CHAPTER 47. Trauma Care
Judy Stevenson
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Identify the impact that the mechanism of injury has on the actual injury.
2. Describe the continuum of trauma care from prehospital to post anesthesia care unit (PACU).
3. List elements of primary and secondary assessments in the PACU as they relate to trauma care.
4. Describe total body systems management of the trauma patient.
5. Identify potential complications as they relate to trauma care and appropriate interventions to treat and/or prevent them.
6. Describe the value of a collaborative approach to care and communication.
7. Identify the types of shock and how they impact the trauma patient.
I. OVERVIEW
A. Trauma care is complex.
1. Many pathophysiological responses
2. May be single surgical intervention
3. May need repetitive surgical interventions
4. Consider multiple disciplines.
B. PACU nurse
1. Focus on vigilant continuous assessment.
2. Anticipate problems.
3. Identify subtle changes.
a. Remember medications can alter expected responses.
4. Intervene appropriately and promptly.
5. Prevent complications.
6. Offers challenge in caring
7. Requires knowledge of current research and treatment
8. Expect the unexpected since trauma happens to:
a. Children
b. Pregnant women
c. The elderly
d. The sick
e. The wealthy
f. The impoverished
g. Families
II. PREHOSPITAL
A. Goal of emergency medical services (EMS)
1. Improve field stabilization
2. Resuscitation
3. Transportation to the appropriate level trauma center
B. The Golden Hour
1. Introduced by R. Adams Crowley, MD
2. Emphasizes the importance of time in resuscitation
3. Goal is to achieve maximal survival.
4. Represents the window of opportunity to institute lifesaving and limb-saving measures
C. Prehospital phase
1. Vital information
a. Condition at the scene
(1) Age of victim
(2) Sex of victim
(3) Mechanism of injury
(4) Obvious injuries
(5) Questionable injuries
(6) Potential injuries
(7) Vital signs
(8) Intervention at the scene
(9) Intravenous (IV) fluids
(10) Response to interventions
(11) Stabilization
(12) Presence of drugs or alcohol
(13) Pertinent past medical history
(a) AMPLE
(i) Allergies
(ii) Medications
(iii) Past medical history
(iv) Last meal
(v) Events
(14) Transport time
(15) Any other pertinent information
b. Mechanism of injury (factors that can influence outcome)
(1) Motor vehicle
(a) Restraint devices
(b) Air bag deployment
(c) Patient ejection
(d) Car rolling
(e) Windshield star or shatter
(f) Speed of vehicle
(g) Where impact occurred on vehicle
(h) Other fatalities at the scene
(2) Motorcycle
(a) Speed of cycle
(b) Object with impact
(c) Front, rear, or side impact
(d) Ejection from cycle (front, rear, or side)
(e) Helmet usage
(f) Protective covering (e.g., leather jacket, gloves)
(g) Burns in addition to other injuries
(h) Other fatalities at the scene
(3) Strike with blunt object (e.g., fist, ball bat, ball)
(a) Object that struck
(b) Place struck
(c) Speed at which struck
(d) Presence of protective covering
(e) One strike or multiple strikes
(f) Injury after initial injury (e.g., fall to the ground)
(4) Strike with penetrating object (e.g., gunshot, knife, screwdriver)
(a) Object penetrated
(b) Depth of object
(c) Diameter of object
(d) Twisting or stationary
(e) Direction of penetration
(f) Location of penetration
(g) One wound or multiple wounds
(h) Entrance or exit wound
(i) Object stabilized and secure or removed
(j) Injury after initial injury (e.g., fall to the ground)
(5) Fall
(a) Height from fall
(b) Body position upon landing (e.g., feet, buttock)
(c) Incident before landing (e.g., hit head, slipped)
(d) Protective equipment (e.g., hard hat)
(6) Crush injury
(a) Weight of object
(b) Area compressed
(c) Other injuries
(d) Protective equipment
c. Victim assistance
(1) Bystanders before EMS
(a) Movement of victim before treatment
(2) EMS providers
(a) Dressings
(b) Stabilization of possible fractures
(c) Cervical collar
(d) Spine board
(e) Safety straps
(f) Airway confirmation
(g) Lifesaving interventions
(h) Vascular access
III. MECHANISM OF INJURY
A. Basic understanding
1. Related to the type of injuring forces and subsequent tissue response
2. Helps to determine the extent of potential injuries
B. Factors that influence injury
1. Amount of force: energy is unloaded onto the body.
2. Mass of the object
3. Mass of the body
4. Velocity at which the object is moving
5. Deceleration forces
a. Stop or decrease velocity of moving object
b. Examples: falls, person striking dashboard
6. Acceleration forces
a. Stationary person struck by object
b. Example: pedestrian struck by car
7. Multiple forces
a. Both deceleration and acceleration forces together
b. Example: pedestrian struck by car pushing into another vehicle
c. Three impacts involved in auto crash
(1) Automobile to object
(2) Body into automobile
(3) Organs within body
8. Blunt injury
a. Direct impact
b. Acceleration or deceleration
c. Continuous pressure, shearing, or rotary forces
d. May be less obvious and therefore more serious
e. Can leave little outward evidence of internal damage
f. Underlying tearing by rotary and shearing forces
g. Disrupts blood vessels and nerves
h. Can cause widespread epithelial and endothelial damage
i. Stimulates cells to release their constituents activating the complement
j. Coagulation cascade can begin.
k. Masks more serious complications
9. Penetrating injury
a. Definition: that which cuts or pierces
b. Multiple objects can be impaled (e.g., knife, firearms, handlebars).
c. Causes penetrating and crushing of underlying tissue
d. Produces capillary injury and destruction of tissue
e. Bullets (important factors affecting injury)
(1) Size and type of gun
(2) Velocity
(3) Range
(4) Mass
(5) Trajectory
(6) Entrance and exit wound
f. Stab wounds
(1) Length of object
(2) Force applied
(3) Angle of entry
(4) Twisting or stationary
(5) Penetrating object left in place or removed
g. Firearms
(1) More than bullets
(2) Include explosives such as bottle rockets, missiles, bombs
(3) Occurs many times more than penetrating injury occurs
h. Wounds cause disruption of tissue and cellular function.
i. Introduces debris and foreign bodies into wounds
j. May occur as local ischemia or may extend to fulminate hemorrhage
10. Compression injury
a. Blunt trauma significant to produce capillary injury and destruction
b. Contusion of tissue occurs.
c. Extravasation of blood causes discoloration, pain, and swelling.
d. Massive hematoma increases myofascial pressure.
e. Significant myofascial pressure can result in compartment syndrome.
(1) Increased pressure inside an osteofascial compartment
(2) Impedes circulation and causes cellular ischemia
(3) Results in alteration in neurovascular function
(4) Damaged muscular vessels dilate in response to histamine.
(5) Dilated vessels leak fluid into tissue; loss of capillary integrity
(6) Microvascular perfusion is impeded, and edema increases.
(7) Tissue pressure occurs.
(8) Most commonly occurs in lower leg or forearm
(9) Compartment pressure can be measured.
(a) Normal is <10 mm Hg.
(b) Greater than 30 mm Hg is significant.
(10) Fasciotomy is treatment to prevent muscle or neurovascular damage.
11. Chemical
a. Can be topical, ingested, or inhaled
b. Caustic agent
(1) Alkaline
(2) Acids
(3) Petroleum-based products
c. Damage often limited to localized area
d. Factors to include
(1) Route
(2) Amount
(3) Concentration of substance
(4) Type of substance
(5) Time lapse after exposure
(6) Prehospital treatment
12. Electrical
a. Always think of safety of rescuer.
b. Internal burn not obviously seen
c. Presents in unusual ways
(1) Burned hair on affected extremity
(2) Chest pain
(3) Thermal burn
(4) Enter and exit wounds (often hands or feet)
d. Factors that influence
(1) Voltage
(2) Time of exposure
(3) Area affected
(4) Systemic symptoms
13. Radiant
a. Events generating heat and/or flames
b. Topical or inhalation
c. Can occur in combination with other injuries
d. Burn can occur to skin and underlying structures.
e. Vasoactive chemicals released from mast cells
f. Intravascular volume lost because of tissue disruption and protein leakage
g. Hyperemia increases blood flow and increases fluid loss.
h. Seriousness of injury dependent on:
(1) Surface area
(2) Degree of burn: percent calculated on the amount of second- and third-degree burns only
(3) Presence of systemic problems
(4) Prehospital treatment
i. Inhalation reaction from radiant event
(1) Damage to respiratory vasculature can occur.
(2) Low inhaled oxygen and increased inhaled carbon dioxide can cause hypoxia.
(3) Carboxyhemoglobin levels
(4) Smoke inhalation causes:
(a) Edema of small airways
(b) Atelectasis
14. Predicable injuries
a. Can be based on specific mechanism of injury
b. All injuries cannot be predicted based on mechanism of injury.
C. Scoring systems
1. Numerous scoring mechanisms can be used.
a. Anatomic
(1) Abbreviated Injury Score (AIS)
(2) Injury Severity Score (ISS)
(3) New Injury Severity Score (NISS)
b. Physiological
(1) Glasgow Coma Scale (GCS)
(2) Revised Trauma Score (RTS)
(3) Trauma and Injury Severity Score (TRISS)
c. Injuries assigned to body parts
(1) General
(2) Head and neck
(3) Chest
(4) Abdomen
(5) Extremities and pelvis
2. Assists in determining severity of injuries
3. Assists in determining likelihood of outcome
4. Accuracy limitations can occur despite score used.
IV. STABILIZATION PHASE
A. Initial assessment, resuscitation, and stabilization
1. Initiated in emergency department (ED) or trauma center
2. Extend into operating room (OR)
3. Continue into PACU
4. Will further continue in the critical area or the surgical floor
5. Can extend even beyond discharge
a. Significance of discharge instructions cannot be overstressed.
B. Hypovolemia in trauma patient
1. Most common cause of shock
a. Result of acute blood loss
b. Result of fluid redistribution
2. Fluid resuscitation necessary
a. Prompt fluid replacement
(1) Assists in tissue perfusion
(2) Assists in delivery of oxygen to the tissues
(3) Often requires use of rapid-volume fluid infuser
(a) Can deliver IV fluids at rate of 500 to 700 mL/min
(4) Beneficial to give warm IV fluids
(a) Prevents hypothermia
b. Fluid selection
(1) Crystalloids
(a) Electrolyte solution
(i) Lactated Ringer’s (LR) closely resembles electrolyte composition of blood serum.
(ii) LR may decrease bleeding when compared with normal saline.
(b) Diffuses through capillary endothelium
(c) Distributed throughout extracellular compartment
(i) Only one fourth stays in vascular space.
(d) Common selections are LR and normal saline.
(e) Recommended first line for replacement
(f) Administration should be three to four times blood loss.
(g) Use LR in caution with suspected liver injury.
(h) Cheaper than colloids
(2) Colloids
(a) Contain protein or starch molecules
(b) Molecules remain in intravascular space.
(c) Increase osmotic pressure gradient within vascular compartment
(d) Administration is volume per volume.
(e) Half-life longer than crystalloids
(f) Common selections are:
(i) Plasma protein fraction
(ii) Dextran
(iii) Albumin
(iv) Hetastarch
(3) Hypertonic solutions
(a) Controversial in treatment
(b) Resuscitative in shock
(i) Volume expander (from extracellular source)
(c) Common selections are hypertonic or isotonic saline.
(d) Pulls fluids from extracellular space to support blood pressure (BP)
(e) Can be helpful in head injury patients
(i) Decreases brain edema
(ii) Decreases intracranial pressure
(iii) Increases cerebral pulse pressure
(f) May protect gut and inhibit acute lung injury
(g) Cautions
(i) Renal insufficiency
(ii) Hypernatremia
(4) Blood products
(a) Only blood can replace blood.
(b) Restores capacity to carry oxygen
(c) Given after fluid administration
(d) Packed red blood cells most common
(e) Universal donor is O negative.
(f) O positive can be given to nonchildbearing females and males.
(g) Type-specific blood preferred when waiting is an option
(h) Platelets may be indicated if coagulopathy suspected.
(i) Massive transfusion
(i) More than 10 to 50 units in first 12 to 24 hours
(5) Hemoglobin-based oxygen carriers/blood substitutes
(a) Modified hemoglobin molecule able to carry oxygen to tissue
(b) Longer shelf life
(c) Absence of ABO antigens
(d) No incompatible reactions
(e) Currently only available through research protocols
c. Delayed fluid administration (permissive hypotension)
(1) Can be useful in hemorrhagic patients
(2) Fluids delayed until the start of surgery
(3) Early fluid administration may delay transport.
(4) Restoration of volume can have adverse complications.
(a) Hemodilutes/disrupts body’s hemostatic mechanisms and clot formation
(5) Exacerbation of blood loss can occur from increased BP.
(a) Radial pulse is guideline.
(6) Controversial among trauma surgeons
d. Volume replacement guidelines
(1) Hemorrhage
(a) 3:1 Rule
(i) Administer 3 mL electrolyte solution to 1 mL blood loss.
(2) Burns
(a) Parkland burn formula employs LR alone for first 24 hours.
(i) Adults: LR 2 to 4 mL × Body Weight (kg) × Percent of Burn
(ii) Pediatrics: LR 3 to 4 mL × Body Weight (kg) × Percent of Burn
(iii) Add maintenance fluids with 5% dextrose in water (D 5W) to prevent hypoglycemia and to maintain adequate urine output of 1 mL/kg/hr.
(3) Combination patients (burns and hemorrhaging)
(a) Receive volume calculated for burns.
(b) Also receive volume estimates for hemorrhage loss.
e. Monitoring effective resuscitation
(1) BP goal: Systolic >90 mm Hg
(2) Hourly urine output
(a) Adults: 0.5 mL/kg per hour (30-50 mL/hr)
(b) Peds: 1 mL/kg per hour
(3) Lactate levels
(4) Base excess
3. Other causes of shock in trauma patient
a. Cardiogenic shock can result from:
(1) Cardiac tamponade
(2) Tension pneumothorax
b. Neurogenic shock
(1) Related to spinal cord injury
(2) Spinal anesthesia
c. Septic shock
(1) Usually late
(2) Caused by infectious process
V. DIAGNOSTIC STUDIES AND PROTOCOLS
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A. Diagnostic tests
1. Vital role in establishing injury
2. Necessary for accurate diagnosis
3. Assists in planning effective treatment
4. X-rays
a. Lateral cervical spine
b. Upright chest anteroposterior (CXR)
(1) Repeat if initial CXR done flat (on backboard).
c. Anteroposterior pelvis
d. Any extremity with questionable injury
e. Thoracic and lumbar spine
f. Any other identified injured area
g. Soft tissue films can be helpful if impaled object suspected.
5. Computed tomography (CT) scan
a. Head (without contrast)
b. Chest
c. Abdomen
d. Pelvis
6. Ultrasound (FAST exam)
a. FAST
(1) Focused
(2) Assessment
(3) Sonography
(4) Trauma
b. Rapid, accurate, and inexpensive
c. Blunt trauma
d. Reveals presence of hemoperitoneum
e. To be positive, 200 to 500 mL fluid must be present.
f. Four areas to evaluate
(1) Hepatorenal fossa
(2) Splenorenal fossa
(3) Pericardial sac
(4) Pelvis
g. Cannot diagnose hollow visceral and retroperitoneal injuries or injuries not associated with hemoperitoneum
7. Twelve-lead electrocardiogram
a. Useful with chest injury
b. May be needed if after chest pain, additional trauma occured
8. Diagnostic peritoneal lavage
a. Controversial
b. Used only with suspected abdominal injury and severe hypotension
c. Abdominal CT scan more useful with specific injury information
d. Accuracy rate for presence of blood: 98%
e. Not useful for retroperitoneal blood
f. Before performing lavage, must place nasogastric (NG)/orogastric tube and Foley catheter to decompress bladder and stomach so that inadvertent puncture avoided
9. Arteriogram: perform if vascular injury suspected
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