TNCC, Tncc, TNCC Written Exam, TNCC Written Exam, TNCC class, TNCC/TCRN, TNCC Written Exam, Exams of Nursing

Download TNCC, Tncc, TNCC Written Exam, TNCC Written Exam, TNCC class, TNCC/TCRN, TNCC Written Exam and more Exams Nursing in PDF only on Docsity! TNCC, Tncc, TNCC Written Exam, TNCC Written Exam, TNCC class, TNCC/TCRN, TNCC Written Exam Review, TNCC, TNCC Skill Demonstration, Tncc, TNCC, TNCC EXAM, TNCC Written Exam, TNCC Written Exam, Tncc, TNCC, Trauma Nursing II, TNCC All Possible Questions and Answers Primary concern when a person cannot stop coughing/clearing their throat following house fire/smoke? - ANSWER-Airway/Intubate Lab evidence of cellular perfusion - ANSWER-Base Excess (Less than -6 is BAD) Multiple people are in the ER of different ages who all go to the same church. They all have the same symptoms. What is the most likely cause? - ANSWER-Biologic Suspected shock type with a spinal cord injury - ANSWER-Distributive Shock (Includes neurogenic) Patient has GCS of 3, unequal pupils (one sluggish, one blown), and is posturing. What is the cause? - ANSWER-Herniation Middle Meningeal Artery - ANSWER-Epidural Hematoma (results from collection of blood that forms between dura mater and skull) Prior to having a concussion (TBI), the patient had a brain injury that was not fully healed. What is the cause? - ANSWER-2nd Impact Syndrome Bowel sounds heard in the L chest. What is this a symptom of? - ANSWER-Ruptured diaphragm Symptoms of __________________: include muffled heart sounds and hypotension - ANSWER-Pericardiocentesis How should you dress a severed limb? - ANSWER-Sterile gauze with normal saline THEN put ice on it Amylase level looks at _____________ - ANSWER-Pancreas What should you do if your patient has hyphema (collection of blood inside the front part of the eye?) - ANSWER-Sit HOB up to 30 degrees Principle that people have to take action after suffering a loss in order to decrease severity, seriousness, or painfulness - ANSWER-Mitigation What organ is most at risk following a gunshot - ANSWER-Liver 8 year old child with longitudinal thigh lacerations - ANSWER-Sign of child abuse Bleeding around belly button - ANSWER-Cullen's Sign What would cause an inaccurate reading from an 02 saturation probe? - ANSWER- Carboxyhemoglobin (increase FiO2 to 100%) General study of forces and their effects on living tissue and the human body - ANSWER-Biomechanics Study of energy transfer as it applies to identifying actual or potential injuries - ANSWER-Kinematics Refers to the separation of tissue resulting from a sound and/or hydraulic wave force- the effect is a crushing pressure wave which creates a temporary cavity, followed by a rapid and violent closing of the cavity. - ANSWER-Cavitation This rapid motion can lead to crushing, tearing, and shearing forces on tissue - ANSWER-Cavitation Used in OR; does not provide protection against aspiration and not recommended in patients who have eaten recently. It is a supraglottic airway. - ANSWER-Laryngeal Mask Airway Single tube retroglottic device inserted into the esophagus and traps the glottis opening between an esophageal cuff and an oropharyngeal cuff. Designed with 2 ports/lumens each with a separate cuff. Does NOT provide protection against aspiration and is not indicated in children. It is a retroglottic airway. - ANSWER-King Tube Types of Shock (4) - ANSWER-Hypovolemic, Obstructive, Cardiogenic, Distributive Hemorrhage is the leading cause. Can result from vomiting, diarrhea, and burn trauma. Decreased circulating volume --> decreased preload. Therapy includes replacing the type of volume that was lost. - ANSWER-Hypovolemic Shock Leading cause of preventable death after injury - ANSWER-Hemorrhage Room Air = ____% FiO2 - ANSWER-21% 1 Liter of O2 = ____% FiO2 - ANSWER-4% Patient snoring = insert __________ airway - ANSWER-Oral Airway (OPA) Avoid _______________ when administering oxygen/ventilation - ANSWER-hyperoxia Resuscitation Adjuncts (LMNOP) - ANSWER-L: Lab M: Monitor cardia rhythm and rate N: Naso or Oro-gastric tube insertion O: Oxygenation or ventilation analysis P: Pain assessment and management Do not place ___________________ in head trauma patients - ANSWER-nasogastric Right breath sound ONLY following intubation = ________________ -- pull out - ANSWER-Mainstem Massive Blood Transfusion: Monitor ___________ levels: sodium acetate binds with ____ so levels decrease. - ANSWER-Calcium Hypercapnia causes _________________; Hypocapnia causes __________________ - ANSWER-Vasodilation; Vasoconstriction Usually seen in athletes, second TBI, 2nd injury occurs BEFORE 1st injury recovers, rare but usually fatal. - ANSWER-Second Impact Syndrome ____________ ___________ Injury: shearing or tearing. Diagnosed with MRI. Widespread microscopic hemorrhage. - ANSWER-Diffuse Axonal Injury (Cannot recover from this; shearing/tearing portion DOES NOT heal) Muffled heart sounds - ANSWER-Cardiac tamponade? Pericardial fluid? Most frequently injured organ - ANSWER-Liver Most frequently injured organ from BLUNT trauma - ANSWER-Spleen Pain Ladder: Step 1: Non-opioids for mild pain Step 2: Weak opioids for mild to moderate pain Step 3: Strong opioids for moderate to severe pain - ANSWER-1: Tylenol, Ibuprofen, Ketorolac 2: Codeine 3: Morphine, Fentanyl, Dilaudid Signs of increased compartment syndrome - ANSWER-Increased pain, feels tight/very painful, but nothing looks wrong Ischemia develops -- Pressure Fasical Development -- Impaired Blood Flow. 6 P's: Pressure, pallor, pulses, paresthesia, paralysis. Extremity goes to level of the ___________!!! NO ______!! - ANSWER-Compartment Syndrome: Level of heart; NO ice!! Control bleeding with direct pressure, elevate, apply tourniquets. - ANSWER- Amputation Wrap in saline gauze, put in bag, then put that bag in another bag filled with ice. Label bag. - ANSWER-Removed limb A ____ and ___ approach is used by all members of the trauma team to provide optimal care for the trauma pt. - ANSWER-Systematic , Organized Trauma is injury to living tissue caused by ... - ANSWER-An extrinsic agent A traumatic incident may be classified as ....(assault or suicide) or ... (falls or collisions) - ANSWER-Intentional;unintentional .... is the study of energy transfer as it applies to identifying actual or potential injuries - ANSWER-Kinematics The general study of forces and their effects - ANSWER-Biomechanics How external forces in the environment are transferred to the body - ANSWER- Mechanism of injury A body at rest will remain at rest, a body in motion will stay in motion - ANSWER- Newton's first law Force = mass x acceleration - ANSWER-Newton's second law For every action there is an equal and opposite reaction - ANSWER-Newton's third law Energy can neither be created nor destroyed but rather I can change form - ANSWER- Law of conservation of energy Kinect is energy is equal to ... - ANSWER-1/2 the mass x by the velocity squared (v^2) Caused by a sudden stop of the body's motion - ANSWER-Deceleration forces Caused from a sudden and rapid onset of motion ( a Parker car being hit by another vehicle) - ANSWER-Acceleration forces An external force applied time of impact, ex. Steering wheels or dashboards that collide with or push up into a person. - ANSWER-Compression force .... is the major cause of preventable death after injury - ANSWER-Uncontrolled hemorrhage .... is suspected in any patient with multi system trauma. - ANSWER-Cervical spine injury ... shock is from hemorrhage and is the leading cause of preventable deaths in trauma patients. Can also be caused by plasma loss in ... - ANSWER-Hypovolemic; burns ... shock results from hypoperfusion of the tissue due to an obstruction in either the vasculature or heart. Two examples include.... - ANSWER-Obstructive;tension pneumothorax, cardiac tamponade. (With tension pneumo the increase in intrathoracic pressure leads to displacement of the vena cava, obstruction to arrival filling leading to decreased preload and decreased cardiac output) ( with cardiac tamponade there is an accumulation of fluid in the pericardial sac impeding diastolic expansion and filling leading to decreased preload, stroke volume,CO and end organ perfusion) ... shock occurs as a result of maldistribution of an adequate circulation blood volume with the loss of vascular tone or increased permeability. 3 examples. - ANSWER- Distributive; anaphylactic, septic and neurogenic .... activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ANSWER-Baroreceptor activation; baroreceptors ...activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP - ANSWER-Chemoreceptors In the ... ... response two catecholamines are released ... and ... . - ANSWER-Adrenal gland response; epinephrine and norepinephrine In the adrenal gland response ... is released to raise blood glucose and promote renal retention of water and sodium. - ANSWER-Cortisol What are two quick tests for general suspicion of CSF leak? - ANSWER-Halo sign and glucose ... is damaged brain tissue usually caused by blunt trauma - ANSWER-Cerebral contusion Where are most cerebral contusions found - ANSWER-Frontal and temporal lobes Signs and symptoms of intracerebral hematoma include ... - ANSWER-Progressive and rapid decline, headache, signs of increasing ICP, pupil abnormalities ... results from a collection of blood forming between the dura Mater and the skull. This is frequently associated with fractures of the temporal or parietal skull that lacerated the .... - ANSWER-Epidural hematoma ; middle meninges artery This is commonly the type of bleed sustained by athletes who suffer a catastrophic head injury. - ANSWER-Acute subdue all hematoma .... are frequently associated with minor injury in older adults, patients taking anticoagulation medications and patients with chronic alcohol abuse. - ANSWER- Chronic subdural Hematoma ... is the shifting of brain tissue with displacement into another compartment as the result of bleeding or edema. - ANSWER-Herniation GCS scores : I. Mild TBI II. Moderate TBI III. Severe TBI - ANSWER-13-15; 9-12; 8 or less ... refers to a condition that occurs when the patient suffers a second milks TBI before recovery from the first - ANSWER-Second impact syndrome Patients who sustain a mild TBI may develop .... . Typically it will manifest several days or moths after head trauma. - ANSWER-Postconcussive syndrome A ... fracture is a complete craniofacial separation - ANSWER-Lefort III Assessment findings with maxillary fractures include - ANSWER-Facial edema, ecchymoses and diplopoa (lefort III) What are some interventions for the patient with a brain, cranial or macillofacial trauma - ANSWER-Elevation of patients head of bed by 30 degrees to decrease ICP, position head midline, ICP monitoring device Treatment of corneal abrasion includes - ANSWER-Topical antibiotics, oral analgesics NO patching , topical anti inflammatory What are the late signs of breathing compromise? - ANSWER-- Tracheal deviation - JVD What are signs of ineffective breathing? - ANSWER-- AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - ANSWER-A tight-fitting nonrebreather mask at 12-15 lpm. What intervention should be done if a pt presents with effective circulation? - ANSWER-- Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? - ANSWER-- Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds What are the interventions for Effective/Ineffective Circulation? - ANSWER-- Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation) What are factors that contribute to ineffective ventilation? - ANSWER-- AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age What medications are used during intubation? - ANSWER-LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - ANSWER-PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry What is a Combitube? - ANSWER-A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Distributive Shock. - ANSWER-Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. What is vascular response? - ANSWER-As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is renal response? - ANSWER-Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes: - Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. Explain adrenal gland response. - ANSWER-When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. Explain Hepatic Response. - ANSWER-Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. Explain Pulmonary Response. - ANSWER-Tachypnea happens for 2 reasons: 1. Maintain acid-base balance 2. Maintain increased supply of oxygen * Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli. Explain Irreversible Shock. - ANSWER-Shock uncompensated or irreversible stages will cause compromises to most body systems. - Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. How would you assess a pt in hypovolemic shock? - ANSWER-(Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery? ICP is a reflection of what three volumes? What happens when one increases? - ANSWER-1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? - ANSWER-- Headache - N/V - Amnesia regarding events around the injury What is a cerebral contusion and its S/S? - ANSWER-A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18-36 post injury. S/S: - Alteration in LOC - Behavior, motor or speech deficits - Abnormal motor posturing - Signs of increased ICP What is an epidural hematoma and its S/S? - ANSWER-Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly: - Compression of underlying brain - rapid increase in ICP - Decreased CBF - Secondary brain injury * Usually requires surgical intervention S/S: - Transient LOC - Lucid period lasting a few minutes to several hours - Rapid deterioration in neurologic status - Severe H/A - Sleepiness - Dizziness - N/V - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma What is a subdural hematoma and its S/S? - ANSWER-A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's What are intracerebral hematoma's and its S/S? - ANSWER-Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia What are the S/S of a linear skull fx? - ANSWER-- H/A - Possible decreased LOC What are the S/S of a depressed skull fx? - ANSWER-- H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site What are the S/S of a basilar skull fx? - ANSWER-- H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea How would you assess a pt with a cranial injury? - ANSWER-(Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness - Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration. - Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction. - Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma. - Position pt, elevate head to decrease ICP (but may also reduce CPP). - Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain - Prepare for ICP monitoring device - Administer mannitol as prescribed. - Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys. - Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Pain, especially on movement - Facial asymmetry and a palpable step-off deformity - Edema or hematoma formation at the fracture site - Blood behind, ruptured, tympanic membrane - Anesthesia of the lower lip What are neck injury S/S? - ANSWER-- Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing) How would you assess a patient with ocular, maxillofacial and neck trauma? - ANSWER-(Initial assessment) HISTORY - MOI? - Acceleration/Deceleration? - What was it caused by? - Pt restrained? Airbags deployed? Etc. - What are the pt's complaints? - Pt normally wear glasses or contacts? - Pt have hx of eye problems? - Pt ever have eye surgery? - Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION: - Inspect eye, orbits, face and neck - Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas - Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents - Determine whether lid lac's - Assess pupil's (PERRL) - Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome - Bilateral fixed and pinpoint pupils = pontine lesion or drugs - Mildly dilated pupil w/sluggish response may early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Assess for consensual response - Assess redness, eye watering, blepharospasm - Assess extraocular movement, except when an open globe injury is known or suspected. - Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle - Perform visual acuity exam - Use Snellen or handheld chart. Check uninjured eye first - Assess for blurred or double vision with injured eye and then with both eyes open - Inspect for rhinorrhea or otorrhea - If drng present, may indicate CSF leak - Observe for impaled objects - Assess occlusion of mandible and maxilla - Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx - Observe for uncontrolled bleeding PALPATION - Palpate periorbital area, face and neck for: - Tenderness - Edema - Step-off defects or depressions - Subcutaneous emphysema (esophageal or tracheal tear) - Palpate trachea above suprasternal notch - Trach deviation = late indication of tension pneumothorax or massive hemothorax - Assess sensory fx of perioribital areas, face and neck - Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side. - Check position of trachea DIAGNOSTIC STUDIES: - Xrays, CT scans, MRI's - Fluorescein staining - Slit-lamp exam - tonometry (measures intraocular pressure) - Bronchoscopy or esophagoscopy What are the nursing interventions for a pt with an ocular injury? - ANSWER-- Assess visual acuity & reassess - Elevate HOB to minimize intraocular pressure - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects - Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe. - Provide psychosocial support - Obtain an ophthalmology consultation - Provide d/c instructions: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer What are the nursing interventions for a patient with a maxillofacial or neck injury? - ANSWER-- Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present. - Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds With any eye injury, what should the evaluation and ongoing assessments be? - ANSWER-- Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's What are the most common type of injury associated with chest trauma? - ANSWER- blunt; MVC's. Penetrating; firarm injuries or stabbings What are S/S of a rib fracture? - ANSWER-- Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What are S/S with blunt cardiac injury? - ANSWER-"Cardiac contusion" or "concussion." Common with MVC or falls from heights. - ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis What are the S/S of pericardial tamponade? - ANSWER-A collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling. - Hyotension - Tachycardia or PEA - Dyspnea - Cyanosis - Beck's Triad (hypotension, distended neck veins + muffled heart sounds) - Progressive decreased voltage of conduction complexes on ECG What are aortic injuries S/S? - ANSWER-- Hypotension - Decreased LOC - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia How would you assess a pt with a thoracic injury? - ANSWER-(Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe chest wall - Assess breathing effort and RR - Symmetry - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) Palpation: - Palpate chest wall, clavicles and neck for: - Tenderness - Swelling or hematoma - Subcutaneous emphysema - Note presence of bony crepitus - Palpate central and peripheral pulses and compare quality between: - Right and left extremities - Upper and lower extremities - Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax) - Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury). Auscultation: - Auscultate compare BP in both UE's and LE's - Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain). - Auscultate chest for presence of BS (diaphragmatic rupture) - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP What are S/S of Hepatic Injuries? - ANSWER--Upper Right Quadrant Pain -Abdominal Wall Muscle Rigidity, Spasm, Involuntary Guarding -Rebound Tenderness -Hypoactive or Absent Bowel Sounds -Signs of hemorrhage or hypovolemic shock What are S/S of Splenic Injuries? - ANSWER--Signs of hemorrhage or hypovolemic shock -Pain in the left shoulder (Kehr's sign) when lying supine or Trendelenburg -Tenderness in the upper left quadrant -Abdominal wall muscle rigidity, spasm, or involuntary guarding S/S of Large and Small Bowel Injuries? - ANSWER--Peritoneal irritation manifested by abdominal wall muscle rigidity, spasm, involuntary guarding, rebound tenderness, or pain -Evisceration of small bowel or stomach -Hypovolemic Shock -Gross blood from rectum S/S of Gastric Injury? - ANSWER--Abdominal Pain -Peritoneal irritation -Evisceration of stomach -Gross blood in gastric aspirate S/S of Esophageal Injury? - ANSWER--Subcutaneous emphysema -Peritoneal irritation -Pain radiating to the neck, chest, shoulders, or throughout the abdomen -Gross blood in gastric aspirate S/S of Renal Injuries? - ANSWER--Hematuria -Flank or abdominal tenderness elicited during palpation -Ecchymosis over flank may occur, but normally develops 6 to 12 hours after injury How would you care for a pt with an Abdominal Injury? - ANSWER-(Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe the lower chest for asymmetric chest wall movement. -Observe the contour of the abdomen. Distention may indicate bleeding -Inspect lower chest, abdomen, flanks, and back for seat belt abrasions or soft tissue injuries -Inspect pelvic area for soft tissue bruising Percussion: - Percuss for hyperresonance or dullness. Hyperresonance indicates air, dullness indicates fluid. Palpation: - Palpate all four quadrants. Press and quickly release to determine presence of rebound tenderness. -Palpate pelvis for bony instability, asymmetry, or pain. -Palpate flanks for tenderness -Palpate anal sphincter for presence or absence of tone Auscultation: -Auscultate the chest. If bowel sounds heard in chest may have diaphragmatic rupture with herniation of the stomach or small bowel -Auscultate bowel sounds. Absence indicative of visceral injury. Diagnostic Procedures: - Xrays - MRI - IVP and DPL - CT's - FAST - Labs (cardiac enzymes) -Cystogram or urethrogram -Angiography Nsg Interventions for Pelvic Fracture - ANSWER--Stabilize pelvis by wrapping in folded sheet -Apply a pneumatic antishock garment to splint pelvic fractures -Prepare for application of an external fixator What are signs of ineffective circulation? - ANSWER-- Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds Nsg Interventions for Compartment Syndrome - ANSWER--Elevate the limb to the level of the heart to promote venous outflow and prevent further swelling. Elevation above the heart may decrease perfusion to a compromised extremity -Assist with measurement of fascial compartment pressure -Prepare for fasciotomy to preven muscle or neurovascular damage What are the interventions for Effective/Ineffective Circulation? - ANSWER-- Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation) What are factors that contribute to ineffective ventilation? - ANSWER-- AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age 24 Hour Burn Fluid Calculation - ANSWER-Dosage x Kg x % - ml in first 24 hours -More than 20% of their TBSA burned require: *Adults: 2-4 ml of crystalloid solution x kg x % *Peds: 3-4 ml of crystalloid solution x kg x % *Infants: fluid with 5% dextrose at a maintenance rate in addition to the Peds rate protocol (1/2 the amount should be infused in first 8 hours) What medications are used during intubation? - ANSWER-LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - ANSWER-PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry What is a Combitube? - ANSWER-A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. What is a Laryngeal Mask Airway? - ANSWER-Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What is Needle Cricothyrotomy - ANSWER-Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema What is Surgical Cricothyrotomy? - ANSWER-Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include: - Aspiration - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis How do you confirm ET Tube/Alternative Airway Placement? - ANSWER-- Visualization of the chords - Using bronchoscope to confirm placement - Listening to breath sounds over the epigastrum and chest walls while ventilating the pt - CO2 detector - Esophageal detection device - Chest x-ray How do you inspect the chest for adequate ventilation? - ANSWER-Observe: - mental status - RR and pattern - chest wall symmetry - any injuries - patient's skin color (cyanosis?) - JVD or tracheal deviation? (Tension pneumothorax) What are you looking for when auscultating lung sounds? - ANSWER-Absence of BS: - Pneumothorax - Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain What are you looking for when percussing the chest? - ANSWER-Dullness: - hemothorax Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. Explain Hepatic Response. - ANSWER-Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. Explain Pulmonary Response. - ANSWER-Tachypnea happens for 2 reasons: 1. Maintain acid-base balance 2. Maintain increased supply of oxygen * Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli. Explain Irreversible Shock. - ANSWER-Shock uncompensated or irreversible stages will cause compromises to most body systems. - Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. ICP is a reflection of what three volumes? What happens when one increases? - ANSWER-1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? - ANSWER-- Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? - ANSWER-- Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia What is Cushing's phenomenon or Cushing's Reflex? - ANSWER-Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? - ANSWER-1. Uncal herniation 2. Central or transtentorial herniation Why does herniation occur? What are the symptoms? - ANSWER-Because of uncontrolled increases in ICP. S/E's - Unilateral or bilateral pupillary dilation - AsyDimmetric pupillary reactivity - Abnormal motor posturing - Other evidence of neurologic deterioration Define uncal herniation. - ANSWER-The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. Define central or transtentorial herniation. - ANSWER-A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? - ANSWER-Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess Define Minor Head Trauma. - ANSWER-GCS 13-15 Define Moderate Head Trauma - ANSWER-Postresuscitative state with GCS 9-13. Define Severe Head Trauma. - ANSWER-Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? - ANSWER-A temporary change in neurologic function that may occur as a result of minor head trauma. S/S: - Transient LOC - H/A - Confusion and disorientation - Dizziness - N/V - Loss of memory - Difficulty with concentration - Irritability - Fatigue What are the signs and symptoms of postconcussive syndrome? - ANSWER-- Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression What is diffuse axonal injury and its signs and symptoms? - ANSWER-(DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - severe DAI, coma = weeks/months or persistent vegetative state - Elevated ICP - Abnormal posturing - HTN - Hyperthermia - Inspect nose and ears for drainage - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness - Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration. - Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP. - Prolonged hyperventilation NOT RECOMMENDED. - Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction. - Hyperoxygenate pt with 100% O2 via bag-mask - Apply direct pressure to bleeding sites except depressed skull fractures - Cannulate 2 large IV's - Hypotension doubles pt's death rate (w/severe head trauma) - Vasopressors used to maintain CPP. - Insert OG or NGT. OG should be used with severe facial trauma. - Position pt, elevate head to decrease ICP (but may also reduce CPP). - Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain - Prepare for ICP monitoring device - Administer mannitol as prescribed. - Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys. - Administer anticonvulsant - Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis: - Depressed skull fx - Sz at time of injury - Sz on arrival to ED - Hx of sz's - Penetrating brain injury - Acute subdural/epidural hematoma - Administer antipyretic med/Cooling blanket - Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP - Do not pack ears/nose if CSF leak suspected - Admin tetanus prophylaxis - Wound repair for facial/scalp Lac's - Admin other meds - Analgesics, sedatives, narcan, romazicon, etc. - Admin antibiotics - Pt's w/basilar skull fx need prophylaxis against meningitis - Prepare pt for OR, hospital admin or transfer. GCS breakdown - ANSWER- What are signs of a serious eye injury? - ANSWER-- Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure What is hyphema and its S/S? - ANSWER-Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure Needle decompression insertion site - ANSWER-2nd intracostal space What are s/s of chemical burns to the eye? - ANSWER-Chemical injuries require immediate intervention if it is to be preserved. S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids What are S/S of penetrating trauma/open or ruptured globe? - ANSWER-- Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements What are the S/S of orbital fracture (orbital blowout fracture)? - ANSWER-- Diplopia (double vision) - Loss of vision - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid - Infraorbital pain or loss of sensation - Orbital bony deformity What is LeFort I fracture and its S/S? - ANSWER-Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion What is LeFort II fracture and its S/S? - ANSWER-Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea What is LeFort III fracture and its S/S? - ANSWER-Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects - Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe. - Provide psychosocial support - Obtain an ophthalmology consultation - Provide d/c instructions: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer What are the nursing interventions for a patient with a maxillofacial or neck injury? - ANSWER-- Administer oxygen - For facial trauma, place pt in high-fowler's position if no spinal injury is present. - Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected - Monitor for progressive airway assessment - Prepare for intubation, PRN. - Cannulate 2 large IV's, initiate isotonic crystalloid IV solution - Control external bleeding w/direct pressure - Monitor for continued bleeding + expanding hematomas - Apply cold compresses to face to minimize edema - Assist w/repair of oral lac's, PRN - Admin antibiotics - Stabilize impaled objects - Admin analgesic meds With any eye injury, what should the evaluation and ongoing assessments be? - ANSWER-- Reassessing visual acuity at reasonable intervals - Reassessing pain, including response to nonpharmacologic + pharmacologic interventions - Monitoring appearance, position, movements of globe and pupillary responses - Monitoring airway patency, respiratory effort and ABG's What are the most common type of injury associated with chest trauma? - ANSWER- blunt; MVC's. Penetrating; firarm injuries or stabbings What are S/S of a rib fracture? - ANSWER-- Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What is a flail chest? - ANSWER-A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases. What could a flail chest be associated with? - ANSWER-- Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma What are the S/S of flail chest? - ANSWER-- Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. Define Pneumothorax. - ANSWER-Results when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. What are the S/S of a pneumothorax? - ANSWER-- Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) Define tension pneumothorax. - ANSWER-Life-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. Immediate decompression should be performed. Treatment should not be delayed. What are the S/S of a tension pneumothorax? - ANSWER-- Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign) Define Hemothorax. - ANSWER-Accumulation of blood in the pleural space. What are the S/S of Hemothorax? - ANSWER-- Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side What is a pulmonary contusion? - ANSWER-They occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. What are the S/S of pulmonary contusion? - ANSWER-- Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions What happens to a ruptured diaphragm? - ANSWER-Potentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver. - Herniation of abdominal contents - Respiratory compromise b/c impaired lung capacity + displacement of normal tissue. - Mediastinal structures may shift to opposite side of injury TXA - ANSWER-tranexamic acid inhibits activation of plasminogen (dissolves clots) TXA reduces clot breakdown safely reducing bleeding What are S/S of a ruptured diaphragm? - ANSWER-(Anything below the nipple line and should be evaluated for potential diaphragmatic injury). - Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP Cullen sign - ANSWER-bruising around umbilicus What are S/S of Hepatic Injuries? - ANSWER--Upper Right Quadrant Pain -Abdominal Wall Muscle Rigidity, Spasm, Involuntary Guarding -Rebound Tenderness -Hypoactive or Absent Bowel Sounds -Signs of hemorrhage or hypovolemic shock Grey turner sign - ANSWER-Bruising of the flanks. Between last rib and top of hip What are S/S of Splenic Injuries? - ANSWER--Signs of hemorrhage or hypovolemic shock -Pain in the left shoulder (Kehr's sign) when lying supine or Trendelenburg -Tenderness in the upper left quadrant -Abdominal wall muscle rigidity, spasm, or involuntary guarding Kehr sign - ANSWER-shoulder pain referred from the diaphragm when it is irritated by blood within the abdominal cavity S/S of Large and Small Bowel Injuries? - ANSWER--Peritoneal irritation manifested by abdominal wall muscle rigidity, spasm, involuntary guarding, rebound tenderness, or pain -Evisceration of small bowel or stomach -Hypovolemic Shock -Gross blood from rectum AVPU - ANSWER-Alert, Verbal, Pain, Unresponsive S/S of Gastric Injury? - ANSWER--Abdominal Pain -Peritoneal irritation -Evisceration of stomach -Gross blood in gastric aspirate MATCH - ANSWER-Massive hemorrhage, Airway, Respiration, Circulation, Head Injury/Hypothermia S/S of Esophageal Injury? - ANSWER--Subcutaneous emphysema -Peritoneal irritation -Pain radiating to the neck, chest, shoulders, or throughout the abdomen -Gross blood in gastric aspirate ABCDEFG(LMNOP)HI - ANSWER-Airway+Alertness Breathing+Ventilation Circulation/Control of Hemorrhage Disability (neuro stat) Exposure/Environmental Control Full set of vitals + family Get resuscitation adjuncts -monitor cardiac rhythm, naso/gastric tube, oxygen, ETCO2, pain History +Head to toe Inspect posterior surface What is the major cause of death after injury? - ANSWER-Uncontrolled external hemorrhage S/S of Renal Injuries? - ANSWER--Hematuria -Flank or abdominal tenderness elicited during palpation -Ecchymosis over flank may occur, but normally develops 6 to 12 hours after injury What end tidal carbon dioxide ETCO2 measurement shows effective ventilation? - ANSWER-between 35-45 mm Hg note: level above 50 mm Hg signifies depressed ventilation How would you care for a pt with an Abdominal Injury? - ANSWER-(Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe the lower chest for asymmetric chest wall movement. -Observe the contour of the abdomen. Distention may indicate bleeding -Inspect lower chest, abdomen, flanks, and back for seat belt abrasions or soft tissue injuries -Inspect pelvic area for soft tissue bruising Percussion: - Percuss for hyperresonance or dullness. Hyperresonance indicates air, dullness indicates fluid. Palpation: - Palpate all four quadrants. Press and quickly release to determine presence of rebound tenderness. -Palpate pelvis for bony instability, asymmetry, or pain. -Palpate flanks for tenderness -Palpate anal sphincter for presence or absence of tone Auscultation: -Auscultate the chest. If bowel sounds heard in chest may have diaphragmatic rupture with herniation of the stomach or small bowel -Auscultate bowel sounds. Absence indicative of visceral injury. Diagnostic Procedures: - Xrays - MRI - IVP and DPL - CT's - FAST - Labs (cardiac enzymes) -Cystogram or urethrogram -Angiography Types of shock - ANSWER-*Hypovolemic*: hemorrhage/burns *Distributive*: Neuro/anaphylactic/Septic *Cardiogenic*: MI/Dysrythmias/blunt cardiac trauma *Obstructive*: Cardiac Tamponade/Tension pneumo/Tension hemo Nsg Interventions for Pelvic Fracture - ANSWER--Stabilize pelvis by wrapping in folded sheet -Apply a pneumatic antishock garment to splint pelvic fractures -Prepare for application of an external fixator types of distributive shock - ANSWER-neurogenic, anaphylactic, septic Nuerogenic shock - ANSWER-Distributive shock Develops from spinal cord injuries and results in the loss of sympathetic nervous system control of vascular tone, which produces venous and arterial vasodilation. With the loss of SNS unopposed vagal activity may result in bradycardia > atropine or tanscutaneous pacing. Nsg Interventions for Open Fracture - ANSWER--Irrigate any wound with sterile saline -Cover open wounds with dry, sterile dressings. -Administer antibiotics, as prescribed -Inspect dressings frequently for continued bleeding -Administer tetanus prophylaxis, as indicated anaphylactic shock - ANSWER-Distributive shock A severe reaction that occurs when an allergen is introduced to the bloodstream of an allergic individual. Histamines are released which cause bronchoconstriction, labored breathing, widespread vasodilation, increased vascular permeability, circulatory shock, and sometimes sudden death. Nsg Interventions for Crush Injury - ANSWER--Administer intravenous isotonic crystalloid solution to increase urinary output and facilitate excretion of myoglobin -Elevate the injured extremity above the level of the heart to reduce swelling and pain unless compartment syndrome is suspected. For compartment syndrome, maintain at level of the heart -Gently clean open wounds -Prepare the patient for surgical debridement, fasciotomy, or amputation acidosis electrolyte abnormalities Class 3 Hemorrhage - ANSWER-Vasoconstriction no longer maintains BP -blood loss 30-40% or 1,500-2,000mL Cardiac output decreases and becomes life-threatening Effects - Patient becomes more confused, restless, and agitated - Rapid heart rate - over 120 - Decreased systolic BP - Rapid respiratory rate 30-40 - Pale, cool, clammy extremities 1. A- airway and Alertness with simultaneous cervical spinal stabilization 2. B- breathing and Ventilation 3. circulation and control of hemorrhage 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces - ANSWER-ABCDEFGHI Class 4 Hemorrhage - ANSWER-Vasoconstriction is problematic and further impairs tissue perfusion and cellular oxygenation -blood loss greater than 40% and 2,000mL. Effects - Severely decreased mental status or loss of consciousness - lethargic - Marked tachycardia - over 140 -RR over 35 - Ultimately leads to organ failure and death Tracheobronchial injurt - ANSWER-penetrating or clothesline injury, hoarseness or crepitus, difficult intubation Late assessment findings of increased ICP include: - ANSWER-- DILATED, NON- REACTIVE PUPILS - UNRESPONSIVENESS to verbal/painful stimuli - ABNORMAL POSTURING (flexation, extension, flaccidity) - CUSHING RESPONSE Widening pulse pressure Reflex bradycardia Decreased respiratory effort Glascow Coma Scale (GCS) - ANSWER-Neurologic assessment of a patient's BEST verbal response, eye opening, and motor function. Lowest score is a 3, highest is 15, Intubate at 8. In those with traumatic brain injury where should you maintain the systolic pressure? - ANSWER-greater than 90 mmHG The meninges consist of three layers of protective coverings ... - ANSWER-(PAD) pia matter, arachnoid matter and dura matter BLUNT ESOPHAGEAL INJURY - ANSWER-air in the mediastinum with possible widening, sub q emphysema A moderately dilated pupil with sluggish response may be an early sign of what? - ANSWER-herniation syndrome from increased ICP Cushing's triad/response - ANSWER-r/t loss of auto regulation due to ICP Signs of increased intracranial pressure: 1. hypertension 2. bradycardia 3. irregular respirations - ANSWER-Prehospital shock index pg. 85 Normal ICP range - ANSWER-0-15 mmHg. Maintain below 20 mmHg Rib fractures - ANSWER-doom, anxiety, vascular injuries, heart To maintain cerebral perfusion pressure (CPP) 50- 70 mm Hg - ANSWER-Administer norepinephrine Elevate HOB 0-30 Degrees Drain CSF Beck triad of cardiac tamponade - ANSWER-hypotension, distended neck veins, distant heart sounds Signs of impending herniation - ANSWER-unilateral or bilateral pupillary dilation asymmetric pupillary reactivity abnormal posturing **give brief period of hyperventilation until definitive measures** Adequate perfusion of oxygen and supply of nutrients to the brain tissue is dependent on ... and ... - ANSWER-CPP; CBF Early signs of ICP - ANSWER-Decreased LOC - Amnesia Behavior changes- impaired judgment, restlessness, drowsiness) Pupil changes Vision abnormalities (brain swelling is putting pressure on the optic and oculomotor nerves) Headache Vomiting (pressure on the vagal nerve center of the brain that controls vomiting) Nuchal rigidity Flail chest - ANSWER-3 or more ribs fractured in 2 or more places, parodoxical rise and fall of chest wall Airway -*6 - ANSWER--tongue obstruction -loose or missing teeth -foreign objects -blood, vomitus, secretions -edema -snoring, stridor, gurgling trauma its need early supplemental oxygen, start with 15 mL O2 and titrate oxygen delivery. - ANSWER-Oxygen on trauma patients Breathing- *8 - ANSWER--spontaneous breathing -symmetrical chest rise and fall- flail -depth, pattern, rate of respiration -increase WOB -skin color -open wounds, deformities, sub q emphysema -tracheal deviation, JVD -breath sounds equal and present tension pneumothorax - ANSWER-a pneumothorax with rapid accumulation of air in the pleural space, needle decompress Intubation- post assessment - ANSWER-- secure at the lip, number at the teeth -state need for a vent ... is defined as the pressure gradient across the brain tissue, or the difference between the pressures of the cerebral artery and venous vessels. - ANSWER-CPP; CPP = map - icp parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. ???;.][''''''''''''''''''' - ANSWER-this card was created by a cat. enjoy. Stroke volume - ANSWER--preload, after load, contractibility Difficult intubation elderly - ANSWER-Cervical arthritis TNCC - ANSWER-A systematic, organized approach using specific roles to provide universal care ... pain originates from skin and musculoskeletal structures (burns) - ANSWER-Somatic Cardiac tamponade - ANSWER-Pericardial window Distributive - ANSWER-Neurogenic Septic Anaphylactic Neurogenic - ANSWER--loss of vasomotor tone due to decrease in sympathetic control -vasodilation, SCI, BRADY Septic - ANSWER-mediated by SIRS with hypotension and perfusion, endotoxins from bacterial cells cause vasodialtion A- Alertness, Airway, Cspine - ANSWER--*APVU -*Hold c-spine and use jaw thrust if not talking (2 people) -*Determine patency and protection of airway using inspection, palpation, auscultation -*States need for OPA Mandate report - ANSWER-6 yr old loop bruising Progressive (uncompensated) - ANSWER-SNS fails, body cant perfuse organs, low SBP, confused, disoriented, narrow pulse pressure apply direct pressure to bleeding elevate extremity apply pressure over arterial sites Consider a pelvic binder for pelvic fractures consider a tourniquet cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation d. use rapid infusion device - ANSWER-C Interventions: B-breathing and ventilation - ANSWER--*determine effectiveness of breathing using inspection, palpation, auscultation -*state need for BVM (10-12/min) Obese hypo-ventilation - ANSWER-Increase airway resistance Decrease chest wall compliance Increase intra-abd pressure Adrenal response - ANSWER-Release of catecholamines (epi and norepi) that increase contractility and HR ... pain originates from organs and may lead to referred pain. (Trauma) - ANSWER- Visceral Intubation with RSI-assess 5 - ANSWER--assess placement with CO2 detector, bilateral chest rise and fall, auscultation of breath sounds and epigastrium, 5-6 breaths CO2, skin color Facial Fx - ANSWER-CSF What is diffuse axonal injury and its signs and symptoms? - ANSWER-(DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - severe DAI, coma = weeks/months or persistent vegetative state - Elevated ICP - Abnormal posturing - HTN - Hyperthermia - Excessive sweating because of autonomic dysfunction - Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits C-circulation and hemorrhage - ANSWER--*determine adequacy of circulation using inspection, auscultation, palpation -assess medic line -*2nd large bore IV, warm crystalloid infusing at controlled rate if not shocky Tamponade - ANSWER-Muffled heart tones JVD Hypo-tension If injury causes the CPP to fall outside the range of 50 - 160, the brain loses its ability to ... and CBF is directly dependent on ... for perfusion - ANSWER-Auto regulate ; MAP Tamponade Tx - ANSWER-Peri-cardio-centesis E-exposure - ANSWER--*need to remove all clothing and inspect for hemorrhage, injury, deformity -warm patient- blankets, fluids, temp -forensics Disability - Neurologic Status 1. Assess pupils for equality, shape, and reactivity (PERRL) 2. Assess GCS (eye opening, verbal response, and motor response) - ANSWER-D F- full set of vitals and family presence - ANSWER-- full set of vitals -liaison for family What fluid not given in TBI - ANSWER-D5W and NA Hr 146 RR increased BP decreased Moan to pain - ANSWER-Decomp shock Intracerebral hematoma - ANSWER-deep in brain tissue, HA, increased ICP, LOC, pupil changes, frontal lobe more risk for sig herniation G- LMNOP - ANSWER-- labs- lactate, ABG, type and cross, glucose -m-monitor -n-NG/OG -o-pulse ox -p-pain- pharma and nonpharm Normal Co2 ... - ANSWER-35-45 Herniation syndrome - ANSWER-uncontrolled increases in ICP, uncal and central (shift down) or transtentorial, midline shift is seen with uncal herniation Early sign of Increased ICP - ANSWER-N/V MIST - ANSWER-Mechanism of action -inhalation injury, unable to breath due to pain, apnea, high risk for aspiration/decompensation Amputation - ANSWER-In bag, on ice Surgical airways - ANSWER--performed only when ETT can not be done -cricothyroid membrane -hemorrhage, lac to cricoid ring, vocal cord damage Exposure and Environmental Control Remove all clothes and assess for any obvious injuries and uncontrolled bleeding - ANSWER-E Crush injury - ANSWER-Myoglobinuria Renal failure + gurgling over epigastrium - ANSWER--in stomach, pull out, preoxygenate, try again Early findings of increased ICP include - ANSWER-Headache, nausea and vomiting, amnesia, behavior changes, altered level consciousness no gurgling, decreased breath sounds L - ANSWER--in too far, pull out to 3xlength of tube Nursing intervention prevent infection - ANSWER-Saline gauze Nsg Interventions for Compartment Syndrome - ANSWER--Elevate the limb to the level of the heart to promote venous outflow and prevent further swelling. Elevation above the heart may decrease perfusion to a compromised extremity -Assist with measurement of fascial compartment pressure -Prepare for fasciotomy to preven muscle or neurovascular damage Older adult intubation - ANSWER--relaxed oropharyngeal muscles -cervial arthritis Nursing intervention shiney/tight - ANSWER-Level of heart Shock - ANSWER-inadequate tissue perfusion, mismatch of O2 supply and demand Late findings of increased ICP include - ANSWER-Dilated, nonreactive pupils, unresponsiveness, abnormal posturing, Cushing response, bradycardia, decreased respiratory Effort CO - ANSWER-=stroke volume+HR Pregnant misshape uterus - ANSWER-Uterine rupture IF clothing is needed for evidence preserve in paper bag. Maintain body temp - cover the pt, turn up heat in room, administer warm fluids - ANSWER-E Interventions: Hypovolemia/ hemorraghic - ANSWER--loss of plasma, blood, volume -decrease preload -fluid resus Pregnant supine hypo-tension - ANSWER-Tilt spine board Cardiogenic - ANSWER--ineffective perfusion caused by inadequate contractility of heart -blunt cardiac injury -pressors, dop, epi, NO FLUIDS .... can produce bleeding that may not be evident until several hours after injury - ANSWER-Basilar skull fractures Obstructive - ANSWER--inadequate circulating blood volume bc of obstruction of the great veins, aorta, pulm arteries, heart -cardiac tamponade (muffled heart sounds, tachy), tension pneumo (deviated trachea), tension hemo Occular nursing intervention - ANSWER-Elevate HOB What are signs of ineffective breathing? - ANSWER-- AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. Trauma pt DvT - ANSWER-Pelvic fx The three areas of basilar skull fractures include ... - ANSWER-Periodontal D.C. my Isra (raccoon eyes - fossa fracture) Mastoid process ecchymoses (behind the ear) Hemotympanum (blood in the tympanic membrane/middle ear) Obese Increase abd pressure Decrease venous return - ANSWER-Emboli Anaphylactic - ANSWER-Vasodilation due to allergens, IM epi Full set of vitals and family presence - ANSWER-F Compensated stage - ANSWER--SBP is normal, rising DBP, tachy bounding, lactate builds up Baby ok Then decrease LOC Weak cry - ANSWER-Hypoglycemia ... is a test that requires fluid to be sent to the lab and is considered the gold standard for identifying CSF - ANSWER-Beta2-Transferrin Irreversible damage - ANSWER-obtunded comatose, sbp 50-60, brady, shallow resp death Young girl does not remember - ANSWER-Head CT Cerebral response - ANSWER--brain autoregulates so blood is shunted from other organs to brain -SBP >50 cerebral ischemia occurs and the increase in CO2 in the brain stimulates the CNS response Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - ANSWER-A tight-fitting nonrebreather mask at 12-15 lpm. Renal response - ANSWER-Vasoconstriction of arterioles and some veins, reabsorption of Na and H20 MVA diff breathing Tachycardia - ANSWER-Liver lac What are two quick tests for general suspicion of CSF leak? - ANSWER-Halo sign and glucose Inflammatory response - ANSWER-activated by hypoxia, neutrophils travel to injury site Decrease cranial calcification - ANSWER-CT normal without radio graphic abnormality Post concussive syndrome - ANSWER-Ha, NV, dizzy, memory impairment, depression Shock improve - ANSWER-Lactic acid This is commonly the type of bleed sustained by athletes who suffer a catastrophic head injury. - ANSWER-Acute subdue all hematoma Preventable cause of death - ANSWER-uncontrolled hemorrhage Depressed - ANSWER-extends below surface of head What are signs of ineffective circulation? - ANSWER-- Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds basilar - ANSWER-base of skull, CSF leaks, periorbital edema, mastoid ecchymosis is battles sign Compartment syndrome - ANSWER-Pain Pulse Pallor Pressure Paralysis Parasthesia .... are frequently associated with minor injury in older adults, patients taking anticoagulation medications and patients with chronic alcohol abuse. - ANSWER- Chronic subdural Hematoma Post concussive syndrome - ANSWER-Mild TBI Nausea Dizzy HA Memory/judgement impaired Insomnia Irritability Noise/light sensitivity Attention problems History and Head to toe MIST - prehospital report MOI Injuries sustained S s/s in the field T treatment in the field if patients family present get a better hx on them - ANSWER-H Lefort II - ANSWER-Frontal process of MAXILLA, NOSE bones , & inferior / medial ORBITAL WALL fractures Rhinorhea Trauma nursing - ANSWER-Standardized systematic approach ... is the shifting of brain tissue with displacement into another compartment as the result of bleeding or edema. - ANSWER-Herniation preparation and triage - ANSWER-trauma team activated prep complete (rapid infuser, chest trauma equipment) don ppe What are the late signs of breathing compromise? - ANSWER-- Tracheal deviation - JVD Across-the-room Observation - ANSWER-assess for obvious uncontrolled hemorrhage GCS scores : I. Mild TBI II. Moderate TBI III. Severe TBI - ANSWER-13-15; 9-12; 8 or less A - ANSWER--AVPU -Cervical spine (2nd person and jaw-thrust maneuver - inspect palate ausvultate + 4 issues -state need for OPA -or definitive airway -reassess airway after insertion of opa (no snoring heard) Sample is part of history S symptoms associated with injury A allergies and tetanus status M meds currently on including anticoagulant therapy P past medical hx L last oral intake E Events and environment factors related to the injury - ANSWER-SAMPLE demonstrates and describes techniques for determining latency of airway using inspection, ausculataton, and palpation. Identifies at least FOUR - ANSWER--is tongue obstructing airway -are there any lose or missing teeth -are there any foreign bodies is there any blood, vomitus or other secretions -is there any edema -is there any snoring, gurgling, or stridor ... refers to a condition that occurs when the patient suffers a second milks TBI before recovery from the first - ANSWER-Second impact syndrome B - ANSWER--Determine breathing effectiveness -state need for assisted ventilation with bag-valve mask device -assess ET placement -Et secure, number at teeth documented -need for manuel ventilation What are the interventions for Effective/Ineffective Circulation? - ANSWER-- Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation) B Demonstrates and describes techniques for determining breathing effectiveness using components of inspection, auscultation, and palpation. identifies at least FOUR - ANSWER--is there spontaneous breathing -is there symmetrical chest rise -what are the depth, pattern and rate of respirations -is there increased work of breathing -skin color -open wounds or deformities, subcutaneous emphysema -tracheal deviation or jugular venous distention -great sounds present and equal Patients who sustain a mild TBI may develop .... . Typically it will manifest several days or moths after head trauma. - ANSWER-Postconcussive syndrome any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles lacs, contusions, auscilate lung sounds and heart sounds - ANSWER-Head to toe assessment: Chest what reevaluation adjuncts will you expect for this patient? - ANSWER-CT Chest Xray or CT abdominal CT wound cleaning tetanus C What are the primary benefits of a team approach to trauma care - ANSWER-it provides a systemic approach to care and organizes care What findings will you reevaluate? - ANSWER--primary assessment -vital signs -pain -injuries and the effectiveness of their treatments/interventions What are signs of ineffective breathing? - ANSWER-- AMS - Cyanosis, especially around the mouth - Asymmetric expansion of chest wall - Paradoxical movement of the chest wall during inspiration and expiration - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. A ____ and ___ approach is used by all members of the trauma team to provide optimal care for the trauma pt. - ANSWER-Systematic , Organized A In the primary survey AVPU is performed to determine if the patient can: - ANSWER- Protect their aiway Trauma is injury to living tissue caused by ... - ANSWER-An extrinsic agent don't forget flanks!!! inspect of lacs, puncture wounds, contusions, auscultate then palpate: bowel sounds? any rigidity, guarding? begin with light palpation start to palpate with side that does not hurt maybe do a fast scan? - ANSWER-Head to toe assessment: Abdomen A traumatic incident may be classified as ....(assault or suicide) or ... (falls or collisions) - ANSWER-Intentional;unintentional B WHich may lead to unreliable pulse ox reading - ANSWER-carboxyhemoglobin .... is the study of energy transfer as it applies to identifying actual or potential injuries - ANSWER-Kinematics What medications are used during intubation? - ANSWER-LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents The general study of forces and their effects - ANSWER-Biomechanics A The systemic inflammatory response is a normal part of the body's response to shock from traumatic injury. what best describes this response - ANSWER-it is activated by tissue hypoxia and sends neutrophils to injury site How external forces in the environment are transferred to the body - ANSWER- Mechanism of injury any lacs? deformities? blood at the urtheral meatus palpate pelvis with high pressure over the iliac wings downward and medially - ANSWER-Head to toe assessment: pelvis and perineum A body at rest will remain at rest, a body in motion will stay in motion - ANSWER- Newton's first law A what is an early assessment finding to increased ICP in pt with a brain injury - ANSWER-vomiting Force = mass x acceleration - ANSWER-Newton's second law What are the Rapid Sequence Intubation Steps? - ANSWER-PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry For every action there is an equal and opposite reaction - ANSWER-Newton's third law A an unrestrained driver was involved in a frontal collision without airbag deployment. he is hypotensive and tachycardic with shallow respirations, distended JVD and muffled heart tones the nurse prepare for what - ANSWER-pericardiocentesis Energy can neither be created nor destroyed but rather I can change form - ANSWER- Law of conservation of energy any deformities? bleeding? contusions, lacs? skin temp?? place splints on deformities, pulses - ANSWER-Head to toe assessment: Extremities Kinect is energy is equal to ... - ANSWER-1/2 the mass x by the velocity squared (v^2) D An unrestrained driver is brought into the emergency department following a frontal impact MVC. she is pale, anxious, and c/o SOB. what is the potential injury - ANSWER- Lumbar fx Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - ANSWER-A tight-fitting nonrebreather mask at 12-15 lpm. Caused from a sudden and rapid onset of motion ( a Parker car being hit by another vehicle) - ANSWER-Acceleration forces B pt to ER after being pinned to brick retaining wall. knwoing crushing injuries can result to significant damage to muslces the priority asessment for trauma nruse is for - ANSWER-myoglobinemia nd renal failure What is a Laryngeal Mask Airway? - ANSWER-Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What stage of shock: anxiety, restless, confused, norm systolic pressure, rising diastolic pressure, slightly tachycardiac, increased RR and decreased urine output - ANSWER- Stage I: compensated Bduring the primary survery which of the following has the greatest priority - ANSWER- cervical spine injury What stage of shock:patient is unconscious or intended, normal systolic pressure, narrowing pulse pressure, tachycardia, weak and threads pulses, rapid and shallow respiration, cool and clammy, worsening base excess and increasing Lacoste levels - ANSWER-Stage II: decompensated or progressive shock Capnography monitors numeric value, as well as continuous waveform, indicating real- time measurement and trending over time. - ANSWER-Quantitative: What stage of shock?: this will lead to death without rapid intervention, obtunded, stuporous or comatose, marked hypotension and heart failure, bradycardia, decreased and shallow respirations, pale, cool and clammy, organ failure and severe acidosis - ANSWER-Stage III: irreversible shock D restrained driver is involved in a severe head on MVC and presnts with a seatbelt mark along the neck and upper chest area. bilateral decreased breath sounds, hemoptysis and diffuse sub q emphysemato the neck and upper chest area - ANSWER- tracheobronchial injury ... is a principle that confuses on prevention rather than intervention. - ANSWER- Damage control resuscitation What intervention should be done if a pt presents with effective circulation? - ANSWER-- Insert 2 large caliber IV's - Administer warmed isotonic crystalloid solution at an appropriate rate The components of the neurological system involved with pain transmission include... - ANSWER-Neurons, neuron synapses and neurotransmitters B a pt involved in an MVC develops asymmetric pupillary reactivity, bilateral pupillary dilation and abnormal motor posturing. what does the nurse suspect as the most likely cause - ANSWER-herniation syndrome ... pain is persistent and usually lasts longer than 3 to 6 months. - ANSWER-Chronic Colorimetric CO2 detectors provide info about the presence or absence of CO2. A chemically treated indicator strip changes color revealing the presence or absence of exhaled CO2 - ANSWER-Qualitative ... describes the concept of under treatment of pain. - ANSWER-Oligoanalgesia B which of the following hemodynamic support strategies is the prioririty intervention for a pt with traumatic pulmonary contusion - ANSWER-judicios use of IV fluids The most reliable and valid tool for pain assessment is ... - ANSWER-Self-report What is Needle Cricothyrotomy - ANSWER-Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema Causes of oligoanalgesia include... - ANSWER-Failure to assess initial pain; failure to implement guidelines and protocols; failure to document pain; failure to meet patients expectations B the unrestrained fron seat passenger in a MVC develops echymosis around umbillicus. this assessment finding is most commonly associated with: - ANSWER- bleeding in the peritoneal cavity D displaced tube O obstructed or kinked P pneumothorax E equipment failure , such as becoming detached from the equipment or loss of capnopgrahy - ANSWER-DOPE D elevated comaprtment pressure can be the result of - ANSWER-hemorrhage from within the muscle What is Surgical Cricothyrotomy? - ANSWER-Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include: - Aspiration - Hemorrhage or hematoma formation or both - Lac to trachea or esophagus - Creation of a false passage - Laryngeal stenosis A prego trauma pt develops tachy, hypotension, a rigide board like uterus, and dark, red vaginal bleeding. she reports constant back pain which is increasing. the most likely cause of s/s is - ANSWER-placental abruption 1. Preparation 2. Preoxygenation 3. Pretreatment 4. Paralysis and Induction 5. Protecting and positioning - v 6. Placement of proof - secure the tube 7. Post intubation - secure ETT Tube, get X-ray for placement - ANSWER-Steps of Rapid Sequence Intubation A for a ptwho has undergone recent bariatric surgery, flouroscopy is recommended to place - ANSWER-NG tube What are signs of ineffective circulation? - ANSWER-- Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds A identification of vulnerabilities is an example of what phase of disaster management - ANSWER-mitigation from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume. - ANSWER-Hypovolemic Shock A which of the following structures would be hte most affected by teh concept of caviation - ANSWER-Liver How do you confirm ET Tube/Alternative Airway Placement? - ANSWER-- Visualization of the chords - Using bronchoscope to confirm placement - Listening to breath sounds over the epigastrum and chest walls while ventilating the pt - CO2 detector - Esophageal detection device - Chest x-ray D which of the following diagnostic intervention is most appropriate for the unstable pt with a suspectedinternal hemorrhage - ANSWER-focused assessment with sonography for trauma Stroke Volume X HR - ANSWER-Cardiac Output = C an adult pt involved in a brush fire arrives to the er. upon initial assessment in the er the most concerning finding is - ANSWER-hoarse voice and repeatedly decides to clear throat. What are you looking for when percussing the chest? - ANSWER-Dullness: - hemothorax Hyperresonance - Pneumothorax C a college student presents to the er stating afterarriving at a party , she awoke in a dorm rom. she didnt recognize with no memory of the previous evening the trauma nurse prepare for what exam. - ANSWER-sexual assult .. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ANSWER-Baroreceptors: B when assessing a pt following a MVC the nurses asks how fsat the car was going - ANSWER-when volocity is doubled speed is quadroupled What are factors that contribute to ineffective ventilation? - ANSWER-- AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age B which of hte following significant assessment findigns is frequently found in a patient with complete cransiofacial separation involving the maxilla, zygoma, orbits, and bones of the cranial base. - ANSWER-diplopia activation: consist of carotid and aortic bodies. ... detect changes in blood oxygen and Co2 and pH. When Co2 rises or oxygen level of pH falls these receptors are activated and information is relayed to the CNS and the cardiorespiratory centers in the medulla , which increases respiratory rage and depth and BP - ANSWER-Chemoreceptors: A in neurogenic shock, alterations in vital signs include hypotension and which other abnormal VS - ANSWER-bradycardia What are you looking for when palpating the chest wall, clavicles and neck? - ANSWER-- Tenderness - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. C an older adult pt fell in the bathtub 3 days ago. now she is exihibiting decreasd LOC and difficulty with speaking and walking. which of the following injuries is most effective - ANSWER-subdural hematoma 50 to 150 - ANSWER-MAP Range A which of the following values is within the acceptable limits for trauma pt - ANSWER- end tidal CO2 of 40 What is the DOPE mnemonic? - ANSWER-D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing B an occlusive dressing has been applied to a pt with a penetrating injury to the chest. upon assessment the nurse notes that the patient is in respiratory distress nad has absnet breath sounds on hte affected side. what is the priroruty intervention - ANSWER- remove the dressing to the wound the decrease coagulopathy .. you will you bleed more - ANSWER-The colder you are the more acidic you are.. C properly restrained 6 wk old kid was involved in a MVC. after the assessment and stabilization the pt becomes more difficult to rouse. responding with a weak cry to painful stimuli. the pupils remain brisk and reactive. the anterior fontanel is soft and flat. what is the most likely cause and pririty interventions - ANSWER-hypoglycemia What medications are used during intubation? - ANSWER-LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents Cthe trauma nurse would prepare for a definitive airwya for which of the following condition. - ANSWER-GCS of 8 or ls in massive transfusion protocol... responsible for dissolving clots - ANSWER-TXA A during assessment of an extremety with suspected pulses are - ANSWER-can be normal Explain Hypovolemic Shock. - ANSWER-Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes: - Blood loss - Burns, etc. A several groups of people are at higher risk for maltreatment including children, elderly, prego, and ... - ANSWER-pt's with disability stabilized vital signs, improved mental status, improved urine output - ANSWER-What are indicators of increased perfusion? C which of the follwoing is a risk factor for DVT in the trauma pt. - ANSWER-pelvic fx Explain Cardiogenic Shock. - ANSWER-Syndrome that results from ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: MI, Blunt cardiac injury, Mitral valve insufficiency, dysrhythmias, Cardiac Failure A a pt sustrained a penetrating injury of his upper leg. the pre hospital personnel states a large amount of blood loss before hemostasiswas achieved. he presents to the ER responding to painful stimuli with moaning. he is tachy 142 b/p 104/96 and RR 24 - ANSWER-decompensated What are the Rapid Sequence Intubation Steps? - ANSWER-PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: Uncontrolled Hemorrhage - ANSWER-Major cause of preventable death: What is renal response? - ANSWER-Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes: - Vasoconstriction of arterioles and some veins - Stimulation of sympathetic nervous system - Retention of water by kidneys - Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. reorganize care to C-ABC - ANSWER-If uncontrolled hemorrhage .. Air cannot escape intrapleural space.. can begin to compress heart. pt will have sever resp distress, hypotension, JVD. - ANSWER-Tension pneumo Used at the beginning of the initial assessment 1. A Alert. If the pt is alert he or she will be able to maintain his or her airway once it is clear. 2. V responds to verbal stimuli responds to pain. If the patient needs verbal stimulation to respond, an airway adjunct may be needed to keep the tongue from obstructing the airway. 3. P responds to pain. If the pt. responds only to pain, he or she may not be able to maintain his or her airway adjunct may need to be placed while further assessment is made to determine the need for intubation. 4. U Unresponsive. If the pt. is unresponsive, announce it loudly to the team and direct someone to chk in the pt is pulseless while assessing if the cause of the problem is the airway. - ANSWER-Airway and AVPU: What is a Laryngeal Mask Airway? - ANSWER-Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. ask pt to pen his or her mouth - ANSWER-While assessing airway the patient is alert and responds to verbal stimuli you should.. A 14 gauge needle that is inserted into the 2nd intercostal space in the midclavicular line on the affected side over the top of the rib to avoid neuromuscular bundle that runs under the rib. Prepare for chest tube placement. - ANSWER-Tension pneumo intervention jaw thrust maneuver to open airway and assess for obstruction. If pt has a suspected csi, the jaw thrust procedure should be done by two providers. One provider can maintain c-spine and the other can perform the jaw thrust maneuver. - ANSWER-While assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should.. Explain adrenal gland response. - ANSWER-When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. 1. The tongue obstructing the airway 2. loose or missing teeth 3. foreign objects 4. blood, vomit, or secretions' 5. edema 6. burns or evidence of inhalation injury Auscultiate or listen for: 1. Obstructive airway sounds such as snoring or gurgling 2. Possible occlusive maxillofacial bony deformity 3. Subcutaneous emphysema - ANSWER-Inspect the mouth for: Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm. Ensure two large bore IVS are placed. Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred. - ANSWER-Hemothorax: 1. Check the presence of adequate rise and fall of the chest with assisted ventilation 2. Absence of gurgling on auscultation over the epigastrium 3. Bilateral breath sounds present on auscultation 4. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor - ANSWER-If the pt has a definitive airway in what should you do? Explain Hepatic Response. - ANSWER-Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. 1. Suction the airway 2, Use care to avoid stimulating the gag reflex 3. If the airway is obstructed by blood or vomitus secretions, use a rigid suction device If foreign body is noted, remove it carefully with forceps or another appropriate method - ANSWER-If Airway is not patent 1. Hypotension 2. JVD 3. Muffled heart sounds - ANSWER-Becks Triad: 1. Apnea 2. GCS 8 or less 3. Maxillary fractures 4. Evidence of inhalation injury (facial burns) 5. Laryngeal or tracheal injury or neck hematoma 6. High risk of aspiration and patients inability to protect the airway 7. Compromised or ineffective ventilation - ANSWER-Following conditions might require a definitive airway What is Needle Cricothyrotomy - ANSWER-Percutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation