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54: Care of the Shock Trauma Patient
Myrna Eileen Mamaril
Trauma injuries occur at any age, from pediatric to geriatric ages. The science of shock trauma resuscitation is evolving. There are increasing evidence-based trauma standards of care protocols that guide nursing practice. Key damage control resuscitation strategies emphasize control of hemorrhage, permissive hypotension, hemostatic resuscitation, prevention/correction of acidosis, normothermia, and correction of hypocalcemia. Likewise, current research focuses on permissive hypovolemia, trauma-induced coagulopathy, and targeted-blood component therapies. This chapter reviews the evolution from military trauma care to the advancements of civilian shock trauma care. Foremost the chapter will focus on trauma resuscitation management, which has dramatically improved including avoidance of crystalloid resuscitation to transfusion of a more hemostatic blood product–based approach for hemorrhage control. Finally, the chapter covers recognition of different shock syndromes and goal-directed treatments balancing the risks of fluid overload and under-resuscitation in pediatric and pregnant patients.
damage control resuscitation; goal-directed trauma therapies; pediatric trauma; permissive hypotension; postanesthesia nursing care; pregnancy trauma injuries; shock syndromes; shock trauma care
Traumatic injuries continue to be the leading cause of death, disability, and morbidity. Shock trauma science continues to provide foundational advancements from military medical and nursing research learned from combat trauma care in Iraq and Afghanistan and now has successfully been integrated through dissemination and implementation science into civilian trauma services throughout the United States. Specifically, trauma care focuses on damage control resuscitation that emphasizes rapid hemorrhage control, battlefield damage control surgery, and advanced diagnostic techniques. The key to successful trauma outcomes is to ensure that the best trauma evidence-based practices (EBPs) are implemented into the assessments and management of hospital and nursing trauma protocols. Likewise, this approach provides safeguards to the ongoing and sustaining competency training for nursing and medical staff that leads to clinical improvements for better survival outcomes.1
The data reported in the National Trauma Data Bank (NTDB) benchmarks civilian trauma care for effectiveness, best practices, and improved performance. To mirror the NTDB, the Joint Theater Trauma System presents unique opportunities to benchmark combat casualty care with the goal to improve the effectiveness of battlefield care and survival. These medical advances continue to be driven by trauma science directly resulting from military medicine’s evolving combat casualty management from the wars in Iraq and Afghanistan. In peacetime, the civilian trauma centers take the lead in timely research and EBP medicine to establish new trauma protocols and to translate the trauma research to the practice at the bedside. However, in wartime, it is military medicine’s combat medical research and scientific data outcomes that guide the cutting edge benefiting civilian trauma centers.1–3 The history of medical advancements in shock trauma care is directly linked to military conflicts, wars, and the need for battlefield medicine.1 Trauma care continued to advance in the twenty-first century with the wars in Afghanistan and Iraq.
Permissive hypotension resuscitation, innovative surgical and interventional imaging advancements, new techniques in anesthesia, and damage control hemorrhage bring new dimensions in treating and mitigating severe hemorrhagic shock. Consequently, the crucial period in the management of acute injury and the treatment of shock focuses on rapid transport, guided EBP resuscitation within the “golden hour.”1,2 Advances in vascular surgery, salvage strategies for profoundly hypotensive or pulseless patients that may include retrograde balloon occlusion of the aorta and resuscitative thoracotomy may differ in specialty populations for better patient outcomes.2 Today, this expeditious coordination of trauma care requires expert training and trauma competencies with the “ultimate goal of saving lives during the golden hour of resuscitation.”2
This chapter will focus on the epidemiology of traumatic injuries, mechanism of injury (MOI), pattern of injury, anatomy, physiology, and the patient’s presenting symptoms that guide the postanesthesia nurse in the delivery of care for the adult, pediatric, and obstetric patient.
The postanesthesia nurse’s focus includes primary and secondary assessments for systematic prioritization of nursing interventions and outcomes of care. The MOI is vital to understanding the pathogenesis of injury and anticipated complications including shock during the patient’s recovery from anesthesia and surgery. The emphasis of the trauma patient’s postanesthesia care is on ensuring vital life functions, promoting safety, and supporting psychosocial and spiritual needs. Preparedness for emergence delirium from post-traumatic stress disorder (PTSD) assists the nurse in understanding and effectively managing emergence from anesthesia. Finally, the use of EBP brings the best available science to the practice arena and advances trauma care.
Compartment Syndrome A pathologic condition caused by the progressive development of arterial compression and consequent reduction of blood supply.
Damage Control Resuscitation A systematic approach to control bleeding at the point of injury by definitive treatment interventions of minimizing blood loss and maximizing tissue oxygenation.
Injury A state in which a patient experiences a change in physiologic or psychological systems.
Microvascular Pertaining to the portion of the circulatory system composed of the capillary network.
Motor Vehicle Crash (MVC) Occurs when a vehicle collides with another vehicle or object and can result in injuries or death.
Pattern of Injury The circumstance in which an injury occurs, such as sudden deceleration, wounding with a projectile, or crushing with a heavy object.
Permissive Hypotension A guided intervention that limits fluid resuscitation until hemorrhage is controlled.
Primary Assessment The first in order of importance in the evaluation or appraisal of a disease or condition.
Resuscitation Use of emergency measures in an effort to sustain life.
Secondary Assessment Evaluation of a disease or condition with previously compiled data.
Shock An abnormal condition of inadequate blood flow and nutrients to the body’s tissues with life-threatening cellular dysfunction.
Shock Trauma A sudden disturbance that causes a wound or injury and results in acute circulatory failure.
Systemic Inflammatory Response Syndrome (SIRS) Inflammatory disturbance that affects multiple organ systems of the body.
Trauma Tissue injury, such as a wound, burn, or fracture, or psychological injury in which personality damage can be traced to an unpleasant experience related to tissue injury such as a wound, burn, amputation, or fracture.
In the United States, trauma injuries continue to be the fourth leading cause of death, affecting the lives of more than 70 million people each year.4–7 Furthermore, trauma accounts for more deaths in the United States during the first four decades of life than any other disease. Surprisingly, fatality rates for older adults are now higher than rates for younger adults.5,6 Studies reveal that health outcomes following trauma injuries are worse for patients with chronic health conditions.6–8 The increasing prevalence of young and older patients with chronic health diseases has implications not only for treatments but also for ancillary referral resources, support services, rehabilitation services, and survival following traumatic injuries.6–8 Mortality from trauma is the tip of the iceberg, a small indication of a much bigger problem; many patients survive trauma, need surgical intervention, require lengthy rehabilitation, and drive up costs of hospitalization and long-term recovery.6,7
Although 50% of all deaths attributed to trauma occur within minutes to hours after the injury, 30% of patients die within 2 days of neurologic injury; the remaining 20% of deaths occur as a result of complications.3 Overwhelming infection and sepsis result from these traumatic injuries, and trauma patients are at risk for multiple complications including respiratory, circulatory, neurologic, and renal failure. Numerous pathologic conditions and inflammatory derangements can contribute to this high incidence rate of late mortality from sepsis. Trauma patients who need surgery and anesthesia have greater vulnerability to life-threatening conditions and require vigilant astute postanesthesia nursing care.
During the prehospital phase, vital information regarding the trauma patient’s condition at the scene and MOI reveals important clues to the clinical finding of how the patient presents in the resuscitation area or later in the postanesthesia care unit (PACU). If the patient had a prolonged extrication period at the scene, the airway may have been compromised; the patient may have active or uncontrolled bleeding; the patient may have been exposed to environmental elements (e.g., decreasing core temperature); and/or the patient may have been resuscitated at the scene or during transport.
Other conditions at the scene that can influence the trauma patient’s outcome include such considerations as: (1) whether restraint devices were used; (2) whether combat protection gear was worn; (3) whether airbags were deployed during impact; (4) whether the passenger was ejected from the vehicle; (5) in what position the patient was found; (6) whether the vehicle rolled over; (7) whether the windshield was broken; (8) the speed at which the vehicle was traveling; (9) where the impact was on the vehicle; (10) whether the patient sustained an impaled object; (11) whether the patient wore a motorcycle helmet; (12) whether other fatalities occurred at the scene; and (13) what, if anything, bystanders did to assist the victim. All these observations by the first responders help to put together the trauma puzzle to ensure a comprehensive approach to the care of the trauma patient.
The pattern or MOI simply refers to the manner in which the trauma patient was injured.8 For accurate assessment of the trauma patient in the PACU, the nurse needs a basic understanding of the different types of MOIs. Patterns of injury are related to the categories of the injuring force and the subsequent tissue response. A thorough understanding of these aspects of injury helps in determining the extent and nature of the potential injuries. Damage occurs when the force deforms tissues beyond failure limits.8 Injuries result from different kinds of energy (kinetic forces, such as motor vehicle crashes [MVCs], falls, or bullets) or acute exposure (thermal, chemical, electrical, radiation, or high-yield explosives) to the tissues and underlying structures. Some of the major factors that influence the severity of the injury are the velocity of the objects and the force in terms of physical motion to moving or stationary bodies. The force is the mass of an object multiplied by the acceleration. Numerous studies conclude that the MOI helps identify common injury combinations, predict eventual outcomes, and explain the type of injury sustained.8 Although a certain pattern of injury may be predictable for specific injuries, trauma patients may sustain other injuries. A thorough assessment for identification of all actual and potential injuries is needed.8,9
Various forms of traumatic injuries are blunt force (high velocity); penetrating, such as those that cut or pierce; falls from great heights; firearms; and chemical, electric, radiant, and thermal burns. MVCs create impressive forces that can fracture extremities, crush organs, and lead to massive blood loss and soft tissue damage. At the time of a crash, three impacts occur: (1) vehicle to object, (2) body to vehicle, and (3) organs within the body. Forces are exerted in relation to acceleration, deceleration, shearing, and compression.8,9 Acceleration-deceleration injuries occur when the head is thrown rapidly forward or backward, resulting in sudden alterations. The semisolid brain tissue moves more slowly than the solid skull and collides with the skull, causing injury. The injury where the brain makes contact with the skull is called a coup. The brain injury can also occur as the brain tissue is thrown in the opposite direction, causing damage in the contralateral skull surface, which is known as contrecoup injury. Everchanging MOIs also create the need for new nursing educational programs and competencies for postanesthesia nurses to stay up-to-date and to advance practice.
Blunt trauma is one of the major types of trauma injuries that is best described as nonpenetrating trauma. Blunt force refers to physical trauma to a body part, either by impact, injury, or physical force. Blunt forces produce crushing, shearing, or tearing of the tissues, both internally and externally.8–11 High-velocity MVCs and falls from great heights cause blunt trauma injuries associated with direct impact, deceleration, continuous pressure, and shearing and rotary forces.8–13 These blunt trauma injuries are usually more serious and life-threatening than other types of trauma because the extent of the injuries is less obvious and diagnosis is more difficult. Because blunt trauma injuries can leave little outward evidence of the extent of internal damage, the nurse must be extremely vigilant and astute in making observations and ongoing assessments.
When the body decelerates, the organs continue to move forward at the original speed. As the body’s organs move in the forward direction, they are torn from their attachments by rotary and shearing forces.8–13 Furthermore, blunt forces disrupt blood vessels and nerves. This MOI to the microcirculation causes widespread epithelial and endothelial damage and thus stimulates cells to release their constituents and further activates the complement, the arachidonic acid, and the coagulation cascade that activate the systemic inflammatory response syndrome (SIRS). This unique inflammatory response is covered later in this chapter. Finally, blunt trauma may mask more serious complications related to the pathophysiology of the injury.
The increased rate of interpersonal violence as well as mass shootings in the United States and penetrating trauma are contributing to increased morbidity and mortality.12 Penetrating trauma refers to an injury produced by a foreign object such as stab wounds and firearms. The severity of the injury produced by a foreign body is related to the underlying structures that are damaged. This MOI causes the penetration and crushing of underlying tissues and the depth and the diameter of the wound that results from penetrating trauma. Tissue damage inflicted by bullets depends on the bullet’s size, velocity, range, mass, and trajectory. Knives often cause stab wounds, but other impaling objects can cause damage. Tissue injury depends on length of the object, the force applied, and the angle of entry. These penetrating wounds cause disruption of tissues and cellular function and thus result in the introduction of debris and foreign bodies into the wound.8,11,12 Impaled objects are left in place until definitive surgical extraction is available because of the tamponade effect of vascular injuries. Finally, the insult to the body may occur as local ischemia or extend to a fulminant hemorrhage from these penetrating injuries.10–13
When blunt trauma is significant enough to produce capillary injury and destruction, contusion of tissues occurs. Consequently, the extravasation of blood causes discoloration, pain, and swelling.8–13 If a large vessel ruptures, a hematoma may produce a distinct palpable lesion. With a massive contusion or hematoma, an increase in myofascial pressures often results in a sequela known as compartment syndrome.9–13 A compartment is a section of muscle enclosed in a confined supportive membrane called fascia; compartment syndrome is a condition in which increased pressure inside an osteofascial compartment impedes circulation and impairs capillary blood flow and cellular ischemia, resulting in an alteration in neurovascular function.9–13 This syndrome occurs more frequently in the lower leg or forearm but can occur in any fascial compartment. Damaged vessels in the ischemic muscle dilate in response to histamine and other vasoactive chemical substances such as the arachidonic cascade and oxygen-free radicals. This dilation, with resultant leakage of fluid from capillary membrane permeability, results in increased edema and tissue pressure.9 The increased edema and pressure compress capillaries distal to the injury, impeding microvascular perfusion. These pathologic changes cause a repetitive cycle within the confined tissues, which increases swelling and leads to increased compartment pressures. Fascial compartment syndrome can be measured if indicated. Normal pressure is more than 10 mm Hg, but a reading of more than 35 mm Hg suggests possible anoxia.11,13 A fasciotomy may be indicated to prevent muscle or neurovascular damage.9–13
The initial assessment, resuscitation, and stabilization processes initiated in the emergency department and trauma center extend into the operating room (OR), the PACU, and the critical care unit. Temperature of the trauma rooms may be increased to prevent hypothermia during resuscitation. Because the most common cause of shock (Table 54.1) in the trauma patient is hypovolemia from acute blood loss, the ultimate goal in fluid resuscitation is prompt restoration of circulatory blood volume through replacement of fluids so that tissue perfusion and delivery of oxygen and nutrients to the tissues are maintained.10–15 Rapid identification and ensuing implementation of correct hemostatic resuscitation are vital for the trauma patient’s survival.11,13 Although hypovolemia is the most common form of shock in the trauma patient, cardiogenic shock, obstructive shock (tension pneumothorax, cardiac tamponade), and distributive shock (neurogenic shock, burn shock, anaphylactic shock, and septic shock) can occur. Rapid-volume infusers deliver warmed intravenous (IV) fluids at a rate of 950 mL/min with large-bore IV catheters.14,15 Many trauma centers initially infuse 2 to 3 L of lactated Ringer’s or normal saline solutions and then consider blood products. The fluids should be warmed to prevent or minimize hypothermia. Crystalloids, colloids, or blood products can be used for effective reversal of hypovolemia.
Types of Shock
|Decrease in intravascular volume|
|Internal or external hemorrhage, third spacing of fluids, plasma volume loss|
Visible signs of bleeding or fluid loss
Decreased urine output
|Fluids or blood administration|
|Circulatory failure from impairment of contractility|
|Blunt chest trauma|
Injury to heart muscle
Decreased pulse pressure
Cool and clammy skin
|Support cardiac rhythm|
Increase cardiac output
|Decreased cardiac output from compression to aorta or great vessels that prevents atria from filling and decrease in stroke volume|
Muffled heart sounds
Diminished or absent lung sounds
Needle decompression and chest tube
Pericardiocentesis and surgical intervention
Vasodilation from decreased neurogenic tone to vessels
Histamine release into bloodstream after allergic reaction, increased capillary permeability and vasodilation
Massive infection resulting in vasodilation and inadequate tissue perfusion
Spinal cord injury
Decreased HR (if neurologic in origin)
Increased cardiac output
Laryngeal edema with bronchospasm (anaphylaxis)
BP, Blood pressure; CVP, central venous pressure; HR, heart rate; JVD, jugular venous distention; PCWP, pulmonary capillary wedge pressure.
Crystalloids are electrolyte solutions that diffuse through the capillary endothelium and can be distributed evenly throughout the extracellular compartment. Examples of crystalloid solutions are lactated Ringer’s solution, Plasma-Lyte, and normal saline solution. Although controversy exists regarding crystalloid versus colloid fluid resuscitation in multiple trauma, the American College of Surgeons Committee on Trauma recommends that isotonic crystalloid solutions of lactated Ringer’s or normal saline solution be used for that purpose.15 Furthermore, crystalloids are much cheaper than colloids. Administration of crystalloids should be judiciously administered threefold to the blood loss.11,13,15
Colloid solutions contain protein or starch molecules or aggregates of molecules that remain uniformly distributed in fluid and fail to form a true solution.13–16 When colloid solutions are administered, the molecules remain in the intravascular space, thereby increasing the osmotic pressure gradient within the vascular compartment. Volume for volume, the half-life of colloids is much longer than that of crystalloids. Colloid solutions commonly used are plasma protein fraction, dextran, normal human serum albumin, and hetastarch.
Tranexamic acid (TXA) is a synthetic version of the amino acid lysine. TXA is an antifibrinolytic that inhibits activation of plasminogen, a substance responsible for dissolving clots, and should be administered within 3 hours of the injury to be effective in reducing the risk of bleeding and death from exsanguination.17 TXA was added to the World Health Organization’s list of essential trauma medications.17 Although the use of TXA studies have been limited in children, this medication has been shown to be effective in the pediatric population, reducing blood loss in orthopedic, cardiac, and craniofacial trauma injuries.17
Researchers in several randomized controlled trials have used hypertonic saline solutions (HSS) to resuscitate patients in shock.13–21 According to Safiejko et al.,18 HSS (3% sodium chloride) demonstrated the efficacy and safety of using this method of resuscitation of the child with a severe head injury because it maintains blood pressure, heart rate, and cerebral oxygen delivery, decreasing overall fluid requirements, and resulting in improved overall survival rates.18–20 In addition, patients with low Glasgow Coma Scale (GCS) scores from head injuries have improved survival rates in the hospital.18–20
Although crystalloid and colloid solutions serve as primary resuscitation fluids for volume depletion, blood transfusions are necessary to restore the capacity of the blood to carry adequate amounts of oxygen and nutrients to the microcirculation and organ function. Furthermore, blood component therapy is considered after the trauma patient’s response to the initial resuscitative fluids has been evaluated.11,13 In an emergency, universal donor blood (type O negative for women in childbearing years) packed red blood cells can be administered to patients with exsanguinating hemorrhage. Untyped O negative whole blood can also be given to patients with an exsanguinating hemorrhage. Other blood products, such as platelets and fresh frozen plasma, may need to be given to the trauma patient because of a consumption coagulopathy. Most notable are the leukemic trauma patients with low platelet counts. With fluid resuscitation of these patients with immunosuppression, colloids are contraindicated because of the antiplatelet activity that exacerbates hemorrhaging.17 Type-specific blood often is available within 10 minutes and is preferred over universal donor blood. Fully cross-matched blood is preferred in situations that can warrant awaiting type and cross-match, which often takes up to 1 hour.11,13–15 Finally, the therapeutic goal of all blood component therapy is to restore the circulating blood volume and to give back other needed blood with red blood cells and clotting factors to correct coagulation deficiencies.21,22
New evidence recognizes “permissive hypotension” by keeping the patient’s systolic blood pressure at approximately 90 mm Hg correlates with better outcomes owing to conservation of important clotting factors.22,23 In addition, there also seems to be a protective mechanism of myocardial suppressive factors that conserve homeostasis of fluid shifts. The intent of this protective response is to prevent further hemorrhaging or bleeding out of the red blood cells and clotting factors.24 By sustaining the hypotension, the blood pressure supports basic perfusion until the patient is in the OR and surgically resuscitated.19–23 Damage control resuscitation and warm, fresh, whole blood are now associated with better survival rates in combat-related massive hemorrhage injuries. Restoration of blood volume before homeostasis is achieved may have adverse complications of exacerbation of blood loss from increase in blood pressure.18–26
In summary, fluid resuscitation of the trauma patient is essential to ensure that adequate circulating volume and vital oxygen and nutrients are delivered to the tissues. However, new studies recommend permissive hypotension with the use of damage control resuscitation to decrease mortality and morbidity and optimize the patient’s survival.18–26 These combat-related studies are now influencing the management of civilian resuscitation which has been seen in terrorist attacks of massive hemorrhage injuries in trauma centers throughout the United States. See Evidence Based Practice Box.3
Diagnostic tests and laboratory studies have a vital role in establishing the patient’s baseline and current status. The results of these tests predicate the treatment protocols that are initiated. Comprehensive diagnostic studies are required to establish an accurate diagnosis and to plan effective treatment of the patient with multiple injuries. The initial routine studies may be arterial blood gas determinations, urinalysis (myoglobinuria), complete blood count, electrolyte levels, lactate, prothrombin and partial thromboplastin times, and type and cross-match. Other diagnostic studies that can be ordered for suspected injuries include lateral cervical spine, upright anteroposterior chest, and anteroposterior pelvic radiographs; computed tomographic scan; 12-lead electrocardiogram; ultrasound scan; and toxicology laboratory studies. Diagnostic peritoneal lavage is performed only on the severely injured patient with hypotension, especially if the
result of an abdominal examination is suggestive of injury or is unreliable. Pregnancy tests should be performed on all women of childbearing age but should not delay treatment of life-threatening injuries.
Poor and inaccurate communication, including communication gaps, may lead to uncertainty and, frequently, to inappropriate decisions about patient care and ultimately result in patient harm either through inefficiency or suboptimal management.27 Collaborative practice is essential in the care of the trauma patient. During the prehospital phase, vital communication with the trauma team is initiated at the trauma center. Subsequently, when the patient is first admitted to the PACU, the approach to patient care is comprehensive. Together, the postanesthesia nurse, anesthesia provider, respiratory therapist, surgeon, and radiology technician create a collaborative environment so that care becomes focused and directed. This collaborative practice continues through the intraoperative and postanesthesia periods.
Having a standard, evidence-based approach to care delivery decreases the number of communication errors and provides a more reliable approach to patient care.27,28 The anesthesia provider and surgical team communicate a comprehensive system report to the perianesthesia nurse and verbally review any definitive findings of the computed tomographic scan including whether generalized edema or lesions are found. Vital nursing information is communicated to the receiving postanesthesia nurse caring for the trauma patient. The anesthesia provider and trauma surgeon should communicate the significant findings during the intraoperative period that may be problematic during the recovery phase, what the PACU nurse should look for and report promptly to these physicians, and what the PACU nurse should do to prevent harm during the postanesthesia phase of care.27 In many ways, it is even more important that accurate information and anticipatory guidance be effectively transmitted in the PACU handoff.27
Before the shock trauma patient is admitted to the PACU, the postanesthesia nurse begins preparing for the PACU admission with anticipated questions and needed information. When the OR nurse calls the PACU to notify the admitting nurse that the trauma surgeon is beginning to close the patient’s surgical site, important prehospital and intraoperative information is communicated. The transfer of care or handoff communication from the OR nurse to PACU nurse consists of a detailed yet succinct report of all pertinent findings such as surgical operation, type of anesthesia including opioids, isolation status, vital signs, oxygen saturation, ventilation settings, hemodynamic monitoring, drains, vasoactive drugs, IV sites with types of solutions, and other pertinent findings so that the PACU nurse can begin to prepare for the patient’s needs.
Foremost, the trauma nursing assessment that occurs in the combat trauma resuscitation unit or the shock trauma resuscitation bay should always focus first on uncontrolled hemorrhage or massive bleeding to control life-threatening bleeding and prevent death.11 The PACU nursing assessment of the shock trauma patient in the PACU begins with evaluation of the ABCDs (airway, breathing, circulation, and disability). Most important, this vital primary assessment should focus first on the patency of the airway and effective breathing due to the effects of anesthesia and surgery. This airway assessment begins with proper positioning of the patient’s head, with cervical spine protection always maintained if injury is suspected. Cervical collars should not be removed unless specifically directed by the trauma surgeon or neurosurgeon after confirmation of the absence of spinal cord injury. The patient may need to have the airway cleared with suctioning and removal of secretions or blood. In addition, airway adjuncts may be needed, such as oropharyngeal and nasopharyngeal airways. If the patient is intubated via endotracheal tube or nasotracheal tube, ventilatory support should be provided with the proper settings to achieve optimal oxygenation and ventilation.
Next, the postanesthesia nurse evaluates the patient’s work of breathing. While recalling the MOI, such as blunt or penetrating trauma to the chest, the nurse should be highly suspicious of pulmonary contusions, fractured ribs, or injuries from shearing forces. The nurse assesses spontaneous respirations, respiratory excursion, chest wall integrity, symmetry, depth, respiratory rate, use of accessory muscles, and the work of breathing. With palpation, the nurse should evaluate for the presence of subcutaneous emphysema, hyper-resonance or dullness over the lung fields, and tracheal deviation. With auscultation, the nurse assesses the lungs for bilateral breath sounds and evaluates for adventitious breath sounds. In addition, pulse oximetry and end-tidal CO2 monitoring augment the complete respiratory assessment of the trauma patient.
After a thorough evaluation of the airway and breathing, the nurse begins the circulatory assessment. With the use of palpation, the nurse evaluates the circulation; checks the quality, location, and rate of the pulses; and compares the right with the left and the upper extremities with the lower. If the nurse can palpate a radial pulse, the arterial pressure is at least 80 mm Hg. If no radial pulse is palpable, the nurse then palpates the femoral pulse (a situation that indicates a pressure of 70 mm Hg). If only a carotid pulse is palpable, the arterial pressure is approximately 60 mm Hg. The patient’s blood pressure and pulse (rate and rhythm) should be monitored via the cardiac monitor. Any changes in the patient’s appearance should be investigated and prompt the nurse to reassess the patient. Pulseless electric activity may show as electric impulses on the cardiac monitor without the presence of a palpable pulse. Pulseless electric activity may be seen in the trauma patient related to a variety of causes such as pneumothorax, cardiac tamponade, hypovolemia, or hypothermia.
Simultaneously during the palpation of pulses, the nurse assesses the patient’s skin temperature, color, and capillary refill. Capillary refill is a good indicator of tissue perfusion, especially in children. Another aspect of circulatory assessment is observation of the patient for any significant or uncontrollable bleeding from the operative site. The nurse should inspect the peripheral, central, and arterial lines to ensure the patency of the lines and integrity of the sites. Each line should be identified and labeled with the date and time to distinguish the type of parenteral fluid and medication administration in use.
The final component of the primary survey is the disability or neurologic examination. The patient’s mental status should be assessed with AVPU (Alert, Voice, Pain, Unresponsive) scale or the GCS. The AVPU is described as follows: A for awake and responding to nurse’s questions, V for verbal response to nurse’s questions, P for responding to pain, and U for unresponsive.10,11 The GCS is used in many PACUs for evaluating neurologic status and predicting outcomes of severe trauma. This neurologic scoring system allows for constant evaluation from field to emergency room to PACU. One must remember that anesthesia blunts the neurologic response; therefore, the response is not as useful in the immediate postanesthesia period. Next, bilateral pupil response is evaluated for equality, roundness, and reactivity: brisk, slow, sluggish, or no response to light and accommodation. Before the primary assessment is complete, the PACU nurse quickly reassesses the ABCDs for stability and then is ready to receive a report from the anesthesia provider.
The anesthesia provider’s report provides valuable information concerning the trauma patient’s presenting status to the perianesthesia nurse.27 This report includes significant facts that pertain to the MOI, prehospital phase, admitting and stabilization period, operative report, intubation, anesthetic agents, estimated blood loss, fluid resuscitation, cardiopulmonary status, and treatment abnormalities.
In the review of the anesthesia report, the nurse should note any difficulty in intubation of the patient. The nurse should take note if the oral secretions are tinged pink or bloody, which can indicate an infectious process, pulmonary edema, trauma, or uncontrolled hemorrhage.
Another important aspect of the anesthesia report is estimated blood loss and fluid replacement, which are carefully monitored through the hemodynamic status of the trauma patient. With the use of arterial lines and pulmonary artery catheters, the anesthesiologist can closely monitor the patient’s hemodynamic status. In severe chest injuries, closed chest drainage units and auto transfusions or Cell Saver blood recovery systems can be used to conserve the vital life-sustaining resource blood. Because the goal of treatment is to keep the patient in a hemostatic state, the intraoperative trending should reveal that the patient is volume supported because the body responds hypermetabolically to trauma and achieving that state ensures the delivery of oxygen and other nutrients to essential tissues in the body. End-organ perfusion is monitored and measured with the urinary output and hemodynamic monitoring. Urinary catheters are essential in management of fluids in the trauma patient and assessment of kidney function. Hemodynamic monitoring reflects the body’s hydration status and reveals the work of the heart. A detailed operative report reveals the surgical insult to the patient. It also presents a comprehensive review of all anesthetic agents that reflects a rapid sequence of induction, balanced analgesia, and heavy use of opioids including the time these agents were given and the amounts and types of muscle relaxants and reversal agents used. The anesthesia report should reveal any untoward events that occurred during surgery, such as hypothermic or hypotensive events, and significant dysrhythmias including ischemic changes. Chapter 26 also has information on the patient handoff.
After the anesthesia report is received, a brief initial primary survey is completed, and the postanesthesia nurse begins the secondary comprehensive survey with a high degree of suspicion concerning the trauma patient’s MOI for specific perianesthesia problems. The initial surgery often is directed at repair of the major life-threatening injuries such as a ruptured aorta. Consequently, additional injuries may manifest themselves during this later time in the PACU after swelling and bruising are allowed to develop. During the comprehensive secondary survey, head-to-toe assessment is performed as the trauma patient is emerging from anesthesia. The perianesthesia nurse may discover other injuries such as pulmonary, cardiac, or renal contusions and compartment syndrome of different extremities.
The head-to-toe assessment begins with a neurologic assessment including the patient’s level of consciousness; the appropriateness of verbal response; pupillary reactivity, size, and shape; equality of pupillary response to light and accommodation; movement; sensation; and pain response in the extremities. Each aspect is carefully evaluated and documented. Next, the head and face are inspected for abrasions, lacerations, puncture wounds, ecchymosis, and edema. These structures are palpated for subcutaneous emphysema or tenderness. The eyes are assessed for gross vision by asking the patient to identify the number of fingers the nurse is holding up. Furthermore, the eyes are evaluated for ecchymosis, “raccoon eyes,” and possible conjunctival hemorrhage. Extraocular movements are also evaluated by asking the patient to follow the nurse’s finger in six directions. The presence of maxillofacial injuries can be of great concern because of the potential to compromise the patient’s airway.
The ears are inspected for Battle sign (ecchymosis behind the ears). The nose is examined for drainage of blood or clear fluid. Clear fluid draining from the nose or ears should be checked for the presence of cerebrospinal fluid (CSF). A draining nose or ears should never be packed. If CSF is suspected or the Battle sign is seen, a nasogastric tube should never be inserted through the patient’s nose. An orogastric tube is the placement of choice. Finally, the nurse should immediately report a positive CSF finding to the trauma surgeons.
The neck should be evaluated for edema, ecchymosis, tracheal deviation, pulsating or distended neck veins, and subcutaneous emphysema. As the perianesthesia nurse continues the assessment of the chest, the anterior and the lateral thorax and axilla are inspected for lacerations, abrasions, contusions, puncture wounds, ecchymosis, and edema. The nurse carefully palpates the chest for tenderness and subcutaneous emphysema. The chest wall is observed for symmetry, depth, and equality of expansion and excursion. If the trauma patient has a flail chest from the injury sustained, astute monitoring for effective oxygenation and ventilation is essential. Breathing is observed for rate, degree of effort, use of accessory muscles, or paradoxical chest wall movements. Breath and heart sounds are auscultated, noting adventitious lung sounds (e.g., wheezing, rales, friction rubs) or murmurs, bruits, and muffled heart sounds. The perianesthesia nurse carefully notes facial expressions or body reactions that may suggest possible cardiac contusions or rib fractures. The operative site and all dressings and drains should be assessed and described. Furthermore, all drains should be labeled, drainage of fluid measured, and color and consistency described. Precise documentation of all fluid output is essential for accurate fluid replacement.
The next areas to be inspected are the abdomen, pelvis, and genitalia. All abrasions, contusions, edema, and ecchymosis are noted. The abdomen is auscultated for bowel sounds before palpation for tenderness and rigidity. The nasogastric tube, jejunostomy, or tube drainage is examined for color, consistency, and amount of fluid. In suspected internal abdominal or retroperitoneal hemorrhage, abdominal compartment measurements should be assessed. Some common causes of abdominal compartment syndrome are pelvic fractures, hemorrhagic pancreatitis, ruptured abdominal aortic aneurysm, blunt and penetrating abdominal trauma, bowel edema from injury, septic shock, and perihepatic or retroperitoneal packing for diffuse nonsurgical bleeding. If intra-abdominal hypertension or abdominal compartment syndrome is suspected or considered, the standard of care is measurement of bladder pressures.29 A catheter or similar device is connected to a pressure transducer connected to the urinary catheter. The urinary catheter is clamped near the connection, 50 mL of saline solution is instilled to the bladder, the transducer is leveled at the symphysis pubis, and the pressure is measured at end expiration. If the pressure is elevated, a decompression laparotomy should be performed to release the pressure that develops from bowel edema.11,13 The abdomen is then left open and covered with a sterile wound vacuum until the swelling has resolved and the abdomen can be closed.
The pelvis is palpated for stability and tenderness, especially over the crests and the pubis. Priapism, which is persistent abnormal erection, may be noted.11,13 In addition, preexisting genital herpes may also be present. The urinary catheter is inspected for color and amount of drainage. Urinary output should be at least 0.5 to 1.0 mL/kg/h in adults and 1 to 2 mL/kg/h in children.11 Hematuria can indicate kidney or bladder trauma.11 Furthermore, urinary output must be vigilantly monitored to ensure a minimum of 30 mL/h in adults so that the patient does not develop acute renal failure from rhabdomyolysis, which can occur after traumatic injuries. The vagina and rectum are checked carefully for neurologic function and bloody drainage.
All extremities are examined for circulatory, sensory, and motor functions with range of motion. Because the trauma patient is rushed to the OR to correct life-threatening injuries, minor soft tissue injuries often may be missed. Later in the PACU, these soft tissue and musculoskeletal injuries can develop into compartment syndrome. Each extremity must be thoroughly examined for abrasions, contusions, puncture wounds, ecchymosis, and edema. If neurovascular compromise is found, an arteriogram or venogram can be performed as a conclusive diagnostic study.
The patient is then log-rolled onto the side with maintenance of cervical spine integrity for assessment of the back, flanks, and buttocks for abrasions, contusions, and tenderness. Rectal tone is noted if spinal cord injury is suspected. Posterior chest assessment is completed as a last step in the head-to-toe assessment. Finally, a detailed yet succinct description of the primary and secondary assessment is documented.
Pain complaints are one of the most prevalent conditions among trauma patients in the postanesthesia setting. Assessment and management of pain are important parts of the scope of care provided to the trauma patient in the PACU. Pain management of children and older adults is especially challenging because these patients commonly present with complex or chronic medical conditions and/or anxiety. Trauma patients may have musculoskeletal injuries or ruptured organs that cause severe pain, which may include more than the surgical site. The perianesthesia nurse needs to recognize that because pain is subjective, verbal, nonverbal, and hemodynamic changes that indicate the patient may be exhibiting signs of pain should be noted. Pain can manifest itself with increased heart rate, increased blood pressure, pallor, tachypnea, guarding or splinting, and nausea and vomiting. Pain scales should be used to augment the nursing assessment of pain.30,31
Optimal management of acute pain may use the following techniques: (1) use of age-appropriate pain assessment scales, (2) pharmacologic/nonpharmacologic interventions, (3) patient-controlled analgesia with IV or epidural infusions, (4) IV intermittent doses for pain or sedation, (5) major plexus blocks, and (6) multimodal techniques for trauma pain management. Guidance for medications should be based on choosing drugs that minimize cardiovascular depression and intracranial hypertension. A higher incidence rate of substance abuse, both of alcohol and recreational or addictive mind-altering drugs, in the trauma patient population may require higher doses of opioids or analgesics.30,31 Other complementary techniques, such as music therapy and guided imagery, may be initiated and used as adjuncts when the trauma patient returns for subsequent surgical procedures or wound debridement. Finally, continual pain assessment is vital to the patient’s optimal care. See Chapter 31 for more information on pain management.
Nausea can be a concern for the trauma patient. Trauma patients rarely fast before the traumatic event; therefore, patients enter anesthesia with a potentially full stomach. Vomiting can lead to aspiration and a host of issues. Extubation of trauma patients should be delayed until the gag reflex returns to avoid aspiration. Many times, nasogastric tubes are present, but if the patient has consumed food before the event, particles may be too large to be evacuated. Nausea needs to be treated after surgery and is seen with a higher incidence rate in the traumatized patient.
Often, the psychological and emotional condition of the trauma patient is not considered a priority because the initial events are life-threatening. However, when the patient regains consciousness in the PACU, this aspect of the patient’s care may prove to be the most challenging. These trauma patients may suffer from acute stress disorder and also PTSD. Early PACU nursing assessment, diagnosis, and treatment can be most effective in quality outcomes.
Trauma patients can emerge from anesthesia in a confused or combative state because of pain, disorientation, or PTSD. Emergence delirium or emergence excitement is a recognized complication of patients recovering from anesthesia. Trauma patients are at increased risk for emergence delirium because of PTSD that occurs after the experience or witnessing of life-threatening events such as military combat, a terrorist incident, a natural disaster, or sexual assault.32 PTSD is an independent risk factor that is associated with the frequency of emergence delirium events and may even become a debilitating mental disorder.32 The PACU nurse should be prepared to critically assess the patient on emergence from anesthesia for restlessness, agitation, “thousand-mile stare,” or sudden outbursts when the patient experiences flashbacks from the traumatic event.32 The nurse must provide a calm, soft, but direct communication, always remembering to orient the recovering patient from anesthesia. Family or friends may be appropriate visitors in PACU Phase I to help orient the patient to an unfamiliar hospital environment. In severe cases of PTSD, the PACU nurse should consider collaborating with an anesthesia provider to resedate the emerging patient.32 As the patient emerges from anesthesia, the perianesthesia nurse orients the patient to place and time. Because the patient might not remember or recall the event that caused the accident, the nurse orients the patient to the hospital. Fear of death, mutilation, or change in body image can increase the patient’s anxiety. The trauma patient may regain consciousness only to find that the extremities are immobilized or amputated. Because a high incidence rate of injuries is related to alcohol or substance abuse, the patient may have no memory of events before, during, or after the injury.32 The patient may have alterations in visual and auditory functions. If the patient was alert at the scene and remembers that loved ones were severely injured or killed, the patient may become upset or hysterical, often reliving the tragic event. Consequently, the patient not only experiences loss of body integrity and control but also the loss of loved ones.
The perianesthesia nurse needs to be supportive yet focused on maintaining the patient’s integrity and coping skills. The nurse needs to speak to the patient calmly, slowly, and clearly, with simple language that is easily understood. Often, the same information has to be repeated as the patient emerges from anesthesia. The clinician should be honest with the patient. Psychological aspects of trauma care include the following three concepts according to the Emergency Nurses Association: (1) need for information, (2) need for compassionate care, and (3) need for hope.11
The focus of the nursing care of the trauma patient is on vigilant continuous reassessments. Consequently, treatment priorities are established on the basis of vital signs, presenting signs and symptoms, clinical findings, abnormal laboratory values, and diagnostic studies. The perianesthesia nurse must be cognizant of the subtle cues—complex pathophysiologic responses to the traumatic injury—and always anticipate that the trauma patient might exhibit subtle or overt signs of shock. Furthermore, if shock progresses, the perianesthesia nurse should be aware of other complications such as SIRS, which causes a myriad of cascading pathophysiologic etiologies: adult respiratory distress syndrome, clotting derangements (coagulopathies), acute renal failure, and ultimately multisystem organ failure. Nursing care of the trauma patient provides a special challenge because of the unique physiologic responses.
Infection is the predominant complication that delays recovery and threatens the life of the trauma patient. Wound infections are related to virulent microbes that result in infection. However, the disruption of the protective barrier that one’s skin provides also compromises the integrity of the skin. At highest risk are massive open soft tissue injuries such as traumatic amputations, high-energy fractures, burns, degloving, and avulsion injuries. During surgery, the surgeon classifies the wound contamination, which is determined according to the degree of expected bacterial contamination relative to the surgical procedure. The PACU nurse must be diligent in the timing and documentation of postoperative antibiotics. In addition, the type of antibiotic and the time the antibiotic was given should be communicated during the transfer of care.
The most common complication associated with traumatic injuries is shock. Although different types of shock exist, all types exhibit a profound problem with inadequate delivery or utilization of oxygen and nutrients to the cells. Consequently, this anaerobic state results in inadequate tissue perfusion.33–35 A measure of the body’s overall metabolism is expressed as oxygen consumption (Vo2) and oxygen delivery to the cells (DaO2).33 When Vo2 is inadequate, cellular hypoxia evolves. The magnitude of oxygen debt correlates with the lactic acid levels, and this measurement quantifies the severity and prognosis in different shock states.33 Consequently, this complex syndrome of disequilibrium between oxygen supply and demand causes a functional impairment (oxygen debt) in cells, tissues, organs, and eventually body systems.33,34 Vital tissues such as the brain, heart, and lungs require large amounts of oxygen to support their specialized functions. Other important tissues, such as the liver, kidney, and gut, need essential amounts of oxygen to support their specialized functions. Furthermore, these functions can be maintained only with energy derived from aerobic metabolism, and they cease when oxygen is in short supply.
Unfortunately, ischemia rapidly initiates a complex series of events that affect every organelle and subcellular system in the body. As cells become anoxic, adenosine triphosphate stores are depleted, and virtually all energy-dependent functions cease. Protein synthesis is depleted. Changes in ion transport and glycolysis result in the loss of intracellular potassium and the production of lactic acid, which can result in lethal complications for the ischemic heart. Finally, irreversible anoxic cellular injury kills vital tissues.
Clinical manifestations of shock include signs and symptoms of decreased end-organ perfusion: cool clammy skin; cyanosis; restlessness; altered level of consciousness; altered skin temperature; tachycardia; dysrhythmias; tachypnea; pulmonary edema; decreased urinary output; increased platelet, leukocyte, and erythrocyte counts; sludging of blood; and metabolic acidosis.33,34
The four major types of shock are hypovolemic, cardiogenic, obstructive, and distributive (see Table 54.1). The first and most common type of shock, hypovolemic, results from an acute hemorrhagic loss in circulating blood volume that decreases vascular filling pressure.33,34 Cardiogenic shock results from an inadequate contractility of the cardiac muscle; it is rare in the trauma patient but can be caused by blunt cardiac injury or myocardial infarction (MI). In obstructive shock, obstruction or compression of the great vessels or the heart itself is the cause. Both tension pneumothorax and cardiac tamponade can cause obstructive shock.11,13 Distributive shock causes an abnormality in the vascular system and activation of SIRS and produces a maldistribution of blood volume.11,13,36–38 Distributive shock includes neurogenic, anaphylactic, and septic types. The most common type of distributive shock among trauma patients is neurogenic shock from spinal cord injuries.11,13
Hypovolemic shock is the decrease in intravascular volume that results in the fluid volume ineffectively filling the intravascular compartment.36–38 Consequently, hypovolemic shock can evolve from many causes such as internal and external hemorrhage, plasma volume loss in burns, third spacing of fluids, and decreased venous return.36–38 However, the leading cause of preventable death in hypovolemic shock in trauma patients is hemorrhage.
As hemorrhage progresses, the cardiovascular system produces characteristic clinical manifestations that are classified according to approximate blood loss (Table 54.2).11,36–38 The following hemorrhagic classifications are described in the conceptual framework of the Committee on Trauma of the American College of Surgeons Advanced Trauma Life Support Course.13
Identification of Hemorrhagic Shock
|Up to 15%; 750 mL|
|15%–30%; 750–1500 mL|
|30%–40%; 1500–2000 mL|
|>40%; >2000 mL|
|Pulse rate (beats/min)|
|Normal or increased|
|Normal; 90–100 SBP|
|Urine output (mL/h)|
|Slightly restless or anxious|
|Mildly restless and anxious|
|Anxious and confused|
|Confused, lethargic to unresponsive|
SBP, Systolic blood pressure.
From American College of Surgeons, Committee on Trauma. Advanced trauma life support for doctors. 10th ed. ACS: Chicago, IL; 2018.
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