Introduction: Trauma
Introduction: Trauma: Excerpt from Professional Guide to Diseases (Eighth Edition)
Trauma is one of the leading causes of death in the United States. Emergency trauma care basics include triage; assessing and maintaining airway, breathing, and circulation (the ABCs); protecting the cervical spine; assessing the level of consciousness (LOC); and, as needed, preparing the patient for transport and possibly surgery.
Common mechanisms of trauma include motor vehicle and bicycle accidents, automobile-pedestrian accidents, drowning, firearms, burns, and falls.
Triage: First things first
Triage is the setting of medical priorities for emergency care by making sound, rapid assessments. The need for triage usually arises at the scene of injury and continues in the emergency department. Following health care facility protocol, you’ll decide which patient to treat first, which injury to treat first, how to best utilize other members of the medical team, and how to control patient and staff traffic.
In most cases, victims are assigned to the following categories:
❑ emergent — life-threatening or limb-threatening injury requiring treatment within a few minutes to prevent death or further injury; includes patients with moderate to severe respiratory distress, cardiopulmonary arrest, compensated or uncompensated shock, extremity injury with neurovascular compromise, alteration in neurologic status, and patients who have attempted suicide
❑ urgent — serious, but not immediately life-threatening injury that should receive treatment within 2 hours; includes patients with mild wheezing and mild or no respiratory distress, mild to moderate dehydration, and suspected forearm fracture (These patients require periodic assessment because they can deteriorate and become emergent.)
❑ nonurgent — presence of minor or stable illness or injury that doesn’t require treatment within 2 hours; includes patients with ear discomfort, minor or isolated soft tissue wounds, and sore throat.
At any point during the assessment, if the patient is discovered to have a life-threatening condition, appropriate interventions should be initiated immediately. It may also be necessary to prioritize patients within the same triage category based on the severity of each patient’s symptoms.
Trauma care generates a great deal of stress, and much of it falls on your shoulders. In many cases, you must deal with patients and families who are upset, angry, belligerent, intoxicated, or frightened; some may speak only a foreign language. Therefore, you must work calmly and rationally, employing crisis-intervention techniques. You can help the patient a great deal by talking to him. Be sure to tell him what you’re going to do before you touch him. You must also handle difficult situations diplomatically and intelligently, recognize your limitations, and ask for help when you need it.
Begin with the ABCs
Begin your care of an injured patient with a brief primary assessment of the ABCs. Also assess for disability or neurologic status.
To assess airway patency, routinely check for respiratory distress or signs of obstruction, such as stridor, choking, or cyanosis. Be especially alert for respiratory distress in a patient who inhaled chemicals, was in a fire, or has upper body burns. If the airway is obstructed, remove vomitus, dentures, blood clots, or foreign bodies from the mouth.
In a semiconscious or unconscious patient, open the airway using a jaw-thrust maneuver. (Don’t use the head-tilt maneuver for a trauma patient. Suspect cervical spine injury until X-rays rule it out.) Then insert an oropharyngeal or nasopharyngeal airway. A nasopharyngeal airway is contraindicated in patients with massive facial trauma and those with possible basal skull fractures. Assist with endotracheal tube insertion as necessary. If rescue personnel have inserted an esophageal obturator airway, leave it in place until the patient has been tracheally intubated. This will prevent him from vomiting and possibly aspirating.
Next, make sure the patient’s breathing is adequate. Look, listen, and feel for respirations. If the patient isn’t breathing, call for help immediately, begin bag-valve-mask resuscitation, and prepare for intubation. Give supplemental oxygen, then draw samples for arterial blood gas measurement and calculate the supplemental oxygen’s effects to establish a baseline for oxygen and acid-base therapy. Multiple injuries always create a need for supplemental oxygen because of blood loss and overwhelming physiologic stress. A conscious multiple-injury patient should display compensatory hyperventilation. If he doesn’t, expect neurologic involvement or chest injury. Needle thoracentesis may be done to decompress tension pneumothorax.
To assess circulation, check for central and peripheral pulses, as well as capillary refill (which should be less than 2 seconds). If a carotid pulse is absent, institute cardiopulmonary resuscitation. If external hemorrhage is evident, apply direct pressure to the bleeding site and, if the wound is on an extremity, elevate it above heart level if possible. Apply a tourniquet only if the hemorrhage is life-threatening.
Monitor the patient’s vital signs even if he appears stable. Because vital signs can change rapidly, taking them serially can identify subtle and overt changes. Document baseline readings, and obtain new readings every 5 to 15 minutes until the patient is stable. Assess trends in vital sign readings to detect changes. Place him on a cardiac monitor and a pulse oximeter. Remember that the patient may have up to a 25% volume loss before it’s reflected in vital sign readings.
Draw blood for type and crossmatch, complete blood count, prothrombin time, partial thromboplastin time, platelet count, and routine blood studies, including amylase levels. Begin at least two I.V. lines with 14G or 16G catheters for fluid resuscitation with normal saline or lactated Ringer’s solution. Administer tetanus prophylaxis as ordered. (See Managing tetanus prophylaxis.)
Immobilize the patient’s head and neck with an immobilization device, sandbags, backboard, and tape, if this hasn’t been done. Obtain cervical spine X-rays as appropriate and rule out cervical spine injury before moving the patient again. Presume spinal injury and take precautions to prevent further injury, such as logrolling and using adequate staff to move the patient, until spinal injury has been ruled out.
Proceed with assessment of the patient’s disability; assess the patient’s LOC and pupillary and motor response to check the patient’s neurologic status. Determine and report LOC by using a stimulus-response method of reporting, rather than categorizing; don’t use such words as “semiconscious” or “stuporous.” Report decorticate or decerebrate responses immediately. The patient need not have a head injury to exhibit an abnormal neurologic response. Any injury that impairs ventilation or perfusion can cause cerebral edema and raise intracranial pressure.
Expose the patient
Secondary assessment includes removal of the patient’s clothes for a more thorough examination. The clothing is placed in bags, which are labeled with the patient’s name and the date and time he was brought to your facility. The bag will be given to the patient’s family, or to the authorities if an investigation into the circumstances of the trauma is necessary. If the clothing must be given to the authorities, document having done so. Institute environmental controls by providing warming measures, such as warming blankets and units, warmed oxygen and I.V. solutions, and increased environmental temperature.
Assess the patient’s vital signs, and inform the patient’s family of his status. They can help to provide his history, especially his immunization status. Assess the need for comfort measures; pain medication may be given as appropriate, and other techniques may be used to make the patient comfortable.
Head-to-toe assessment
Secondary assessment also includes a thorough head-to-toe assessment of the patient. Quickly and carefully look for multiple injuries by systematically examining the patient. If you detect no spinal injury, carefully logroll the patient over to inspect his back for other wounds.
In chest trauma, assess for open wounds, tension pneumothorax, hemothorax, cardiac tamponade, bruises and hematomas, flail chest, and fractured larynx. Cover open wounds and apply direct pressure to the wound as necessary. Be ready to assist with insertion of chest tubes, pericardiocentesis, cricothyrotomy, or tracheotomy, as appropriate.
Insert an indwelling urinary catheter and a nasogastric tube, and give prophylactic antibiotics and immunizations, as indicated. Appropriate diagnostic studies — such as X-rays, computed tomography (CT) scans, peritoneal lavage, magnetic resonance imaging (MRI), and excretory urography — may be performed based on assessment findings and patient stabilization. Notify medical or surgical specialists, as appropriate.
Stabilize the patient
Because severe injuries commonly lead to shock, check skin temperature, color, and moisture. To control shock, administer I.V. fluids (lactated Ringer’s or normal saline solution) followed by blood or blood products, and use a pneumatic antishock garment as ordered. Don’t inflate the abdominal compartment if the patient is pregnant. Be aware that this garment’s use remains controversial, and it’s primarily used to stabilize pelvic fractures.
In all cases of massive external bleeding or suspected internal bleeding, watch for hypovolemia and estimate blood loss. Remember, however, that a blood loss of 500 to 1,000 ml might not change systolic blood pressure but may elevate the pulse rate. Stay alert for signs of occult bleeding, which commonly occurs in the chest, abdomen, and thigh. Repeat abdominal examinations frequently to assess the patient for abdominal distention; this could be a sign of internal injuries and bleeding.
Increased diameter of the legs or abdomen usually means that blood has leaked into these tissues (as much as 4,000 ml into the abdomen, 3,000 ml into the chest, and 2,000 ml into a thigh). Such blood loss will induce characteristic signs of hypovolemic shock (tachycardia, tachypnea, hypotension, restlessness, decreasing urine output, delayed capillary refill, and cold, clammy skin).
If the patient has renal injuries or a fractured pelvis, look for the classic sign of retroperitoneal hematoma — numbness or pain in the leg on the affected side as a result of pressure on the lateral femoral cutaneous nerve in L1 to L3. Retroperitoneal bleeding may not cause abdominal tenderness. If the patient shows clinical signs of hypovolemia, immediately begin I.V. therapy with two or more large-bore catheters, and regulate fluids according to the hypovolemia’s severity. Although the initial resuscitation fluids are crystalloids, significant hypovolemia due to hemorrhage requires blood transfusion. Assist with insertion of a central venous pressure or pulmonary artery catheter to monitor circulating blood volume.
If spinal trauma is suspected, methylprednisolone may be given I.V. If head trauma is present, the patient may be given emergency medication such as mannitol and ventilation may be controlled. The patient may also require emergency surgery — either exploratory or lifesaving — to help with stabilization depending on the injury’s type and extent.
Extremity fractures can be a source of blood loss. Look for limb fractures and dislocations. Check circulation and neurovascular status distal to the injury by palpating pulses distal to the injury and looking for the classic signs of arterial insufficiency: decreased or absent pulse, pallor, paresthesia, pain, and paralysis. Splint and apply traction as needed.
The patient will require X-rays, CT scan, or an MRI to determine the extent of injury to the extremity, so prepare the patient for transport. Use special care in suspected cervical spinal injury. If necessary, after splinting the injury site, also splint the areas above and below it to prevent further soft-tissue and neurovascular damage and to minimize pain. For example, if the forearm is injured, splint the wrist and elbow, too.
Types of splints include:
❑ air splint — an inflatable splint
❑ hard splint — a rigid splint with a firm surface, such as a long or short board, an aluminum ladder splint, or a cardboard splint
❑ soft splint — a nonrigid splint, such as a pillow or blanket
❑ traction splint — a splint that uses traction to decrease angulation and reduce pain.
Tips on applying a splint
❑ Splint most injuries “as they lie,” except when the patient’s neurovascular status is compromised.
❑ Whenever possible, have one person support the injured part while another applies padding and the splint.
❑ Secure the splint with straps or gauze, not an elastic bandage.
❑ To apply an air splint, slide the splint backward over your arm and grasp the distal portion of the injured limb. Then slip the splint from your arm onto the injured extremity and inflate the splint. Don’t apply the splint too tightly; be sure to reassess neuromuscular integrity often while the splint is in place.
Special considerations
After the patient is stabilized, he’ll need ongoing care and assessment and, possibly, rehabilitation to ensure recovery. Specialists may be consulted for certain types of trauma.
❑ Regularly evaluate the patient’s ABCs, as well as his neurologic status.
❑ Keep the patient’s family informed about his condition and provide support as indicated.
Depending on the type of injury, the patient may be admitted to your facility or transferred to another facility.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
More About Spinal cord injury
More Medical Textbooks Online about Spinal cord injury
Review other book chapters online related to Spinal cord injury:
Medical Books Excerpts
- BACK PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- Back Pain
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Analgesia
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Back pain
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Back Pain
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Analgesia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Back pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Low Back Pain
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Analgesia
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Back pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Back pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Back Pain
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- Analgesia
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- Back pain
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Analgesia (Professional Guide to Signs & Symptoms (Fifth Edition))
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
