Chapter 19

Chapter 19
Trauma and Surgical Management
Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
Introduction to Trauma
 Fifth leading cause of death overall
 Major cause of death and disability ages 16 to
54 years
 Leading cause of death of teens; 11 teens die in
MVCs each day
 Often associated with drugs and alcohol
 Financial implications
 Treatment
 Rehabilitation
 Disability
Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2
Trauma Systems
 Model trauma care systems
 Prevention
 Access
 Acute hospital care
 Rehabilitation
 Research activities
Levels of Trauma Care
 Level I—regional resource, state-of-the-science
care, education, outreach, and research
 Level II—provides care for trauma patients and
transfer to level I if needed
 Level III—community hospital where no Level I
or II exists
 Level IV—provides advanced trauma life support
(ATLS) and transfer
Prevention
 Primary prevention—prevent the event
 Driving safety classes
 Speed limits
 Campaigns to not drink and drive
 Secondary prevention—minimize the impact of the
traumatic event
 Seatbelt use
 Airbags
 Car seats
 Helmets
 Tertiary prevention—maximize patient outcomes after a
traumatic event through emergency response systems,
medical care, and rehabilitation
Critical Thinking Challenge
 Why is it important to not label traumatic events
as “accidents”?
Trauma Team
 Similar to code team
 Team members preassigned
 Trauma surgeons, emergency department physicians,
and specialists
 Nurses
 Ancillary services: radiologic technologists, laboratory
technicians, respiratory therapists, and social workers
 What is the role of pastoral services on a trauma
team?
 Why is it important to have security officers as
part of the trauma team?
Trauma Triage
 Essential for determining if patient needs to be
transferred to a Level I trauma center
 Made by prehospital personnel
 Criteria in place to guide decision
 ABCs and lifesaving interventions
 Ground versus air transport
Disaster and Mass Casualty
Management
 A sudden event that overwhelms EMS,
hospitals, community resources
 Environment, man-made, terrorist
 Internal disaster
 Disaster protocols
 Disaster debriefing
Mechanisms of Injury
 Knowledge helps to identify potential problems
 Uncontrolled source of energy
 Kinetic energy
 Thermal, chemical, electrical, radiation, blast
Blunt Trauma
 Severity depends on • Acceleration
kinetic energy • Deceleration
dissipated to the body
• Shearing
• Crushing
 Common vehicular • Compression
trauma, assault with
blunt objects, falls,
and sports
Patterns of Injury with Blunt
Trauma
Figure 19-1. Potential sites of blunt trauma injury in

unrestrained passenger and driver in a motor vehicle crash.
A, Unrestrained passenger in front seat. B, Unrestrained
driver. C, Lateral impact collision. (From Herm RL.
Biomechanics and mechanism of injury. In Cohen SS, ed.
Trauma Nursing Secrets. Philadelphia: Hanley & Belfus.
2003.)
Penetrating Trauma
 Impalement of foreign objects into the body
 Stab wounds are low-velocity injuries
 Ballistic trauma (e.g., gunshot injuries)
 Medium velocity: handguns, some rifles
 High velocity: assault and hunting rifles
 Velocity and missile (bullet) determine tissue damage
 Cavitation
Blast Trauma
 Blunt and penetrating trauma
 Tissue and organ injury
 Gas containing organ injury (e.g., eardrums, lungs,
intestines)
 Blast injury:
 Primary
 Secondary
 Tertiary
 Quaternary
Prehospital Care/Transport
 Emergency stabilization and quick transport
 ABCs (with cervical stabilization)
 IV access and fluid administration
 Hemorrhage control
 Fracture stabilization
Emergency Care Phase
 Prehospital data obtained
 Trauma unit in emergency department must
always be in a state of readiness
 Trauma surgeon must be present upon patient
arrival, in the operating room, and during critical
care interventions
Primary Survey
 Done in 1 to 2 minutes
 Airway patency (with C-spine immobile)
 Breathing effectiveness
 Circulation, including hemorrhage and pulses
 Disability (overview of neurological status)
 Expose the patient, remove clothing, warm patient
and trauma room
 Identify life-threatening injuries accurately to
establish priorities
 Patients who present to the emergency
department after traumatic injury are at high risk
for hypothermia.
 What factors predispose the patient to hypothermia?
 What nursing interventions can be done to prevent
and/or treat hypothermia?
Secondary Survey
 Performed after life-threatening injuries are
identified and treated
 Examination of all body systems:
 Full set of vital signs; focused interventions, family
presence
 Give comfort measures
 History and more thorough head-to-toe assessment
 Inspect posterior surfaces
Secondary Survey
(continued)
 Maintain C-spine immobilization until cleared by
x-ray
 X-ray studies (as determined by injury)
 Laboratory studies
 Tetanus toxoid administration
 Specialty physician consults
Resuscitation Phase
 Time from injury to stabilization
 Focus: Establishing effective circulatory volume
 ABCDEs
Maintain Airway Patency
 Many factors affect the airway (e.g., facial
fractures, bleeding, vomiting, decreased
sensorium)
 Open airway
 Jaw thrust or chin lift
 Nasopharyngeal or oropharyngeal airways
Maintain Airway Patency
(continued)
 Laryngeal mask airways (LMA)
 Endotracheal intubation
 Cricothyrotomy
 Facial fracture
 Unable to intubate
 Facial or upper airway burns
 Oropharyngeal hemorrhage
 Why are nasal tubes avoided in patients with
maxillofacial trauma or basilar skull fractures?
Ineffective Breathing
 Ongoing assessment is essential
 Respiratory status
 Arterial blood gases (ABGs)
 Chest x-rays
 Computed tomography (CT) imaging
 Improve ventilation and gas exchange
Ineffective Breathing: Interventions
Etiology
Tension pneumothorax Needle decompression
Prepare for chest tube insertion on affected side.
Pneumothorax Prepare for chest tube insertion on affected side.
Open chest wound Seal the wound with an occlusive dressing and tape
on three sides.
Prepare for chest tube insertion on affected side.
Pulmonary contusion Prepare for early intubation and mechanical
ventilation.
Flail chest Prepare for early intubation and mechanical
ventilation.
Administer analgesics as ordered.
Ineffective Breathing: Etiology Interventions
Spinal cord injury Avoid hyperextension or rotation of the
patient’s neck.
Observe ventilatory effort and use of
accessory muscles.
Maintain complete spinal immobilization.
Monitor for signs of distributive
(neurogenic) shock.
Decreased level of consciousness Position the patient’s head midline with
the head of the bed elevated.
Anticipate a computed tomography scan.
Implement interventions to prevent
aspiration.
Prepare for intubation and mechanical
ventilation.
Massive hemothorax Prepare for chest tube insertion on
affected side.
Administer blood or blood products as
ordered.
Anticipate and prepare for emergency
open thoracotomy.
, 1993 by Saunders, an imprint of Elsevier Inc. 31
Copyright © 2013, 2009, 2005, 2001, 1997
Impaired Gas Exchange
 Supplemental oxygen or mechanical ventilation
 Ongoing assessment
 Oxygen saturation
 Respiratory status (rate, work of breathing, depth of
ventilation, breath sounds)
 Secretion removal
Circulation: Hypovolemia
 Hypovolemic shock: Acute blood loss
 External hemorrhage
 Internal hemorrhage
 Ongoing assessment of vital signs, urine output,
mental status, and hemodynamic parameters
 Early rapid identification of cause
Treatment of Hypovolemia
 Stop bleeding
 Venous access
 Two large-bore IVs
 Intraosseous IV access
 Central line may be needed
Intraosseous (IO) Procedure
Figure 19-2. Tibial insertion of an intraosseous (IO) device taped in place with intravenous extension
attached to the needle for fluid and medication installation. (Courtesy Waismed, Ltd. Houston, Texas)
Treatment of Hypovolemia
(continued)
 Administration of crystalloids and blood products
 Lactated Ringer’s is fluid of choice
 Blood administration based on response to initial fluid
resuscitation and laboratory values
 Autotransfusion an option
Response to Treatment
 Rapid responders
 Transient responders
 Patient is still bleeding; surgery needed
 Minimal or no responders
 Emergent surgical intervention needed to stop
bleeding
Ongoing Signs and Symptoms of
Shock
 Tachycardia, tachypnea
 Narrowing pulse pressure
 Falling PaO2
 Decreasing urine output
 Increased serum lactate levels
 Falling hematocrit
Newer Technologies
 Technologies that can be used to assess tissue
perfusion
 Sublingual capnometry
 Near-infrared spectroscopy (NIRS)
 StO2 ≤ 80% indicates shock
Massive Fluid Resuscitation
 Administration greater than 10 units of packed
red blood cells (RBCs) in 24 hours
 Or replacement of patient’s total blood volume in
24 hours
 Restore oxygen transport to tissues
 Stop progress of shock
 Prevent complications
 Electrolyte imbalances
Complications of Massive Fluid
Resuscitation
 Fluid-electrolyte imbalances
 Hypothermia
 Coagulopathies
 Third-spacing and organ dysfunction
 Abdominal compartment syndrome
 ARDS
 Acute kidney injury
 MODS
Focused Assessment with
Sonography for Trauma (FAST)
 Noninvasive
 Determines potential sources of bleeding
 Peritoneal cavity
 Pericardial sac
Specific Organ Injuries
 Neurological
 Chest
 Abdomen
 Musculoskeletal
Neurological
Traumatic Brain Injury (TBI)
 Primary injury associated with trauma
 Establish baseline level of consciousness (LOC)
 Secondary injury associated with:
 Hypoxemia
 Hypotension
 Increased intracranial pressure (ICP)
 Hypocapnia
 Hyperthermia
 Anemia
Neurological
Traumatic Brain Injury (TBI)
(continued)
 Prehospital phase is crucial
 Glasgow Coma Scale score less than 8
 Monitor and treat ICP
 Less than 20 mm Hg
 Cerebral perfusion pressure > 50 mm Hg
 Ongoing neurological assessment
Spinal Cord Injury
 Suspicion: mechanism of injury
 Immobilization
 X-rays and possible CT studies
 Reduction with cervical traction
 Distributive (neurogenic) shock
 May need vasopressors
Basilar Skull Fractures
 Assess for underlying brain injury
 Base of the cranium involving five bones
 Diagnosis based on:
 Presence of CSF from nose, ears, or both
 Ecchymosis over mastoid area or hemotympanum
 Periorbital ecchymosis
Chest (Thoracic Injuries)
Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
Cardiac Tamponade
 Bleeding into pericardial space
 Impairs pumping ability of heart
 May be difficult to diagnose
 Pulsus paradoxus
 Beck’s triad
 Hypotension
 Muffled heart sounds
 Elevated venous pressure
Cardiac Tamponade
(continued)
 Suspect in patient with symptoms of decreased
cardiac output who does not respond to
treatment
 Treated by pericardiocentesis
Cardiac Contusion
 Blunt chest trauma
 “Bruises” heart muscle
 Compromises cardiac function
 Dysrhythmias
 Evaluate cardiac injury
Aortic Disruption
 Life-threatening injury requiring emergency
surgical intervention
 Symptoms include weak pulses, pain, and
hoarseness
 Chest x-ray shows widened mediastinum
 Confirmed by aortogram
 Emergent surgical intervention
Tension Pneumothorax
 Life-threatening
 Increased intrapleural and intrathoracic
pressures cause compression of heart and great
vessels
 Cardiovascular collapse
 Cyanosis: Late manifestation
 Emergent treatment with needle thoracostomy
 Chest tube inserted after needle decompression
Hemothorax
 Blood (hemo) in pleural space
 Hypotension and respiratory distress
 Chest tube insertion needed
 Monitor blood volume evacuated closely
Open Pneumothorax
 Air (pneumo) in pleural space
 Hypoxia and hemodynamic instability
 Three-side occlusive dressing
 Allow small amount of air to escape from occlusive
dressing
 Chest tube insertion needed
Pulmonary Contusion
 Bruising of lung tissue
 Associated with rib fractures and flail chest
 Often results in pneumonia and acute
respiratory distress syndrome (ARDS)
 May require long-term ventilatory support
 Pain relief
Rib Fractures
 Seriousness varies; treatment also varies
 Chest x-ray
 Secondary organ injury: liver, spleen, kidney
 May result in flail chest
 Three or more adjacent ribs fracture in more than one
location
 Paradoxical respirations result
 Treated with intubation, ventilation, and pain
management
Abdominal Injuries
 Diagnosis facilitated by diagnostic:
 FAST
 Abdominal CT
 Laboratory tests can also help in identifying
organ damage (e.g., liver function studies, renal
studies)
 Ongoing assessment essential
 Pain
Abdominal Injuries (continued)
 Trauma can result in damage to any of the
organs
 Liver damage most common
 Grade I to VI
 Splenic injury occurs with blunt trauma
 Kehr’s sign
 Hypotensive shock
 Pneumococcal vaccine
Abdominal Injuries (continued)
 Bowel injury
 Penetrating and blast injury
 Postoperative risks of infection and ineffective
nutrition
 Kidney injury
 Blunt trauma; unilateral injury
 FAST, pyelogram, cystoscopy
 Pelvic injury
 High-speed MVC, falls
 Hypovolemic/hemorrhagic shock
Musculoskeletal Injuries
 Many types of fractures; multiple fractures often
present in trauma patient
 Unstable pelvic fractures and femur fractures
can result in a large amount of blood loss
Musculoskeletal Treatment
 Closed or open reduction; may need traction
 Treatment of hypovolemia and blood loss
 Soft tissue trauma
 Contusions, abrasions, lacerations, puncture wounds,
crush injuries, amputations, avulsions
 Wound care
 Tetanus prophylaxis
 Possible antibiotics
Figure 19-3. Common types of fractures. (From Murray CA. Care of patients with
musculoskeletal trauma. In Ignatavicius D, Workman ML, eds. Medical-Surgical Nursing:
Critical Thinking for Collaborative Care. 6th ed. Philadelphia: Saunders. 2010.)
Musculoskeletal Injuries
(continued)
 Assess for neurological and/or vascular injury
 Assess the five Ps:
 Pain
 Pallor
 Pulses
 Paresthesia
 Paralysis
Compartment Syndrome
 Fascia enclosed muscle compartment
experiences increased pressure
 Compression of nerves, blood vessels, muscles
 Neurovascular assessment (five Ps)
 Treatment: fasciotomy
Rhabdomyolysis
 Muscle destruction
 Secondary to crush injury
 Increased myoglobin and potassium
 Can result in acute kidney injury (AKI) (formerly
called acute renal failure [ARF])
 IV fluids to achieve urine output ≥ 100 mL/hr
Venous Thromboembolism
 High risk in trauma patients
 Virchow’s triad
 Vessel damage
 Venous stasis
 Hypercoagulability
 Pulmonary embolism risk
 Pharmacological and mechanical prophylaxes
Fat Embolism
 Long-bone, pelvic, and multiple fractures
 Symptoms: 24-48 hours after injury
 Symptoms include:
 Low-grade fever, tachycardia, new onset of
respiratory distress, hypoxia, petechial rash, and
thrombocytopenia
 ECG changes, lipuria, decreased LOC
 Treatment: pulmonary and cardiovascular
support
Critical Care Phase
 Postoperative management
 Systemic assessment and monitoring
 Continued resuscitation
 Address ongoing patient care priorities
Damage Control Surgery
 Patients with multiple injuries
 Staged surgeries
 Repair stages:
 Life-threatening injuries
 Definitive repair
 Hemodynamic stabilization
 Correction of metabolic acidosis and coagulopathies
Postoperative Management
 Ready the room
 Warm room
 Equipment
 Zero bed
 Receiving the patient
 Handoff communication
 Quick assessment
 Connect to equipment
 Detailed assessment
Postoperative Management
(continued)
 Early enteral nutrition should be initiated
 Consider nutritional consult
 DVT and stress ulcer prophylaxis
 Monitor serum electrolytes to include glucose
Complications
 Complications may be secondary to:
 Traumatic injury
 Severity of shock (poor tissue perfusion/oxygenation)
 Inflammatory response to injury
 Complications are more likely in patients with
multisystem injuries
Complications
(continued)
 Complications include:
 Infection/sepsis
 Venous thromboembolism
 Acute respiratory failure/acute respiratory distress
syndrome (ARDS)/pneumonia
 Acute kidney injury
 Multiple organ dysfunction syndrome (MODS)
 What strategies can you implement to reduce
the risk of the following complications?
 Infection
 Venous thromboembolism
 Pneumonia
Alcohol and Drug Abuse
 Up to 40% of traumatic events involve alcohol
and/or drugs
 Increased morbidity and mortality
 Trauma centers need to have alcohol and drug
intervention programs
 Withdrawal of drugs and alcohol may occur
during acute hospitalization
 List five special considerations in the care of the
geriatric trauma patient.
 What are unique risk factors associated with
aging that increase morbidity and mortality of the
older trauma patient?
Family and Patient Coping
 Family unit crisis
 Communication
 Critical decisions and support
 Family spokesperson
 Family conference
Rehabilitation
 Begins at admission
 Goal: maximize patient independence
 Nursing care in acute phase impacts patient’s
rehabilitation and recovery

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Chapter 19

Trauma and Surgical Management

Figure 19-1. Potential sites of blunt trauma injury in

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