Chapter 35
Multiple Trauma
Learning Outcomes
35.1
Discuss traumatic injury, including
categories of injury and risk factors that
influence injury patterns.
35.2
35.3
35.4
I
35.5
Describe blunt trauma, including its
associated forces and the clinical assessment
of a patient with blunt trauma.
Apply the clinical assessment format used
to identify life-threatening injuries during
the primary and secondary surveys of an
injured patient.
35.6
Discuss penetrating trauma, including its
associated forces and the clinical assessment
of a patient with penetrating trauma.
Describe trauma resuscitation and nursing
responsibilities based on the trimodal
distribution of trauma-related mortalities.
35.7
Discuss the management of selected
traumatic injuries, including chest,
pulmonary, cardiac, abdominal, and pelvic.
35.8
Link posttrauma complications and
interventions with the physiology of a
traumatic injury and preexisting risk factors.
Demonstrate an understanding of the
mechanisms of injury and mediators of the
response to injury when caring for a patient
with traumatic injury.
njuries are the cause of significant morbidity and mortality in the United States (Figure 35–1). In 2012, the three
leading trauma-injury–related reasons for seeking medical assistance were falls, being struck by a person or object,
and transportation-related injury (Centers for Disease Control and Prevention [CDC], 2014). In a final report on causes
of death in the United States in 2014, unintentional injury,
the fifth-leading cause of death in 2012, became the fourthleading cause in 2014, and intentional self-harm (suicide)
ranked tenth (Centers for Disease Control and Prevention
[CDC], 2016a). While assault (including homicide) dropped
below the top 15 in 2010, it remained a significant cause of
death in 2014 (CDC, 2016a). Adjusting for age, homicide
remains among the 15 leading causes of death (CDC, 2016a).
This chapter provides an overview of traumatic injury.
Particular focus is given to the mechanism of injury in both
blunt and penetrating trauma as an assessment factor that
should raise the index of suspicion for certain injuries.
Many important complications are associated with
severe multiple trauma injury. This chapter briefly profiles
the major complications; however, the reader is referred to
specific textbook chapters for more detailed information, as
follows: acute respiratory distress syndrome (Chapter 12);
abdominal compartment syndrome (Chapter 22); acute kidney injury (Chapter 27); disseminated intravascular coagulation (Chapter 29); shock, including septic shock (Chapter 37);
and multiple organ dysfunction syndrome (Chapter 38).
Section One: Overview
of the Injured Patient
Understanding injury enables the nurse to approach a patient
in crisis with a level-headed, systematic plan based on a solid
body of nursing knowledge. Historically, injuries or accidents were viewed as the result of random chance beyond
human control. Now, injury is viewed as an event with an
identifiable cause: the interaction of energy and force with a
recipient. The recipient may be an inanimate object, such as a
motor vehicle, or an animate object, such as a person.
Injury results from acute exposure to energy, such as
kinetic energy (e.g., a motor vehicle crash [MVC], fall, or bullet); from chemical, thermal, electrical, or ionizing radiation;
879
880 PART 10 Multisystem Dysfunction
136,053 injury
deaths
2.8 million
discharges of
injury
31 million initial
emergency
department
visits for injury
Deaths
Hospital
discharges
Initial
emergency
department
visits
39.5 million
episodes of medically
consulted injuries were
reported in a national
household survey.
the injury may be covert, making diagnosis difficult. The
nature of the injury is related to both the transfer of energy
and the anatomic structure involved.
Penetrating trauma refers to injury sustained by the
transmission of energy to body tissues from a moving
object that interrupts skin and tissue integrity. Penetrating
trauma may also cause surrounding tissue deformation
based on the energy transferred by the penetrating object.
Deformation and displacement of body tissue and
organs occur in both forms of injury because of the transfer
of energy. Injury takes place as the structural limits of a particular tissue or organ are exceeded. Injury may be localized,
as in hematoma formation, or systemic, as in shock states.
The local response varies according to the tissue or organ
involved, such as bone fractures and bleeding vessels.
Figure 35–1 Injuries in the United States.
Risk Factors for Traumatic Injury
SOURCE: Centers for Disease Control and Prevention (2014); Centers for
Traumatic injuries, like other diseases, do not occur at random. Identifiable risk factors are associated with specific
injury patterns. These risk factors include age, gender, and
alcohol use, as well as race, income, and geography.
Disease Control and Prevention (2016b); National Hospital Discharge Survey
(2016b); National Vital Statistics System (2016b).
or from a lack of essential agents (e.g., oxygen [drowning]
or heat [frostbite]). The injury occurs because of the body’s
inability to tolerate excessive exposure to the energy
source. The term traumatic injury, the focus of this chapter, is specific to injuries caused by kinetic injury. The CDC
(2016a) published the National Vital Statistics for 2014,
including the number of injury deaths by mechanism, as
well as the percentages of the top three trauma-related
causes of death: motor vehicle traffic (17%), firearms (17%),
and falls (16%) (CDC, 2016a) (Figure 35–2).
Categories of Kinetic Injury
Although usually unintentional, traumatic injuries may
be intentional (e.g., assault or murder) or self-inflicted
(suicide). Although intent varies, the categories of traumatic
injury remain the same: either blunt or penetrating,
depending on the injuring agent.
Blunt trauma is any traumatic injury in which there is
tissue deformation without interruption of skin integrity.
Blunt trauma may be life-threatening because the extent of
All other
17%
Suffocation
8%
Poisoning
25%
Motor vehicle
traffic 17%
Falls
16%
Firearms
17%
Figure 35–2 Injury death by mechanism: United
States, 2014.
SOURCE: From National Vital Statistics Reports—Deaths (2014).
Age Unintentional injury continues to be the leading
cause of death in all Americans ages 1 through 45 (Centers
for Disease Control and Prevention [CDC], 2016b). The
death rate from injury is highest for persons over 65 years
old. The highest injury rate is for persons between the ages
of 15 through 24 because of their participation in high-risk
activities (including poor judgment with the use of alcohol,
drugs, and driving practices). The highest homicide rate
occurs among persons between 18 and 24 years of age.
Older adults are predisposed to trauma because of
age-related changes in reaction time, balance and coordination, and sensory motor function; falls are the leading
mechanism of injury in people 65 years and older (CDC,
2016b). Trauma in older adults is associated with higher
mortality and morbidity with less severe injury. For example, a 79-year-old with multiple rib fractures will have a
very different clinical course than an 18-year-old with the
same injuries. This is attributed to preexisting medical conditions and the older person’s diminished ability to compensate for severe injury (known as limited physiological
reserve) (Adams & Holcomb, 2015; Joseph et al., 2017). Limited physiological reserve is the concept of limited organ
function in the face of a physiologic challenge. Organ dysfunction may not appear in the resting state, but in a physiological stress situation (such as traumatic injury), the
ability of the organs to augment function is compromised
(Adams & Holcomb, 2015; Joseph et al., 2017). Moreover,
the reduced physiological response to traumatic injury
may mask the seriousness of the older patient’s condition,
causing delayed diagnosis and treatment.
Gender Injury rates are highest for 15- to 24-year-old
males. The risk for men is 2.5 times that for women, possibly
because of male involvement in hazardous activities.
Women are at higher risk for fall injury than are men (CDC,
2014).
Alcohol Motor vehicle crashes (MVCs) involving alcoholimpaired drivers were responsible for about one third of all
CHAPTER 35 Multiple Trauma
traffic-related deaths in 2014 (CDC, 2016a). Alcohol use and
abuse increase the likelihood of virtually all types of injury,
even among young teenagers. An alcohol-related MVC kills
someone every 53 minutes, at an associated annual cost of
over $44 billion (Centers for Disease Control [CDC], 2016c).
Alcohol-related trauma is a major public health problem.
Communities have enacted programs to reduce alcoholrelated MVCs, including lowering the legal blood alcohol
level to 0.08% and initiating sobriety checkpoints.
Severity of Injury, Mortality,
and Payer Source
According to the 2016 American College of Surgeons
National Trauma Data Bank Annual Report (NTDB), of
861,888 trauma patients, almost half (45.29%) sustained
minor injuries, and just less than one third (32.69%) had
moderate injuries based on the Injury Severity Score (ISS), a
system for stratifying injury severity (Chang, 2016). The ISS
ranges from 1 to 75, and the risk of mortality increases with
a higher score. An ISS between 1 and 8 is minor trauma,
between 9 and 15 is moderate trauma, between 16 and 24 is
severe trauma, and greater than 24 is very severe. The case
fatality rate increases as injury severity increases to as high
as 30%. Mortality rates for all severity levels is higher for
patients ages 75 and older. Length of stay in acute care hospitals increases as injury severity increases. Private or commercial insurance has now overtaken Medicare as the
single largest payment source at 35.10%, with Medicare
coming in second at 27%. Medicaid is the third largest
payer source at 16.28% (Chang, 2016).
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The overall mortality rate for all causes of trauma is
4.39% with the largest number of deaths being due to fallrelated injuries, followed by MVCs and firearm-related
injuries. Fatality rates are higher in patients 75 years or
older, with firearm injuries having the highest fatality rates
in all age groups (Chang, 2016).
Age, Gender, Mechanism of Injury,
and Geography
Trauma injuries initially peak in ages 14 to 29 from MVC injuries, then peak again between the ages of 40 to 50 due to an
increase in fall-related trauma injuries. Falls peak in children
at ages 5 to 9 years of age and in adults over the age of 65.
Men account for 70% of all trauma-related injuries up to age
70; after age 71, women account for most trauma-related injuries. Falls accounted for 44.18% of cases in the NTDB, with
these injuries peaking in children under age 7 and adults
over age 75. MVC injuries accounted for 25.97% of cases in
the NTDB, with peaks between ages 16 and 26 years. Suffocation, drowning or submersion, and firearm injuries have the
highest case fatality rates (suffocation 27.12%, firearm 15.30%,
and drowning or submersion 19.20%). At 12 years of age, firearm injuries double and steadily increase until age 22, then
they are followed by a decrease (Chang, 2016).
Rural areas account for a higher unintentional injury
rate, and a higher intentional injury rate is seen in urban
areas (Chang, 2016). Behaviors associated with unintentional injuries in rural areas may include greater use of recreational vehicles and employment in high-risk occupations
such as farming. Intentional injuries in urban areas are
usually related to homicide attempts (Chang, 2016).
Section One Review
1. The death rate from injury is highest for which age
group?
A. 24 to 42 years old
B. 15 to 24 years old
C. 5 to 14 years old
D. Over 65 years old
3. How does the risk for injury among men compare to
the risk among women?
A. It is 2.5 times lower.
B. It is 2.5 times higher.
C. It is 5 times higher.
D. The risks are equal.
2. Why do older adults with traumatic injury have higher
mortality and morbidity rates?
A. They have limited physiological reserve.
B. They are exposed to high-risk activities.
C. They drink more alcohol.
D. They have poor judgment.
4. Reducing legal blood alcohol to what level has been
shown to decrease alcohol-related MVCs?
A. 0.10%
B. 0.05%
C. 0.08%
D. 0.04%
Answers: 1. D, 2. A, 3. B, 4. C
Section Two: Mechanism
of Injury: Blunt Trauma
Blunt trauma is most commonly associated with MVCs,
motor vehicles striking pedestrians, and falls from significant
heights. One of the most basic principles of physics can be
used to explain trauma: the law of conservation of energy.
Energy can be neither created nor destroyed; it is only
changed from one form to another. Blunt trauma is the
translation of energy from one form to another, through
force.
882 PART 10 Multisystem Dysfunction
Forces Associated with Blunt Trauma
Force is a physical factor: the push or pull that changes the
state of an object that is either at rest or already in motion.
Injury resulting from force is related to the velocity of energy
transmission, the surface area to which the energy is applied,
and the elasticity of the tissues affected. The more slowly
the force is applied, the more slowly energy is released, with
less subsequent tissue deformation. The forces most often
applied are shearing, acceleration, deceleration, and compression (Ali, 2014; Cameron & Knapp, 2016).
Shearing Force Shearing refers to a tearing injury that
results when two structures, or two parts of the same structure, slide in opposite directions or at different speeds. For
example, shearing forces are frequently the cause of spinal
injury at the C7–T1 juncture because the mobile cervical
spine attaches at that point to the relatively immobile thoracic spine. Shearing forces are often the cause of aortic
tears, splenic and renal injuries, and liver, brain, or heart
injuries. These structures have a relatively immobile section connected to a relatively mobile section and are therefore subject to shearing forces (Roccaforte, 2017).
Acceleration and Deceleration Forces Acceleration is an
increase in the rate of velocity of a moving body or body
structure. Velocity is the most significant determinant of
the amount of injury sustained. As velocity increases, so
does tissue damage, because a greater amount of energy is
involved. The concept of acceleration is illustrated by the
following example: Upon impact with a solid object (e.g.,
another car, a brick wall, or a telephone pole), the driver of
a car is suddenly propelled forward. He experiences a sudden acceleration of body mass determined by the rate of
speed at which he was traveling and his body mass.
Body weight * mph = pounds per square inch of impact
A person weighing 100 pounds, traveling at 35 miles per
hour (mph), will impact at 3500 pounds per square inch.
This is equivalent to jumping head-first from a three-story
building.
Deceleration is a decrease in the rate of velocity of a
moving object. The same driver in the preceding example
who is moving forward after hitting a solid object will
experience a sudden deceleration after he comes into contact with the mass that impedes his forward (or backward)
progression (e.g., the steering wheel, a tree, the road, or
another passenger).
Acceleration and deceleration injuries are most common with blunt trauma and are closely associated with
shearing-force injuries—for example, injuries involving
the thoracic aorta. MVCs and falls from 20 feet or higher
precipitate stretching, bowing, and shearing in major vessels. Any or all layers of the vessel wall may be damaged.
The vessel wall can tear, dissect, rupture, or form an aneurysm immediately or at any time post-injury. Shearing
damage occurs in the vessels when deceleration occurs at a
different rate than that occurring in other internal structures. For example, the relatively mobile ascending aorta
continues to move after the relatively stationary descending aorta has stopped moving, resulting in a shearing
injury.
Compression Force Compression is the process of being
pressed or squeezed together with a resulting reduction in
volume or size. For example, sudden acceleration or deceleration during an MVC can cause compression of the heart
and lung parenchyma between the posterior and anterior
chest walls. The small bowel may be compressed between
the vertebral column and the lower part of the steering
wheel or an improperly placed seat belt. The bowel may
rupture. The same mechanism can cause compression of
the liver, causing it to burst.
Injuries Associated
with Blunt Trauma
Injuries associated with blunt traumatic forces include
head injuries (the movement of the brain inside the skull
with acceleration, deceleration, and shearing coup injury),
spinal cord injuries (the instability and poor support of the
cervical spine predispose it to shearing and acceleration or
deceleration injury), fractures (from shearing and compression), and abdominal injuries, especially to the spleen and
liver (from shearing and compression).
Each type of tissue has its own characteristic tensile
strength—that is, the tissue’s ability to withstand injury
from the applied forces of shearing, acceleration, deceleration, and compression. Tissue deformation is generally the
result of tensile forces (those that stretch and extend tissue) or shear forces. The tensile strength of a specific tissue
is the greatest longitudinal stretch or stress it can withstand
without tearing apart. Joint dislocations, muscle sprains,
and strains are frequently the result of tensile forces (Roccaforte, 2017).
Section Two Review
1. What is the term for a decrease in the velocity of a
moving object?
A. Acceleration
B. Deceleration
C. Compression
D. Shearing
2. What is the force that causes two structures to slide in
opposite directions or at different speeds?
A. Acceleration
B. Deceleration
C. Compression
D. Shearing
CHAPTER 35 Multiple Trauma
3. The process of being pressed or squeezed is known by
what term?
A. Acceleration
B. Deceleration
C. Compression
D. Shearing
Section Three: Mechanism
of Injury: Penetrating
Trauma
Penetrating trauma is often quickly discovered because,
unlike blunt trauma, the skin has been broken, providing
an obvious clue to the injury. However, although it is easier
to discover, the severity of internal injury is more difficult
to ascertain. Understanding the forces involved in penetrating trauma will facilitate rapid assessment and management of patients with penetrating injuries.
883
4. Which forces cause tissues to stretch?
A. Tensile
B. Shearing
C. Mass
D. Compression
Answers: 1. B, 2. D, 3. C, 4. A
object. Penetrating injuries to the chest below the nipple
line, the sixth rib, or the scapula may involve both thoracic
and abdominal structures.
If the offending missile (e.g., knife, stick, or metal rod)
is impaled in the body, it is critical that it be left in place
and protected from further movement until definitive surgical intervention is available. For example, if a knife is
impaled in the abdomen, protective padding such as gauze
rolls or abdominal pads can be placed around the externally exposed blade and handle. A protective device, such
as a plastic cup, may be used to secure the protruding part
of the missile. Impaled missiles may actually control hemorrhage from damaged structures, and removal may precipitate exsanguination.
Forces Associated with Penetrating
Trauma
Penetrating trauma is the result of the transmission of
energy from a moving object (referred to as a missile) into
body tissues as the object disrupts the integrity of the skin
and the underlying structures. The amount of kinetic
energy transmitted by the object has a direct bearing on the
degree of tissue damage. With tissue or organ penetration,
the severity of the injury depends on the organs and tissues damaged by the transmission of the energy. A penetrating object can be almost anything—for example, a
knife, a bullet, shrapnel, an arrow, a stick, a metal rod, a
fork, or a gear shift.
The amount of kinetic energy available to be transmitted to tissues depends on the surface area of the point of
impact, the density of the tissue, and the velocity of the projectile at the time of impact. Weapons are usually classified
by the amount of energy they are capable of producing:
low-energy weapons include knives, arrows, or any type of
hand missile; medium-energy weapons include handguns
and some rifles; and high-energy weapons include hunting
rifles and shotguns (Ali, 2014; Cameron & Knapp, 2016).
Low- to Medium-energy Missiles
Low- to medium-energy missiles travel less than 2000 feet
per second. The injury sustained usually results from the
missile contacting the tissue. Typically, damage is localized to
those structures directly in the missile’s path (Figure 35–3).
However, special consideration must be given when injury
occurs where body cavities lie in close proximity to one
another. This principle is of critical importance when considering the close proximity of the thoracic and abdominal
cavities, especially with injuries occurring near the diaphragm, which offers very little resistance to the penetrating
Figure 35–3 Patterns of tissue injury secondary to
gunshot wounds. A, Low velocity, small entrance, and exit
wounds. B, Higher velocity, cavitation present with energy
dispersion outward from missile path (blast effect). C,
Same velocity as in B but with penetration of bone and
greater blast effect because of projections of bone being
spread through tissue. D, Higher velocity than in B or C
with greater cavitation effect, small entrance and exit
wounds. E, Same velocity as in D, but person or extremity
hit is thinner, resulting in large exit wound. F, Asymmetrical
cavitation as bullet begins to yaw and tumble.
884 PART 10 Multisystem Dysfunction
High-energy Missiles
High-energy missiles are those traveling more than 2000
feet per second. Also referred to as high-velocity missiles,
they transmit more kinetic energy than low-energy missiles.
As the missile penetrates the tissue, the transmission of
kinetic energy displaces tissues forward and laterally to
form a temporary cavity, a process known as cavitation (see
Figure 35–3). The degree of cavitation is directly related to
the amount of kinetic energy transmitted to the tissues,
which in turn is determined by the velocity of the missile.
The size of the cavity may be up to 30 times the diameter of
the missile. Tissue surrounding the missile tract is exposed
to tensile (stretching), compressing, and shearing forces,
which produce damage outside the direct path of the missile. Vessels, nerves, and other structures that are not directly
damaged by the missile may be affected. The phenomenon
of injury to structures outside the direct missile path is
referred to as blast effect. Higher-velocity missiles produce
more serious injury because of the destructive process of
cavitation and blast effect on surrounding tissue and organs.
Missile Trajectory In addition to the amount of kinetic
energy (low, medium, or high) associated with the missile,
its trajectory (path of the missile) is also an important consideration. Consider a missile moving in stable flight
toward the host. The missile passes from air into human
tissue, which is several hundred times denser than air. As
the missile penetrates the tissue, the surrounding environment changes, precipitating instability in the missile. The
missile may yaw, tumble, deform, fragment, or any combination of these actions. Yaw is the deviation of a missile
either horizontally or vertically about its axis. Tumble is the
action of forward rotation around the center of a mass
(somersaulting) (Figure 35–3F). The action of yawing or
tumbling increases the surface area of the missile impacting
the body (side of the missile versus the point of the missile).
This creates a larger entrance wound and also allows for
increased energy transfer to the surrounding tissues, creating a larger area of tissue destruction. Higher-velocity missiles have a greater propensity for yaw and tumble.
Moreover, the missile can fragment, or break into multiple
pieces, which increases internal deformation and damage.
Secondary Missiles
Another injury mechanism to consider when analyzing the
effects of penetrating injury is the creation of secondary missiles by the penetrating object. A missile or its fragments may
impart sufficient kinetic injury to dense tissue, such as bone
or teeth, to create highly destructive secondary missiles. Furthermore, the primary missile can fragment into multiple
secondary missiles. These secondary missiles may take
erratic, unpredictable courses, resulting in additional injury.
Injuries Associated
with Penetrating Trauma
Wounds caused by the missile must be evaluated, noting
their location, size, and shape. It is also important to determine whether there is any foreign substance on the surrounding tissue, such as gunpowder, and whether the
wound is actively bleeding.
If there are two wounds, noting the location of each
gives the clinician information regarding the trajectory the
missile may have taken if the same missile caused both
wounds. Missiles usually take the path of least resistance,
so the path may not be a straight line between the two
wounds. Entrance wounds are usually smaller than exit
wounds. However, the characteristics of a wound depend
on the forces causing the injury, such as velocity, cavitation,
and blast effect. Identifying the entrance and exit wounds
is not necessary and should be left to experienced personnel. Simply identifying the wounds as wound 1 and wound
2 will suffice. The presence of two wounds does not necessarily mean one is an entrance wound and one is an exit
wound, as there may be two entrance wounds from two
separate missiles. Not all medium- and high-energy penetrating injuries have a resulting exit wound because the
missile may remain inside the body (Roccaforte, 2017).
Section Three Review
1. As a missile penetrates, the tissue is temporarily displaced forward and laterally, creating a tract. What is
this process called?
A. Velocity
B. Yaw
C. Tumbling
D. Cavitation
2. What is the term for structure injury outside the direct
missile path?
A. Cavitation
B. Blast effect
C. Yaw
D. Tumbling
3. How do yaw and tumble affect the area of tissue
destruction caused by a missile?
A. Decrease it
B. Increase it
C. Minimize it
D. Do not affect it
4. A client has an impaled knife in the upper abdomen.
What should the nurse do?
A. Remove the knife and apply pressure.
B. Manipulate the knife to facilitate assessment of
injured organs.
C. Stabilize the knife without removal and with minimal manipulation.
D. Leave the knife alone.
Answers: 1. D, 2. B, 3. B, 4. C
CHAPTER 35 Multiple Trauma
Section Four: Mechanism
of Injury: Patterns and
Mediators of Injury
Response
The mechanism of injury is associated with certain possible injury patterns. This fact makes it possible to associate
the type and extent of injuries based on the mechanism
involved. In addition, when a multiple-trauma patient is
admitted, the nurse should be aware of mediators that may
influence the seriousness and extent of injury.
Mechanisms of Injury
and Injury Patterns
Certain mechanisms of injury result in predictable injury
patterns (Table 35–1). Thus, the events surrounding the
injury, such as pedestrian–motor vehicle injuries, motor
vehicle driver and passenger injuries, fall injuries, and missile injuries, should increase suspicion for certain patterns
of injured structures.
The following example demonstrates the importance
of understanding the mechanism of injury. A 21-year-old
unrestrained male driver crashes into another vehicle
head-on (Figure 35–4). Traveling speed was in excess of
95 mph. Both the steering wheel and windshield were broken. A high index of suspicion must be maintained for the
following potential injuries:
1. Intracranial injury because of the high rate of speed
and shattered windshield
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2. Cervical vertebrae injury because of acceleration or
deceleration at a high rate of speed and the broken
windshield
3. Intrathoracic injuries because of the broken steering
wheel—suspect rib fractures, myocardial and pulmonary contusions, and great vessel injury
4. Intra-abdominal injuries because of the broken steering wheel and acceleration or deceleration mechanism;
could include splenic or liver lacerations, small bowel
injuries, and great vessel injuries
5. Long-bone fractures, especially femur fractures or posterior hip fracture–dislocation, because of the impact
of the knees on the dashboard
6. Multiple skin lacerations, avulsions, punctures from
impact with various parts of the vehicle interior
Factors Affecting the Response
to Injury
Many clinical conditions affect a patient’s response to
injury, including underlying medical disorders, substance
use, and physiological alterations such as pregnancy and
advancing age.
Comorbidities It is extremely important to identify comorbidities or underlying medical conditions when considering
the patient’s physiological and hemodynamic response to
trauma. Chronic conditions such as heart disease, kidney
disease, or diabetes and the medications used to control
their manifestations may alter the physiological response to
trauma. The patient with COPD who sustains a minor pulmonary contusion related to blunt trauma may require
prompt, life-saving intubation because of the alteration in
Table 35–1 Commonly Seen Injuries
Mechanism of Injury
Predictable Injury Pattern
Pedestrian hit by automobile
Adult
Child
Fractures of femur, tibia, and fibula on side of impact; ligamental damage to impacted knee; mild
contralateral brain injury
Fractures of femur, chest injury, contralateral brain injury
Unrestrained driver
Head and/or facial injury, rib fractures, sternum with underlying myocardial or pulmonary contusion,
cervical spine fractures, laryngotracheal injuries, spleen injuries, liver injuries, small bowel injuries,
posterior fracture–dislocation of hip, femur fractures
Unrestrained front seat passenger
Head and/or facial injuries, laryngotracheal injuries, posterior fracture–dislocation of femoral head, femur or
patellar fractures
Restrained driver (lap and shoulder harness)
Contusions of structures underlying harness (e.g., pulmonary contusion, contusion of small bowel)
Restrained passenger (lap belt only)
Flexion-distraction fractures, especially lumbar vertebrae (L1–L4), duodenal injuries, cervical spine injuries
Fall injuries
Compression fractures of lumbosacral spine and calcaneous fractures; fractures of radius or ulna, patella if
victim falls forward
Vehicular ejection
Multiple injuries, especially head and cervical spine injuries; injury risk increases by 300% when ejection
occurs
Low-velocity impalement
Local tissue or organ disruption, little or no cavitation
High-velocity missile, short missile path
Entrance wound larger than missile caliber; large ragged exit wound with cavitation
High-velocity missile, long missile path
Entrance wound larger than missile caliber; exit wound slightly larger than or equal to missile caliber;
extensive cavitation (blast effect to deep structures absorbing lost kinetic energy)
High-velocity missile hitting bone or teeth
Entry wound larger than missile caliber; possibly no exit wound with missile fragmentation; secondary
missile injury in unpredictable, erratic pattern
886 PART 10 Multisystem Dysfunction
Figure 35–4 Typical injuries of an unrestrained driver.
the ventilation–perfusion ratio, inability to compensate, and
lack of pulmonary reserve. Beta blockade used for coronary
artery disease to minimize oxygen demands by the heart
could prevent a normal response to hypovolemia (i.e., tachycardia). The patient with a brain injury who has a history of
stroke may experience an altered level of consciousness, difficulty in communication, or sensory or motor dysfunction
from the prior stroke and not the acute brain injury. Eliciting
a complete medical history, including comorbidity information, is crucial during the initial assessment. This is especially important in older adults who are most likely to be
admitted with at least one comorbid illness; it is estimated
that 80% of people 65 years of age or older have comorbid
illnesses (Adams & Holcomb, 2015).
Substance Use Disorders Substance use disorders (as it
is now called, changed from the previous classification:
substance abuse and substance dependence) are characterized by recurrent and clinically significant adverse consequences related to the repeated use of substances. The
DSM-V definition for substance use includes meeting two
or three (mild substance use diagnosis), four or five (moderate), and six or seven (severe) of the following criteria: (1)
taking the substance in larger amounts or for longer than
intended, (2) wanting to cut down or stop, but not managing to, (3) spending a lot of time getting, using, or recovering from use, (4) having cravings and urges to use, (5)
knowing work, home, or school obligations are affected,
(6) continuing to use, even with relationship problems, (7)
giving up social, occupational, or recreational activities, (8)
using substances again and again, despite dangers, (9) continuing to use, even knowing a physical or psychological
problem is made worse by the substance, (10) needing an
increasing amount of the substance to have desired effect,
and (11) developing withdrawal symptoms (American
Psychiatric Association, 2013).
The high incidence of alcohol as a contributing factor
to injury has been demonstrated (National Highway Traffic
Safety Administration [NHTSA], 2016). The effects of alcohol on the level of consciousness make it extremely difficult
to obtain an accurate baseline assessment of the patient.
Alcohol is a central nervous system (CNS) depressant, and
its effects on the brain are concentration dependent. The
most sensitive tool for evaluating brain injury is level of
consciousness. Therefore, alcohol or other CNS-depressant
intake is a critical consideration because it can delay accurate evaluation for potential brain injury.
Blood alcohol concentration (BAC) is a measurement of
intoxication, given in either milligrams per deciliter (mg/dL)
or grams per deciliter (g/dL). Legal intoxication in all states,
as well as the District of Columbia and Puerto Rico, is a BAC
of 80 mg/dL (0.08 g/dL); however, the effects of alcohol on
the brain are apparent at a level of 20 mg/dL (0.02 g/dL)
(NHTSA, 2016; Kee, 2014). A history of alcohol use should be
obtained because a degree of tolerance develops with frequent alcohol ingestion. As plasma levels increase, sedation,
lack of motor coordination, ataxia, and impaired psychomotor performance become apparent. The concomitant use of
alcohol and other CNS depressants (e.g., barbiturates, opiates, sedative–hypnotics) potentiates each drug’s effects, creating a synergistic effect. CNS stimulants such as cocaine can
also alter the level of consciousness in an injured patient.
Neurologically, changes in mental status range from anxiety
to acute paranoid psychosis. For the high-acuity nurse, it is
very difficult to obtain a baseline level of consciousness
when the patient is intoxicated with alcohol or other drugs
that cloud his or her sensorium.
Pregnancy The pregnant trauma patient presents with
anatomical and physiological changes that must be carefully considered. Major trauma affects 8% of pregnant
patients (Jain et al., 2015). Familiarity with trauma assessment and management during pregnancy is important for
the nurse in the high-acuity setting. Pregnancy testing may
be done on any woman of childbearing age who presents
with multiple trauma (Roccaforte, 2017).
Anatomic Changes. Anatomic rearrangement occurs in
the pregnant woman as the uterus progressively enlarges
in the anterior abdomen and presses many of the abdominal organs to a more posterior abdominal location. During
early pregnancy, the uterus and fetus are well protected
within the pelvis and lower abdomen; in later pregnancy,
however, the prominent anatomic location of the uterus
places both the uterus and fetus at higher risk of injury
(Jain et al., 2015; Limmer et al., 2016). Therefore, different
patterns of injury may occur to the mother, as well as to the
fetus, depending on the stage of pregnancy. Blunt abdominal trauma in the pregnant patient is associated with different injuries from those in the nonpregnant patient.
Hemodynamic Changes. After the tenth week of pregnancy, cardiac output increases by up to 50%. A highoutput, low-resistance hemodynamic state is characteristic
in pregnancy. Maternal heart rate increases by 10 to 15 beats
per minute throughout pregnancy, with a slight increase in
stroke volume. Blood pressure decreases by 5 mmHg to
15 mmHg (Jain et al., 2015). It is important to remember
that some women experience profound hypotension when
placed in the supine position (especially during the third
trimester). This is known as the vena cava syndrome and is
caused by the enlarged uterus compressing the inferior
vena cava against the spinal column, which decreases
CHAPTER 35 Multiple Trauma
venous return and preload. The hypotension can be relieved
by turning the patient to the left lateral decubitus position.
Blood Volume and Composition. During pregnancy,
maternal blood volume increases by 50% by the end of the
third trimester, with maximal volume expansion by 28 to
32 weeks gestation (Jain et al., 2015). Therefore, mild blood
loss as a result of traumatic injury is usually well tolerated.
Because of the hypervolemic state associated with pregnancy, a 30% to 40% (up to 2000 mL) blood loss may occur
in a pregnant patient before signs and symptoms of hypovolemia occur; however, the patient may deteriorate rapidly once a 2500 mL blood loss has occurred.
During pregnancy, a physiological anemia results as
plasma volume increases by 50% and red blood cell volume increases by only 30%. Late in pregnancy, the hemoglobin may fall to 10.5 to 11 g/dL and the hematocrit to
31% to 35%. The white blood cell count increases during
pregnancy (15,000 to 18,000/mm3) and during labor may
be as high as 25,000/mm3 (Jain et al., 2015).
Advancing Age Physiological changes associated with
aging (65 years and older), such as delayed reaction times,
disturbances of gait and balance, diminished visual acuity,
and hearing loss, predispose older adults to traumatic
injury. Also, age-related deterioration in body systems
alters the older adult trauma victim’s response to injury
and increases the risk for complications. The most common
mechanism of injury in this age group is falls, followed by
motor vehicle crashes, pedestrian-versus-automobile
crashes, and penetrating trauma.
Chronic Disease States. Chronic disease states exacerbate or compound the patient’s response to traumatic
injury. The most commonly encountered chronic conditions
in older Americans include hypertension, heart disease,
stroke, cancer, diabetes, chronic obstructive pulmonary
disease (COPD), arthritis, and asthma (Federal Interagency
Forum on Aging-Related Statistics, 2016). The patient not
only may have a chronic medical condition but also may be
following with a polypharmaceutical regimen that could
affect the response to a traumatic injury.
Limited Physiologic Reserve. Recall from Section One
that the higher morbidity and mortality rates associated
with trauma and advancing age can be attributed to limited physiological reserve, most often in the cardiorespiratory, neurological, and musculoskeletal systems.
Cardiorespiratory Changes Cardiorespiratory changes
include decreased distensibility of blood vessels, increased
systolic blood pressure and systemic vascular resistance,
increased vascular resistance, decreased coronary blood
flow, decreased cardiac output, decreased respiratory muscle strength, limited chest expansion, and decreased number of functioning alveoli. These alterations combine to
reduce greatly the ability to sustain adequate tissue perfusion and oxygenation. Mild anemia is also common in this
age group and potentiates alterations in oxygenation by
limiting oxygen transport capabilities.
Neurologic Changes Neurologic changes associated
with advancing age include short-term memory loss and
reduced cerebral blood flow. Preexisting neurologic conditions, such as senility, dementia, and Alzheimer disease,
may significantly affect evaluation of the patient’s neurologic status. Head injuries are common in older adults. A
high index of suspicion for a potential head injury, awareness of the patient’s preexisting neurologic status, and frequent, thorough neurologic assessments are necessary to
avoid detrimental delays in diagnosis and intervention.
Musculoskeletal Changes Osteoporosis and decreasing
muscle mass contribute to the high incidence of fractures.
The incidence of rib fractures with blunt chest trauma is
10% to 76% (Dehghan, de Mestral, McKee, Schemitsch, &
Nathens, 2014). Patients of advancing age have twice the
mortality and morbidity rates of younger patients. Mortality increases with the number of rib fractures. Normal
aging processes diminish blood supply to the skin and
result in delayed healing of soft-tissue injuries and the
development of pressure ulcers.
Shock During the initial assessment, difficulties related to
normal aging may be noted by the clinician. Shock is difficult to diagnose secondary to age-related changes that affect
the patient’s response to trauma, including decreased cardiac output, decreased maximal heart rate, and increased
peripheral vascular resistance (Adams & Holcomb, 2015;
Calland et al., 2012). Because of the decline in gag and cough
reflexes, airway patency may be difficult to maintain. Shock
may be difficult to detect because of older adults’ propensity toward hypertension. Thus, normal blood pressures
may actually indicate low perfusion states. Aggressive care
and resuscitation significantly improve patient outcomes;
therefore, older adults require a more aggressive approach
during their initial emergency management than do
younger patients with similar injuries (Calland et al., 2012).
Section Four Review
1. A restrained driver (lap and shoulder harness)
involved in an MVC can receive what type of injuries
from the restraints?
A. Pulmonary contusions
B. Lumbar fractures
C. Femur fractures
D. Facial injuries
887
2. Which statement about vehicular ejection is true?
A. It increases the risk for injury.
B. It decreases the risk for injury.
C. It is not related to the risk for injury.
D. It is associated with seat belt use.
888 PART 10 Multisystem Dysfunction
3. A broken steering wheel should induce a high suspicion of injury to which part of the body?
A. Head
B. Neck
C. Abdomen
D. Long bones of the legs
4. Why is eliciting a medical history crucial during the
initial assessment? (Select all that apply.)
A. Comorbidities alter the physiologic response to
trauma.
B. It is essential to determining mechanism of injury.
C. A medical history helps to identify the cause of injury.
D. The client may be comatose later.
Answers: 1. A, 2. A, 3. C, 4. A
Section Five: Primary
and Secondary Surveys
Trauma should always be approached as a multisystem
disease. The nurse must develop a rapid, systematic
approach to assessing each trauma patient to identify injuries. Trauma presents myriad potentially life-threatening
injuries that must be evaluated quickly, with immediate
interventions. Trauma care based on Advanced Trauma
Life Support (ATLS) principles is divided into three phases:
primary survey, resuscitation, and secondary survey, with
the primary survey and resuscitation phases occurring
simultaneously (Cameron & Knapp, 2016; Roccaforte,
2017). This section provides an overview of the ATLS survey process.
The Primary Survey
The purpose of the primary survey is to identify life-threatening injuries and intervene appropriately. The primary
survey is done using the ABCDE approach:
• A—Airway (with cervical spine immobilization):
The nurse assesses the patient for airflow from nose
and mouth, normal chest movements, the presence of
foreign bodies in the mouth, and abnormal breathing
sounds that suggest airway obstruction.
• B—Breathing: The nurse assesses breathing rate,
rhythm and depth and pattern, abnormal breathing
sounds, use of accessory respiratory muscles, and oxygen saturation.
• C—Circulation: The nurse assesses blood pressure;
heart rate, rhythm, and quality; bleeding; and signs of
shock.
• D—Disability: The nurse assesses the patient’s level
of consciousness and motor function.
• E—Exposure and evacuation: The nurse completely
undresses the patient to allow visualization of external
causes of injury. If the severity of the patient’s injury
exceeds the capability of the hospital, the patient
should be transported to a hospital with the appropriate level of trauma care.
Each step of the primary survey is explored in more
detail here, providing information needed to assess the
patient with multiple injuries using critical thinking and
problem-solving strategies.
A–Airway The first step in the primary survey is assessment of the patency of the patient’s airway. The goal of airway management is to maintain an open airway while
protecting the cervical spine. An injury to the cervical spine
should always be assumed in the patient with multisystem
trauma, especially in the patient with an injury above the
clavicle. Excessive manipulation of the head, face, or neck,
such as hyperextension or hyperflexion of the cervical
spine, while performing airway management may convert
a fracture without neurologic deficits into a fracture–
dislocation with spinal cord contusion, laceration, compression, or transection. Therefore, cervical immobilization
is imperative during airway assessment.
Airway Obstruction. Potential causes of partial or complete airway obstruction include the tongue falling back
into the oropharynx; blood, vomitus, secretions, or foreign objects in the airway; and fractures of the facial bony
structures or crushing injuries of the laryngotracheal tree.
Signs and symptoms of an inadequate airway are listed in
Box 35–1.
Airway Management Techniques. Airway management techniques range from simple positional maneuvers
to complex surgical procedures. During all maneuvers, it
is critical that the cervical spine be maintained by in-line
immobilization, applied either by a caregiver or with a
hard cervical collar, with the patient’s head in the neutral
position (Figure 35–5). Disposable head blocks or towel
rolls may be placed on both sides of the patient’s head
with tape across the forehead to immobilize the cervical
spine. These actions prevent forward flexion, hyperextension, and lateral rotation of the cervical spine. Sandbags
are no longer an acceptable means of lateral cervical
immobilization because of the increased lateral pressure
to the cervical spine that occurs with turning or tilting of
the backboard (Sundstrom, Asbjornsen, Habiba, Sunde, &
Wester, 2014).
Simple Airways. The first and simplest maneuver used
to open the airway is a chin lift or modified jaw thrust
(Figure 35–6). The airway can be suctioned for debris, secretions, blood, or vomitus. An oropharyngeal or nasopharyngeal airway may be used to facilitate airway maintenance.
The oropharyngeal airway should be used only in patients
who are unconscious and have no gag reflex. Using this airway in a conscious patient may precipitate gagging, vomiting, and potential aspiration. Improper placement of the
CHAPTER 35 Multiple Trauma
889
BOX 35–1 Inadequate Airway, Breathing, and Circulation in the Trauma Patient:
Manifestations and Immediate Interventions
Airway
• Signs and symptoms:
○
No signs of breathing; no air heard or felt at nose and mouth
○
Presence of foreign bodies in airway
○
Abnormal chest movements or breathing effort limited to
abdominal breathing
○
Partial obstruction: nasal flaring; abnormal sounds, such as
stridor, hoarseness, snoring, gurgling
○
Conscious patient: difficulty or inability to speak, or raspy or
hoarse voice quality
• Potential immediate interventions:
○
Open airway (e.g., jaw-thrust maneuver); oro- or nasopharyngeal airway
○
Suction airway
○
Assess for or to remove foreign bodies
○
○
○
•
Potential immediate interventions:
○
Apply oxygen at high-flow (usually 100%)
○
Inspect for signs of chest trauma
○
Position on side after neck is stabilized
○
Positive pressure ventilation (e.g., bag-valve-mask with
manual ventilation; intubation, mechanical ventilation)
○
Rescue breathing if respiratory arrest
Circulation
•
Signs and symptoms:
○
Pulse, blood pressure outside of normal parameters; weak
or absent peripheral pulses; poor capillary refill
○
Bleeding
○
Skin: pale coloring, cool temperature
•
Potential immediate interventions:
○
Control bleeding
○
Treat for shock
○
Perform CPR if cardiac arrest develops
Breathing
• Signs and symptoms:
○
Rate, rhythm, or depth outside of normal parameters
○
Absent or diminished breath sounds
○
Abnormal breathing sounds, such as gurgling, crowing,
gasping
Cyanosis
Use of accessory respiratory muscles
Hypoxemia, hypercapnia
SOURCE: Data from Limmer et al. (2016), Section 5: Trauma Emergencies.
oropharyngeal airway may cause airway obstruction
(Figure 35–7). The nasopharyngeal airway can be used
in the conscious victim with an intact gag reflex. However, it should be avoided if a basal skull fracture is
suspected.
Figure 35–5 Neutral neck positioning and placement
Endotracheal Intubation. If the aforementioned procedures
are inadequate in establishing an airway, more aggressive
measures must be taken. Endotracheal intubation is
achieved either orally or nasally. Nasotracheal intubation
may be performed in the injured patient because hyperextension of the neck is minimized. With the nasotracheal
method, the tube is advanced during the inspiratory effort
of cervical collar for neck stabilization.
SOURCE: Katarzyna Bialasiewicz/123RF.com
Figure 35–6 Jaw-thrust maneuver. Note that the fingers are positioned at the angle of the lower jaw directly below
the ears. Lift lower jaw by gently pushing the angle of the lower jaw forward.
SOURCE: Michal Heron/Pearson Education, Inc.
890 PART 10 Multisystem Dysfunction
Figure 35–7 Proper placement of oropharyngeal
airway. The airway is inserted with curved end up,
advanced over the tongue, then turned 180 degrees
to point down.
when the epiglottis is open. Orotracheal intubation is necessary when the patient is apneic or a cribriform plate fracture is suspected, as with basilar skull fractures. With
fractures of the cribriform plate, the nasally inserted endotracheal tube could pass into the cranial vault, injuring
brain tissue. If orotracheal intubation is necessary, vigilant
care must be taken to avoid hyperextension of the cervical
spine. The most important determinant when choosing the
method of intubation is the experience of the provider. The
clinician should first auscultate over the epigastrium for
gurgling sounds to rule out an esophageal intubation. After
intubation is achieved, breath sounds are auscultated to
confirm tracheal intubation. Repeated assessment of breath
sounds in any intubated patient is a critical nursing action.
Surgical Airway. The indication for a surgical airway is the
inability to intubate the trachea, which may result from
edema of the glottis, laryngeal fracture, severe oropharyngeal hemorrhage, or gross instability of the midface. A surgical airway can be achieved by a needle cricothyroidotomy,
surgical cricothyroidotomy, or tracheostomy. Surgical cricothyroidotomy is performed by making an incision through
the cricothyroid membrane and passing an endotracheal or
tracheostomy tube into the trachea. Tracheostomy must be
considered in the patient with suspected laryngeal trauma.
Symptoms of laryngeal injury include tenderness, hoarseness, subcutaneous emphysema, and intolerance of the
supine position. The supine position is poorly tolerated by
these patients because, on assuming the position, the airway will collapse where the laryngeal injury has occurred.
With the patient sitting upright, an open airway is maintained even though the larynx is injured.
Assurance of airway integrity is the priority in the primary survey. Airway integrity does not ensure adequate
ventilation, but the airway must be opened and secured
before ventilation is assessed. After a definitive airway has
been secured, placement of a gastric tube decompresses the
stomach.
B–Breathing The next step in the primary survey is to
assess adequacy of ventilation. The primary goal of ventilation is to achieve maximum cellular oxygenation
by providing an oxygen-rich environment. All trauma
patients should receive high-flow oxygen during the initial
evaluation.
Breathing is evaluated by the look, listen, and feel
parameters. Look to detect the presence of respiratory
excursion, listen for breath sounds, and feel for breathing.
Positive pressure ventilation (PPV) may be required in
some patients and is provided in a number of ways: mouthto-mask, bag-valve-mask, or mechanical ventilator. A frequent complication of ventilation with PPV is gastric
distention. Increased risks secondary to distention include
vomiting, aspiration, and diaphragmatic impingement.
Gastric distention can be minimized by not using too large
a volume or too many breaths.
The adequacy of ventilation and oxygenation is confirmed by evaluating the PaO2 and PaCO2 obtained from
an arterial blood gas (ABG) or by continuous monitoring of
end-tidal carbon dioxide and arterial oxygen saturation
using noninvasive measures. Other signs and symptoms of
inadequate breathing and immediate interventions are
listed in Box 35–1. If arterial blood gases are inadequate,
the airway patency is re-evaluated and the patient is
assessed for the presence of pneumothorax, hemothorax,
hemopneumothorax, or tension pneumothorax (discussed
in Section Seven). Tube thoracostomy is indicated for all of
these conditions because they are life-threatening injuries.
C–Circulation The third step in the primary survey is
assessment of circulation. The trauma patient is at very
high risk of hypovolemic shock from acute blood loss and
the shifting of fluid from inside the blood vessels to the
interstitial space. The trauma team must identify hypovolemia quickly and search for the etiology. Inadequate circulation is manifested as shock, a clinical state characterized
by inadequate organ perfusion and tissue oxygenation.
Assessment for adequate circulation includes palpating for
strength, rate, rhythm, and symmetry of carotid, radial,
femoral, and pedal pulses. Skin temperature is evaluated,
as is capillary refill. Adequacy of tissue perfusion is
reflected in the patient’s level of consciousness. Signs and
symptoms of inadequate circulation and immediate interventions are listed in Box 35–1.
Shock from Trauma. Shock is considered a preventable
cause of death. One of the most frequently encountered
clinical states in the injured patient is traumatic shock.
Shock has been defined as the consequence of insufficient
tissue perfusion that results in inadequate cellular oxygenation and the accumulation of metabolic wastes (Ali,
2014; Roccaforte, 2017). The most common cause of shock
in the injured patient is hypovolemia resulting from acute
blood loss. Blood loss can occur externally, as with lacerations, open fractures, avulsion injuries, or amputations,
or internally within a body cavity, as with bleeding into
the chest cavity, abdominal cavity, retroperitoneum, or
soft tissue.
Exsanguination is the most extreme form of hemorrhage. There is an initial loss of 40% of the patient’s blood
CHAPTER 35 Multiple Trauma
volume, with a rate of blood loss, or hemorrhage, exceeding 250 mL per minute. If uncontrolled, the patient may
lose 50% of the entire blood volume within a very few
minutes. Loss of up to 15% of circulating volume (700 to
750 mL for a patient weighing 70 kg) may produce little in
terms of obvious symptoms, whereas loss of up to 30% of
circulating volume (1.5 L) may result in mild tachycardia,
tachypnea, and anxiety. Hypotension, marked tachycardia
(pulse 110 to 120 beats per minute), and confusion may not
be evident until more than 30% of blood volume has been
lost. Loss of 40% of circulating volume (2 L) is immediately
life-threatening. Most injuries precipitating exsanguination
are from penetrating trauma. Regardless of the mechanism of injury, exsanguination leads to hypovolemic shock
(Cameron & Knapp, 2016; Roccaforte, 2017).
D–Disability After airway, breathing, and circulation are
assessed and adequately managed, the fourth step in the
primary survey is quick initial assessment of neurologic
disability. The purpose of the neurologic examination in
the primary survey is to quickly establish the patient’s
level of consciousness, and to assess pupil size and reactivity. Level of consciousness is determined using the AVPU
scale.
• A—Alert
• V—Responds to verbal stimulation
• P—Responds to painful stimulation
• U—Unresponsive
891
A more detailed neurologic examination is included in
the secondary survey.
E–Exposure At this point in the primary survey, the
patient is completely disrobed in preparation for the secondary survey. Exposure to the cold ambient temperatures
of resuscitation areas, infusion of large volumes of room
temperature IV fluids and/or cold blood products, and
wet clothing all predispose the trauma patient to hypothermia. The need for careful attention to the maintenance of
body temperature cannot be overemphasized.
The Secondary Survey
The secondary survey begins after the primary survey is
completed and all immediately life-threatening injuries
have been addressed. A head-to-toe approach is used,
with a thorough examination of each body system. A critical point to remember is that if the patient becomes hemodynamically unstable at any point during the secondary
survey, immediately return to the primary survey format
(ABCDE) to troubleshoot the problem. During the secondary survey, the trauma patient requires repeated
re-evaluation so that any new signs or symptoms are not
overlooked. Other life-threatening problems may appear,
or exacerbation of previously treated injuries may occur
(such as tension pneumothorax, pericardial tamponade,
or intracranial bleeding). Continuous monitoring of vital
signs is critical. Key points in the secondary survey are
presented in Table 35–2.
Table 35–2 Key Points in the Secondary Survey
Surveyed System
Evaluated Criteria
Head
Complete neurologic examination using a tool such as the Glasgow Coma Scale (GCS); re-evaluation of pupil size and reactivity;
inspection and palpation of cranium for lacerations, fractures, contusions, hemotympanum, cerebrospinal fluid leakage, and
edema
Maxillofacial
Assessment for facial fractures via inspection; palpation for open fractures, lacerations, and mobility or instability of facial structures
Cervical spine or
neck
Inspection and palpation of neck anteriorly (maintaining cervical spine immobilization); palpation anteriorly and posteriorly for pain,
crepitus, bony step-offs indicating fracture–dislocation, neck vein distention, and tracheal deviation
Chest
Inspection for paradoxical movement, flail segments, open chest wounds, and ecchymosis; palpation for rib fractures, subcutaneous emphysema, respiratory excursion, and sternal fractures; auscultation for quality, equality of breath sounds, and presence of
adventitious sounds; auscultation of heart sounds for quality, extra heart sounds, murmurs, or pericardial friction rubs possibly
indicating pericardial effusion
Abdomen
Inspection and auscultation before palpation to prevent precipitation of misleading bowel sounds by manual manipulation; inspection
for abrasions, contusions, lacerations, and distention; auscultation for bowel sounds in four quadrants, bruits, and breath sounds;
light and deep palpation precipitating a painful response may indicate intraperitoneal bleeding and should be quickly attended
Pelvis, perineum,
genitalia
Inspection of pelvis for deformation; palpation for stability; inspection of perineum and genitalia for bleeding at the meatus, hematoma, vaginal bleeding, and lacerations; rectal examination to evaluate rectal wall integrity, presence of blood, position of prostate,
presence of palpable pelvic fractures, and quality of sphincter tone
Musculoskeletal
Visual evaluation of extremities for contusions or deformities; palpation of all extremities for tenderness, crepitation, or abnormal
range of motion, which may raise index of suspicion for fracture; all peripheral pulses should be evaluated, and capillary refill, skin
color, temperature rechecked
Back
All patients should be log-rolled with careful attention to spinal immobilization to afford clinician a full view of patient’s posterior
surfaces, including neck, back, buttocks, and lower extremities, which should be carefully inspected and palpated to detect any
area of injury
Complete neurologic
examination
Motor and sensory evaluation of the extremities; re-evaluation of the patient’s GCS score and pupils; any evidence of paralysis or
paresis should prompt immediate immobilization of the entire patient if not already done
SOURCE: Data from Ali (2014); Cameron & Knapp (2016); Roccaforte (2017).
892 PART 10 Multisystem Dysfunction
Section Five Review
1. When are life-threatening injuries detected?
A. Primary survey
B. Resuscitation
C. Secondary survey
D. Tertiary survey
2. During the secondary survey, a client becomes hemodynamically unstable. What should the nurse do?
A. Stop the secondary survey and reinstitute the
primary survey.
B. Finish the secondary survey, looking for potential
etiologies of instability.
C. Start again at the beginning of the secondary
survey.
D. Re-evaluate patency and flow rates of IVs.
Section Six: Trauma
Resuscitation
During the primary survey and resuscitation phases,
which occur simultaneously, other therapies are also initiated. For example, a Foley catheter is inserted (unless contraindicated) and a nasogastric tube is placed to prevent
aspiration. This section discusses management of the
trauma patient based on changing priorities through the
crisis period.
Trimodal Distribution
of Trauma Deaths
In 1975, Cowley (1976) introduced the concept of the
“golden hour” for resuscitation of the severely injured
patient. The first hour following the trauma was the most
opportune time to increase the chances of survival through
primary assessment, diagnostic testing, and initiating
definitive therapy (resuscitation, stop bleeding, hemodynamic stabilization, and surgical care). In a seminal paper
published in 1983, Trunkey described trauma mortality as
having a trimodal distribution based upon the time interval from injury to death—that is, death from trauma has
three peak periods of occurrence (Figure 35–8) (Cameron &
Knapp, 2016; Trunkey, 1983). The first peak occurs within
minutes of the injury, before the patient arrives at the hospital. These deaths usually result from devastating injuries
to the brain, upper spinal cord, heart, aorta, or other major
blood vessel. The second peak occurs minutes to hours
after arrival in the emergency department, and death usually is related to subdural or epidural hematoma(s), hemopneumothorax, ruptured spleen, lacerated liver, fractured
femur(s), or other injuries resulting in significant blood
loss. The third peak occurs days to weeks after the injury,
3. What is the purpose of the secondary survey?
A. To identify and intervene with life-threatening
injuries
B. To identify all injuries
C. To facilitate treatment of airway and breathing
D. To assess response to resuscitative interventions
4. The presence of abdominal pain on light or deep palpation in the injured client usually indicates which
condition?
A. Gastritis
B. Presence of intraperitoneal blood
C. Pelvic fracture
D. Intracerebral pathology
Answers: 1. A, 2. A, 3. B, 4. B
usually in the intensive care unit, and death results from
complications of systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome
(MODS), or sepsis (Cameron & Knapp, 2016).
Comprehensive trauma healthcare systems targeting
all three peak times for trauma deaths have developed
over the past 25 years to improve the outcomes of trauma
patients (West, Trunkey, & Limm, 1979). Evidence-based
programs to reduce trauma mortality include injury prevention, use of prehospital and emergency department
advanced life support interventions, rapid transport, designated trauma centers with personnel and resources to
care for the injured trauma patient, evidence-based protocols for acute care, advances in critical care medicine, multidisciplinary care approaches, and an emphasis on
rehabilitation and reintegration back into the community
(West et al., 1979). More recent studies have shown that
trauma-related deaths now have a largely bimodal, rather
than a trimodal distribution with diminished late peak in
deaths that could reflect improvements in access to better
trauma, resuscitation, and critical care (Abdelrahman et al.,
2014; Evans et al., 2010; Gunst et al., 2010). The golden hour
is still important as the majority of deaths occur rapidly
following a severe injury.
How does an understanding of this distribution
enhance clinical practice? It can empower the nurse to
anticipate the needs of the patient based on time from
injury and physiological manifestations. If a patient
is received within minutes of injury, what are the lifethreatening injuries that may cause death in this time
frame? Has the patient experienced brainstem compression or laceration resulting in respiratory center dysfunction? What assessments and interventions must be
performed to identify and treat these injuries?
If an unstable patient arrives within 30 minutes of
injury, the injuries that pose a risk for trauma-related death
during this time frame must be assessed and monitored to
CHAPTER 35 Multiple Trauma
893
Deaths
TRAUMA DEATHS
Lacerations
Brain
Brainstem
Aorta
Cord
A Heart Epidural
Subdural
Hemopneumothorax
B Pelvic fractures
Long bone fractures
Abdominal injuries
0 1 hour 3 hours
A) Deaths due to massive
injuries. Seconds to
minutes.
B) Death due to hemorrhage.
Hours.
Sepsis
C Multiple organ
failure
2 weeks
C) Death due to late
complications of trauma.
Days to weeks.
*golden hour – in the 1st
hour, 30% of death
takes place.
4 weeks
Time
Figure 35–8 Trimodal distribution of trauma deaths.
anticipate a life-threatening situation. These injuries might
include hemopneumothorax (assess respiratory effort,
lung sounds, possible need for a chest tube), ruptured
spleen or lacerated liver (assess for a tense and painful
abdomen, hypotension with no signs of obvious blood
loss), and fractured femur (assess for a painful leg with
obvious fracture).
The high-acuity nurse caring for a patient 3 days postinjury anticipates quite different causes for trauma-related
death during this time frame. The nurse identifies precipitating or contributing factors in a patient experiencing sepsis or MODS, such as overhydration during the first 24 to
48 hours, with development of acute respiratory distress
syndrome (ARDS) or a missed intra-abdominal injury that
predisposes the patient to sepsis.
Trauma Resuscitation
Of the causes of early post-injury deaths in the hospital
that are amenable to effective treatment, hemorrhage is
predominant. The most common cause of shock in the
injured patient is hypovolemia resulting from acute blood
loss. Successful treatment of shock depends on early recognition, controlling obvious hemorrhage, and fluid resuscitation, with fluid resuscitation being the fundamental
treatment for hypovolemic shock until definitive surgical
intervention is available to treat the site (or sites) of injury.
Recognition of the source of blood loss is critical. Blood
volume loss in quantities large enough to produce a shock
state can occur in any of five areas: chest, abdomen, pelvis
and retroperitoneum, femur fractures, and external hemorrhage. See Table 35–3 for more details. Because of the
potential for large-volume hemorrhage from abdominal
and pelvic trauma, rapid evaluation of these two areas is
critical (Cameron & Knapp, 2016; Roccaforte, 2017).
Resuscitation of the patient who is exsanguinating is
based on the aggressive application of basic principles of
circulation management. Intravenous access is established
quickly with large-bore (e.g., 14- or 16-gauge) catheters.
Because the underlying source of the hypotension is hypovolemic shock, administering fluids (usually normal
Table 35–3 Estimating Potential Blood Volume Loss
Location
Volume Loss
Chest
In the adult, 2.5 L of blood can be lost in each
hemothorax. Thus, a total of 5 L can be lost
inside the chest, which would be the total blood
volume of a person weighing 70 kg.
Abdomen
As much as 6 L of blood can be lost via intraperitoneal bleeding from damaged organs or vessels.
Pelvis and
retroperitoneum
Unstable pelvic fractures, especially those involving
the posterior elements of the pelvis, can precipitate liters of blood loss. A patient may actually
exsanguinate from an unstable pelvic fracture
involving posterior bony elements.
Femur fractures
For each femur fracture, 500 to 1000 mL of blood
can be lost.
External
hemorrhage
Bleeding wounds are a consideration. A scalp
laceration, in particular, requires proper
hemostasis because a significant amount of
blood can be lost with this injury.
saline) is crucial. Vasopressors are not given to treat hypotension until fluid volume has been restored. Blood and
blood products may be given in addition to IV fluids. Typespecific blood should be given, but in an emergency situation low-titer O-positive blood may be given to men and
O-negative to women of childbearing age.
Other infusion devices are available in the acute phase
of resuscitation of the patient with exsanguination. Rapid
infusion devices are available that can deliver large amounts
of crystalloid and colloid quickly (up to 1400 mL/minute).
The use of autotransfusion devices facilitates resuscitative
efforts in patients with chest tubes by transfusing the
patient’s own blood during massive bleeding from trauma.
Major advantages of autotransfusion are that it reduces the
usual risks of banked-blood transfusions (e.g., transfusion
reactions and transmission of disease [McGinty, 2017]).
Emergency department open resuscitative thoracotomy
also may be performed to manage the exsanguinating
patient, especially if exsanguination is suspected to be
related to injury to the great vessels (e.g., aorta) or the heart.
894 PART 10 Multisystem Dysfunction
Open resuscitative thoracotomy is an emergency last-resort
procedure in which an incision is made through the chest
wall to gain access to the chest and its contents. This allows
direct viewing of the heart and great vessels to control hemorrhage and treat life-threatening injuries.
Critical analysis of assessment data during the primary assessment and quick recognition of traumatic shock
are essential skills in the resuscitative phase of trauma. The
number of preventable trauma-related deaths can be
reduced with improved prehospital and hospital care provided by highly skilled clinicians trained to evaluate the
injured patient rapidly and effectively (Sanddal et al., 2011;
Vioque et al., 2014).
Table 35–4 End Points in Trauma Resuscitation
TRADITIONAL HEMODYNAMIC PARAMETERS
Parameter
Blood pressure
Heart rate
Urine output
Skin
GLOBAL PARAMETERS
Parameter
Oxygen delivery index
Oxygen consumption index
Systemic mixed venous
oxygen saturation
Lactate
Base deficit
Tissue arteriovenous carbon
dioxide gradient
Sublingual capnography
Gastric pHi
End Points of Resuscitation
How is it determined that a patient has been adequately
resuscitated? The goal of the resuscitation is to treat shock
so it does not progress to an irreversible state. Determining
when tissue perfusion has been restored is a challenge. Traditional signs of sufficient tissue perfusion alone (normal
blood pressure, heart rate, and urine output) cannot be
used in shock states because seemingly “normal” vital
signs and urine output may be the result of compensatory
mechanisms (renin-angiotensin-aldosterone system, or
RAAS) and the sympathetic nervous system. Currently, the
best indicators of adequate tissue perfusion in shock
include traditional hemodynamic parameters, global
parameters, and organ-specific parameters (Table 35–4).
The nurse should not be lulled into a false sense of security when vital signs and basic hemodynamic parameters
End-point Value
Systolic blood pressure greater than
90 mmHg; mean arterial pressure (MAP)
greater than 70 mmHg
Less than 100 beats per minute
Greater than 30 mL per hour
Warm, dry
End-point Value
Greater than 500 mL/min/m2
125 mL/min/m2
65% to 80%
Less than 2.2 mmol/L
± 3 mmol/L
Less than 11 mmHg
Less than 70
pHi greater than 7.35
have been restored to normal values. During resuscitation
from traumatic hemorrhagic shock, normalization of blood
pressure, heart rate, and urine output are not adequate, as
occult hypoperfusion, oxygen debt, and ongoing tissue acidosis (compensated shock) may be present, which may lead
to organ dysfunction and death. Optimizing hemodynamic
variables to improve cardiac output or index, oxygen delivery, and oxygen consumption may be beneficial.
Emerging Evidence
• Goldsmith, Curtis, and McCloughen (2017) explored immediate
post-hospitalization incidence, intensity, and impact of pain in
recently discharged adult trauma patients at 2 weeks postdischarge from a level one trauma center. Ninety-eight percent
experienced a blunt injury. Eighty-two patients completed a pain
inventory questionnaire assessing their injury-related pain experience (pain severity, impact of pain) 2 weeks postdischarge from
the hospital. The questionnaire assessed injury severity and
impact of pain through a score from 0 to 10. Eighty patients (98%)
reported experiencing pain since discharge, with 65 patients still
experiencing the pain 2 weeks after discharge. These trauma
patients reported that their normal work patterns were most
affected by their pain, with an average score of 6.6 out of 10 on
the Brief Pain Inventory, followed by effect on general activity
(6.1/10) and enjoyment of life (5.7/10). The highest pain severity
was reported by those with injuries from road trauma, with low
injury severity scores reported by those who were female and did
not speak English at home. The authors concluded that pain was
common in this sample of trauma patients; it was intense, enduring, and interfered with quality of life. This study has implications
in the importance for nurses and physicians to identify barriers to
effective pain management while implementing interventions to
address the barriers in order to manage pain and optimize functional outcomes of trauma patients (Goldsmith et al., 2017).
• Leske, McAndrew, Brasel, and Feetham (2017) examined the
effects of family presence during resuscitation (FPDR) in patients
who survived trauma from motor vehicle crashes (MVCs) and gunshot wounds (GSWs). Family members of 140 trauma patients
•
(MVC = 110, 79%; GSW = 30, 21%) participated in the study
within 3 days of admission to the critical care unit. Results indicate
that participation in the FPDR may help family members to be better able to assist the patient during the initial critical care period.
Participation in FPDR significantly reduced family reports of anxiety
(p = .04) and stress (p = .005) and fostered family reports of wellbeing (p = .001). There was no statistically significant difference in
satisfaction with critical care (p = .78) between the FPDR group
and the no-FPDR group. Family resources moderated the stress in
the FPDR group participants (p = .01) (Leske et al., 2017).
Harada et al. (2017) conducted a retrospective review of medical
records of 1571 trauma patients who sustained moderate to
severe injury and who received crystalloid resuscitation in the ED
at an urban level one trauma center (1) to characterize how the
center has responded to changes in crystalloid resuscitation
practice trauma practices and (2) to describe associated patient
outcomes over time. They compared clinical characteristics and
outcomes between high- and low-volume resuscitation patients.
Of these patients, 82% (n = 1282) received low-volume resuscitation and 18% (n = 289) received high-volume resuscitation. The
patients in the low-volume group presented to the ED with a
higher mean arterial pressure (p < 0.001). Low-volume patients
had lower injury severity compared to high-volume patients (p <
0.001); mortality was lower in the low-volume group (p < 0.001).
Decreased high-volume resuscitation with crystalloids was associated with a reduced mortality over the 10-year study period,
and mortality was higher in those patients who received highvolume resuscitation (Harada et al., 2017)
CHAPTER 35 Multiple Trauma
895
Section Six Review
1. Trauma-related mortalities exhibit which distribution?
A. Modal
B. Bimodal
C. Trimodal
D. Bell shaped
2. Which shock state is most common in injured clients?
A. Hypovolemic
B. Cardiogenic
C. Neurogenic
D. Septic
3. Which parameter is the BEST indication that resuscitation efforts have improved the shock state?
A. MAP greater than 80 mmHg
B. Heart rate 110 beats per minute
C. Urine output 20 mL per hour
D. Lactate less than 2.2 mmol
4. Why are traditional signs of tissue perfusion such as
heart rate and urine output unreliable indicators of
sufficient tissue perfusion?
A. The effects of base deficit
B. The effects of RAAS
C. Effects of parasympathetic response to injury
D. Effects of fluid administration on hemodynamics
Answers: 1. B, 2. A, 3. D, 4. B
Section Seven:
Management of Selected
Injuries
The focus of this section is to provide a profile of the management of chest, abdominal, and pelvic injuries, which
are commonly seen in trauma patients in high-acuity units.
Some of these injuries require interventions during the primary survey.
Chest Injuries
Injuries to the chest are usually a result of an MVC or a
violent crime and are a major cause of death in North
America. Chest injuries involve trauma to the chest wall,
lungs, and heart.
Rib Fractures Rib fractures are typically caused by blunt
trauma. Multiple ribs can be fractured. Rib fractures are
very painful; the pain is aggravated by any movement of
the chest wall, even breathing. Therefore, the patient with
rib fractures often takes shallow breaths. Atelectasis can
develop, and the patient is at risk for developing pneumonia. Nonsteroidal anti-inflammatory agents, intercostal
nerve block, thoracic epidural analgesia, and narcotics may
be used to optimize pain management. There is no treatment for nondisplaced rib fractures other than to let the
fractures heal naturally over time. Incentive spirometry
reduces atelectasis and risk for pneumonia (Kaafarani
et al., 2016). Trauma patients with blunt trauma to the torso
should be evaluated for rib fractures that could result in
pleural or diaphragmatic injury.
Flail Chest Flail chest results when two or more rib fractures occur in two or more places, causing the flail segment
to separate from the rib cage (Figure 35–9). The flail portion
Figure 35–9 Flail chest. Physiologic function of the chest wall is (A) impaired as the flail segment (B) is sucked inward
during inspiration and (C) moves outward with expiration.
896 PART 10 Multisystem Dysfunction
of the chest wall does not have bony support and moves
independently of the normal chest wall movement. Complications develop as a result of extreme pain with inspiration and expiration, and hypoxemia often results from
inadequate respiratory effort. Signs of a flail chest include
uncoordinated, paradoxical movement of the flail portion
of the chest wall, crepitus, and hypoxemia on blood gas.
Flail chest requires immediate treatment during the primary survey to stabilize breathing. Treatment goals are
directed at preventing and treating hypoxemia. Positivepressure mechanical ventilation may be required.
Pulmonary Injuries
Traumatic injury to the lungs can be readily assessed in
some instances—for example, a penetrating gunshot
wound to the chest—or it can be initially hidden, particularly when it is associated with blunt chest trauma. Pulmonary injuries are potentially life-threatening because the
lungs are necessary for gas exchange and tissue oxygenation. (See Table 35–5.)
Table 35–5 Traumatic Injuries and Associated Sequelae
Condition
Pathophysiology
Complication
Thoracic Trauma
Great vessel tears
Hemothorax
Tension pneumothorax
Open pneumothorax
Hemorrhage
Decreased gas exchange
Decreased gas exchange
Disruption in skin integrity
DIC, AKI
ARDS
ARDS
Sepsis
Extravasation of GI
contents into peritoneum
Hemorrhage
Sepsis
Hemorrhage
Disruption of fat-containing
tissue, increased flow
of fat globules in
microcirculation
DIC, AKI
ARDS, AKI
Abdominal Trauma
Perforation of intestine
Liver or splenic laceration
Orthopedic Trauma
Femur or pelvis fracture
Long-bone fractures
DIC, ACS, AKI
DIC = disseminated intravascular coagulation; AKI = acute kidney injury; ARDS = acute
respiratory distress syndrome; ACS = abdominal compartment syndrome
Pulmonary Contusions Blunt trauma to lung parenchyma can result in a unilateral or bilateral pulmonary
contusion, or bruising. These injuries can be quite serious
because the bruising can lead to alveolar hemorrhage,
edema, and inflammation within the lung. A large pulmonary contusion can result in respiratory failure. Clinical
manifestations of pulmonary contusion may not appear for
several days. A chest x-ray may reveal pulmonary infiltrates. Crackles may be auscultated. Because the patient is
at risk for impaired gas exchange, nursing care must focus
on improving gas exchange through deep breathing exercises, ambulation, and removal of secretions. The patient is
monitored for worsening respiratory status. Intubation
and mechanical ventilation may be required if signs of
respiratory failure are present. As with rib fractures, pain
management is paramount.
Tension Pneumothorax A tension pneumothorax occurs
when air leaks from the lung or through the chest wall. Air
trapped in the thoracic cavity without means of escape collapses the affected lung (Figure 35–10). As intrathoracic
pressure continues to increase, it is transmitted to the heart,
causing decreased venous return and cardiac output. Tension pneumothorax is characterized by chest pain, air hunger, respiratory distress, tachycardia, neck vein distention,
trachea displaced from midline, and absent breath sounds
on the affected side. It is treated during the primary survey
to stabilize breathing. In an emergent situation, the
increased intrathoracic pressure is relieved by needle thoracotomy using a large-bore (14-gauge) needle or immediate placement of a chest tube.
The nurse can distinguish hypotension resulting from
hypovolemia from that associated with increased pericardial pressure by assessing for the presence of a paradoxical
pulse (pulsus paradoxus), a decrease of 10 mmHg or more
in the systolic blood pressure on inspiration that occurs in
the presence of tension pneumothorax. In these conditions,
the increased thoracic pressure from inspiration further
decreases left ventricle filling and results in blood backing
up into the right heart, compromising CO. If a right atrial
pressure (RAP) catheter or pulmonary arterial catheter is
Figure 35–10 Tension pneumothorax.
CHAPTER 35 Multiple Trauma
in place, the RAP reading is elevated because of increased
right atrial filling with decreased emptying. A RAP reading greater than 15 cm H2O is significant. Jugular venous
distention will be present. Hypotension resulting from
hypovolemia is associated with flat neck veins.
Decreased pedal pulses and pale or mottled skin also
may be present.
Open Pneumothorax An open pneumothorax is a penetrating chest wall injury that sucks air, causing intrathoracic pressure and atmospheric pressure to equilibrate
(Figure 35–11). The clinical manifestations are the same as
for a tension pneumothorax. Initial treatment includes covering the wound with a sterile occlusive dressing taped on
three sides, which creates an occlusion with inspiration
(the dressing is sucked into the wound as the patient
breathes in), with an outlet through the lower edge for
expiration. Open pneumothorax is treated during the primary assessment to stabilize breathing with placement of a
chest tube. Surgery may also be required.
Massive Hemothorax Massive hemothorax is defined as
the accumulation of more than 1500 mL of blood in the
chest cavity (Roccaforte, 2017). Usually, the cause is a penetrating wound that disrupts the great vessels. Assessment
findings may include decreased breath sounds or dullness
to percussion on the affected side and hypotension. Management would be aimed at restoring blood volume and
decompressing the chest cavity with a chest tube and
would occur during the primary survey to stabilize breathing. An autotransfusion device may be attached to the
chest tube collection chamber. Surgery may be required
for patients who have continued bleeding requiring persistent transfusions and changes in physiologic status
(McGinty, 2017).
Cardiac Injuries
897
Cardiac Tamponade Whether from penetrating or blunt
trauma, cardiac tamponade causes the pericardium (the
sac around the heart) to fill with blood. This restricts the
heart’s ability to pump and impedes venous return. Signs
and symptoms include Beck’s triad (elevated right atrial
pressure with neck vein distention, hypotension, and muffled heart sounds), pulsus paradoxus, and pulseless electrical activity (PEA). Cardiac tamponade would be treated
during the primary survey to stabilize circulation. Treatment is initially directed at volume resuscitation until pericardiocentesis can be performed (Figure 35–12).
Blunt Cardiac Injury Blunt cardiac injury, formerly called
cardiac contusion, is bruising of the myocardium. Chest discomfort, sinus tachycardia, and hypotension are suggestive
of this injury, but many patients are asymptomatic. Electrocardiogram (ECG) changes may also be present and may
include ST changes, dysrhythmias, or heart block. If the ECG
is abnormal on admission, the patient is admitted to the highacuity unit for continuous ECG monitoring for 24 to 48 hours
(Clancy et al., 2012). An echocardiogram may be done to
evaluate cardiac function, as well as troponin lab values.
Abdominal Injuries
Blunt trauma creates potentially life-threatening abdominal injuries. In a motor vehicle crash, a compression and
possibly shearing injury from a steering wheel or seat belt
may rupture solid organs such as the liver or spleen. Deceleration may cause lacerations to the spleen and liver
because these organs are movable from the fixed structures
surrounding them. The incidence of injury to the spleen is
the highest (40%–55%), followed by injury to the liver
(35%–45%) (Cameron & Knapp, 2016). Penetrating trauma
from stab wounds most commonly involves the liver, small
bowel, diaphragm, or colon. Gunshot wounds have a
greater kinetic energy and more often involve the small
bowel, colon, liver, and abdominal vascular structures.
Cardiac injuries are potentially life-threatening and should
always be suspected when a patient is admitted with
potential chest trauma.
Spleen Injuries The spleen is located in the left upper
quadrant of the abdomen and is the organ most commonly
Figure 35–11 Open pneumothorax.
Figure 35–12 Pericardiocentesis.
898 PART 10 Multisystem Dysfunction
injured in blunt trauma to the abdomen. The spleen has
important immunologic functions; therefore, steps are
taken to let the spleen wound heal after injury instead of
removing it. Diagnosis of injury to the spleen is made by
focused assessment with sonography in trauma (FAST)
and CT scan. Patients are admitted to a high-acuity unit for
serial monitoring of vital signs, abdominal exam, and
hematocrit. It is crucial to monitor vital signs for evidence
of continued bleeding in or around the spleen. Continued
hemodynamic instability may indicate the need for angiography for embolization or surgical intervention (Hildebrand et al., 2014). Patients who do have a splenectomy are
at risk for infections and require vaccinations prior to discharge from the hospital.
Liver Injuries Although anterior and lateral portions of
the liver are protected by the lower rib cage, the liver
remains vulnerable to injury in blunt or penetrating
trauma. The majority of liver injuries are minor and do not
require surgery. However, mortality may be greater than
50% with a complex liver injury, and death is usually the
result of hemorrhage. Diagnosis of liver injury is made by
CT scan. Liver injuries are graded on a scale of 1 to 6, with
6 being a complete hepatic avulsion and the worst injury
possible. Bleeding is the most common complication, and
patients must be monitored for changes in vital signs and
continued decline in hematocrit values.
Patients with liver injuries are usually admitted to a
high-acuity unit for serial monitoring of vital signs and
hematocrit. Medical management may include hepatic
arteriography to embolize any bleeding in the liver, or
surgery may be required to stop the bleeding. In the event
the patient becomes hemodynamically unstable from
continued bleeding and develops hypovolemic shock, the
high-acuity nurse must be prepared to implement volume resuscitation as ordered. This may include crystalloids and blood or blood products. Coagulopathies may
be corrected with fresh-frozen plasma, platelets, or cryoprecipitate. It is crucial that the nurse monitor the
patient’s response to these interventions. Continued
hemodynamic instability may require surgical interventions to find and control the source of hemorrhage within
the liver.
Damage Control Surgery Patients with abdominal injuries that need an operative procedure may require a technique referred to as damage control surgery. This surgical
technique has three phases: initial operation, resuscitation,
and definitive restoration. During the initial operation, time
in the operating room (OR) is kept to a minimum. The goal
is to quickly locate and control sources of hemorrhage. The
longer this takes, the greater the risk of three conditions—
hypothermia, continued bleeding, and systemic acidosis—
which create a self-propagating cycle that can eventually
lead to an irreversible physiological insult (Cameron &
Knapp, 2016). Therefore, the goal of this initial operation is
to quickly control hemorrhage, which may be done by simply packing the abdomen with sterile dressing to control
the bleeding.
After this initial phase, the patient is taken to the ICU
for trauma resuscitation. The goal is to correct hypothermia, acidosis, and coagulopathies. Serial measurements of
lactate and base deficit are assessed for signs of improving
metabolic acidosis. Coagulopathies are corrected with
blood and blood products. During this time, the patient is
assessed for abdominal compartment syndrome.
Abdominal Compartment Syndrome. Abdominal compartment syndrome (ACS) is essentially intra-abdominal
hypertension, or too much pressure within the abdominal
cavity. It is caused by continued bleeding or visceral
edema. Signs and symptoms include a taut distended
abdomen, decreased cardiac output, elevated central
venous pressure and pulmonary capillary wedge pressure, increased peak pulmonary pressures, and decreased
urine output (Kirkpatrick et al., 2013). ACS is discussed in
Chapter 22.
Intra-abdominal pressures may be indirectly measured via a Foley catheter. Fluid is instilled to create a
fluid-filled column that transmits pressure from the bladder to the transducer. The transducer should be leveled
and zeroed to the midaxillary line with the patient in the
supine position. The measurement is obtained at end
expiration (Kirkpatrick et al., 2013). These pressures can
be monitored intermittently or continuously, as ordered.
Abdominal pressures greater than 15 to 25 mmHg are
considered high and may indicate that the abdomen
needs to be opened to relieve the pressure (Kirkpatrick
et al., 2013).
Once the hypothermia, acidosis, and coagulopathies
are corrected (usually within 72 hours of the initial operation), the patient is returned to the OR for definitive repair
of injuries.
Pelvic Injuries
Pelvic fractures can be life-threatening injuries. They are
associated with blunt trauma—an MVC or a crushing
injury to the pelvic region. Because the pelvis protects
major blood vessels, patients with pelvic fractures are at
high risk for hemorrhage. Signs of a pelvic fracture include
perianal ecchymosis, pain on palpation or “rocking” of the
iliac crests, hematuria, and lower extremity rotation or
paresis. Confirmation of pelvic fractures is made by CT
scan.
Initial management includes the prevention or treatment of life-threatening hemorrhage. Stabilization may be
temporary with a pelvic binder or external fixation device
for patients who are unstable. While the preferred management includes internal fixation, endovascular balloon
occlusion of the aorta is in the early stages of development
(Constantini et al., 2016).
Nursing management focuses on monitoring for signs
of continued hemorrhage and resuscitation with fluids.
Before the patient can be moved or turned, the nurse must
determine if the physician has established whether the pelvic fracture is stable or unstable. A stable pelvic fracture
implies that no further pathologic displacement of the pelvis can occur with turning. An unstable pelvic fracture
means that further pathologic displacement can occur with
turning. The nurse should monitor the color, motion, and
sensitivity of the bilateral lower extremities for signs of
neurologic or vascular compromise.
CHAPTER 35 Multiple Trauma
899
Section Seven Review
1. What is an important intervention for the client with
multiple rib fractures?
A. Chest tube placement
B. Needle aspiration
C. Pain management and pulmonary hygiene
D. Placing a gauze dressing over the wound
3. During damage control surgery, the initial operation
time is restricted to prevent which conditions?
A. Cardiac dysrhythmias
B. Coagulopathy
C. Metabolic alkalosis
D. Hyperthermia
2. Clients with injuries to the spleen or liver may require
operative repair under which condition?
A. Their abdominal girth increases.
B. They have a change in level of consciousness.
C. The hematocrit increases.
D. They become hemodynamically unstable.
4. Before turning a client with a pelvic fracture, what
must the nurse do first?
A. Medicate the client.
B. Determine if the fracture is stable or unstable.
C. Remove the fixation device.
D. Assess the color, motion, and sensitivity of the legs.
Answers: 1. C, 2. D, 3. B, 4. C
Section Eight:
Complications of Traumatic
Injury
As discussed in Section Six, trauma deaths occur in three
peaks. The third (final) peak occurs days to weeks after the
injury event; death is usually attributable to complications
of critical illness. This section focuses on common complications during this phase.
The primary responsibilities of the nurse caring for a
trauma patient in the final phase are prevention and surveillance. Treatment of trauma sequelae is controversial
because research in this area, compared to trauma resuscitation research, is still in its infancy. Therefore, the goal of
nursing care is to prevent complications.
Patients with traumatic injuries are at increased risk
for multiple complications, such as venous thromboembolism (VTE), undernutrition, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation
(DIC), acute kidney injury (AKI), and multiple organ dysfunction syndrome (MODS). All of these complications are
discussed in detail in other chapters of this text, but they
are reviewed here briefly, as they relate to the patient with
traumatic injuries.
Risks for Complications
Several types of injuries predispose the trauma patient
to complications. Table 35–5 summarizes traumatic injuries and their associated sequelae. Thoracic trauma may
produce massive hemorrhage in addition to disruption
in the lung parenchyma. Thus, the thoracic trauma
patient is at high risk for DIC and ARDS. Abdominal
trauma increases the likelihood of hemorrhage, abdominal compartment syndrome, and infection. Orthopedic
trauma predisposes the patient to VTE and prolonged
immobility, which may negatively impact gas exchange
should pulmonary complications occur, such as pulmonary embolus or severe atelectasis. The physiological
complications of trauma are interrelated, as it is common
for a patient to have a combination of complications.
Although the etiologies of these complications may differ slightly, the result is the same: inadequate oxygen
delivery to the tissues. For this reason, it is important to
keep in mind that the patient may be at higher risk for
one complication because of the initial injury, but in reality, any one—or more than one—complication may
develop.
Metabolic Response to Injury: Risk
for Undernutrition
The metabolic response to stress after injury occurs in two
phases: ebb phase and flow phase. The ebb phase occurs in
the first 3 days during acute resuscitation. Characteristics of
the ebb phase are summarized in Table 35–6. The body
Table 35–6 Metabolic Response to Trauma
Ebb Phase
(first 72 hours after injury)
Flow Phase
(begins 72 hours after injury)
• Hypometabolism
• Decreased energy expenditure
• Normal glucose production with
insulin resistance
• Decreased oxygen consumption
• Mild protein catabolism
• Increased glucocorticoids
• Increased catecholamines
• Decreased cardiac output
• Decreased body temperature
• Vasoconstriction
• Hypermetabolism
• Increased energy expenditure
• Increased glucose production
• Increased oxygen consumption
• Profound protein catabolism
• Increased glucocorticoids
• Increased catecholamines
• Increased potassium and sodium
losses
• Loss of serum proteins through
wounds, exudates, drains, and
hemorrhage
900 PART 10 Multisystem Dysfunction
requires a large amount of glucose during this time, which
is supplied by the breakdown of glycogen stores through
glycogenolysis. Prolonged glycogenolysis depletes skeletal
muscle protein and can lead to wasting. This phase typically
ends after the resuscitative phase, about 72 hours after
injury. The second phase is the flow phase, which is characterized by a hypermetabolic response. This phase results in
catabolism of lean body mass, negative nitrogen balance,
and altered glucose metabolism (Ali, 2014).
Nutritional support is required to supply amino
acids and adequate energy for protein synthesis as new
tissues are synthesized and wounds are repaired. Starting nutritional support as early as possible is essential in
the trauma patient as malnutrition is associated with
increased morbidity and mortality, whereas those
patients whose nutritional requirements are adequately
met experience reduced time on a ventilator, fewer complications, and shorter time in rehabilitation (Kaafarani
et al., 2016). Following nutritional guidelines helps
ensure patients receive adequate nutritional support.
The use of algorithms encourages early initiation and
rapid achievement of therapeutic nutritional support
goals to ensure optimal delivery of nutrition to patients
(Simmons & Adam, 2014).
Venous Thromboembolism
Venous thromboembolism (VTE) encompasses deep vein
thrombosis (DVT) and pulmonary embolism (PE), both of
which constitute a major health problem with significant
morbidity and mortality. Trauma patients have one of the
highest incidences of VTE among hospitalized patients for
myriad reasons, including stasis from immobility and
increased coagulability from the inflammatory process of
injury (Van & Schreiber, 2016). Prophylaxis in the trauma
patient may be difficult because injuries with a high risk of
bleeding preclude anticoagulant use, and lower-extremity
injuries hinder the use of pneumatic sequential compression devices, or SCDs (Toker, Hak, & Morgan, 2011). The
high-acuity nurse must be ever vigilant in ensuring the use
of SCDs when indicated and in monitoring for complications of VTE.
Sepsis
Sepsis is the SIRS phenomenon in the presence of bloodborne infection, and septic shock is the severe physiologic
response to an infection that results in hemodynamic instability. Gram-negative and gram-positive bacteria, viruses,
and fungi can produce sepsis. The offending pathogens
may be part of the patient’s normal flora or may be present
in the external environment. The patient with traumatic
injuries is at particular risk for infection and sepsis because
of so many potential ports of entry, including urinary
catheters, endotracheal tubes, surgical wounds, invasive
hemodynamic monitoring catheters, and IV catheters.
Foreign devices in the nose, such as a nasotracheal tube,
represent a major risk factor for the development of
healthcare-associated sinusitis, which itself is a risk factor
BOX 35–2 Risk Factors for Infection
in the Patient with Traumatic Injury
•
•
•
•
•
•
•
•
•
•
•
•
High injury severity
Shock on admission
Prolonged ICU length of stay
Age greater than 60 years
Size of ICU (more than 10 beds)
Parenteral nutrition
Days with arterial catheter
Days with mechanical ventilation
Days with central venous catheters
Tracheostomy
Neurologic failure at day 3
ICP monitor
for the development of pneumonia. Additional risk factors
for infection are summarized in Box 35–2.
Acute Respiratory Distress
Syndrome
The trauma patient is at risk for acute respiratory distress syndrome (ARDS) as a result of direct and indirect
lung injury. Primary lung injury includes direct blunt or
penetrating injury to the lungs, aspiration, and inhalation. Indirect injuries include sepsis, fat embolism, ischemia or reperfusion, and missed injuries. ARDS is
characterized by acute dyspnea and hypoxemia within
hours to days of the inciting event. In 2011, with agreement among the European Society of Intensive Care
Medicine, the American Thoracic Society, and the Society
of Critical Care Medicine, a new definition was developed to better describe ARDS (Fanelli et al., 2013). ARDS
is defined as the presence of early (within 1 week) onset,
bilateral pulmonary infiltrated, and respiratory failure
(not explained by cardiac failure or fluid overload). Oxygenation status is characterized as mild (PaO2/FiO2 ratio
< 300), moderate (PaO2/FiO2 < 200), and severe (PaO2/
FiO 2 < 100), all with PEEP requirements of 5 cm H2O
(Fanelli et al., 2013).
Disseminated Intravascular
Coagulation
Acute disseminated intravascular coagulation (DIC)
is an exaggerated response to a condition such as sepsis or
multiple trauma that causes excessive clotting. Excessive
systemic clotting leads to depletion of clotting factors and
platelets and results in serious bleeding (MacLeod, Winkler, McCoy, Hillyer, & Shaz, 2014). Normal clotting is a
localized reaction to injury, whereas DIC is a systemic
response. The healthy individual maintains a balance
between clot formation and lysis. In trauma, both the
extrinsic and intrinsic pathways of coagulation may be
stimulated. Brain injury can precipitate the release of tissue
CHAPTER 35 Multiple Trauma
901
thromboplastin (extrinsic pathway). Hypoxia and acidosis
also stimulate the extrinsic pathway. Crush injuries, burns,
and sepsis result in blood cell injury as well as platelet
aggregation (intrinsic pathway).
• Diaphoresis
Acute Kidney Injury (AKI)
• Changing trends in vital signs or hemodynamic readings (e.g., elevated CO, decreased systemic vascular
resistance, SVR)
In the trauma patient, kidney failure rarely occurs as a
result of direct trauma to the kidneys. Often AKI is the
result of acute tubular necrosis from renal hypoperfusion
or toxin-mediated damage to the tubules. Toxin-mediated
kidney injury may be caused by many of the drugs trauma
patients frequently receive, including aminoglycosides,
nonsteroidal anti-inflammatory agents, and radiologic
contrast dyes used for CT scanning. Myoglobin from
crushed skeletal muscle can accumulate in the tubules and
cause obstruction and renal failure.
Systemic Inflammatory Response
Syndrome and Multiple Organ
Dysfunction Syndrome
Underlying the high mortality associated with severe
trauma injury is systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome
(MODS). The pathophysiologic basis of SIRS provides an
explanation for the injury and failure of one or more
organs, leading to MODS. When SIRS is severe and
MODS involves multiple organs, the probability of death
is high. Specific risk factors for development of MODS in
trauma patients include severe injury; massive volumes
of fluid resuscitation, including blood products, crystalloids, and fresh-frozen plasma; multiple preexisting
comorbidities, particularly liver disease; and development of significant shock (with prolonged abnormal base
deficit and lactate levels) (Frohlich et al., 2014; Minei
et al., 2012). For an explanation of the SIRS and MODS
phenomena, see Chapter 38: Multiple Organ Dysfunction
Syndrome.
Nursing Assessment and Diagnosis
Complications may develop at any time in the post-injury
phase. Baseline laboratory and diagnostic data are important in the trauma patient. With these data, the nurse can
monitor for subtle changes which indicate that a complication is developing. The following assessment data would
indicate the presence of a posttrauma complication:
• Elevation of white blood cell count
• Fever
• Change in characteristics of wound drainage (foul
odor, thick, and colored)
• Decreasing oxygenation (e.g., decreasing SpO2, PaO2)
• Decreasing level of responsiveness (related to
decreased oxygenation or increased serum ammonia
levels)
• Decreased urine output
• Cool, mottled skin
• Presence of bleeding (melena, hemoptysis, hematemesis, petechiae, or hematuria)
Nursing diagnoses that pertain to the trauma patient
can be clustered into the two broad areas of pulmonary gas
exchange and perfusion.
Pulmonary Gas Exchange Without adequate pulmonary gas exchange, the tissues do not receive the oxygen
they require. Therefore, meticulously managing the airway and optimizing oxygenation are major priorities in
the care of the trauma patient. Alterations in pulmonary
gas exchange can occur due to increased capillary permeability, decreased alveolar surface area for gas exchange,
or obstruction in pulmonary capillary perfusion. Ventilation impairments result from abnormal breathing patterns from respiratory muscle fatigue or brain injury.
Fatigue, decreased level of consciousness, and inability to
clear secretions can interfere with the ability to adequately
ventilate.
Perfusion Optimizing perfusion is often a challenge, particularly during the initial phases of trauma care related to
hemorrhage with significant loss of circulating blood volume. Hypovolemia can impair tissue perfusion and results
from bleeding and interstitial fluid shift from leaky vessels
that occur due to systemic inflammatory response and
shock. Tissue perfusion can also be affected by capillary
obstruction from vasoconstriction that occurs with bleeding. Decreased vascular volume and systemic vascular
resistance can impair cardiac output.
In addition, trauma patients may experience acute kidney failure from obstruction (microemboli and myoglobin)
of renal blood flow. In the period following a traumatic
injury, patients have an acute catecholamine release with
activation of inflammatory response resulting in a hypermetabolic state with decreased or absent oral intake leading to nutritional compromise. There is also an increased
risk for infection because of open wounds, invasive procedures, surgical incisions, debilitated state, and altered
nutrition.
Psychosocial Nursing
Considerations
The emphasis here has been on physical manifestations of
posttrauma complications; however, psychosocial aspects
must not be ignored. These patients may remain in highacuity environments for prolonged periods and are susceptible to sensory disturbances. Extensive rehabilitation may
be necessary to regain skeletal muscle mass and neurologic
function. Quality-of-life issues should be considered by the
patient and the family. The family’s standard of living may
decline because of financial factors related to healthcare
costs and changes in the patient’s role.