NURS356 final exam notes PDF

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1 Assessment and Management of the Trauma Patient Overview ● ITLS Patient Assessment ○ Primary Survey ○ Ongoing Exam ○ Secondary Survey ● Initial Assessment related to ○ Rapid Trauma Survey vs. Focused Exam ○ Interruptions for life-saving interventions Primary Survey ● Rapid Trauma Survey ● Head-to-toe looking for and treating life threatening injuries Secondary Survey - More thorough ● Head-to-toe ● Including back No significant MOI - Initial Assessment normal ● Focused Exam ITLS Primary Survey ● ITLS Primary Survey ○ Scene Size-up ■ Hazards ● power lines, gas, animals, people, combat ■ Number of patients ● Establish casualty collection point ● Additional resources ■ MOI (mechanism of injury) ● Anticipate type and severity of injuries ■ PPE - take care of self FIRST ○ Initial Assessment ○ Rapid Trauma Survey vs. Focused Exam Immediate Interventions ● Know when not to start medical care ● Do not stop your assessment unless (hemorrhage, ABCs) ○ There is life-threatening bleeding ○ Scene becomes unsafe ○ Airway obstruction ○ Cardiac arrest ■ CPR may be appropriate to perform Primary Survey - Initial Assessment ● General impression ● Evaluate for life-threatening hemorrhage (CAB) ● Level of consciousness ● Manual stabilization of cervical spine, if able

2 Prioritize patient ○ Identify immediate life-threatening conditions ● Less than 2 minutes ○ Initial Assessment and Rapid Trauma Survey ○ Delegate any intervention ● Interrupt survey only for: ○ Life-threatening hemorrhage ○ Unsafe scene ○ Airway obstruction ○ Cardiac arrest (expectant) ● General Observations ○ Obvious major injuries or bleeding – immediately control life-threatening bleeding (CAB) ○ Approximate age, sex, weight ○ General appearance ○ Position of patient body and surroundings ○ Patient activity ● Triage multiple patients Interventions ● Initial Level of Consciousness (AVPU) ○ Cervical-spine stabilization ○ Alert ○ Responds to Verbal stimuli ○ Responds to Pain ○ Unresponsive ● Control Hemorrhage ○ Pressure (direct; use hand or knee) ○ Tourniquet ○ Hemostatic agents ● Airway: look,  listen, feel ○ Simple positioning and suctioning ○ If not adequate, perform whatever procedures are indicated and available ● Breathing: look, listen, feel ○ High-flow(10 liters/min) oxygen if available (by mouth) ○ If not adequate, perform whatever procedures are indicated and available ● Circulation: peripheral  pulse ○ No peripheral, check carotid or groin ○ Too fast, too slow, quality (strong, weak/thready) ○ Interrupt (no pulse): cardiac arrest ○ Skin: color, temperature, moisture, condition ●

Primary Survey - Rapid  Trauma Survey ● Head and neck ● Chest ● Abdomen ● Pelvis ● Lower and upper extremities ● Back -------------------

3 Transfer to sked, or just transport Obtain baseline vital signs If altered mental status: ○ Brief neurological exam ■ Pupils, GCS (below 8 = intubate), and signs of cerebral herniation ■ Consider other causes *Decorticate posturing to pain **Decerebrate posturing to pain ● ● ●

Urgent Transport Indicators ● Initial Assessment ○ Altered mental status ○ Abnormal respiration ○ Abnormal circulation ● Shock Potential ○ Abnormal chest exam ○ Tender, distended abdomen ○ Pelvic instability ○ Bilateral femur fractures ○ GSW (gunshot wound) near vital area - look for exit wound Critical Interventions ● If situation and equipment allow: ○ Control major bleeding ○ Manage airway ○ Assist ventilation ○ Administer oxygen ○ Seal sucking chest wound ○ Decompress tension pneumothorax ○ Stabilize impaled object ○ Bind unstable pelvis ○ Prevent hypothermia (decreases O2 circulation) ○ Prepare for transport Ongoing Exam ● Change in condition ○ Patient ○ Interventions ● Perform and record ○ Critical: every 5 minutes ○ Stable: every 15 minutes ○ Each time patient moved ○ With each intervention ● Mental status (LOC and pupils) ● ABCs ● Neck, chest, abdomen ● Previously identified injuries ● Reassess interventions

4 Secondary Survey ● More comprehensive exam ○ Evaluation for all injuries, not just life-threatening ○ Establishes baseline for treatment decisions ● Performed ○ Critical patients—done during evacuation, unless delayed ○ Noncritical patients—at point of injury ● Initial assessment ○ Repeat routinely ● Vital signs ○ Repeat routinely ○ Monitoring ● Detailed exam ○ Head-to-toe ○ FAST exam - ultrasound @ bedside Deformities Contusions Abrasions Penetrations/ Pulses

Burns Lacerations Swelling

Tenderness Instability Crepitation

Summary ● ITLS Patient Assessment ○ Key to trauma care ○ Not difficult ○ Rapid, orderly, thorough ● Remain calm ○ Maximize speed through organization and teamwork

Stop The Bleed ●

When is bleeding life-threatening ? ○ There is pulsing or steady bleeding from the wound ○ Blood is pooling on the ground ○ The overlying clothes are soaked with blood ○ Bandages or makeshift bandages used to cover the wound are ineffective and steadily becoming soaked with blood ○ There is a traumatic amputation of an arm or leg ○ There was prior bleeding and the patient is now in shock (unconscious, confused, pale)

How long does it take to bleed to death from a complete femoral artery and vein disruption? As little as 3 minutes A preventable death - did not have an effective tourniquet applied → bled to death from a leg wound Tourniquet Application ● Applied without delay if indicated ● Both the casualty and the medics are in grave danger while a tourniquet is being applied in this phase - do not use tourniquet for wounds with only minor bleeding

5 Te decision regarding the relative risk of further injury versus that of bleeding to death must be made by the person rendering the care ● Non life threatening bleeding should be ignored until the tactical field care phase ● Apply the tourniquet without removing the uniform - make sure it is clearly proximal to the bleeding site ● If you are uncertain about where the bleeding site is, apply the tourniquet high a high (as proximal to possible) on the arm or leg ● Tighten the tourniquet until bleeding is controlled ● If first the tourniquet fails to control the bleedings, apply a second just above the first ● Don't put tourniquet directly over knee or elbow ● Don't put directly over holster or cargo pocket that contain bulky items Steps (1 handed application) 1. Insert the injured limb through the loop and position tourniquet 2-3 inches above the bleeding site a. If most proximal bleeding iste not readily identifiable, place tourniquet as high as possible on the limb 2. Pull band tightly and fasten it back on itself all the way around the limb, but not over the rod clips a. Bands should be tight enough that tips of three fingers cannot be slid between the band and the limb b. If the tips of 3 fingers slide under band, retighten and re-secure 3. Twist rod until bleeding has stopped 4. Snap the rod inside clip to lock in place a. Check bleeding and distal pulse b. If bleeding not controlled , or distal pulse present, consider more tightening or applying second tourniquet above and side by side to the first c. Reassess Steps (2 handed application) 1. Route band around limb, pass the red tip through the slit of the buckle, and position 2-3 inches above bleeding site a. If most proximal bleeding site not identifiable, place tourniquet as high as possible on limb 2. Pull band tightly and fasten it back on itself all the way around the limb, but not over the rod clips a. Bands should be tight enough that tips of three fingers cannot be slid between the band and the limb b. If the tips of 3 fingers slide under band, retighten and re-secure 3. Twist the rod until bleeding has stopped 4. Snap the rod inside clip to lock in place a. Check bleeding and distal pulse b. If bleeding not controlled , or distal pulse present, consider more tightening or applying second tourniquet above and side by side to the first c. Reassess 5. Route band over the rod and between the clips a. Secure with grey securing strap b. Record time of application Types ● SOFTT - soft tactical tourniquet ● EMT - emergency and military tourniquet Tourniquet Mistakes To Avoid LOOOKK UPPPP Pain ● Tourniquets HURT when applied effectively ● Does not necessarily indicate mistake ●

6 ● Doesn't mean you should take off ● Manage pain per TCCC guidelines After Application ● Monitor casualty closely to ensure tourniquet remains tights and bleeding controlled ● REASSESS Points to Remember ● 1. DO not remove tourniquet if: ○ Extremity distal to the tourniquet has been traumatically amputated ○ Casualty is in shock ○ Tourniquet has been on for more than 6 hours ○ Casualty will arrive at a medical treatment facility within 2 hours after time of application ○ Tactical or medical considerations make transition to other hemorrhage control methods inadvisable ● 2. Consider removing the tourniquet if: ○ Bleeding can be controlled by other methods ○ Transport time to definitive care is prolonged ○ The team medic is the only person who should assess and remove the tourniquet. ● 3. Once applied DO NOT periodically loosen it to allow circulation to return to limb ○ Causes unacceptable additional blood loss ○ Has caused at least one near fatality in 2005 Removing Tourniquet ● Loosen the tourniquet slowly. ○ Observe for bleeding. ● Apply a hemostatic agent to the wound if it is still bleeding. ● If bleeding remains controlled, cover the hemostatic agent with a pressure dressing. ○ Leave loose tourniquet in place. ● If bleeding is not controlled, retighten the tourniquet. Hemorrhage control ● Some wounds are located in places where a tourniquet cannot be applied: ○ Neck ○ Axilla ○ Groin ● The use of a hemorrhagic agent (combat gauze) is generally not tactically feasible in CUF because of the requirement to hold direct pressure for 3 minutes

Chest Trauma Overview ● Anatomy of chest ● Chest Injuries ○ Open pneumothorax ○ Tension pneumothorax ○ Hemothorax ○ Flail chest ○ Pericardial tamponade ○ Other chest injuries

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Mechanisms of Injury ● Blunt Trauma ○ Direct compression ■ Laceration of solid organs ■ Rupture of hollow organs ○ Acceleration/Deceleration force ○ Energy transmitted from mass and velocity ■ Blast injuries ■ Tearing of organs and blood vessels ● Penetrating Trauma ○ Piercing of organs and/or vasculature ○ How deep? (superficial or problematic) Chest (Thoracic) Trauma ● A common trauma injury ○ 50% of multiple trauma incidents ○ 25% of trauma deaths ● Potentially fatal thoracic injuries can be averted by early recognition of the injury and appropriate intervention(s) Tissue hypoxia ● Due to: ○ Inadequate oxygen delivery ○ Hypovolemia ○ Ventilation/perfusion mismatch ○ Intrathoracic pressure changes ○ Cardiac (“Pump”) failure Manifestations ● Shortness of breath ● Chest pain ● Hemoptysis ● Cyanosis ● Distended neck veins ● Tracheal deviation - one side of chest has air leakage, causing overinflation on the other (late sign) ● Asymmetrical chest wall movement - rib fractures ● Chest wall contusion ● Open “sucking” chest wound - hole in chest wall → air sucked in through hole with breath ● Subcutaneous emphysema - bubble/crackles (air leak) ● Shock - bp falls, (Increased HR) ● Tenderness, instability, crepitation (TIC) - friction rub, bone on bone or air ● Abnormal breath sounds Primary Survey ● 1. Massive hemorrhage ● 2. Airway obstruction ● 3. Respirations ● 4. Circulation ● 5. Hypothermia Secondary Survey

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Cardiac contusion Pulmonary contusion Tracheal or bronchial tree injury Aortic dissection/ruptured aorta Diaphragm tear - loss of main muscle for respiration Diffuse blast injury/shock lung

Open Pneumothorax a.k.a “Sucking Chest Wound” ● ● ●

Air enters pleural space on inhalation (hole in chest wall) Ventilation impaired hypoxia s/s proportional to size of defect

Open “simple pneumothorax” cover chest all defect

Tension Pneumothorax SOB, rapid breathing Anxiety Distended neck veins Tracheal deviation Breath sounds diminished ○ Hypertympany if percussed ● Shock with hypotension Treatment ● Decompress the affected side ○ Place needle urgently ○ Chest tube follow up ● Urgent evacuation ● ● ● ● ●

Hemothorax ● Bleeding into chest cavity s/s (of shock) ● Anxiety and confusion ● Neck veins ○ Flat = hypovolemia ○ Distended = mediastinal compression ● Decreased breath sounds ● Dullness on percussion ● Shock (hypotension/tachycardia) Massive hemothorax ● Treat shock ● Fluid/blood administration ○ Titrate to palpate a peripheral pulse (80-90 mmHg) ● Urgent evacuation

Flail chest ● ●

Assist ventilation Consider endotracheal intubation

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Stabilize the flail segment ○ Sandbags, manual, or body pressure Monitor closely for signs of ○ Pulmonary contusion ○ Hemothorax ○ Pneumothorax

Cardial (Pericardial) Tamponade Beck’s triad ○ Muffled heart sounds ○ Hypotension ○ Distended neck veins ● Paradoxical pulse ● Equal breath sounds Treatment ● Treat for shock ● Fluid administration ○ Titrate to peripheral pulse ● Pericardiocentesis ● Monitor and treat dysrhythmias ● Monitor for: ○ Hemothorax ○ Pneumothorax ●

Myocardial Contusion ● Most common cardiac injury due to blunt trauma ● Treat as myocardial infarction Similar symptoms as myocardial infarction ● Chest pain ● Dysrhythmias ● Cardiogenic shock (rare)

Pulmonary Contusion ● ● ● ●

Commonly occurs due to blunt trauma to the chest Takes hours to develop Patient displays significant hypoxemia May have concurrent tracheal or bronchial tree injury

Diaphragmatic Rupture ● ● ●

Results from a significant blow to abdomen Herniation of abdominal organs ○ More common on left side ○ Diminished breath sounds ○ Bowel sounds auscultated in chest (rare)

Traumatic Aortic Rupture

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Most common cause of death at the scene ○ Motor vehicle crash or fall from a height ○ 80% fatality rate Mechanism of injury and history are crucial ○ No obvious sign of chest trauma ○ Sudden cardiac arrest

Summary ● Trauma to the chest occur often. ● You may be unable to rapidly evacuate the patient. You must be prepared to provide ongoing care ● Chest trauma may be life-threatening. ● Many injuries may be temporized with prompt recognition and rapid treatment

Head Trauma Overview ● Anatomy of head and brain ● Pathophysiology of traumatic injury ● Primary and secondary injury ○ Mechanisms of secondary brain injury ● Assessment, management, potential problems ● Management of cerebral herniation syndrome Head Trauma ● Traumatic brain injury (TBI) ○ Major cause of death and disability ○ CNS injury in 40% multiple trauma ■ Death rate twice of non-CNS injury ○ 25% of trauma fatalities ○ Assume spinal injury with serious injury ○ Potential for altered mental status Brain Injury ● Primary ○ Immediate damage to brain tissue ○ Direct result of injury force ○ Little can change injury after it occurs ● Secondary ○ Result of hypoxia or decreased perfusion ○ Prehospital care can help prevent Brain Anatomy ● Intracranial volume ○ Brain ○ CSF ○ Blood vessel volume ■ Dilatation with high pCO2

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Constriction with low pCO2 ● Slight effect on volume

Increasing ICP ● Cushing's response ○ As ICP increases, systolic BP increases ○ As systolic BP increases, pulse rate decreases Vital Sign

Change With Increasing ICP

Respiration

Increase, decreased, irregular

Pulse

Decrease

Blood pressure

Increase, widening pulse pressure

Cerebral Herniation Syndrome ● Brain forced downward ○ CSF flow obstructed, pressure on brainstem ● Level of consciousness ○ Decreasing, rapid progression to coma ● Associated symptoms ○ Ipsilateral pupil dilatation, out-downward deviation ○ Contralateral paralysis or decerebrate posturing ○ Respiratory arrest, death Hyperventilation Rates Age Group

Normal Rate

Hyperventilation

Adult

8-10 per min

20 per min

Children

15 per min

25 per min

Infant

20 per min

30 per min

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Capnography ○ Maintain ETCO2 30-35 mmHg

Scalp Wound ● Highly vascular, bleeds briskly ○ Shock: child - may develop ○ Shock: adult - another cause ● Management ○ No unstable fracture: direct pressure, dressings ○ Unstable fracture: dressings, avoid direct pressure Skull Injuries ● Linear nondisplaced ● Depressed ● Compound

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Suspect fracture ○ Large contusion or darkened swelling Management ○ Dressing, avoid excess pressure

Brain Injuries Concussion ● No structural injury to brain ● Level of consciousness ○ Variable period of unconsciousness or confusion ○ Followed by return to normal consciousness ● Retrograde short-term amnesia ○ May repeat questions over and over ● Associated symptoms ○ Dizziness, headache, nausea and/or ringing in ears Cerebral contusion ● Bruising of brain tissue ○ Swelling may be rapid and severe ● Level of consciousness ○ Prolonged unconsciousness, profound confusion or amnesia ● Associated symptoms ○ Focal neurological signs ○ May have personality changes Diffuse axonal injury ● Diffuse injury ○ Generalized edema ○ No structural lesion ○ Most common injury from severe blunt head trauma ● Associated symptoms ○ Unconscious ○ No focal deficits Hypoxic brain injury ● Small cerebral artery spasms due to anoxia ● No-reflow phenomenon ○ Cannot restore perfusion of cortex after 4–6 minutes of anoxia ○ Irreversible damage occurs > 4–6 minutes ● Hypothermia seems protective Intracranial hemorrhage ● Epidural ○ Between skull and dura ○ Acute epidural hematoma ■ Arterial bleed ● Temporal fracture common ● Onset: minutes to hours ■ Level of consciousness ● Initial loss of consciousness ● “Lucid interval” follows ■ Associated symptoms

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Ipsilateral dilated fixed pupil, signs of increasing ICP, unconsciousness, contralateral paralysis, death

Subdural ○ Between the dura and arachnoid ○ Acute subdural hematoma ■ Venous bleed ● Onset: hours to days ■ Level of consciousness ● Fluctuations ■ Associated symptoms ● Headache ● Focal neurologic signs ■ High-risk ● Alcoholics, elderly, taking anticoagulants Intracerebral ○ Directly into brain tissue ○ Intracerebral hemorrhage ■ Arterial or venous ● Surgery is often not helpful ■ Level of consciousness ● Alterations common ■ Associated symptoms ● Varies with region and degree ● Pattern similar to stroke ● Headache and vomiting Subarachnoid ○ Between the arachnoid and pia mater ○ Subarachnoid hemorrhage ■ Blood in subarachnoid space ● Intravascular fluid “leaks” into brain ● Fluid “leak” causes more edema ■ Associated symptoms ● Severe headache ● Vomiting ● Coma ● Cerebral herniation syndrome possible

Head Trauma Assessment ● ITLS Primary Survey ○ Every trauma patient initially evaluated in the same sequence ○ Limit patient agitation, straining, vomiting ■ Contributes to elevated ICP ○ Airway ■ Vomiting common within first hour ■ Advanced airway insertion ■ Supraglottic device ■ Endotracheal intubation (DAI) ● Rapid Trauma Survey

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Head ■ ■ ■ ■

Lacerations Depressed or open skull fractures Stability of skull Signs of basilar skull fracture ● Battle’s sign ● Raccoon eyes

Pupils ■ ■ ■ ■

3rd cranial nerve Bilateral dilated, unreactive probable brain stem injury Unilateral dilated, reactive may be ICP Other causes ● Hypothermia ● Drugs ● Anoxia ● Ocular trauma Extremities ■ Decorticate -  Arms  flexedand legs extended ■ Decerebrate - Arms extendedand legs extended

Secondary survey ○ Evacuate as soon as possible if critical Ongoing Exam ○ Record ■ Level of consciousness ■ Pupil size and reaction ■ Weakness or paralysis ■ GCS (Glasgow  Coma Scale) →  Suspect severe brain injury < 9

The Injured Brain ● Hypotens...