Mechanism of Trauma

Fitriany Suangga, S.Kp.,MSN

Objectives
 Definition
 Types
 Physiology
Definition
 Trauma is defined as a tissue injury that occurs more or
less suddenly due to violence or accident and is
accountable for initiating hypothalamic-pituitary-adrenal
axis, immunologic and metabolic responses for restoring
homeostasis
 Physiological wound caused by an external source. It can
also be described as “ physical wound or injury, such as a
fracture or blow
  Leading cause of death
Types of Trauma
 Penetrating trauma
 Blunt trauma
 Deceleration trauma
ATLS guidelines Evaluation
 “ABCDE” Rule”
 Airway – Airway and c-spine protection
 Breathing and ventilation
 Circulation with hemorrghage control
 Disability – Neurologic status
 Exposure/environmental control
Related Testing
 Focused abdominal sonogram for trauma or FAST exam
(exam uses USG to identify free fluid in the abdomen)
 CT Scan
 Blood type and croos match in a case of transfusion
 Depending on the patient’s initial evaluation and
assessment, futher testing may be warranted
Pathophysiology of Penetrating Trauma
 Penetrating trauma  hypovolemic shock , if not treated
promptly → death
 Hypovolemic shock manifested by:
 Hypotension
 Tachycardia
 Tachypnea
 Cold skin
 Acute blood loss → less circulating →  organ perfusion
(kidneys, brain heart, liver and colon)
Pathophysiology of Penetrating Trauma
 Autonomic nervous system work to maintain adequate
oxygenation  goal is maintain cardiac output (CO) :
heart rate x stroke volume.

 Activation of the sympathetic nervous system (SNS),
causing the releasing of plasma catecholamines such as
vasopressin and norepinephrine

 Increasing heart rate  CO
Pathophysiology of Penetrating Trauma
 Another goal is to increase systemic vascular resistance
(SVR); via the renin-angiotensin-aldosterone system
(RAA)
 Renin is released in response to a  is systemic blood
pressure and a  NaCL
 Renin converted to angiotensin I, angiotensin II and
aldosteron
 During hypovolemia, angiotensin II act on blood vessels
 vasoconstriction and hypothalamus release of the anti-
diuretic hormon  water reabsorption ; limit baroreceptor
reflex bradycardia  maintain of CO
Pathophysiology of Blunt Trauma
 Blunt trauma is s force striking the body, and its
consequenses are dependent on the location of the trauma
 Most common cause and location of blunt force trauma in
adult are abdomen after motor vehicle accidents
 Solid organ blunt abdominal trauma include the liver,
spleen and kidneys

Venous hemorrhage , arterial hemorrhage 
Pathophysiology similar to penetrating trauma
Pathophysiology of Blunt Trauma
 Blunt abdomen trauma also cause inflammation
accompanied by edema
 Cardinal signs of infammation : redness, swelling, pain
and also loss of function
 Traumatic injury  mast cells release histamin and
bradykinin  vasodilation and increase blood flow
 Bradykinin also sensitizes nerve endings → pain
 Edema due to endothelial contraction and endothelial
damage. Distubtion Endothelial lining the vessels →
“leaky” → shift of fluid from postcapillary venules into
interstitial space
Pathophysiology of Blunt Trauma
 Blunt trauma → Neurologic injury : Epidural hematomas,
secondary to skull fractures are caused by arterial rupture
(most common: middle meningeal artery)
 Arteries are under high pressure → hemorrhage occurs
quickly vs a subdural hematoma , which is under venous
pressur
 
 Uncal herniation → 3th cranial nerve palsy or “ blown”
pupil
Pathophysiology of Deceleration Trauma
 Deceleration trauma is an injury caused by a sudden stop
in motion → affect different organ
 Acceleration – motion of the brain hittng one area of the
skull and bouncing back
 Deceleration – hitting the direct opposite side of the
brain on the other side of the skull

 Neurochemicals and prostaglandins are release
 The aorta also a potential site for deceleration injury 
traumatic aortic ruprure
Clinical Sifnificance
 It is essential to recognize the clinical signs as a result of
trauma
 The physcial exam, along with the patient’s history, is
pertinent to initiating the correct treatment
 Missing these clinical clues can delay patient treatment
and can lead to adverse outcomes, including death
Proses Keperawatan Keperawatan
Gawat Darurat
Latar Belakang
 Proses keperawatan adalah aktivitas yang mempunyai
maksud yaitu praktik keperawatan yang dilakukan dengan
cara yang sistematik
 Keperawatam gawat darurat bersifat cepat dan perlu
tindakan tepat, serta memerlukan pemikiran kritis tingkat
tinggi
 Perawat gawat darurat harus mengkaji pasien mereka
dengan cepat dan merencanakan intervensi sambil
berkolaborasi dengan dokter gawat darurat
Prinsip Proses Keperawatan Pasien
Gawat Darurat
 Life support perlu diprioritaskan kondisi yang memerlukan
tindakan segera. Terkadang tindakan dilakukan bersamaan
dengan pengkajian.
 Penulisan dapat dilakukan setelah keselamatan terjamin atau
dan sudah teratasi.
 Ringkas dan mudah dimengerti
 Mayor kondisi dan holistik diprioritaskan pada kondisi-
kondisi utama yang mengganggu kehidupan atau kebutuhan
dasar pasien dan keluarga dari segi fisik, psik dan sosial
 Aktual dan benar keakuratan dalam pengkajian dan
perumusan diagnosa keperawatan dan tindakan keperawatan
merupakan hal utama yang harus diingat
Proses Keperawatan
 Assessment
 Constantly assess the patient for subtle changes in condition
 Primer survey and secondary survey
 Physical and psychological status
 Incorporate lab and diagnostic study findings
 Monitor all equipment being used
 Planning
 Set realistic patient goals : consider the pt’s psychological and
physiologic needs
 Anticipate changes in the patient’s condition → change and
establish new goals
Proses Keperawatan
 Implementation
 Address existing and potential patient problems
 Common problems
 Pain
 Cardiac arrhythmias
 Respiratory distress
 Mental status changes
 Altered hemodynamic states
 Impaired physical mobility
 Impaired skin integrity
 Fluid volume deficit
 Evaluation
 Continually evaluate a patient’s response to interventions
 Use such evaluation to change the care plans as needed
 Primary Survey with Simultaneous
Resuscitation

 Airway
 Assessment : airway patency
 Inteventions
 Open airway ; head tilt , chin lift , jaw thrust
 Inspect foreign bodies, identifing facia,mandibular, tracheal/laringeal
fractures and other injuries that can result in airway obstruction →
suctioning
 Use OPA, NPA
 Cervical spine immobilization until X-ry determine whether of the pt has
a cervical spine injury
 To open the airway, make sure that the neck is midline and stabilized 
jaw-thrust maneuver
 Airway surgically if intubation is contraindicated or cannot be
accomplished
Primary Survey with Simultaneous Resuscitation
 Breathing
 Assessment
 Respiratons (rate, depth,effort)
 Breath sounds
 Chest wall movement and chest injury
 Position of trachea (mid-line or deviation)
 Inspect and palpate injuries to the chest wall
 Interventions
 Administer O2 100% with mask, if pt not intubated
 SPO2
 Treat life-threatening conditions, such as pneumothorax or tension
pneumothorax  chest decompression
Primary Survey with Simultaneous Resuscitation
 Circulation
 Assessment :
 Pulse and BP
 Bleeding or hemorrhage
 CRT and color of skin and mucous membranes
 Cardiac rhythm
 Interventions
 Start CPR, medication,defibrilation
 Control hemorrhaging with direct pressure or pneumatic divices
 IV access (2 lines) and fluid therapy (isotonic fluids and blood) , if
cannot be accessed, intraosseous infusion, CVC, venous cutdown
 Treat life-threatening conditions such as cardiac tamponade
 Primary Survey with Simultaneous Resuscitation

 Disability
 Assessment
 Neurologic ass: LOC, pupils motor and sensory function
 Intervention
 cervical spine immobilization
 APVU, GCS
 Exposure and environment
 Assessment : exposure for injuries and maintain a warm environment
once exposed
 Interventions
 Examine the pt to determine the extent of injuries
 Warm blaket, warmed fluid

*ABCDE survery is a rapid ass

Primary Survey with Simultaneous Resuscitation
GCS (Glasgow Coma Scale)
Adjuncts to the Primary Survey with
Resuscitation
 ECG monitoring, Pulse oximetry CO2 monitoring,
assessment of ventilatory rate, ABG measurement,
X-Ray Exam
 Urinary catheter, gastric catheters
 ECG Monitoring
 Unexplained tachycardia, atrial fibrillation, premature
ventricular contractions, and ST segement changes → blunt
cardiac injury
 Pulseless electrical activity (PEA)  cardiac tamponade,
tension pneumothorax, and profound hypovolemia
 Extreme hypothemia also produces dysrhythmias
Adjuncts to the Primary Survey with
Resuscitation
 Pulse Oximetry
 SPO2 compared with ABG
 Assessment ventilation rate
 Tidal CO2 levels → capnography
 ABG provide information oxigenation and ventilation
 Low pH and base excess levels indicate shock
 Urinary catheters
 Indicator of the patient’s volume status and reflects renal
perfusion
 Gastric catheters
 Decrease the risk aspiration and check for upper GI hemorrhage
from trauma
Adjuncts to the Primary Survey with
Resuscitation
 X-Ray Examination and Diagnostic Studies
 Chest X-ray can show potentially life-threatening injuries
 Pelvic film can show fractures of the pelvic  early blood
transfusion
 FAST, eFAST (Focused Assessment Sonography for Trauma)
and DPL (diagnostic Peritoenal Lavage → intraabdominal
blood, pneumothorax, and hemothorax
Secondary Survey
 Head to toe evaluation
 History
 Physical examination (reassessment of all vital signs)
Secondary Survey – History
 AMPLE
 Allergies
 Medications currently used
 Past illnesses/pregrancy
 Last Meal
 Events/Environment related to injury
Secondary Survey – History
 Blunt and penetrating trauma
 Blunt trauma
 Result from automobile collisions, falls,and other injuries r/t to
transportation,recreation, and occupations
 Penetrating trauma
 In gutshot victims, the velocity, caliber, presumed path of the
bullet, and distance from the weapon to the wound can provide
information clues regarding the extent of injury
Secondary Survey – History
 Thermal injury
 Can occur alone or in conjunction with blunt and or/penetrating
trauma
 Information regarding the circumtances of the burn injury can
increase the index or suspicius for inhalation injury or toxic
exposure from combustion of plastic and chemical
 Hazardous Environment
 History of exposure to chemical, toxins and radiation important
for 2 main reasons:
 Agents can produce a variety of pulmonary, cardiac, and internal
organ dyspunctions in injured patients
 They can present a hazard to healthcare providers
Secondary Survey – Physical Examination
 Sequence of Head,maxillofacial structures, cervical spine
and neck, chest, abdominal and pelvis,
perineum/rectum/vagina/ musculoskeletal system, and
neurological system
Secondary Survey – Physical Examination
 Head
 Scalp and head :examined for lacerations, contusions, and
evidence of fractures
 Eyes : visual acuity, pupillary size, hemorrhage of the
conjunctiva and/or fundi, penetrating injury, contact lenses
(remove before edema occurs), dislocation of the lens, ocular
entrapment
Secondary Survey – Physical Examination
 Maxilofacial Structures
 Palpation of all bony structures, assessment occlusion, intraocular
examination and assessment of soft tissues
 Cervical spine and neck
 Maxillofacial or head trauma should be presumed to have a cervial spine
injury
 Inspection, palpation and auscultation of the neck
 Cervical spine tenderness, subcutaneous emphysema, tracheal deviation and
laringeal fracture
 Palpate and ausculatated carotid arteries for bruits
 Blunt carotid injury can present with coma or without neurologic finding.
 Check for penetrating injury
 Unexplained paralysis of an upper extrimity → cervical nerve root injury
Secondary Survey – Physical Examination
 Chest
 Inspect : anterior and posterior → identify conditions such as open
penumothorax and large flail segments
 Palpation : entire chest cage, including the clavicles, ribs and sternum.
 Sternal pressure can be painful if the sternum is fractured
 Conctusions and hematomas?
 Significant chest injury can manifest with pain, dyspnea, and hypoxia
 Auscultation : anterior chest wall for pneumothorax ; posterior bases for
hemothorax
 Distant heart sounds and  pulse pressure can indicate cardiac temponade
 Cardic temponade and tension pneumothorax : presence of distended
neck veins
 Percussion : hyperresonance
Secondary Survey – Physical Examination
Abdominal and Pelvis
 Close observation and frequent reevaluation of the abdomen
(same observer)
 Pelvic fractures: ecchymosis over the iliac wings, pubis, labia
or scrotum
 Unexplained hypotension, neurologic injury, impaired
sensorium secondary to alcohol and/or other drugs → DPL ,
abdominal USG,CT
Secondary Survey – Physical Examination
 Perineum, rectum and vagina
 Examine for contusion, hematomas, lacerations, and urethral
bleeding
 A rectal examination : presence of blood within the bowel
lumen, integrity of the rectalwall, quality of sphincter tone
 Vaginal examination should be performed in patients who are at
risk of vaginal injury : present blood & vaginal lacerations
 Performed pregnancy test on all females of chilbearing age
Secondary Survey – Physical Examination
 Musculoskeletal system
 Inspect for contusions and defromities
 Palpation of the bones and examination for tenderness and
abnormal movement aids in the identification of occult
fractures
 Ligament ruptures produce joint instability
 Impaired sensation and/or loss of voluntary muscle contraction
strength: nerve injury or ichemia including that d/t
compartment syndrome
 Examine the patient’s back
Secondary Survey – Physical Examination
 Neurological system
 Motor and sensory evaluation of the extremities
 Reevaluation of pt’s LOC and pupillary size and response
 Monitor patients frequently for deterioration in LOC and
change in the neurological examination
 Head injury? Reassess O2 and adequacy of ventilation and
perfusion of the brain
 Assess sensation. Any loss of sensation, paralysis or weakness
suggests major injury to the spinal column or peripheral
nervous system
 Protection of the spinal cord
Adjuncts to the Secondary Survey
 Additional X-ray examinations of the spine and
extremities
 CT scans of the head, chest, abdominal, and spine
 Contras urography, and angiofraphy
 Transesophageal ultrasound
 Bronchoscopy, esophagoscopy, and other diagnostic
procedureds
 Lab
Reevaluation
 Must be reevaluated constanly.
 Continous monitoring of vital signs, SPO2 and urinary
output is essential
 Periodic ABG analisis
 Relief of severe pain