TRAUMA NURSING
By: Diana Blum RN MSN
Metropolitan Community College
PRIORITY EMERGENCY MEASURES FOR
ALL PATIENTS
Make safety the first priority
 Preplan to ensure security and a safe environment
 Closely observe patient and family members in the
event that they respond to stress with physical violence
 Assess the patient and family for psychological
function


Patient and family-focused interventions
 Relieve anxiety and provide a sense of security
 Allow family to stay with patient, if possible, to
alleviate anxiety
 Provide explanations and information
 Provide additional interventions depending upon the
stage of crisis
COMMON TRAUMA
 Heat
 Bites
 Cold
 Electrical
 Altitude
 Near
drowning
 Spinal
 Head
 Musculoskeletal
 Stab/gunshot wounds
 rape
HYPERTHERMIA
Acute Medical Emergency
 Failure of heat regulating mechanisms
 Elderly and young at risk
 Exceptional heat exhaustion
 Stems from heavy perspiration



Need to stay hydrated!
Causes thermal injury at cellular level
TREATMENT

Lower temp as quickly as possible(102 and lower)
How can this be done?

Mortality =duration of hyperthermia
ABC’s
 Give 02, Start large bore IV
 Insert foley
 Labs:


Lytes, CBC, myoglobin. Cardiac enzymes
ASSESSMENT
status…Seizure may occur
 Monitor vitals frequently
 Renal status
 Mental
Monitor temp continuously
 EKG, Neuro status


Hypermetabolism due to increased body temp

Increases 02 demand
Hyperthermia
may recur in 3 to 4
hours; avoid hypothermia
HEAT
Exhaustion
 Stroke

HEAT EXHAUSTION
 Caused


by dehydration
Stems from heavy perspiration
Poor electrolyte consumption
 Signs/Symptoms
Normal mental status
 Flu like
 Headache
 Weakness
 N/V
 Orthostatic hypotension
 Tachycardia

HEAT EXHAUSTION
 Treatment

Outside hospital
Stop activity
 Move to cool place
 Cold packs
 Remove constrictive clothing
 Re-hydrate (water, sports drinks)
 If remains call 911


In hospital
IV 0.9% saline
 Frequent vitals
 Draw serum electrolyte level

HEAT STROKE
Leads to organ failure and death
 Mortality rate up to 80%
 2 types:


Exertional
Sudden onset
 Too heavy clothes


Classic
Occurs over period of time
 Chronic exposure to heat
 Example (no air conditioning)

HEAT STROKE


Assessment
 Monitor mental status
 Monitor vitals
 Monitor renal status
Treatment
 At site
 ensure patent airway
 Move to cool environment
 Pour water on scalp and
body
 Fan the client
 Ice the client
 Call 911

At hospital
 O2
 Start IV
 Administer normal saline
 Use cooling blanket
 DO NOT give ASA
 Monitor rectal temp q15
minutes
 Insert foley to monitor I/Os
closely and measure specific
gravity of urine
 Check CBC, Cardiac
enzymes, serum
electrolytes, liver enzymes
ASAP
 Assess ABGs
 Monitor vitals q 15 minutes
 Administer muscle
relaxants if the client
shivers
 Slow interventions when
core temp is 102 degrees or
less
MANAGEMENT OF PATIENTS WITH HEAT STROKE
Remember ABCs (decrease temp to 39° C as quickly as
possible
 Cooling methods

Cooling blankets, cool sheets, towels, or sponging with cool
water
 Apply ice to neck, groin, chest, and axillae
 Iced lavage of the stomach or colon
 Immersion in cold water bath

Monitor temp, VS, ECG, CVP, LOC, urine output
 Use IVs to replace fluid losses

–
Hyperthermia may recur in 3 to 4 hours; avoid
hypothermia
PATIENT TEACHING
Ensure adequate fluid and foods intake
 Prevent overexposure to sun
 Use sunscreen with at least SPF 30
 Rest frequently when in hot environment
 Gradually expose self to heat
 Wear light weight, light colored, loose clothing
 Pay attention to personal limitations: modify
accordingly

HYPOTHERMIA
COLD
 Most


common
Hypothermia
Frostbite
 Synthetic
clothing is best because it wicks
away moisture and dries fast
 “cotton kills” it holds moisture and
promotes frostbite
 A hat is essential to prevent heat loss
though head
 Keep water, extra clothing, and food in car
in case of break down
HYPOTHERMIA
Internal core temperate is 35° C or less
 Elderly, infants, persons with concurrent illness, the
homeless, and trauma victims are at risk
 Alcohol ingestion increases susceptibility
 Hypothermia may be seen with frostbite; treatment
of hypothermia takes precedence
 Physiologic changes in all organ systems
 Monitor continuously

ASSESSMENT
Apathy, drowsiness, pulmonary edema,
coagulopathies
 Weak HR and BP
 Hypoxemia
 Continuous temperature and EKG
 Watch for dysrhythmias

REWARMING

Warm fluids, blankets

Cardiopulmonary bypass

Warm lavage
FROST BITE
Inadequate insulation is the culprit
 3 stages




Superficial (frost nip)
Mild
Severe
Frostnip produces mild pain, numbness,pallor of
affected skin
 Graded like burns-partial thick or full thick





1st degree- hyperemia, edema
2nd degree- fluid blisters with partial thick necrosis
3rd degree- dark fluid blisters, sub cutaneous necrosis
4th degree- no blisters, no edema, necrosis to muscle
and bone
SNAKE BITES
SNAKE BITES
Most species non venomous and harmless
 Poisonous snakes found in each state except
Maine, Alaska, and Hawaii
 Fatalities are few
 Children 1-9 yrs old victims during daylight
hours
 AWARENESS is KEY
 Most bites between April and October



Peak in July and August
2 main types in North America are

pit vipers (look for warm blooded prey)
Water moccasins, copperheads, rattlesnakes
 Most of bites


Coral snakes

From North Carolina to Florida and in the Gulf
states, Arizona, and Texas
SNAKE BITES

Pit Vipers


Depression between eye and nostril
Triangular head indicative of venom

Venom function is to immbolize, kill and aid in digestion of
prey (systemic effects happen with in 8 hours of puncture)










impairs blood clotting
Breaks down tissue protein
Alters membrane integrity
Necrosis of tissues
Swelling
Hypovolemic shock
Pulmonary edema, renal failure
DIC
2 retractable curved fangs with canals
Rattlers have horny rings in tail that vibrates as a
warning
SNAKE
BITES
 Treatment

At site







Move person to safe area
Encourage rest to
decrease venom
circulation
Remove jewelry and
restrictive clothing
Splint limb below level of
heart
Be calm and reassuring
No alcohol or caffeine 2nd
to speed of venom
absorption
At hospital




Constrict extremity but
not to tight
Do NOT incise or suck
wound
Do NOT apply ice
Use Sawyer extractor if
available if used within 3
minutes of bite and leave
for 30 minutes in place

At hospital continued














O2
2 large bore IV sites
Crystalloid fluids (NS or
LR)
Continuous tele and bp
monitoring
Opiod pain management
Tetanus shot
Broad spectrum antibx
Lab draw (coagulation
studies, CBC, creatinine
kinase, T and C, UA)
ECG
Obtain history of wound
and pre-hospital tx
measure circumference of
bite every 15-30 minutes
Possibly give antivenom if
ordered (see page 177)
Monitor for anaphylaxis
Notify poison control
SNAKE BITES
 Coral


Snakes
Corals burrow in the ground
Bands of black, red, yellow
“red on yellow can kill a fellow”
 “red on black venom lack”

Are generally non aggressive
 Ability to inject venom is less efficient
 Maxillary fangs are small and fixed
 Use chewing motion to inject
 Venom is neurotoxic and myotoxic


Enough in adult coral to kill human
SNAKE BITES

Action of venom


Blocks binding of acetylcholine at post synaptic junction
S/S








pain mild and transient
Fang marks may be hard to see
Effects may be delayed 12 hours but then act rapidly
after
N/V
Headache
Pallor, abd pain
Late stage: parathesias, numbness, mental status
change, crainal and peripheral nerve deficit , flaccid,
difficulty speaking, swallowing, breathing
elevated creatinine kinase
SNAKE BITES
Coral Treatment
 At site



Try to ID snake
Same as pit viper
without concern of
necrosis

At Hospital






Continuous tele
Continuous bp and
pulse ox
Provide airway
management (possible
ET tube)
Provide antivenom
treatment as ordered
Monitor for
anaphylaxis from
antivenom
Notify poison control
http://www.expotv.com/videos/reviews/19/169/Coghlan27sSnakeBiteKit/
156505
PATIENT TEACHING







Avoid venomous snakes as pets
Be cautious in areas that harbour snakes like tall
grass, rock piles, ledges, crevices, caaves, swamps
Don protective attire like boots, heavy pants and
leather gloves. Use a walking stick
Inspect areas before placing hands or feet in them
Do not harass snakes….striking distance is the
length of the snake
Snakes can bite even 20—60 minutes after death due
to bite reflex
Use caution when transporting snake with victim to
hospital…make sure it is in a sealed container.
ARTHROPOD BITES AND STINGS
 Spiders:



carnivorous
Almost all are venomous
Most not harmful to humans
Brown recluse, black widow, and tarantula
are dangerous for example
 Scorpions:
England


Sting with tail
Bark scorpion is most dangerous
 Bees


not in Midwest or New
and Wasps
Wide range of reactions
African or killer bees are very aggressive
found in southwest states
http://www.videojug.com/film/how-to-treat-an-insect-bite
BROWN RECLUSE SPIDER
Bites result in ulcerative lesions
 Cytotoxic effect to tissue
 Medium in size
 Light brown color with dark brown fiddle
shaped mark from eyes
 Shy in nature..hide in boxes, closets,
basements, sheds, garages, luggage, shoes,
clothing, bedsheets, clothes

 Over
1-3 days lesion becomes dark and
necrotic…eschar even forms, and sloughs
 Surgery is often needed

Skin grafting
 Rare:
Malaise, Joint pain, Petechaie, N/V
Fever, Chills
 Pruritis
 Erythema
 Extreme: hemolytic, renal failure, death

Treatment

At site
Cold compress initially
and intermittently over
4 days (may limit
necrosis)
 Rest
 Elevation of extremity
 NEVER use heat


At hospital






Topical antiseptic
Sterile dressing
changes
Antibx
Dapsone:
polymorphonuclear
leukocyte inhibitor:
50mg twice/day
Monitor lab work
closely
Surgery consult

Debridment and skin
grafting
BLACK WIDOW
Found in every state but Alaska
 Prefers cool, damp, environment
 Black in color with red hourglass pattern on abd
 Male are smaller and lighter color that females
 Carry neurotoxic venom
 Bites to humans are defensive in nature
 Main prey other bugs, snakes, and lizards
 Bite is can be painful, local reactions
 Systemic reactions can happen in 1 hour and
involve the neuromuscular system




Causes lactrodectism
Venom causes neurotransmitters to release from nerve terminals
s/s

Abd pain














Peritonitis like symptoms
N/V
Hypertension
Muscle rigidity
Muscle spasms
Facial edema
Pytosis
Diaphoresis
Weakness
Increased salavation
Priapism
Respiratory difficulty
Faciculations
parathesias

At site
Apply an ice pack
 Monitor for systemic
involvement
 ABCs


At hospital








Monitor vitals
Pain meds
Muscle relaxants
Tentanus
Monitor for seizures
Antihypertensives
Anti venom if needed
Call poison control
TARANTULAS
Largest spider
 Found mostly in tropical and subtropical parts of
USA
 Some are in dry arid states like New Mexico and
Arizona
 Can live 25 years
 Venom paralyzes prey and causes muscle
necrosis
 Most human bites have local effects
 Have urticating hairs in dorsal abd area that can
be launched for a defensive technique landing in
skin and causing an inflammatory response

 USA
trantulas don’t produce systemic
reactions
 Worldly ones do
 S/S
Pain at site
Swelling
 Redness
 Numbness
 Lymphangitis
 Intense pruritis
 Severe ophthalmic reactions if hairs come in
contact with eyes



Treatment






Pain meds
Immobolize extremity
Elevate site
Remove hairs with sticky tape followed by irrigation
For eyes: irrigation with saline
Antihistamines and steroids for pruritis
SCORPIONS
 Found
in many states
 Not usual in midwest or new england
unless pet, or transported in baggage
 Venom in stinger located on the tail
 s/s



Localized pain
Inflammation
Mild symptoms
 Treatment:
pain meds, wound care,
supportive management
BARK SCORPION
 Deadly
 Has
a fatal sting
 Found in tress, wood piles, and around
debris
 Humans stung when it gets in clothing,
shoes, blankets, and items left on ground
 Solid yellow, brown, or tan in color
 Have thin pinchers, thin tail, and a
tubercle
 Found in Arizona, New Mexico, Texas,
Nevada, and California
 Has neurotoxic venom

s/s






Involve cranial nerves
May be symptom free
Pain
Respiratory failure
Pancreatitis
Musculoskeletal dysfunction
Gentle tap at possible sting site while client not
looking greatly increases pain, and is
confirmation of bite
 Symptoms begin immediately and reach
maximum intensity in 5 hours
 Most symptoms resolve in 9- 30 hours
 Pain and parathesia can last 2 weeks

 Treatment










Monitor vitals
May need intubation
Supply O2
IV Fluids
Ice pack to sting site
Pain meds and sedatives with caution in non
intubated client
Wound care
Call poison control
Atropine gtts to help with hypersalavation
Antivenom if needed
BEES/WASPS


Stings cause wide array of reactions
S/S

Anaphylaxis most severe





Respiratory failure
Hypotension
Decrease in LOC
Dysrhythmias
Cardiac arrest
Pain
Local reaction
Swelling
N/V
Diarrhea
Pruritis
 Urticaria
 Lip swelling






TREATMENT

At site
Remove stinger
 Ice pack
 Epipen if allergy to
bees
 Call 911 if needed


In hospital







ABCs
Check history for
allergy
Epinephrine
Antihistamine
O2
NS 0.9%
corticosteroids
PATIENT EDUCATION
Wear protective clothing when working in areas
with known venomous athropods (bees, scorpions,
wasps)
 Cover garbage cans
 Use screens in windows and doors
 Inspect clothing and, shoes and gear before putting
on
 Shake out clothing and gear that is on ground
 Exterminate the exterior house
 Do not place hands where eyes can not see
 Do not keep insects as pets
 Epi pen if allergy to bee/wasp

POISONING
OVERDOSE
POISONING


According to your book, Poison is any substance that
when ingested, inhaled, absorbed, applied to the skin, or
produced within the body in relativity small amounts
injures the body by its chemical action
Treatment goals:

Remove or inactivate the poison before it is absorbed

Provide supportive care in maintaining vital organ systems

Administer specific antidotes

Implement treatment to hasten the elimination of the poison
ASSESSMENT OF PATIENTS WITH
INGESTED POISONS

Remember ABCs

Monitor VS, LOC, ECG, and UO

Assess lab values


Determine what, when, and how much substance was
ingested
Assess signs and symptoms of poisoning and tissue
damage

Assess health history

Determine age and weight
INTERVENTIONS FOR THOSE WITH
INGESTED POISONS

remove the toxin or decrease its absorption

Use emetics

Gastric lavage

Activated charcoal

Cathartic when appropriate

Administration of specific antagonist as early as possible

Other measures may include diuresis, dialysis, or
hemoperfusion


Corrosive agents such as acids and alkalis cause
destruction of tissues by contact
DO NOT induce vomiting with corrosive agents
MANAGEMENT OF
CARBON MONOXIDE POISONING
Inhaled carbon monoxide binds to hemoglobin as
carboxyhemoglobin, which does not transport oxygen
 Manifestations: CNS symptoms predominate



Skin color is not a reliable sign

pulse oximetry is not valid
Treatment
Get to fresh air immediately
 Perform CPR as necessary



Administer oxygen: 100% or oxygen under hyperbaric
pressure
Monitor patient continuously
Draw blood levels


May need HBO
MANAGEMENT OF
FOOD POISONING

A sudden illness due to the ingestion of contaminated
food or drink

Food poisoning has the ability to result in respiratory
paralysis and death depending on the cause

ABCs and supportive measures are key

Treatment

correct fluid and electrolyte imbalances

Control nausea and vomiting

Provide clear liquid diet and progression of diet after
nausea and vomiting subside
PATIENTS WITH
SUBSTANCE ABUSE

Acute alcohol intoxication

Alcohol poisoning may result in death

Maintain airway

Observe for CNS depression and hypotension
Rule out other potential causes of the behaviors before
it is assumed the patient is intoxicated
 Use a nonjudgmental, calm manner
 Patient may need sedation if noisy or belligerent



Examine for withdrawal delirium, injuries, and
evidence of other disorders
Commonly abused substances: ???
 see Table 71-1
LIGHTNING
LIGHTNING

Year round problem


Most common in summer
Caused by electrical charge in cloud

Large energy with small duration
High voltage is 1000 volts
 Lighting is 1 million volts

Cloud to ground is most dangerous
 Flash over phenomenon: force powerful enough
to blow off or damage the victims clothing
 Injury is by:




Direct strike
Spashing or side flash off of near by structure
Through the ground
LIGHTNING
Best remedy: AVOIDANCE
 Education



Observe forecasts
Seek shelter when your hear thunder
DO NOT stand under tree
 DO NOT stand in an open area
 Isolated sheds and caves are dangerous








Leave water immediately
Avoid metal objects
If camping stay away from metal tent poles and wet
walls
Stay away from open doors, windows, fireplaces
Turn off electrical equipment
Stay off of telephone
Move to valley area and huddle in ball if in open area
(this minimizes target area)
LIGHTNING



Most lethal effect is asystole or Vfib
Most victims suffer cardiac injury
S/S














Mottled skin
Cardiac arrest
Respiratory arrest
Decreased or absent peripheral pulses
Temporary paralysis
Loss of Consciousness
Amnesia, confusion, disorientation
Photophobia
Seizures
Fatigue and PTSD
Ruptured tympanic membranes
Blindness, cataracts, retinal detachment
Skin burns
Ferning marks: branching on the skin
INTERVENTIONS

At site




Spinal immobilization
Monitor ABCs
CPR
Sterile dressings for
burns

Hospital care










ACLS
Telemetry
ABC support
Ventilator prn
Creatinine kinase level
to determine muscle
damage
Monitor for kidney
failure
Monitor for
rhabdomyolosis
(muscle destruction)
Burn precautions
Tetanus
Xfer to burn center
ALTITUDE RELATED ILLNESS
High altitude is elevations above 5000 feet 
most ski resorts
 As altitude increasesbarametric pressure
decrease


This means less o2 the higher you go
Oxygen is 21% of the barametric pressure
 Acclimatizationthe process of adapting to high
altitudes


Increased RR
Decrease in CO2
 Respiratory alkalosis
 Impaired REM



Excess bicarb excretion through the kidneys
Cerebral blood flow increases

3 most common altitude illnesses
 Acute Mountain Sickness (AMS)
 Precursor for HACE/HAPE
 Throbbing headache, anorexia, N/V
 Chilled, irritable
 Similar symptoms to alcohol hangover
 VS variable
 DOE or at rest
 High altitude cerebral edema (HACE)
 Unable to perform ADLs
 Ataxia w/o focal signs (decreased motor coordination)
 Confusion, impaired judgment , seizures
 Stupor, Coma, Death from brain swelling
 Increased ICP over 1-3 days
 High altitude pulmonary edema (HAPE)
 Most frequent cause of death
 Poor exercise intolerance and recovery
 Fatigue and weakness
 Tachycardia and tachypnea, rales, pneumonia
 Increased pulmonary artery pressure
ALTITUDE ILLNESS

Site




Descent to lower
altitude
Monitor for symptom
progression
Rest
O2 if available

Hospital

Acetazolamide
Acts as bicarb diuretic
 Sulfa drug
 Take 24 hours before
ascent and take for 1st 2
days of the trip
 125mg-250mg po BID
or 500mg SR cap daily






Dexamethazone: 4mg –
8mg po or IM initially
then 4mg q6hours
during descent
O2
Monitor airway
Lasix
Critical care
ALTITUDE EDUCATION
 Plan
a slow descent
 Avoid overexertion and over exposure to
cold
 Avoid alcohol and sleeping pills
 Stay hydrated and have adequate
nutrition
 If symptoms develop descend immediately
 O2 if able
 Wear protective gear
 Wear sunscreen
DROWNING
NEAR DROWNING

Rip currents are powerful currents of water moving away from shore.

More people die every year from rip currents than from shark attacks,
tornadoes, lightning or hurricanes.

According to the United States Lifesaving Association, 80 percent of surf
beach rescues are attributed to rip currents, and more than 100 people
die annually from drowning when they are unable to escape a rip current.

Rip currents can attain speeds as high as 8 feet per second Some rip
currents last for a few hours; others are permanent.

Rip currents range from 50 to 100 feet or more in width. They can extend
up to 1000 feet offshore.
If caught in a rip current:
 •Remain calm to conserve energy and think
clearly.
 •Never fight against the current.
 •Think of it like a treadmill that cannot be
turned off, which you need to step to the side of.
 •Swim out of the current in a direction following
the shoreline. When out of the current, swim at
an angle--away from the current--towards shore.
 •If you are unable to swim out of the rip current,
float or calmly tread water. When out of the
current, swim towards shore.
 •If you are still unable to reach shore, draw
attention to yourself by waving your arm and
yelling for help.

 6,000
to 8,000 people drown in the U.S. each year.
Most drownings occur within a short distance of
safety. Immediate action and first aid can prevent
death.
 A person who is drowning usually can NOT shout
for help. Be alert for signs of drowning.
 Suspect an accident if you see someone in the water
fully clothed. Watch for uneven swimming motions,
which indicate a swimmer is getting tired. Often the
body sinks, and only the head shows above the
water.
 Children can drown in only a few inches of water.
 It may be possible to revive a drowning victim even
after a prolonged period of submersion, especially if
the person was in very cold water.
Causes
 Leaving small
children unattended
around bathtubs and
pools
 Drinking alcohol while
boating or swimming
 Inability to swim or
panic while swimming
 Falling through thin
ice
 Blows to the head or
seizures while in the
water
 Attempted suicide
















Symptoms
Symptoms can vary, but
may include:
Abdominal distention
Bluish skin of the face,
especially around the lips
Cold skin and pale
appearance
Confusion
Cough with pink, frothy
sputum
Irritability
Lethargy
No breathing
Restlessness
Shallow or gasping
respirations
Chest pain
Unconsciousness
Vomiting
First Aid
 When someone is drowning:
 Extend a long pole or branch to the person, or use a throw
rope attached to a buoyant object, such as a life ring or life
jacket. Toss it to the person, then pull him or her to shore.
 People who have fallen through ice may not be able to
grasp objects within their reach or hold on while being
pulled to safety.
 Do not place yourself in danger. Do NOT get into the water
or go out onto ice unless your are absolutely sure it is safe.
 If you are trained in rescuing people, do so immediately if
you are absolutely sure it will not cause you harm.
 If the victim's breathing has stopped, begin rescue breaths
as soon as you can. This often means starting the
breathing process while still in the water.
 Continue to breathe for the person every few seconds while
moving them to dry land. Once on land, give CPR if
needed.

Always use caution when moving a drowning victim.
 Assume that the person may have a neck or spine injury, and
avoid turning or bending the neck.
Keep the head and neck very still during CPR and while moving
the person.
You can tape the head to a backboard or stretcher, or secure the
neck by placing rolled towels or other objects around it.
Follow these additional steps:
Keep the person calm and still. Seek medical help immediately.
Remove any cold, wet clothes from the person and cover with
something warm to prevent hypothermia.
Give first aid for any other serious injuries.
The person may cough and have difficulty breathing once
breathing re-starts. Keep Reassuring the person without providing
false hope.

DO NOT





DO NOT go out on the ice to rescue a drowning person that you can reach
with your arm or an extended object.
DO NOT attempt a swimming rescue yourself unless you are trained in
water rescue.
DO NOT go into rough or turbulent water that may endanger you.
Do not perform the Heimlich maneuver unless repeated attempts to
position the airway to use rescue breathes failed and you suspect the
person’s airway is blocked. It increases the chances that an unconscious
victim will vomit and subsequently choke
When to Contact a Medical Professional


If you cannot rescue the drowning person without endangering yourself,
call for emergency medical assistance immediately. If you are trained and
able to rescue the person, do so and then call for medical help.
All possible drownings should be checked by a doctor.

Prevention








Avoid drinking alcohol whenever swimming or
boating.
Observe water safety rules.
Take a water safety course.
Never allow children to swim alone or unsupervised
regardless of their ability to swim.
Never leave children alone for any period of time, or
let them leave your line of sight around any pool or
body of water.
Drowning can occur in any container of water. Do not
leave any standing water (in empty basins, buckets,
ice chests, kiddy pools, or bathtubs). Secure the toilet
seat cover with a child safety device.
Fence all pools and spas. Secure all the doors to the
outside, and install pool and door alarms.
If your child is missing, check the pool immediately.
MULTISYSTEM TRAUMA
SPINAL CORD INJURIES (SCI)

tetraplegia (quadriplegia): paralysis from neck
down
Loss of bowel and bladder control
 Loss of motor function
 Loss of reflex activity
 Loss of sensation
 Coping issues
*Christopher Reeve is example of this injury*

Complete: spinal cord severed and no nerve
impulses below level of injury
 Incomplete: allow some function and movement
below level of injury

CAUSES OF SCI

Primary






Hyperflexion (moved forward excessively)
Hyperextension (MVA)
Axial loading (blow at top of head causes shattering)
Excessive rotation (turning beyond normal range)
Penetrating (knife, bullet)
Secondary





Neurogenic shock
Vascular insult
Hemorrhage
Ischemia
Electrolyte imbalance
CERVICAL INJURIES




Anterior cord syndrome
 Damage to anterior portion of gray and white matter as
a result of decreased blood supply..pt will have a loss of
motor function, pain, and temperature sensation but
touch, vibration, and position remain intact
Posterior cord lesion
 Damage to posterior white and gray matter..pt has
intact motor function but loss of vibratory sense, crude
touch, and position sensation
Brown Sequard syndrome
 Result of penetrating injury that causes hemisection of
spinal cord.
 Motor function , proprioseption, vibration, and deep
touch are lost on the same side as injury (ipsilateral)
 On the other side (contralateral) the sensation of pain,
temperature and light touch are affected
Central cord syndrome
 Loss of motor function in upper extremities and varying
degrees of sensation remain
ASSESSMENT OF SCI

1st assess respiratory status
 ET tube may be necessary if compromised
 2nd assess for intra-abdominal hemorrhage
(hypotension, tachycardia, weak and thready
pulse)
 3rd assess motor function







C4-5 apply downward pressure while the client shrugs
C5-6 apply resistance while client pulls up arms
C7 apply resistance while pt straightens flexed arms
C8 check hand grasp
L2-4 apply resistance while the client lifts legs from bed
L5 apply resistance while client dorsiflexes feet
S1 apply resistance while client plantar flexes feet
EMERGENCY CARE OF SCI

Observe for signs of autonomic dysreflexia

Sever HTN, bradycardia, sever headache, nasal
stuffiness, and flushing


Caused by noxious stimuli like distended bladder or
constipation
Immediate interventions








Place in sitting position
Call doctor
Loosen tight clothes
Check foley tubing if present
Check for impaction
Check room temp
Monitor BP q10-15 minutes
Give nitrates or hydralazine per md order
NRSG DX
Ineffective tissue perfusion r/t interruption of
arterial flow
 Ineffective airway clearance r/t SCI
 Ineffective breathing pattern r/t SCI
 Impaired gas exchange r/t SCI

TREATMENT OF SCI
 Immobilize
fx
 Proper body alignment

Traction is possible
 Monitor
vs q4 hours or more
 Neuro checks q4 hours or more
 Monitor for neurogenic shock
(hypotension and bradycardia)
 Prepare for possible surgery
 Teach skin care, ADLs, wound prevention
techniques, bowel and bladder training,
medications, and sexuality
BRAIN INJURIES (TBI)


Open- skull fx or when skull is pierced by penetrating
object
 Linear fx- simple clean break
 Depressed fx- bone pressed in towards tissue
 Open fx-lacerated scalp that creates opening to brain
tissue
 Comminuted fx- bone fragments and depresses into
brain tissue
 Basilar- unique fx at base of skull with CSF leaking
though the ear or nose
Closed- blunt trauma
 Mild concussion-brief LOC
 Diffuse axonal injury- usually from MVA
 May go into coma
 Contusion-bruising of brain
 Site of impact (coupe)
 Opposite side of impact (contrecoupe)
 Laceration-tearing of cortical surface vessels that leads
to hemorrhage edema and inflammation
Always assume c-spine injury
 ABC highest priority
 Control bleeding right away

MOTOR VEHICLE COLLISIONS

Frontal
Front of car stops and driver keeps going
 Injuries: Seatbelt, Steering wheel, TBI, cspine, flail
chest, myocardial contusion


Side


Rear


Injuries: Cspine, flail chest, pneumothorax
Hyperextension, cspine
Rollover

Multiple injuries
FIGURE 74.2 UNRESTRAINED FRONTAL
IMPACT.
OTHER TYPES OF MULTIPLE INJURIES

Motorcyle


Pedestrian


Tib/fib, chest, abd, TBI, cspine, femur
Femur, chest, lower extremities
Falls

Calcaneous, compression, wrist, TBI
Battles sign
 Raccoon eyes
 Flail chest
 Tension Pneumothorax
 Hemothorax

BLUNT TRAUMA BY FORCE


Acceleration-caused by external force contacting
head
Deceleration- when head suddenly stops or hits a
stationary object
INCREASED ICP
Normal ICP is 10-15mmHg
 Normal increases occur with coughing, sneezing,
defecation
 Leading cause of death for head trauma
 As ICP increases cerebral perfusion decreases
causing tissue hypoxia, decrease serum pH, and
increase in CO2

ICP CONTINUED

3 types of edema
Vasogenic: increase in brain tissue volume
 Cytotoxic: result of hypoxia
 Interstitial: occurs with brain swelling

HEMATOMA
Epidural- bleed b/w dura and inner table
 Subdural-bleed below dura and above arachoid
 Intracerebral-accumulation of blood in brain
tissue

HYDROCEPHALUS
abnormal increase in CSF volume
 Causes: impaired reabsorption from subarachnoid
hemorrhage or meningitis
 may be congenital or acquired



Acquired hydrocephalus= develops at the time of birth or
at some point afterward. It can affect individuals of all
ages and may be caused by injury or disease.
Symptoms vary with age, disease progression, and
individual differences in tolerance to the condition
BRAIN HERNIATION
 Increased
ICP will shift and move brain
tissue downward
 Central Herniation

Downward shift to brainstem

S/S

Cheyne stokes , pinpoint pupils, hemodynamic instability
 The
most life threatening is Uncal
because it causes pressure on the 3rd
cranial nerve

S/S

Dilated, nonreactive pupils, ptosis, rapidly decreased
LOC
INTERVENTIONS FOR MUSCULOSKELETAL
TRAUMA

Fractures









Open
Closed
Spontaneous
Stress
Compression
Greenstick
Spiral
Oblique
Impacted
Displaced
 Non-displaced
 fragmented

STAGES OF HEALING
48-72 hours after injury hematoma forms at
break site
 Area of bone necrosis forms secondary to
diminished blood flow
 Fibroblasts and osteoblasts come to site
 Fibrocartilage forms =new foundation
 Callus forms 2-6 weeks after initial break
 3 weeks to 6 months later new bone is formed

FACTORS THAT AFFECT HEALING
Age
 Severity of trauma
 Bone injured
 Inadequate immobilization
 Infection
 Avascular necrosis

MUSCULOSKELETAL ASSESSMENT
Assess for life threatening complications
 Skin color and temp
 Movement
 Sensation
 Pulses especially distal to the injury
 Cap refill
 Pain
 Listen for crepitation-grating sound
 Look for ecchymosis
 Assess for subcutaneous emphysema-bubbles
under skin (like bubble wrap when pushed)
 Assess clients feeling of situation
 Some fractures can causes internal injuryhemorrhage

DIAGNOSTICS
No special lab tests except maybe D-Dimer for
clots
 H/H could be low due to bleeding
 CT
 Bone scan
 MRI
 X-rays


Affected extremity
NURSING DIAGNOSIS
Acute pain
 Risk for infection
 Impaired physical mobility
 Etc.

INTERVENTIONS
Inspect fx site
 Palpate area lightly
 Assess motor function
 Immobilize extremity
 Realignment
 Cast
 Traction
 Surgery


open reduction with internal fixation
EDUCATION
Provide education regarding medication
 Instruct the client on s/s of infection (foul
discharge, purulent drainage, fever, lethargy, etc)
 Instruct on dressing changes and importance of
them
 Instruct about pressure ulcer prevention
 Instruct on use of crutches or walker if needed
 Instruct about HHC and other available
resources

Fx of clavicle usually from a fall
 Fx of scapula not common and caused by direct impact
 Fx of humerus common in older adult
 Fx of olecrenon usually from fall directly onto elbow
 Fx of radius and ulna usually Fx together
 Fx of wrist and hand most common site is the carpal scaphoid
bone in young adult men..one of the most misdiagnosed Fx
b/c of poor visibility on x-ray
 Fx of hip caused by falls
 Fx of femur caused from trauma
 Fx of patella result from direct impact
 Fx of tibia and fibula usually break together
 Fx of ankle and foot difficult to heal because of instability of
ankle bone

Fx of ribs and sternum caused by chest trauma
and potentially can puncture lungs, heart and
arteries
 Fx of pelvis can also cause major internal damage
because of the vascular structure present
 Compression Fx of the spine usually caused by
osteoporosis. This causes pain, deformity,
neurologic compromise

FEMUR AND PELVIC FRACTURES
High incidence of hemmorage
 Femur fx-cast, brace, splint, traction



Fat embolism: fat from bone released into blood and
into heart, lungs, etc
Pelvic- girdle, assess for stability
Large amount of force
 Rectal exam

FIGURE 56.10 VASCULAR ANATOMY OF THE
PELVIS.
DISLOCATIONS
Painful
 Needs to be reduced ASAP
 Can cause nerve damage
 Avascular Necrosis


Dislocation occludes blood supply
OTHER SURGERIES
Vertebroplasty
 Kyphoplasty

Both are minimally invasive
 Both use a bone cement to provide immediate relief of
pain

COMPLICATIONS
Acute compartment syndrome: increase pressure
compromises circulation to are. Most common in lower leg
and forearm.
 Fat embolism: fat from bone released into blood and into
heart, lungs, etc. Most common with long bone fx
 DVT
 PE
 INFECTION: from break or from implanted hardware..bone
infection most common with open fx
 Fracture blisters: associated with twisting injury..fluid
moves into vacant spaces..leads to infection
 Ischemic necrosis: blood flow to bone is disrupted
 Delayed union: unhealed after 6 months
 Nonunion:never completely heal
 Malunion: heal incorrectly

CRUSH SYNDROME

CAUSES
Wringer type injuries
 Natural disasters
 Work related injuries
 Drug or alcohol overdose


CHARACTERISTICS
Acute compartment syndrome
 Hyperkalemia
 Rhabdomyolosis – myoglobin released into blood


S/S


Hypovolemia, hyperkalemia, compartment syndrome
TX

IVF, diuretics, low dose dopamine, sodium bicarb,
kayexelate, hemodialysis is possible.
COMPLEX REGIONAL PAIN SYNDROME
s/s: debilitating pain, atrophy, autonomic
dysfunction (excessive sweating, vascular
changes), and motor impairment (muscle paresis)
 Caused by hyperactive sympathetic nervous
system
 Results from trauma
 Common in feet and hands
 3 stages:

1: lasts 1-3 months; local severe burning pain, edema,
vasospasm, muscle spasms
 2: 3-6 months; pain, edema, muscle atrophy, spotty
osteoporosis
 3: marked muscle atrophy, intractable pain, severely
limited mobility, contractures, osteoporosis

TX
Pain control
 PT
 OT
 ROM
 Gentle skin care
 Support groups, etc

SPORTS RELATED INJURIES
Tears
 Lock knee
 Torn ACL
 Tendon rupture
 Dislocation
 Subluxation
 Strains
 Sprains
 Torn rotator cuff

INTERVENTIONS FOR MUSCULOSKELETAL
TRAUMA
Casts
 Braces
 Splints
 Traction
 Surgery
 Reduction (realignment)

AMPUTATIONS
Removal of part of the body
 Types

Surgical-example digit
 Traumatic- example digit


Levels
Lower extremity: digits, bka, aka, midfoot
 Upper extremity: hands, fingers, arms


Complications






Hemorrhage
Infection
Phantom limb pain: perceive pain in the amputated
limb
Immobility
Neuroma: sensitive tumor consisting of nerve cells
found at several nerve endings
Contractures
ASSESSMENTS
Skin color
 Temp
 Sensation
 Pulses
 Cap refill
 Assess feelings r/t amputation

Young: bitter, hostile, uncooperative, loss of job, loss
of hobbies, altered self concept, feeling a loss of
independence
 Assess families perceptions also

Routine preop xrays done
 BP done in all extremities
 Angiography to look at layout of vessels

STAB WOUNDS

4 types of wounds
Incised = Sharp cut like injuries
(knives, glass)
 Slash wounds= more longer than deep
 Stab wound= depth longer than
length
 Defense wound= warding wounds
(like on hand)

Defense Wound
Stab Wound w/ single
edge blade
GUN SHOT WOUNDS
4




types
Close contact= illustrates a patternized
abrasion around the wound
Contact= barrel has contacted the skin and the
gases have passed into SQ tissues faint
abrasion ring and sone grey/black discoloration
Intermediate wound= powder tatooing
Exit wound= slit like exit wound…no powder
or soot

Wound Care Treatment (at Site)
 Bleeding can usually be stopped by applying direct
pressure to the wound.
 Very large foreign objects stuck in a wound should be
stabilized. Do not remove them.
 All wounds require immediate thorough cleansing with
fresh tap water.
 Gently scrub the wound with soap and water to remove
foreign material. If a syringe is available, it should be
used to provide high-pressure irrigation.
 Remove dead tissue from the wound with a sterile
scissors or scalpel.
 After cleaning the wound, a topical antibiotic ointment
(bacitracin) should be applied 3 times per day.
 Wounded extremities should be immobilized and
elevated.
 Puncture wounds are usually not sutured (stitched)
unless they involve the face.

If the wound is clean, the edges can be drawn
together with tape.

(Do not cover wounds inflicted by
animals or that occurred in seawater
with tape.)
Oral antibiotics are usually recommended to
prevent infection.
 If infection develops, continue antibiotics for at
least 5 days after all signs of infection have
cleared.


Inform the doctor of any drug allergy
prior to starting any antibiotic


Some may cause sensitivity to the sun, so
sunscreen (at least SPF 15) is mandatory while
taking these antibiotics.
Pain may be relieved with Tylenol or ibuprofen
IN HOSPITAL TREATMENT
•Stay Safe. If you are not the victim, practice Universal precautions and wear PPE.
•Try to control bleeding before anything else.
•Putting pressure directly on the puncture wound while holding it above the
level of the heart for 15 minutes should be enough to stop bleeding.
•Avoid Tourniquets unless medical care will be delayed for several hours.
•Call 911 if any Deep puncture wounds (or those of unknown depth) to the abdomen,
back, pelvis, thigh, chest, or if bleeding will not stop
•Holes in the chest can collapse the lungs
• Deep puncture wounds to the chest should be immediately sealed by hand or
with a dressing that does not allow air to flow ( 3 sided).
• IF complaints of SOB occur or victim gets worse after sealing the chest
puncture wound then unseal it.
•Once bleeding has been controlled, wash the puncture wound with warm water and
mild soap
SEXUAL ABUSE
SEXUAL ABUSE



Sexual abuse (also referred to as molestation) is defined as the forcing of
undesired sexual acts by one person to another.
Incest is defined as sexual abuse between family members
Different types of sexual abuse involve:




Acquaintance rape - forced sexual intercourse between individuals who
know each other.


Non-consensual, forced physical sexual behavior
Psychological forms of abuse, such as verbal, sexual behavior, or stalking
The use of a position of trust for sexual purposes.
Usually related to drinking
http://www.youtube.com/watch?v=PvXxzZUuIn0
SEXUAL ABUSE

Signs of sexual abuse
Unexplained injuries (especially to parts of the
female body that can be covered by a two-piece
swimsuit)
 Torn or stained clothing or underwear
 Pregnancy
 Sexually transmitted diseases (STDs)
 Unexplained behavioral problems
 Depression
 Self abuse and/or suicidal behavior
 Drug and/or alcohol abuse
 Sudden loss of interest in sexual activity
 Sudden increase of sexual behavior


The doctor in the emergency room will examine the
victim for injuries and collect evidence.

The attacker may have left behind pieces of evidence such as clothing
fibers, hairs, saliva or semen that may help identify him.

In most hospitals, a "rape kit" is used to help collect evidence.
 Samples of evidence may be used in court.

blood tests are done to check for pregnancy and diseases that can be
passed through sex.
 Cultures of the cervix may be sent to a lab to check for disease, too.
The results will come back in several days or a few weeks.

Follow up with PCP is important. If any of the tests are positive,
treatment options will be discussed.

If a birth control pill or intrauterine device (IUD) the chance of
pregnancy is small.

If no birth control is taken the victim may consider pregnancy prevention
treatment.

Pregnancy prevention consists of taking 2 estrogen pills when you first get to the
hospital and 2 more pills 12 hours later. This treatment reduces the risk of
pregnancy by 60% to 90%. (The treatment may make you feel sick to your
stomach.)

If not already vaccinated for hepatitis B, the victim should get that
vaccination followed by one after 1 month and a third in 6 months.

The doctor will also discuss (HIV) infection. you can take 2 medicines–
Retrovir and Epivir -- for 4 weeks to aid in prevention
RAPE
Classified as assault
 Primary cause is an aggressive desire to
dominate according to experts
 Difficult to prosecute b/c of lack of evidence
 Statistics

Women by men: 90-91% most frequent
 Male by male: 9-10% less common
 Little to no research on women offenders


Definition

Intercourse , is attempted or happens without
consent of one of the parties involved (penetration
with penis or objects etc)
TYPES OF RAPE

Gang

Multiple offenders, one victim
Date
 Custodial
 Serial
 Marital
 Prison
 Acquaintance
 Wartime
 Statuatory

EFFECTS OF RAPE

Unpredictable emotions
Feeling numb and detached
 Memory problems
 Avoidance of things
 anxiety


PTSD can occur

Relive the rape over and over
Disturbed sleeping patterns
 Eating habits affected

MORE STATS
If reported to police 50% chance an arrest will be
made
 If arrest made, 80% chance of prosecution
 If prosecuted, 58% chance of felony conviction
 If felony conviction, 69% chance of jail time

MANDATORY REPORTING

If abuse suspected
Child
 Domestic
 Any type
