Complex Care Nursing (Critical Care Nursing)
Complex Care Nursing (Critical Care Nursing) NSG 4413
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Ch. 55: Trauma CC Exam 4 Chapter 55: Trauma Mechanism of Injury Knowing the mechanism of injury is important because this information can be helpful to explain the type of injury and predict eventual outcomes, and identify common injury combinations. An injury may exist without exhibition of classic signs, and thus, knowing the mechanism of injury can prompt additional diagnostic workup and reassessment Mechanism of injury is related to the type of injuring force and subsequent tissue response Factors including environment, age, sex and presence of underlying disease and anatomical location also play a part in presentation of injury Forces depends on energy delivered and area of contact force=mass x acceleration • Blunt injury o MVCs, falls, assaults, and contact sports Often more deadly than penetrating because trauma can be masked and diagnosis more difficult o Combination of forces: acceleration, deceleration, shearing, crushing, and compressive resistance Injury caused by direct contact between body and injuring agent Injury occurs as a result of energy released and tendency for tissues to become displaced o Size and shape of vehicle can change injury pattern Three collisions in MVC Car vs another object Occupants body with interior of car Internal tissues with the rigid body surface structure Restraints reduce incidence and severity of injury • Penetrating injury o Foreign objects penetrating the tissue Severity related to structures damaged Damages in determines by amount of energy created and dissipated into surrounding tissues and the time it takes for the damage to occur, external appearances do not reflect internal injury Velocity determines extent of cavitation and tissue damage low velocity missiles localize injury and do not create much cavitation essentially pushing tissue aside high velocity causes more serious injury because of the amount of energy and cavitation produced o damage depends on three factors density and compressibility of tissue injured, missiles velocity, and fragmentation of primary missile o Gunshot, stab wound Make sure to obtain weapon, ammo, and ballistics Stab wound is low velocity injury Main determinant are depth and length, trajectory, and presence of vital organs Assessment & Management try to figure out what precipitated injury • Prehospital management 1 Ch. 55: Trauma CC Exam 4 o Greater chance of positive outcome if admitted to trauma center and definitive care initiated within one hour of injury o Emphasis for prehospital management should be airway maintenance, external bleeding, shock prevention, and spinal column stabilization • Maintain the airway, ensure adequate ventilation, control external bleeding and prevent shock, maintain spine immobilization, and transport to the closest appropriate facility. • Transporting the patient to a level I facility allows definitive care to be initiated earlier in the process, thereby reducing patient mortality. InHospital Management Optimal care involved a preplanned emergency phase involving a predetermined response team with defined roles and expectation o Necessary so that multiple procedures can be acco0mplished simultaneously • Primary survey o Life threatening injuries identified and managed o Airway, breathing, ventilation, and lifethreatening injuries identified o ET intubation, Chest tube insertion, IV access o Chest, abd, and pelvis imaging done at this time o Assess for hypovolemia Poor skin integrity, diaphoresis, tachycardia, hypotension o EkG performed, pulse ox, Foley, ng tube, labs drawn (H&H, ABGS), hypothermia • Secondary survey o Detailed headtotoe survey, plan for appropriate diagnostic tests o Nonlife threatening injuries assessed at this time, xrays, ultrasounds, and CT studies done now o More detailed patient history obtained now, MVC? Wearing a seatbelt, where did it happen? Speed of impact? Fatalities? Falls or trauma? • Tertiary survey o On admission to the ICU, another headtotoe examination, assess response to interventions, labs and xrays reviewed Fluid Administration • Crystalloids o Isotonic, hypotonic, and hypertonic, typically at least 2 liters of isotonic (NS, LR) o Typically used for trauma patients, contain water and electrolytes including sodium, potassium, and chloride o Mimic body extracellular fluid and expand intra and extravascular fluid volume o Can be broken down by tonicity which is based on the amount of sodium in fluid Hypertonic 3% saline solution, pulls fluid into intravascular space Isotonic 0.9% NS, causes minimal shift of fluid Hypotonic D5W, pulls fluid into extracellular space may cause swelling o Hypertonic saline has been shown to improve cardiac function with a smaller volume of fluid, depending on the strength (3, 7.5, or 23.4) as little as 4ml/kg given rapidly can have the same effect as several liters of isotonic crystalloids Pulls water into intravascular space causing a rapid increase in CO, BP and peripheral vasodilation o Studies have shown that infusion of isotonic solutions in patient with hypotension may displace a hemostatic clot and cause more bleeding 2 Ch. 55: Trauma CC Exam 4 • Colloids o Rapid volume expander (albumin, hetastarch) o Albumin, dextran create oncotic pressure which encourages fluid retention and movement of fluid into the intravascular space o Longer duration of action because they are larger molecules and are more3 efficient in expanding plasma volume, use a smaller volume, and increase colloid osmotic pressure Less volume of fluid needed to obtain hemodynamic stability o No evidence to suggest colloids are superior to crystalloids for resuscitation of trauma patient • Blood products o Hemodynamically unstable or are showing signs of tissue hypoxia despite crystalloid infusion o RBC increase O2 carrying capacity and allow for volume expansion Maintenance of adequate oxygen delivery is critical to the bleeding trauma patient o Blood stays in the intravascular compartment for longer than other resuscitation fluids o Blood should be transfused when patients are hemodynamically unstable or are showing signs of tissue hypoxia despite crystalloid infusion o ONEG is preferred because of no need for cross matching o OPOS may be used in men and women postmenopausal o If large amounts of blood are needed, FFP is administered to ensure replacement of coagulation factors o With admin of blood products, ARDS and DIC risks are heightened o Auto transfusion is also an option for trauma patients, blood is captured from chest tube, filtered and reinstilled to patient • Blood substitutes o Don’t require crossmatching o Long shelf life, are not immunosuppressive Damage Control stabilizes unstable patients and uses staged surgery after initial resuscitation; designed to avoid lethal triad of hypothermia, acidosis, and coagulopathy before definitive treatment can be performed • Stage 1: Stop hemorrhage; control contamination and closure methods to close wounds temporarily. • Stage 2: Correct physiological abnormalities in the ICU by warming and ensuring adequate resuscitation as well as correcting coagulopathy. • Stage 3 (final stage): Definitive operative management • Goal is to abbreviate surgical interventions before development of irreversible physiological end points Thoracic Trauma • Range from Minor abrasions to lifethreatening insults to thoracic viscera • Managed with chest tube insertion, mechanical ventilation, aggressive pain control, and supportive care • Great vessel injuries or disruption to the heart usually results in immediate death. • Airway obstruction, tension pneumothorax, cardiac tamponade, open pneumothorax, massive hemothorax, and flail chest require immediate treatment. o Can lead to early death (30 minutes to 3 hours after injury) 3 Ch. 55: Trauma CC Exam 4 • Thoracic aortic disruption, tracheobronchial disruption, myocardial contusion, traumatic diaphragm tear, esophageal disruption, and pulmonary contusion should be addressed during the secondary survey • First priority is always airway patency; adequate oxygenation, protection from aspiration, airway obstruction by tongue, loosened teeth, dentures, and blood • Tracheobronchial trauma o Ruptured bronchi often associated with upper rib fractures and pneumothoraxes o Airway injuries often subtle Signs include dyspnea (often only sign), hemoptysis, cough, subcutaneous emphysema, anxiety, and air hunger Cyanosis is late sign o Chest xray may show injury, diagnosis is made with bronchoscopy or surgery o Small pleural tears or lung lacs can be managed with mechanical ventilation • Bony thorax fractures o Rib and sternal fractures, and flail chest are commonly seen and are clinically significant as Markers of serious intrathoracic and abdominal injuries Sources of significant pain and Predictors of pulmonary deterioration o Rib fractures commonly associated with pneumothorax, hemothorax, and pulmonary contusion, and the most frequently injured intraabdominal organs are liver and spleen o Greatest concerns are ineffective ventilation and secretion control o Ribs 1 and 2 often protected by clavicle, scapula, humerus and surrounding muscles and fracture often indicates high impact trauma o Robs 410 most commonly fractured in blunt force trauma and often associated with lung injury o Flail chest Injury involving multiple rib fractures; can be anterior, posterior, or lateral and usually a sternal fracture is present as well, Stability of thorax is disrupted and rib cage no longer moves in unison This creates a free floating structure and segment does not respond to action of respiratory muscles; rather it moves with changes in pleural pressure Flail chest causes a decrease in normal negative pressure and decreases ventilation and causing hypoxia If allowed to progress, can lead to need for mechanical ventilation Turn patient injured side down to improve oxygenation • Pleural space injuries o Pneumothorax(intrapleural air collection) o Hemothorax (intrapleural blood collection) o Hemopneumothorax (intrapleural air and blood collection) o Caused by disruption of intrathoracic structures allowing air to build up in the pleural layers leading to a decrease in negative intrathoracic pressure o Mechanism of injury make cause a nurse to suspect this type of injury (MVC where driver hits steering wheel) o CXR is used to diagnose o Maintain ABCs Large bore chest tube inserted to reexpand lung and drain air or blood, th Inserted midaxillary line b/w 4&5 intercostal space 4 Ch. 55: Trauma CC Exam 4 o Drainage of more than 250mL/hr for 2 consecutive hours may indicate missed injury o Massive hemothorax is defined as 1.5 to 4L of blood in chest cavity Left massive hemo is more common than right and associated with aortic rupture o Tension pneumothorax formed when air escaped into pleural space with no escape, compress heart and lungs with increased pressure o Difficult to dx Difficult to ventilate despite open airway, drop in O2, chest asymmetry, tracheal shift, neck vein distention (unless hypovolemic), decreased breath sounds of affected side, decreased CO Treat with decompression of air with thoracentesis • Pulmonary contusion o Bruising of lung parenchyma, most common lung injury o Appears on CT as illdefined ground glass density regions of opacity, CT is more sensitive b/c may take up to 24 hours to show up on chest xray Presence of scapular fracture, rib fracture, or flail chest should lead to suspicion of Pulmonary contusion o Occurs when rapid deceleration ruptures cell walls causing hemorrhage and extravasation of plasma and protein into alveolar in interstitial spaces, this results in atelectasis and consolidation leading to intrapulmonary shunting and hypoxemia o Treatment is supportive and ABGs may be drawn frequently o Severe pulmonary embolism may require mechanical ventilation with PEEP • Blunt cardiac injuries o Myocardial bruising to cardiac rupture and death o Include cardiac wall rupture, valvular disruption, coronary artery dissection, cardiac contusion Class 1 BCI w/ cardiac free wall rupture Class 2 BCI with septal rupture Class 3 BCI with coronary artery injury Class 4 BCI with cardiac failure Class 5 BCI with complex dysrhythmias Class 6 BCI with minor EKG or cardiac enzyme abnormalities • Penetrating cardiac injuries o Most result in prehospital death, those who survive do so because of cardiac tamponade o Cardiac tamponade and hypovolemic shock are common signs o Right ventricle is most commonly injured due to its anterior location • Cardiac tamponade o Caused by blood filling the pericardium and compressing the heart, causing decreased cardiac filling which leads to reduced CO and eventually shock o Classic signs include decreased BP, muffled heart sounds, and increased central venous pressure manifested by distended neck veins (Beck’s triad) o Another key is pulsus paradoxus inspiratory systolic fall in arterial pressure of 10mmHg or more during normal breathing o Treatment involves airway control, oxygenation, hemodynamic support and rapid transport to definitive care center • Aortic injury o Death is immediate in 7590 percent, location and size determine significance o Aortography is the gold standard for diagnosis of aortic injury 5 Ch. 55: Trauma CC Exam 4 o Three common locations of vessel rupture; because the aorta is very mobile, tears occur at points of fixation Aortic isthmus most common, just distal to the left subclavian artery where vessel is attached to the chest wall by the liagamentum arteriosum Ascending aorta where aorta leaves pericardial sac Entry to the diaphragm o Inner layers tear on impact from decel. Outer layers balloon into pseudoanuerysm o Penetrating mediastinal injuries or thoracic injuries caused by blunt trauma, first or second rib fractures, high sternal fractures, clavicular fractures at sternal margin and massive leftsided hemothorax o Main physiological problem is loos of blood transport to organs o Widene3d mediastinum on cxr may indicate tear. o Nursing care focuses on hemodynamic monitoring with pulmonary catheter and titrating medications to maintain optimal blood flow Abdominal Trauma; can lead rapidly to death from hemorrhage, shock, and sepsis, associated with more fatalities because they can be hidden and lead to a delay in diagnosis, deaths after 48 hours are due to sepsis and complication. • The three areas are the following: • The peritoneal area, which includes the diaphragm, liver, spleen, stomach, transverse colon, and the portion covered by the bony thorax • The retroperitoneal area, which includes the aorta, vena cava, pancreas, kidney, ureters, and parts of the duodenum and colon • The pelvis, which includes the rectum, bladder, uterus, and the iliac vessels • MVCs are the most common cause, followed by assaults, falls, pedestrian–motor vehicle collisions, and industrial accidents. o Injuries occur as a result of compressive, crushing, shearing, and deceleration forces • Abdominal tenderness or guarding, hemodynamic instability, lumbar spine injury, pelvic fracture, retroperitoneal or intraperitoneal air • Solid organs respond to trauma with bleeding, hollow organs rupture and release contents into peritoneal cavity • Abdomen is assessed and reassessed, and laboratory and diagnostic tests are performed. • Stab wounds, impalements, and gunshot wounds can cause penetrating trauma o Knowledge about the size, shape and length of the instrument used is helpful in determining the extent of intraabdominal trauma o Impalement is considered a dirty wound which can lead to high mortality rate second to infection o GSW are difficult to evaluatevelocity and amount of energy dispersed by bullet determine extent of injury; bullets can rebound off organs or bone changing trajectory and causing massive internal damage • Unrecognized abdominal trauma is a cause of preventable death, nurse must understand mechanism of injury as well as patient’s complaints to perform adequate assessment • Orogastric or nasogastric tube, and Foley catheter • Local wound exploration o Necessary to determine extent of damage o If wound if on anterior aspect of abdomen the likelihood of penetration of the peritoneum is low o If injury occurred in the thoracoabdominal region, exploration is not recommended due to increased risk for tension pneumo 6 Ch. 55: Trauma CC Exam 4 o Exploration of back wounds is difficult and usually requires triple contract CT • Laparoscopy, thoracoscopy, or exploratory laparotomy • Focused abdominal sonography for trauma (FAST), diagnostic peritoneal lavage (DPL), a chest radiograph, and an abdominal CT scan o Diagnostic peritoneal lavage Indications Blunt abdominal injury with o Altered mental status o Unexplained hypotension, decreased hematocrit, shock o Equivocal results of abdominal examination o Spinal cord injury o Distracting injury (orthopedic factors, chest trauma) Penetrating abdominal trauma (if exploration is not indicated) Possible contraindication Hx of multiple abd operations 3 trimester Advanced cirrhosis of liver Morbid obesity Known hx of coagulopathy Technique Insert lavage cath in peritoneal cavity through 12cm incision Attempt to aspirate peritoneal fluid Infuse NS or LR by gravity Turn pt. from side to side Allow fluid to run back in by gravity Send specimen to lab Positive results 1020mL gross blood on initial aspirate Greater than 100,000 RBD >50,000 WBC Elevated amylase Presence of bile, bacteria, or fecal matter o Focused abdominal sonography for trauma is ideal because its fast, portable, and reproducible Areas evaluated are Morison’s pouch in the right upper quadrant, the pericardial sac, the splenorenal region in the left upper quadrant, and the pelvis o CT scans are also being used for trauma; CT allows visualization of the retroperitoneal, peritoneal, and pelvic areas and permits estimation of the amount of fluid in these areas • Trauma to the esophagus and diaphragm o Esophageal injury is rare and very difficult to diagnose because of the initial lack of clinical signs and severity of other injuries; high death rate o Penetrating trauma is the most likely cause and usually the cervical esophagus is where injury occurs o Diagnosis includes CT of chest, abd, and pelvis with and without contrast o NPO and NG tube to suction o Diaphragm rupture is more common in blunt injury than penetrating o Usually occurs on left side because there the diaphragm is not protected by the liver 7 Ch. 55: Trauma CC Exam 4 o Rupture can lead to bowel strangulation due to herniation of bowel into the thorax o Respiratory dysfunction may occur due to impairment of lung capacity and displacement of normal lung tissue o Difficult to diagnose Minimal bleeding and often asymptomatic Marked respiratory distress, dyspnea, decreased breath sounds on the affected side and paradoxical movement with breathing • Trauma to the stomach and small bowel o Stomach Gastric injury is rare, small bowel injuries much more common Frequently damaged by penetrating, can also be ruptured by forced Multiple convolutions sometimes form closed loops which can rupture when subjected to blunt force pressure o Steering wheel or seat belt Blood in the NG tube aspirate or hematemesis Diagnosis often not made until peritonitis develop, positive DPL, usually requires surgery Postop decompression with NG tube maintained until bowel function returns Due to relatively small amount and risk of bacteria in stomach and small intestine, sepsis is small, however the gastric acid can irritate the peritoneum causing peritonitis o Trauma to the duodenum and pancreas Great deal of force needed to rupture these organs since they are so well protected, most injuries are penetrating Injuries to adjacent organs almost always present, diagnosis with abd CT Small lacs or contusions may only require drains, but larger injuries require surgical repair s/s acute abd, increased serum amylase levels, epigastric pain radiating to back, nausea and vomiting damage to pancreas is associated with duodenal injury and sever hemorrhage because of its close proximity of vascular structures nursing care includes; patency of drains, must be monitored for the development of fistulas due to the high enzymatic action of pancreatic fluid primary repair or resection with reanastamosis is sufficient to manage most penetrating duodenal injuries Blunt trauma can lead to intramural hematoma and duodenal obstruction. Diagnosis made with gastrograffin upper GI study o Trauma to the colon Usually a result of penetrating injury, often almost always dictates surgical exploration Primary repair may be considered if pt. is hemodynamically stable and injury is small without fecal contamination Spilling of contents into the peritoneum can result in severe sepsis and abscess formation Postop nursing care focuses on prevention of infection, dressing changes are needed for open incisions and prophylaxis abx may be used. If colostomy is used for repair, bud must be kept covered and moist with nonadherent dressing, imaging studies may be used to find and drain abscesses 8 Ch. 55: Trauma CC Exam 4 o Trauma to the liver Along with spleen, the liver is the most commonly injured abd organ, can be caused by both penetrating and blunt force Fractures of the lower right ribs increase suspicion for a liver injury s/s may include right upper quadrant pain, rebound tenderness, hypoactive or absent bowel sounds or signs of hypovolemic shock if stable, most patients are treated nonoperatively; observation is standard treatment unless hemodynamically unstable or has frank peritonitis liver is manifested to heal itself serial CT scans are needed to confirm bleeding has stopped hepatic trauma can lead to large blood loss into the peritoneum large liver injuries need postoperative drainage of bile and blood with closed suction drains After surgery, coagulopathies may be present: bleeding may arise from numerous sites, whereas incomplete hemostasis is mainly from the surgical site. Treatment includes replacement of blood products while monitoring the hematocrit and coag studies Potential complications include hepatic or peripheral abscess, biliary obstruction or leak, sepsis, ARDS, and DIC; patient should refrain from contact sports until clear CT o Trauma to the spleen Most commonly injured organ along with the liver; in 60% of pts with blunt trauma, the spleen is the only organ injured; vascularloses blood rapidly Left lower rib fractures increase suspicion for splenic injury S/S: left upper quadrant pain radiating to left shoulder (Kehr’s sign), hypovolemic shock, nonspecific finding of increased WBC FAST, DPL, or ABD CT needed for DIAGNOSIS Management includes observation, embolization, or surgery (unstable patient’s require immediate surgery to determine source of bleeding), pts hemodynamically stable can be observed closely (see chart on pg. 1252) 5070% of hemodynamically stable pts are observed. 5 days is standard, observed for hypotension and signs of bleeding, H&H q6 till stable Early complications include recurrent bleeding, subphrenic abscess, pancreatitis resulting from surgical trauma Splenectomy predisposes the patient to an increased risk for infection and overwhelming post splenectomy sepsis OPSS frequently begins with onset of pneumococcal pneumonia which progresses to a fulminant sepsis Complications of OPSS include: adrenal insufficiency and DIC o Trauma to kidneys Sudden deceleration tears renal artery intima and avulses smaller vessels leading to a free bleed Blunt and penetrating trauma can lead to laceration of contusion Can be suspect with lower rib fractures, liver and spleen injuries S/S: hematuria, flank pain, flank hematoma, ecchymosis over flank Difficult to detect, helical CT, ultrasound, or IV pyelogram used Graded on severity increased grade correlates to decreased function Can be treated conservatively unless severe vascular injury is present and surgical repair of nephrectomy is present 9 Ch. 55: Trauma CC Exam 4 Postop assessment and support of renal function is vital, optimal fluid balance must be maintained; low dose dopamine may be ordered to promote renal perfusion o Trauma to bladder Can be lacerated, ruptured or contused most often as a result of blunt trauma (usually because of a full bladder at time of injury) Frequently associated with pelvic fractures Gross hematuria associated with bladder rupture, presence of blood at the urethral meatus, a scrotal hematoma, or a displaced prostate gland requires examination for urethral injuries with a CT scan or conventional cystography before insertion of urinary catheter May require suprapubic cystostomy Musculoskeletal Injuries • Usually not considered life threatening unless there is a traumatic amputation or pelvic fracture • Assessment is done in the secondary survey after hemodynamic stabilization. • Major causes MVCs, falls, assaults, industrial, farming, and home accidents • Important to understand the circumstances surrounding and the mechanism • Cervical spine, chest, and pelvis films are obtained first, CT, MRI. o Pelvic fractures commonly caused by MVC, MCC, or motor vehicle –pedestrian collision o Thought to contribute to traumatic death, 1840% mortality rate within first 24 hours, most due to acute blood loss o Pelvic ring fractures associated with motor vehicles and high energy mechanisms, patients often have soft tissue injury o Treatment goal of pelvic fracture is to stop bleeding and prevent loss of function and sepsis caused by open fractures o Permanent orthopedic repair of pelvic fractures usually with 2448 hours when the patient is hemodynamically stable • Limb swelling, ecchymosis, or deformity is noted, that extremity should be immobilized. • Test the extremities for capillary refill, pulses, crepitus, muscle spasm, movement, sensation, and pain. o Injuries can include fractures, fracture dislocations, amputations, and trauma to the soft tissue Fracture classification is based on type, cause, and anatomical location If skin is broken, it is an open fracture, skin closed is a closed fracture Dislocation occurs when articulating surfaces of a joint are no longer in contact because of joint disruption usually accompanied by ligament injury Amputation classified according to the amount of tissue. Nerve, and vascular damage Can be clean or crush or avulsion amputation • Require continuous assessment for hypovolemia o Traumatic amputation and pelvic ring fractures known for extensive blood loss; rarely do patients receive musculoskeletal injuries without other systemic injuries • Monitor for vascular or neurological compromise. o Nerves are very sensitive to impaired circulation and compression • Bleeding can occur from arterial or venous sites as well as cancellous bone • Infection is common with open injuries. o Ideally brought to operating room within six hours of injury for a washout of affected area 10 Ch. 55: Trauma CC Exam 4 o Tetanus booster given to all patients with open injuries • Related Musculoskeletal Injuries o Compartment syndrome When pressure inside fascia enclosed muscle compartment is increased causing blood flow to muscle and nerves in the compartment to become compromised Final result is cellular anoxia, ischemia leads to tissue damage which compromises nerve and muscle function Prolonged elevation of compartments pressure leads to death of muscles and nerves involved Normal is 08mmHg, compression happens at 20mmHg, pain develops at 2030, ischemia occurs at greater than 30 Fasciotomy is recommended when compartment pressure approaches 20 mmHg below diastolic pressure Pain out of proportion to injury, decreased sensation, pallor and pulselessness late signs o Deep venous thrombosis Virchow’s triad Venous stasis from decreased blood flow, decreased muscular activity, a and external pressure on the deep veins Vascular damage or concomitant pathological state Hypercoagulability Positive homans sign, swelling of the affected area, tachycardia, fever, and distal skin color and temp changes o Pulmonary embolus Clot dislodges from the vein, travels through the heart and lodges in the pulmonary artery, obstructing blood flow Sudden onset of dyspnea is classic sign of PE but signs and symptoms may vary Decline in oxygenation, substernal chest pain, hypovolemic relative shock, tachypnea, SOB, anxiety, feeling of impending doom, low grade fever o Fat embolism syndrome Fat globules in the lung tissue and peripheral circulation after a long bone fracture or major trauma Classic triad of symptoms Hypoxemia, neurological decline, and petechial rash Usually within 24 72 hours of injury Tachypnea, dyspnea, and hypoxemia Pts develop neurological changes after respiratory distress Usually completely reversible Rask occurs on the head neck and anterior thorax and subconjucntiva Maxillofacial Trauma (DO NOT PUT AN NG TUBE IN) • Degree of maxillofacial injury is directly related to the force at impact. o Rated using le fort fracture grading scale pg. 1256 • Priorities remain airway, breathing, and circulation. o Establish airway critical due to sift tissue damage and swelling • Assess soft tissues as well as bony structures o Palpates soft and bony structures for movement of bony structures 11 Ch. 55: Trauma CC Exam 4 • Cranial nerves are assessed. • Neurological examination since head trauma usually accompanies facial injury • Need for tetanus with soft tissue injury • May require an operation for washout to debride the tissue and clean the area Complications of Multiple Traumas • Death from multiple traumas may occur immediate or short thereafter or as a result of complications later o Most common causes of immediate deaths are brainstem or high spinal cord injury o Cardiac rupture, transection of the great vessels o Airway obstruction • Early complications o Head trauma, hemorrhage o Can often be prevented with quick assessment, resuscitation, and management of injuries o Hemorrhage must be controlled and volume resuscitation begun with infusion of crystalloids and blood • Late complications o Hypovolemic shock, Massive hemorrhage or continued bleeding leading to decreased tissue perfusion o infection and sepsis, Increased risk after short range shotgun blasts, highvelocity penetrating injuries, penetrating wounds to colon, prolonged surgery, multiple blood transfusions, and injury to multiple organs Can range from minor wound to sepsis, in septic shock, release of toxins results in dilation of vessels leading to venous pooling and decreased systemic vascular resistance Source of infection must be found and eradicated, cultures obtained, BAX prescribed, rays done Hemodynamics are altered and metabolic demands are increased during sepsis Elevated cardiac output, decrease SVR, and increased oxygen consumption Research shows that nutritional support decreases development of sepsis and MODS o ARDS, Syndrome of lung injury characterized by dyspnea, sever hypoxemia, decreased lung compliance, and diffuse bilateral pulmonary infiltrates Sepsis may predispose pt. to ARDS, in addition, head trauma, pulmonary contusion, and multiple major fractures, major transfusions, aspiration, and pneumonia can increase chance of ARDS Mortality of 5080%, treatment targeted at underlying cause o SIRS, Pathological response to cascade of events precipitated by shock which usually occurs after trauma Controlled inflammatory response takes place designed to heal and ward off infection, continuous stimulation or severe infection may result in sustained inflammation resulting in an imbalance of cellular oxygen and demand causing an oxygen extraction deficit o MODS 12 Ch. 55: Trauma CC Exam 4 Factors include hemorrhage, massive blood transfusion, hypovolemic shock and sepsis Characterized by the failure of two or more organs, MODS accounts for many late deaths in trauma patients Usually lungs are first to fail, then liver, GI tract, and kidneys Liver failure can result from initial damage, vascular compromise, shock or sepsis leading to jaundice; failure can lead to decreased LOC, abnormal clotting and hypoglycemia. GI failure manifest with hemorrhage from stress ulcers, prophylaxis of gastric secretions can prevent risk of bleeding Renal failure can be precipitated by renal injury, ischemia, radiographic contrast material, rhabdomyolysis, hypovolemia, or sepsis, initial signs include increased BUN, dialysis may be necessary Cardiovascular failure, DIC, metabolic changes, and CNS changes ranging from obtundation to confusion may be evident in MODS 13 Ch. 56 CC Exam 1 Chapter 5: Relieving Pain and Providing Comfort Pain • A complex, subjective phenomenon • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (American Pain Society) • “Pain is whatever the experiencing person says it is, existing whenever he or she says it does.” (McCaffery) • Categorized based on duration (acute or chronic) and source (somatic, visceral, or nerve) • Acute vs. Chronic o Acute Type that most ICU patients experience Identified cause Resolves within a given time frame Responds to opioid and nonopioid therapies o Chronic Caused by physiological mechanisms that are less well understood Lasts for an indefinite period Usually exceeding 3 to 6 months Difficult to treat completely Responds poorly to pain management strategies Adversely affects the quality of life for the individual o Acute, critical illness, regardless of the etiology, is painful o Nearly all ICU patients will experience moderate to severe pain o ICU patients with chronic illnesses are likely to experience a combination of both acute pain and the chronic pain stemming from the chronic illness o Chronic pain in a critically ill patient is often associated with additional symptoms, such as respiratory distress, fatigue, and cognitive impairment, that must be managed • Factors Affecting Pain o Physical Symptoms of critical illness (angina, ischemia, dyspnea) Wounds—posttrauma, postoperative, postprocedural, or penetrating tubes and catheters Sleep disturbance and deprivation Immobility, inability to move to a comfortable position due to tubes, monitors, restraints Temperature extremes associated with critical illness and the environment— fever, hypothermia o Psychosocial Anxiety, depression Impaired communication, inability to report and describe pain Fear of pain, disability, or death Separation from family and significant others Boredom or lack of pleasant distractions Sleep deprivation, delirium, or altered sensorium o Environment and routine Continuous noise from equipment and staff 1 Ch. 56 CC Exam 1 Continuous or unnatural patterns of light Awakening and physical manipulation q12 hours for vital signs or positioning Continuous or frequent invasive, painful procedures Completing priorities in care—unstable vital signs, bleeding, dysrhythmias, poor ventilation—may take precedence over pain management • Pain Management o Determine need for sedation/analgesia Sedation assessment, pain assessment, and delirium assessment need to be recognized as having equal importance with BP and HR o Identify causes of agitation Painful procedure Sleep deprivation Fear, anxiety PTSD o Analgesics and sedative needed for patient and safety o Excessive sedation can cause complications Prolong ventilation Create physical and psychological dependence Increase length of hospital stay Sedation • Utilize sedation scales to assess and record levels of sedation and agitation • Use of standardized scale ensures that sedatives are titrated to a specific goal • LIGHT sedation o Minimal sedation, anxiolysis • MODERATE sedation with analgesia o “Conscious” or “procedural” o ensures comfort during painful or invasive procedure • DEEP sedation and analgesia o Used when patient must be unresponsive so care can be delivered safely o Ability to maintain ventilator function independently is impaired • General anesthesia Patients’ Report of Pain Procedure Level of Pain Simple dressing change Least painful Central line removal Painful Position changes/turning Painful Tracheal suctioning More painful Deep breathing and coughing exercises More painful Drain removal Most painful • Tolerance o Adaptation to a drug, which results in decrease of the drug’s effects over time Increase dose by 50% and assess effect Tolerance to side effects, such as respiratory depression, will increase as the does requirement increases • Physical dependence o Withdrawal syndrome that is produced with abrupt cessation or dose reduction o Should not be confused with addiction Gradually taper opioid dosage to discontinuation to avoid withdrawal symptoms 2 Ch. 56 CC Exam 1 • Addiction o Characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving o One of the greatest concerns and impediments associated with analgesia and pain control Rarely seen in critical care patients unless patient is admitted for drug overdose or other sequelae of illicit drug use • Barriers to Effective Pain Control o Low priority due to the lifethreatening nature of the patient’s illness and the other life saving interventions that are required o Fear of addiction o Tolerance and physical dependence o Should not restrict pain treatment in patients with a hx of opioid abuse; be more aggressive o Use of opioids should be tapered in patients with a long hx of abuse • Pain Assessment o Assess at regular intervals—to keep them at the right blood levels o Reassess after pain medications (ex: q30min) o Selfreport is gold standard o Behavioral observation and physiological parameters when the patient cannot selfreport o Use of standardized pain scale Interventions • Nonopioid analgesics o NSAIDS—preferred choice, decrease pain by inhibiting the synthesis of inflammatory mediators at the sight of injury and effectively relieve pain without causing sedation, respiratory depression, or problems with bowel or bladder fx o When combined with an opioid, the opioid dose can be reduced and still produce effective analgesia • Opioid analgesics • Spinal analgesics • Epidural analgesics • Intrathecal analgesics • Sedatives/anxiolytics • Hypnotics Opioid Analgesics • PRN vs. scheduled o Analgesic medications should always be administered on a regular schedule around the clock and not on an “as needed” (PRN) basis o PRN should be reserved for breakthrough pain or when the patient has recovered from the critical illness and is predominantly pain free, and continuous analgesia is no longer required • Dosing—individualized; use equianalgesia (appropriately equal) when appropriate • Administration o Oral—simple, noninvasive and inexpensive and provides effective analgesia—preferred route for patients with cancer and chronic malignant pain o Rectal—same disadvantages as oral administration, including variability in dosing requirements, delays to peak effect, and unstable serum drug levels—morphine and hydromorphone are available in rectal form 3 Ch. 56 CC Exam 1 o Transdermal—Fentanyl is available in transdermal path—must exercise caution when administering o IM—should not be used to provide acute pain relief for the critically ill patient b/c: Injections are painful Absorption is extremely variable in critically ill pts because of alterations in CO and tissue perfusion Anticipated discomfort associated with injection increases the pt’s anxiety Repeated IM injections can cause muscle and softtissue fibrosis o IV—usually the preferred route for opioid therapy o Spinal, epidural, intrathecal, PCA o Don’t give many medications orally in ICU because of aspiration • Side effects o Constipation, urinary retention, sedation, respiratory depression, and nausea Benzodiazepines • Control anxiety and muscle spasms; produce amnesia • Midazolam is recommended for conscious sedation • Reversible with flumazenil • Break from sedation at least once a day in the ICU Propofol • Rapid acting sedation/hypnotic agent; has no analgesic properties and minimal amnesic effects • Need appropriate airway and ventilator management • Ultrashort halflife and high rate of elimination…a couple minutes after stopping, they are awake • Reversibility by stopping the drug • Contraindicated with egg or soy allergy • We can maintain a drip but anesthesia PUSHES it!! Agitation/Sedation • Medications prescribed for sedation may exacerbate symptoms of delirium • Haloperidol (Haldol) commonly used—given IM o Delirium reduced o Flat affect, diminished interest in surroundings o Can become sedated o Dosedependent QTcinterval prolongation may increase incidence of ventricular dysrhythmias • Sedation vacation o Sedation discontinued once a day o Patient allowed to awaken for clinical assessment o Protocol to restart the sedatives if patient becomes agitated o Nursing responsibility to maintain safety during anesthetic or sedative drug withdrawal Nonpharmacological • Environmental modification • Distraction • Relaxation techniques • Touch • Massage 4 Ch. 56 CC Exam 1 Chapter 6: Palliative Care and EndofLife Issues EndofLife Issues Health care providers now recognize death is inevitable and use of technology to prevent death is limited Recognize need for quality death Patients have dies in ICU surrounded by health care providers, not family Critical care nurses are in position to help patients and families make transition to endoflife care SUPPORT study found o Physicians were not aware of the patient’s preference to avoid CPR o 40% of patients who died spent at least 10 days in the ICU o 50% of family members of conscious patients reported moderate to severe pain IOM report: seven recommendations to improve endoflife care Palliative Care Definition: (taken from the WHO) Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care: o provides relief from pain and other distressing symptoms; o affirms life and regards dying as a normal process; o intends neither to hasten or postpone death; o integrates the psychological and spiritual aspects of patient care; o offers a support system to help patients live as actively as possible until death; o offers a support system to help the family cope during the patients illness and in their own bereavement; o uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; o will enhance quality of life, and may also positively influence the course of illness; o is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications Core principles:
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