy could lead to
possible trauma.
 Examples of Kinetic energy injury are:
o Penetrating trauma is an injury produced
when a foreign object passes through
the tissue.
o Blunt trauma is an injury caused by force
that impacts the body without
penetration. No obvious bleeding
occurs and is often multisystem. There
could be signs of injury, but no foreign
object is penetrated.
o Some common causes include motor
vehicle collisions, falls, aggravated
assaults crush injuries and contact
sports.
MECHANISM OF INJURY (MOI)
 The way which the traumatic injury occurs.
o Motor Vehicular Accident (MVA), fall,
assault, pedestrian, Gunshot Wound
(GSW), stab wound etc.
 Mechanism of Injury has two components:
1. The physics of the energy transfer
 Influenced by the type and
magnitude of the energy and the
duration of the exposure to the
energy.
 Example, the accident is a gunshot or
MVA, one of the most important
question that you need to ask is the
speed of the car or was the shot high
velocity or low velocity because you
should always remember that speed
is very important. The kinetic energy is
the result of the squared of the
speed.
 Example, the speed of the car is
doubled or x2, the square of 2 is 4. So,
when you double the speed, the
kinetic energy would be quadruple.
 The more injury = it could lead to
more injury 4x.
of  Duration of exposure: for an example
a person is exposed to radiation, you
could expect for more injury because
of the longer duration.
 Magnitude of energy: the higher the
radiation would lead to more organs
affected.
2. The biological response of the human
body to receiving such energy
 Influenced by the tolerance of the
tissues, organs and structures
involved.
 Example, you have a kinetic injury,
the bones (like your hip bone) could
tolerate the kinetic energy better
compared to your soft tissues or soft
organs like your liver and skin.
 Remember: for abdominal trauma,
the most common organs involved
are the spleen and liver. The bones
could tolerate the force compared
to skin or liver.
Implication: Ask important question during
history taking in order to establish the possible
mechanism of injury. MOI would help us predict
which patient might have a major or minor
injury. MOI would not always help you locate
the damage, but it would help us predict the
damage.

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 NURSING PRACTICE THROUGH THE CYCLES OF
TRAUMA
Remember: A trauma nurse would work not only
on the immediate phase, but a trauma nurse
would also help on establishing the recovery
and adaptation of your patient.
PRINCIPLE IN TRAUMA ASSESSMENT AND
INTERVENTIONS
Rapid Primary Survey
 immediate treatment. In the trauma
Lifesaving therapies
 deformities. You have to perform your
Secondary/tertiary survey
 to determine less-obvious injuries that
Definitive management

Monitoring and Evaluation
 Perform primary survey in order to provide
lifesaving therapies or emergent therapies.
After that, you may perform your secondary
or tertiary survey in order to provide a more
definitive management. Then, monitor and
evaluate your patient.
o It does not mean that if you are done
with the primary survey or you were able
to give lifesaving therapies, stop na
‘yon. It’s not like that.
o If you do give therapies or interventions,
you have to monitor and evaluate the
patient’s response.
o Always remember the nursing process
(ADPIE)
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o These activities may overlap to each
other. They may occur simultaneously or
overlap depending on the patient’s
case.
 The AIR (Assessment, Intervention, and
Reassessment) approach.
o Assess what’s the possible problem and
based on the assessment, we formulate
our plans and interventions. After giving
the said interventions, you have to
reassess the patient’s response.
 Remember: The primary and secondary
survey should be repeated frequently to
assess for deterioration in the patient status
especially if the patient is not stable.
Activities of the primary and secondary
surveys may occur simultaneously.
 Remember: Safety of both the healthcare
provider and patient must be a priority.
 Important considerations during rapid
trauma assessment:
o Identify less-obvious injuries that require
nursing, you’re not just after the obvious
primary and secondary survey in order
may require immediate treatment
because sometimes, your patient may
not have gross wound, however, there is
a problem internally (like internal
bleeding or fracture) which may not be
apparent initially.
o Baseline VS is taken after rapid trauma
assessment and immobilization of
patient is done.
PHASE I: FIELD STABILIZATION AND
RESUSCITATION
 Goal: Perform rapid trauma assessment,
stabilize and transport the patient to the
appropriate trauma center via the safest
and most rapid transport mode.
o It is important that the rescuer would be
communicating with the trauma center.
 Urgent Care Priorities: Establish and maintain Primary Assessment of the Trauma Patient
airway, ensure effective ventilation, control (ABCDE)
hemorrhage.  Remember: The key to good trauma care is
directed assessment and timely intervention
and subsequent directed reassessment – the
AIR (Assessment, Intervention, and
Reassessment) approach.

PRIORITY ASSESSMENT POTENTIAL INTERVENTIONS

A – AIRWAY and C SPINE  Speak to the patient – if able to  Head tilt/Chin lift or jaw
Stabilization verbalize in a comprehensible thrust maneuver.
oriented way.  Suctioning and foreign
o Is he able to talk in full body removal.
Airway Assessment should sentences or words?  Provide artificial airway
be done simultaneously Incomprehensible speech?  Avoid neck manipulation,
with NECK STABILIZATION  Look for the presence of airway provide cervical collar
because of potential for compromise. Inspect for: o Manual immobilization
cervical spine injury. o Foreign bodies (vomitus or of the head or
blood) placement of cervical
o Evidence of airway burns. collar is maintained
specifically, if there are burn during the duration of
injuries on the nasal area, assessment.
mouth, chest area. o If you are suspecting
o Fracture or lacerations. cervical injury, provide
Specifically, on the face or cervical collar until you
truncal injury have proven there is no
 Listen for abnormal sounds such possible cervical injury.
as: Snoring, Stridor, changes in
voice quality or speech which
signal airway compromise.
 Check for air movement or rise or
fall of the chest.
B – BREATHING and  Identify breathing pattern.  Expose the chest in order to
Oxygenation  Observe for spontaneous assess the chest wall
respirations, chest excursions, RR integrity.
Once the airway is and depth of respirations, and  Provide O2 support e.g. High
deemed patent and respiratory effort. flow oxygen via a non-
protected, the adequacy  Examine chest wall integrity breather mask.
of ventilation should be  Auscultate breath sounds  Bag-valve-mask ventilation.
assessed.  Feel for crepitus, subcutaneous  Assist with intubation or
air on the chest or neck area. surgical airway placement.
Parang plastic balloon na  Treat serious thoracic
Remember the principles
pinuputok injuries.
of BLS or Basic Life Support.
Note: Adequate ventilation requires
optimum functioning of the lungs,
chest and diaphragm.
C- CIRCULATION  Look for: Obvious signs of external  Direct pressure/elevation to
bleeding, skin color for pallor or external bleeding sites.
Maintenance of adequate cyanosis, level of consciousness,

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tissue perfusion, especially
of the brain, is the primary
objective of the circulation
component of the primary
survey.
Remember: Hemorrhage is
the principal cause of
preventable death in
traumatic injury. Take note
of the signs of possible
hemorrhage and possible
decrease tissue perfusion.
Remember: All
hypotension is considered
hypovolemic (decrease
blood circulation) until
proven otherwise.  Listen for: Muffled heart sounds
D - DISABILITY (brief
neurological Examination)
A decreased level of
consciousness is due to 
hypoxia or hypovolemia
until proven otherwise
 Voice: The patient makes some
Beware of hypoglycemia.
Once excluded as cause
of decreased level of
consciousness, the priority
is to determine the 
presence or absence of an
intracranial injury that
requires urgent
neurosurgical intervention
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neck veins (collapsed or  Insert two or larger bore IV
distended), abnormalities lines. Hemorrhage is one of
underneath the collar, capillary the principle cause of
refill time. preventable death in
o For patients who have dark traumatic patients. Usually,
color skin, where will you we are giving hydration or
check for presence of blood transfusion.
cyanosis or pallor? Check the  Bolus of crystalloids or blood
tongue area, conjunctiva or transfusion.
other mucous membranes or  Splinting to control
part of the skin with less hemorrhage or if you want
melatonin (soles of the feet). to immobilize the affected
o Restless patient would mean extremity.
there is a probable  Facilitate surgical
decreased perfusion on the intervention for severe
brain. internal or external
o Level of sensorium is a very bleeding.
sensitive indicator for the  Provide CPR or ALS as
blood supply on your brain. needed.
o Muffled heart sounds are
sounds which seem to be
distant (mahina).
o This is one sign for some
cardiac conditions.
 Feel: Assess skin for moisture and
temperature, palpate pulses for
presence, quality, rate and
rhythm.
o A weak pulse could be a sign
of a possible hemorrhage or
hypovolemic shock
 Assess neurological status or level  Do not allow the patient to
of sensorium using the AVPU become hypotensive or
mnemonic (Alert, Voice, Pain, hypoxic in order to avoid
Unresponsive) decrease blood perfusion to
Alert: The patient is fully awake the brain.
and does not need stimuli for their  Maintain spinal precaution
eyes to open. to avoid the severity.
 Consider mannitol
kind of response when you talk to administration, measures to
them, which could be in any of improve cerebral venous
the three component measures outflow, surgery, or a brief
of eyes, voice or motor trial of hyperventilation.
Pain: The patient makes a
response on any of the three
component measures on the
application of pain stimulus, such
as a central pain stimulus like a
sternal rub or a peripheral stimulus
such as squeezing the fingers or
application of pain near the eyes.
  Unresponsive: no response to
voice or painful stimuli.
o Inspect pupils for symmetry
and light reactivity.
o Mobility of extremities

If you are suspecting a patient who

had neurological or intracranial
injury, perform a fast neurological
assessment.

Fast assessment: REMEMBER THE

ACRONYM SPERM (sensorium, pupils,
eyes movement, respiration, motor)
E – EXPOSURE AND  Inspect the entire body and  Remove clothing.
ENVIRONMENT CONTROL potential hazards.  Provide warming measures.
 Remove the patient’s clothing to  Ensure privacy if possible.
Exposure of the trauma assess for injuries, hemorrhage, or
patient is the final step of other abnormalities.
the primary survey. o Ask permission.
o If you are in the hospital,
provide privacy to ensure
psychological safety of the
patient.
 Observe the patient’s overall
general appearance noting
body appearance, asymmetry,
guarding behavior or the
presence of odors such as
alcohol, petrol and urine in order
to have possible idea of the
mechanism.
o Alcohol – is the patient drunk
or intoxicated?
o Petrol – is there possible
intoxication?
o Urine – is there possibility of
uncontrollable urination
which may signify other
problems and the likes?

Important Considerations During Rapid Trauma PHASE II: HOSPITAL RESUSCITATION AND
Assessment OPRATIVE PHASE

 Most EMTs assess obviously injured areas only  Goals:

after looking for less obvious injuries.
 Baseline VS is taken after rapid trauma
assessment and immobilization of patient is
done.
o Perform secondary assessment while
maintaining stability.
o Perform emergent surgical procedure.
o Identify less evident, but still life-
threatening respiratory or cardiovascular
dysfunctions.

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 Priorities:  During the secondary survey, all
o Quick assessment while ensuring ABCDE. components of the primary survey should be
o Stabilization of Life Threatening repeated and the team should be
Conditions. responsive to any new findings
o Identification of less evident, but still life-  Obtain a full set of vital signs. VS should only
threatening respiratory or cardiovascular be obtained after the primary survey.
dysfunctions.  Identify all injuries with a head to toe
o Detection/evaluation of more subtle assessment. Perform a head to toe
injuries that may contribute to morbidity assessment or Focus assessment.
and mortality but are not necessarily life  Ensure the patient is log rolled to check the
threatening. back. Check not only the chest, but also the
back in order to check for less-evident injury.
Note: After initial resuscitation, many traumatic
 May do GCS for the neurological evaluation
injuries require a surgical intervention
especially for trauma
 Remember the acronym FGHI:
Secondary Assessment of a Trauma Patient
o F – Full set of Vital Signs, Five interventions
(FGHI) and Family Presence
 Can be modified to Focused Trauma o G – Give comfort measures.
Assessment. o H – History taking, head to toe
assessment.
 A detailed systematic head-to-toe
o I – Inspect posterior surface.
examination to detect all injuries and
enable planning of definitive care.
 Only done once the primary survey and
resuscitation is complete.
PRIORITY ASSESSMENT POTENTIAL INTERVENTIONS
F - FULL SET OF  Baseline VS 1. Initiate continuous cardiac
VITAL SIGNS, FIVE  Assess the patient’s and family’s monitoring.
INTERVENTIONS, psychosocial needs. 2. Place an NGT or OGT.
AND FAMILY 3. Insert an IFC.
PRESENCE 4. Collect and send specimen
appropriate laboratory studies.
5. Initiate continuous monitoring of
O2 saturation.

These can be done on secondary

phase. Do not forget to provide the
psychosocial needs of your patient
and the relatives especially for
patients who had traumatic injury,

G – GIVE COMFORT  Assess pain level. Rate the pain  Provide pain medications as
MEASURES intensity (1-10), the aggravating ordered.
factors, provoking factors (PQRS pain  Non – pharmacological means
assessment). of pain relief (verbal
reassurance, touch)
o Explain the patient’s
condition
o Touch is another stimulus
that could counteract pain
for some patients.
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H – HISTORY  If patient is alert, use SAMPLE for  Obtain MIVT (Mechanism,
history taking. Injuries Suspected, Vital Signs on
 Should include o Symptoms the Scene, Treatment
mechanism of
o Allergies Received) from EMS.
injury. o Medications  Assist in providing definitive care
 Can be
o Past illnesses/Pregnancy
obtained from o Last meal
family if the
o Events leading up to accident
patient is
unconscious.
For head to toe assessment, we have
DCAP-BTLS which is used for traumatic
H - Head to toe nursing.
assessment
D Deformities
C Contusions
A Abrasion
P Penetrations
B Burn
T Tenderness
L Lacerations
S Swelling

 Head: Battle Sign, Raccoon eyes,

Fractures
 Face: Fluid draining from the ear or
nose.
 Neck: Neck Vein distention, Tracheal
deviation
 Chest: Penetrating trauma,
Subcutaneous air
 Abdomen: Distention, evisceration
 Pelvis: Priapism for males and
bleeding for females. High riding
prostate, blood at urinary meatus,
scrotal hematoma.
 Extremities: Sensorimotor and
neurovascular status
I – INSPECT Logroll the patient. Inspect and palpate Remember, if you would be moving
POSTERIOR all posterior surfaces. your patient to check the back,
SURFACES always maintain spinal
immobilization or maintain cervical
collar.

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 PHASE III: CRITICAL CARE or acute care unit from the resuscitation unit,
ED or PACU.
 Address: physiologic, psychological and
 Priority: to maintain continuity of patient
sociologic derangements.
care.
 Coordination with other members of HCT
o Continuity of care: the smooth transition
 Goal: Provides CONTINUITY OF CARE +
or transfer of patient from one facility to
critical and ongoing assessment
another facility or one unit to another
o In order to determine early detection of
unit or from one nurse to another.
sequelae of injuries & complications.
o If your patient is more stable, from ICU,
 Total system assessment
he will be transferred to a Step Down
o System by system in the nursing record at
Ward.
least once every 24 hours.
o Check the different systems of the body CRITICAL CARE ACUTE CARE
frequently.  Care that requires  Short-term
life-saving actions medical care for
PHASE IV: INTERMEDIATE AND ACUTE CARE and close serious injuries or
 Some patients may NOT require critical care monitoring of illnesses.
patients.  Examples:
and are admitted directly to the immediate
patients who

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  These are patients need stitching for A. CARDIAC TAMPONADE
who need to be their lacerated
admitted at the wound, or burn
ICU. injury which are
 Critical care units not that severe.
focus on
providing
treatment and
surgical care for
life-threatening
injuries that
require long-term
stays in hospital

PHASE V: REHABILITATION  Cardiac denotes the heart; tamponade

 Once physiologic stability is achieved,
emphasis of care progresses to recovery
and adaptation.
 Priority nursing goal:
o Assist the patient in overcoming
disabilities or adapting to his environment
within confines of permanent disabilities
caused by trauma.
o Part of the rehabilitation is the physical
therapy and occupation therapy in order
to help the patient adjust on the use of
assistive devices, etc.
o Nursing care does not stop on the
emergency or acute phase, but it also
entails or includes the rehabilitation
phase.
INJURY TO THE HEART AND GREAT VESSELS
 The heart is a vital organ encased in the
chest cavity and protected by the sternum,
and rib cage.
 This organ may be injured by trauma, which
may cause myocardial contusion, coronary
artery injury, atrial or ventricular rupture,
cardiac tamponade and valvular rupture or
septal defect. The aorta and arch vessels
may also be affected by trauma, either by
rupture or by penetrating trauma.
denotes presence of blockage or
accumulation of fluid.
 A life-threatening condition caused by rapid
accumulation of fluid (Pericardial Effusion),
usually blood, in the pericardial sac causing
compression.
o The heart is compressed by excessive
fluid in the pericardial sac.
o If there is building of fluid, there is
increased pressure and that would lead
to compression of the heart.
 This is usually secondary to a penetrating or
blunt trauma in the chest.
 The most common causes are gunshot
wounds and stab wounds, causing
laceration of the myocardium or coronary
vessels.
 Cardiac tamponade may also be caused
by non-traumatic conditions like
malignancies, inflammatory diseases,
infectious diseases, aortic dissection,
ruptured aortic aneurysm, etc.
REVIEW OF ANATOMY & PHYSIOLOGY

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 The heart is encased in a thin, fibrous sac
called the pericardium, which is composed
of two layers.
o Fibrous pericardium: the outermost layer
o Serous Pericardium: parietal layer of
serous pericardium and visceral layer of
serous pericardium
o There is a space between the parietal
and visceral layer. This is where the
pericardial fluid is located.
 Adhering to the epicardium is the visceral
pericardium. Enveloping the visceral
pericardium is the parietal pericardium, a
tough fibrous tissue that attaches to the
great vessels, diaphragm, sternum, and
vertebral column and supports the heart in
the mediastinum.
 The space between these two layers
(pericardial space) is normally filled with
about 20 mL of fluid, which lubricates the
surface of the heart and reduces friction
during systole (Brunner and Siddhartha,
2018).
o If there is RAPID ACCUMULATION OF
FLUID, that would lead to cardiac
tamponade.
o For some patients who have chronic
cardiac tamponade, the amount could
be 100 to 300 mL or more, but for
traumatic patients, the rapid increase is
more important than the amount. The
acuteness is more important when we
speak of traumatic cardiac
tamponade.
 In cardiac tamponade, there is increase in
amount of pericardial fluid which may be
hemorrhage (blood) that causes
compression and obstruction in the specific
area.
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 Normally, the pericardial sac is filled with
pericardial fluid.
 In cardiac tamponade, there is rapid
accumulation of fluid = pressure on cardiac
function, compression then dysfunction of
the cardiac cavity.
 If there is compression, the heart would not
be able to relax and contract. There would
be signs of decrease cardiac function.
 Cardiac tamponade can be caused by
various causes. An Example of a traumatic
cause is chest trauma and this could lead to
pericardial hemorrhage or effusion
(increase in the fluid in the pericardial sac or
cavity).
 Rapid increase in fluid could lead to an
increased pericardial fluid which could
compress heart. Once the heart is
compressed, it would elevate the pressure
on the cardiac chambers (atrium &
ventricles) and this would lead to the
inability of the ventricles to relax.
o The ventricles cannot relax or contract.
So, the function of the heart will
decrease and this would mean a
decrease in cardiac output.
 The basic function of the heart is to pump
blood throughout the body. If you have a
cardiac tamponade and your heart cannot
relax nor contract, the blood supply through
the body will decrease.
 NCM 0118: LECTURE
MODULE 7: TRAUMATIC EMERGENCIES
1ST SEMESTER | S.Y. 2021-2022

 Your blood reaches the heart through your is backflow, the blood will go to the vein
vena cava and it would leave your heart (superior vena cava).
through your aorta. o In cardiac tamponade, the heart is
 The aorta would distribute the blood compressed so it could not move blood
throughout the different tissues. forward. The blood stays in the heart or
o If it is compressed, the blood would stay there is backflow
at the heart or there is backflow. If there
PATHOGENESIS

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  Pulsus paradoxicus – systolic pressure drops
greater than 10 mmHg during inspiration.
o Normally, when we breathe or during
CLINICAL MANIFESTATIONS inspiration, there is a decrease in the
systolic pressure. The decrease should
not be more than 10 mmHg.
o For patients with cardiac tamponade,
since there is change on the pressure on
the cardiac cavity, there is greater than
10 decrease in the systolic pressure.
 Hamman’s crunch – crunching, rasping
sound, synchronous with the heartbeat.
o Due to the building up of pressure on the
pericardial sac or cavity.
 Tachycardia
 Cyanosis
 Altered Mental Status, dysphoria
 Signs of low oxygen:
o Restlessness/dysphoria, syncope,
fatigue.
 Restlessness/dysphoria are early
The signs and symptoms of pericardial indications on the changes on the
effusion can vary according to whether the level of sensorium.
problem develops quickly or slowly.  Patient may verbalize feeling
uncomfortable or irritable.
 Early sign: Fullness in the head, neck and  Syncope – loss of consciousness.
abdomen, neck vein distention.  There is restlessness/dysphoria or
o Blood would backflow in the vena cava. syncope due to decreased cardiac
o There could be neck vein distention output which affects the brain. So, a
because of the backflow of blood into sensitive indicator of hypoxia in the
the vein. The blood could go to the brain would be restlessness or
jugular vein and cause neck vein dysphoria.
distention. o Tachycardia
 Sudden chest pain, tachypnea and  It’s a compensatory mechanism of
dyspnea. the heart since there is decreased
o Because of the increased pressure on cardiac output. If the problem is
the cardiac cavity which may also chronic or will prolong, the heart
impede or compress other structures like could not sustain contraction and
the lungs. this could lead to asystole. The heart
o Sudden chest pain: chest pain is slightly could no longer pump because of
relieved when leaning forward because the pressure.
when you lean forward, there is o Sudden chest pain, tachypnea and
decrease pressure on the cardiac cavity dyspnea.
( pressure =  pain).  Sudden chest pain can also be
o Most of the patients with cardiac secondary to the decreased
tamponade would like to be placed in oxygen perfusion even on the heart.
a sitting position while leaning forward.
This provides comfort.

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  There could also be difficulty of
breathing or signs of respiratory
distress.
 There are 2 important parameters that
determine the CO: Heart Rate (HR) & Stroke
Volume (SV)
 CO is the product of you HR and SV.
 SV is the amount of blood pumped in every
heart rate. HR is directly proportional to your
CO and same with the SV.
 In cardiac tamponade, there is:
o  Stroke Volume
o  Cardiac Output
o  Oxygen Delivery
o Question: there is tachycardia, so bakit
hindi magi-increase yung CO?
Remember tachycardia is just a
compensatory mechanism. Even
though the heart will be pumping and
pumping, but if there is no relaxation or
there is still compression of the heart,
there could still be decreased SV which
could lead to decrease CO. Eventually,
the heart could not sustain the pressure
and this could lead to decreased
cardiac rate and eventually, asystole.
 Late manifestation of Cardiac Tamponade:
Beck’s triad
o Hypotension
o Muffled Heart Sounds
o Increased Venous pressure
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1. Decreased pulse pressure (hypotension)
 Since the heart could no longer pump,
relax nor contact, this could lead to
decreasing systolic pressure.
 Pulse pressure = SBP – DBP
o Example: 120 SBP – 80 DBP = 40
o Usually, the pulse pressure is 30 to 40.
For patients with cardiac
tamponade, it is less than 30.
2. Distended Neck Vein
 Because of distention of the jugular vein
or probable backflow of blood to the
heart or to the veins secondary to the
increased pressure.
3. Distant (muffled) heart sounds
 Since there is accumulation of fluid on
the cavity, you would be able to
appreciate faint heart sounds.
Note: Beck’s Triad may not be present to all
patients. Some patients would just be
presenting 1 component or 2 components but
for some, they would be presenting the
complete triad of beck’s.
 Blood pressure is the product of cardiac
output and systemic vascular resistance or
peripheral resistance.
DIAGNOSIS
 Focused Abdominal Sonography for Trauma
(FAST)
o Rapid bedside UTZ of four specific
abdominal areas (Pericardial,
perihepatic, perisplenic and pelvic). It
may be done with resuscitation and
takes less than 5 minutes.
 Bedside UTZ, Echocardiography
 Chest radiography, widened mediastinum
 ECG, cardiac enzymes
 Ultrasound of the abdomen
 2D echo (ultrasound of the heart) – makikita
yung pleural effusion and abnormal
movement of the heart (there is
compression).
 Chest x-ray – there could be enlargement of
the cardiac silhouette
 ECG – this is very important. There could be
sinus tachycardia and low voltage QRS
which is usually uneven. Iba-iba yung size ng
QRS because your ventricles are being
compressed.
 There could also be order for cardiac
enzymes like your Troponin I or CK-MB just to
evaluate possible injury to the heart or
myocardial infarction.
 As a nurse, our role is to facilitate these tests
as ordered. Faciliate na magawa sila
kaagad specifically, the 2D echo and ECG
especially if you are in the ER. You also have
to facilitate blood extraction.
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MANAGEMENT
 Monitor and support vital functions
 Isotonic IVF to temporarily to increase
cardiac filling pressure or output.
o You want to increase the circulating
volume in the body in order to increase
CO.
Surgical interventions:
 Pericardiocentesis. Centesis means
puncture. It’s a puncture in the pericardial
sac in order to evacuate the fluid.
Remember, in cardiac tamponade, the
primary cause of the increased pressure is
the increase in the amount in the pericardial
sac or cavity.
o During pericardiocentesis, the patient is
positioned in a supine position with head
of the bed elevated to 30o (low fowler’s
position).
o Throughout the pericardiocentesis, the
ECG is being monitored. As a nurse,
ensure that there is an available and
functioning ECG machine.
o Observe sterile technique throughout
the procedure.
o When stitches are given, the insertion is
usually below the xiphoid area.
o An ECG lead is usually inserted or
connected on the needle.
o After the puncture is done, the doctor
would ensure that the puncture site is
correct.
o After the process, they would collect the
fluid.
o The main purpose of pericardiocentesis
is to evacuate fluid.
o Sterile technique must be applied so the
nurse must prepare all necessary
materials including the ECG machine
and assist in positioning your patient.
 Definitive Repair of the cardiac muscles if
injured
 Emergency Thoracotomy. A thoracotomy is
a surgical procedure in which a cut is made
between the ribs to see and reach the lungs
or other organs in the chest or thorax.
 NOTE
If cardiac function becomes seriously
impaired, pericardiocentesis (puncture of the
pericardial sac to aspirate pericardial fluid) is
performed.
Note: During this procedure, the patient is
monitored by continuous ECG and frequent
vital signs.
SAMPE NURSING PROBLEMS
NURSING INTERVENTIONS
Nursing Alert:
When signs and symptoms related to
cardiac tamponade are present, call a rapid
response, immediately notify the patient's
healthcare provider, and prepare the patient
for diagnostic testing and therapeutic
interventions.
Important Nursing Actions:
1. Immediate patient transfer to the intensive
care unit (ICU) is a priority.
2. Nurses have a primary role in monitoring
patients for any deterioration in clinical
status. Monitoring includes:
o oxygenation, ventilation, vital signs, ECG,
mental status, heart and lung sounds. As
a nurse, these are the most important
assessment that we should do
throughout the patient monitoring.
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3. Assess for respiratory distress and prepare to
administer supplemental oxygen as needed
or ordered.
4. Properly position the patient. Keep patients
with cardiac tamponade who are
hypotensive on bed rest with their legs
elevated above heart level to increase
venous blood return to the heart.
o Trendelenburg position if your patient is
showing signs of shock.
5. Patients who are not hypotensive should be
maintained on bed rest in semi-Fowler
position or leaning forward.
o Semi-fowler’s or leaning forward if
patient has no symptoms of shock.
o Semi-fowler or leaning forward would
decrease the pain.
6. Start two large-bore IVs as ordered. Have
fluids available for resuscitation
7. Ensure Chest x-ray and echo are done
8. Give medications as ordered (analgesia)
o Pain is one of the most common
problems.
o There could also be cardiac
medications to increase cardiac
contraction.
9. Have pericardiocentesis tray ready
including the ECG machine.
10. Refer as needed. If the patient has:
o Low blood pressure
o Diminished heart sounds
o Low oxygenation
o Altered mental status
o Thready pulse
o New set dysrhythmia
o Note: refer to the doctor most
especially if the patient is already
done in pericardiocentesis because
after pericardiocentesis, there would
be improvement in the heart sounds,
oxygenation, and on the patient’s
status. If there will be persistent low
BP, diminished sounds, etc., you
have to inform the physician
immediately.
In summary, Cardiac Tamponade is a
medical emergency. It is a condition
characterized by rapid accumulation of fluid in
the pericardial sac which increases the pressure
on the pericardial cavity which causes
compression of the heart and that would lead
to decreased cardiac function. If there is
decreased cardiac function, this would mean
decreased cardiac output. This would give signs
for decreased perfusion explaining the various
clinical manifestations.
B. BLUNT CARDIAC INJURY
PATHOGENESIS
Compression of the heart or traction or torsion
 penetrating injury.
Sudden elevated pressure
 rhythm.
Valvular injury, septal wall tear, chamber
rupture, contusion

Decreased cardiac output & abnormal cardiac
rhythm
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 Bruising of the heart muscle usually brought
by blunt trauma involving significant
acceleration/deceleration force through he
sternum.
 May also be induced by chest compressions
during cardiopulmonary resuscitation.
 Dysrhythmias are the most significant
concern with cardiac contusion.
 Common for contact sports.
 An example is in a patient with ecchymosis
or contusion on the chest area, you may
assess for presence of blunt cardiac injury.
 If there is a force, that could lead to rapid
increase in the intracavitary pressure which
would also compress the heart or cause
traction or torsion.
 Traction or torsion could lead to further
elevated pressure on the intracavitary
cavity of the heart. This could lead to
possible injury of the different parts of the
heart like the valves, septum, chambers, etc.
There could be various injuries because of
the elevated pressure.
 Remember that there is rapid increase in the
intracavitary pressure that could lead to
anatomical injury of the heart kahit walang
 Various injuries could lead to decrease
cardiac output and abnormal cardiac
o Decreased CO because this would lead
to decrease cardiac function.
 In blunt cardiac injury, one of the most
import concerns is, dysrhythmias.
o There could be dysrhythmias because of
the injury in the different cardiac
structures, specifically, it would involve
 the structures of the SA node, AV node,
purkinje fibers, ventricles, etc.
CLINICAL MANIFESTATIONS
 Pain and tenderness over the anterior chest
wall.
 Evidence of chest wall contusion,
ecchymosis, and anterior rib fractures.
 Signs of decrease oxygenation and
increasing pressure.
 Hemodynamic instability
 External jugular vein distention
 Dyspnea
 Dysrhythmias apparent in the first hour but
may be delayed Up to 24 hours.
o As a nurse, hook your patient in a
cardiac monitor for the first 24 hours to
monitor signs of dysrhythmias.
DIAGNOSIS
 Diagnosis is also similar to patient with
cardiac tamponade.
 12 Lead ECG monitoring for 48 to 72 hours
 Cardiac Isoenzymes and troponin
 2D echo
MANAGEMENT
 Monitor and support vital functions
 Supplemental oxygen administration
 Semi – Fowler’s position with complete bed
rest
 Inotropic Agents
 Analgesia
 Dysrhythmia management
 Note: Blunt cardiac injury should always be
suspected from a detailed history and
physical examination, prompting further
diagnostic testing. If you have a patient with
ecchymosis, and contusion on the chest
area, suspect presence of cardiac injury
most especially if there is dysrhythmias.
NURSING INTERVENTIONS
*Nursing care plans are similar to Cardiac
tamponade*
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1. Rapid response. Immediately notify the
patient’s healthcare provider, and prepare
the patient for diagnostic testing and
therapeutic interventions.
2. Transfer to the intensive care unit (ICU)
3. Monitor patient’s oxygenation, ventilation,
vital signs, ECG, mental status, heart and
lung sounds.
4. Assess for respiratory distress and prepare to
administer supplemental oxygen as
needed.
C. PENETRATING CARDIAC INJURIES
 An injury produced when a foreign object
passes.
 Penetrating cardiac injuries are associated
with a very high mortality rate. These are
primarily the result of gunshot and stab
wounds.
 A subset of stab wounds consists of
penetrating cardiac wounds from
iatrogenic needles, trocars, and catheters.
o Iatrogenic – secondary to medical
procedures.
o Ex. insertion of needle in the wrong area
during pericardiocentesis. This could
lead to penetrating cardiac injury.
PATHOGENESIS
Direct damage to the cardiac structures and
other contiguous like the lungs (can lead to
hemo/pneumothorax)

Hemorrhage  effusion  tamponade
 Usually, for patients with penetrating injury,
you could also expect for lung injury like
hemothorax (blood in the lungs) and
pneumothorax (accumulation of air in the
thoracic cavity).
CLINICAL MANIFESTATIONS
 Same of effusion/ cardiac tamponade and
other cardiac trauma.
DIAGNOSIS
 Aortogram
 Chest X ray with the following results:
o Widened mediastinum
o Tracheal deviation to the right
o Depressed left mainstem bronchus
o First and Second Rib Fractures
o Hemothorax or pneumothorax (there is
affectation of the lungs)
 Complete blood count
o May also show signs of hemorrhage.
o Decrease RBC
o Decrease hematocrit and hemoglobin,
o Elevated WBC as a reaction to
bleeding.
MANAGEMENT
 Support the patient’s ABC.
 Establish IV access and infuse crystalloids
and blood.
 Immediate surgical intervention to repair a
rupture or replace a valve.
 Infuse inotropic agents to improve
myocardial contractility.
 Emergency thoracotomy
 THORACOTOMY: is a surgical procedure in
which a cut is made between the ribs to see
and reach the lungs or other organs in the
chest or thorax.
NURSING INTERVENTIONS
Nursing care plans are similar to Cardiac
tamponade
1. Rapid response. Immediately notify the
patient’s healthcare provider, and prepare
the patient for diagnostic testing and
therapeutic interventions.
2. Transfer to the intensive care unit (ICU)
3. Monitor patient’s oxygenation, ventilation,
vital signs, ECG, mental status, heart and
lung sounds.
4. Assess for respiratory distress and prepare to
administer supplemental oxygen as
needed.
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REMEMBER
Immediate surgical intervention to repair a
rupture or replace a valve.
Infuse inotropic agents to improve
myocardial contractility
D. AORTIC DISSECTION/DISRUPTION
 Aortic Dissection: a tear in the inner lining of
the aorta.
o Blood surges through the tear, causing
the inner and middle layers of the aorta
to separate.
 Aortic Disruption: occurs when the wall of
the aorta tears completely or is ruptured as
a result of trauma.
o The whole wall of the aorta was
disrupted or ruptured.
 Aortic Dissection and Aortic Disruption are
life-threatening conditions.
 An aortic dissection is a serious condition
caused by tearing of the inner layer of the
aorta, this usually occurs in deceleration
injuries. It usually occurs at points of
attachment particularly the ligamentum
arteriosum and aortic root. Other sites of
disruption include the aortic arch,
ascending aorta, distal descending aorta,
and the diaphragm.
 Patients rarely survive. Death from aortic
disruption usually results from pericardial
tamponade or massive blood loss.
 Aorta: main and largest artery in the human
body.
o Originating from the left ventricle of
the heart and extending down to the
 abdomen. It is one of the arteries that Due to the slowing or stopping of the flow of
can be injured in abdominal or chest blood around the body, there would be:
injuries since it is very long.
 Sudden severe chest pain, back
o Main function: distributes oxygenated
pain/abdominal pain, decrease urine
blood to all parts of the body through
output, tachycardia.
the systemic circulation. If aorta is
o Severe chest pain, back pain or
dissected or disrupted, there will be
abdominal pain are usually the
decrease in oxygen perfusion
common initial symptoms.
throughout the body tissues. The
o Chest pain, back pain or abdominal
manifestations would be problems
pain can also be a manifestation of
with tissue perfusion.
increase in the pressure on the cardiac
o 3 layers: tunica externa, tunica
or abdominal cavity because of the
media, and tunica intima.
bleeding.
 Tunica externa: outermost layer
o Decrease urine output: because there is
and also termed as adventitia.
decrease perfusion in kidneys.
 Tunica media: middle layer
 Signs of hypovolemic shock
 Tunica intima: in aortic dissection,
 Signs of pericardial tamponade
it is the tunica intima that is
 Dyspnea
primarily affected and there
 Loss of consciousness due to decrease
would be separation of tunica
perfusion.
intima and media. In aortic
 Ecchymosis or signs of trauma over the chest
disruption, all of the 3 layers are
 BP higher in upper extremities than in lower
affected.
extremities.
PATHOGENESIS o Because aorta could not pump blood
on the lower extremities. It is hard due to
Trauma gravity.

 DIAGNOSTIC AIDS

Tearing of the inner layers of the aorta  Chest Imaging / CXR CT Scan
o Widened mediastinum
 o Obliteration of aortic knob
o Presence of pleural cap
Gushing of blood through the tear (between
o Hemothorax
tunica intima and media) causing the
o Elevated right main stem bronchus and
separation of the aorta’s layers
low left mainstem bronchus
  Thoracic aortogram
o The gold standard to detect the
Rupture, Hemorrhage, effusion/ tamponade. presence of aortic dissection, aneurysm
Depending on which part of the aorta is or aortic disruption.
affected. o This is the direct visualization of the
vessel.
Remember: the problem in aortic dissection is
o This is the definitive test or the gold
that, there is tearing of the intima in which there
standard.
would be gushing of blood through the tear
causing separation of intima and media. MANAGEMENT
CLINICAL MANIFESTATIONS  Monitor and support vital functions
 Support ABC’s

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 Isotonic IVF to temporarily to increase
cardiac filling pressure
 Establish IV’s and infuse crystalloids
 Transfuse blood as needed.
 Provide medications: Beta Blockers or
Sodium Nitroprusside lower BP and decrease
wall shearing forces. There could be
hypotension but for some patients who
would present with hypertension, we don’t
want hypertension to prevent further injury.
o If there is hypertension, this would lead
to further injury to the aorta. This could
lead to further damage.
 Prepare for urgent surgical repair: Emergent
Thoracotomy. A thoracotomy is a surgical
procedure in which a cut is made between
the ribs to see and reach the lungs or other
organs in the chest or thorax. Otomy means
open.
IMPORTANT NURSING INTERVENTIONS
Nursing care plans are similar to Cardiac
tamponade
Immediate patient transfer to the
intensive care unit (ICU) is a high priority.
Nursing interventions should begin as soon as
aortic dissection is suspected, and typically
include the following:
 Institute intubation or mechanical
ventilation, as ordered, if the patient is
hemodynamically unstable.
 Begin continuous cardiac monitoring (or
ECG). Assess for tachycardia and other
irregular rhythms.
 Provide continuous blood pressure
monitoring.
 Insert two large-bore I.V. lines.
 Check vital signs every 15 minutes, or
according to protocol.
 Observe the patient’s mental status and
check for neurologic and peripheral
vascular changes.
o Mental status is a sensitive indicator for
decrease perfusion in the brain.
 Measure urine output frequently.
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o In abdominal aortic aneurysm, you
could expect for a decrease on the
blood supply on the kidneys.
 Restrict patient activity.
o This is applicable to all conditions that
were discussed.
 Provide reassurance and a calm
environment.
o Remember your patient is in pain or he is
anxious.
o Explain the procedures or tests as
explained by the doctor or as what is
written on the chart.
o Answer patient’s simple questions.
Postoperative nursing care
 Postoperative nursing interventions in the
ICU or step-down unit include administering
drugs, maintaining target blood pressure
and heart rate, monitoring and observation,
preventing skin breakdown, and providing
patient teaching.
o Remember in aortic aneurysm, we don’t
want hypotension or hypertension.
 Expect to give pain medications (such as
morphine sulfate) as needed for pain
control; beta blockers and vasodilators
(such as nitroprusside or nitroglycerin) to
control heart rate and blood pressure; and
norepinephrine to prevent hypotension.
 For the first 2 or 3 days postoperatively, keep
the head of the bed lower than 45 degrees
and elevate the patient’s legs 20 to 30
degrees, to avoid pressure on incision sites.
Monitoring, observation, and other
interventions
 Assess the patient’s vital signs and
peripheral pulses, according to facility
protocol.
o Expect a thready pulse in patients with
aortic dissection.
 Stay alert for increased abdominal
distention and postoperative complications,
such as hemorrhage, MI, arrhythmias, heart
failure, cardiac tamponade,
thromboembolism, renal impairment,
 pneumonia, cerebral or spinal cord
ischemia, and stroke.
 Evaluate for signs and symptoms of
hypovolemia.
o Hypotension
o Weak pulses
o Changes in sensorium
o Decreased urine output
 Check chest tube drainage and drains; note
drainage on dressings, and mark the
boundaries.
o Monitor if there is excessive bleeding on
the drainage. Take note of it.
 Monitor hourly fluid output, Monitor skin
condition, and take steps to prevent skin
breakdown.
 Increase the patient’s activity level
gradually, as appropriate.
 Encourage the patient to use an incentive
spirometer and to splint when coughing.

SUMMARY

In aortic dissection, there is shearing

force which separates the intima and media.
This could lead to disruption on the function of
the aorta. So you would expect that the clinical
manifestations would also be due to decrease
CO. There should be rapid interventions and
interventions are somehow similar with the other
conditions.

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