1. Trauma Nursing By: Diana Blum RN MSN Metropolitan Community College

2. Priority Emergency Measures for All Patients  Make safety the first priority  Preplan to ensure security and a safe environment  Closely observe patient and family members in the event that they respond to stress with physical violence  Assess the patient and family for psychological function

3.  Patient and family-focused interventions  Relieve anxiety and provide a sense of security  Allow family to stay with patient, if possible, to alleviate anxiety  Provide explanations and information  Provide additional interventions depending upon the stage of crisis

4. Common Trauma  Heat  Bites  Cold  Electrical  Altitude  Near drowning  Spinal  Head  Musculoskeletal  Stab/gunshot wounds  rape

5. Requirements to work in ER  Graduated RN program  Med/Surg and or ICU experience  BLS  ACLS  PALS  Some facilities require ER certification

6.  Triage is from a French word meaning to sort. Emergency services regularly face patient loads that overwhelm resources. To better serve patients and make sure the worst patients get treatment as quickly as possible, emergency medical providers use a method of prioritizing patients by medical severity

7.  Triage Nurse has 2-3 minutes to decide how long each patient should wait for medical care and assign a corresponding Triage Category

8.  The nurse will use their expertise to process data obtained from the presenting problem, physiological observations, general appearance and all important gut feelings

9.  urgency based on vital signs, complaints, appearance, and history  Coming by ambulance think of the following  Code 1 did not need ambulance  Code 2 minor injuries  Code 3 serious injury  Code blue =coding

10. A client arrives in the emergency room with multiple crushing wounds of the chest, abdomen, and legs. The assessments that assume the greatest priority are: select all that apply: A. Level of consciousness and pupil size B. Abdominal contusions and other wounds C. Pain, respiratory rate, and blood pressure D. Quality of respirations and presence of pulses

11. The charge nurse is overseeing care of 10 clients on a general obstetrical floor. Concerning which of the following patient-care situations should the nurse notify the physician FIRST? a. Prenatal client at 7 weeks gestation with nausea and vomiting and a whitish vaginal discharge. b. A gravida 2 para 1 client at 28 weeks gestation with brownish facial blotches and +1 glucose and trace protein in a random urinalysis. c. Seventeen-year-old client at 15 weeks gestation with missed abortion and bleeding from IV site. d. Rh-negative client at 38 weeks gestation with blood pressure of 150/105, brisk reflexes, and generalized edema in hands and ankles.vomitingurinalysisblood pressure

12.  You are asked what the correct steps in CPR are. Number them in the correct order.  ___ initiate breathing  ___ Open the client airway  ___ Determine breathlessness  ___ Perform chest compressions  ___ determine unconsciousness by shaking the client and asking “ Are you Okay?”

13.  You are preparing to suction a client with a trach. List the order of priority for the actions to take during this procedure.  ____ hyperoxygenate the client  ____ Place the client in a semi fowler position  ____ turn the suction on and set regulator to 80 mmHG  ____ Apply gloves and attach the suction tubing to the suction catheter  ____ Insert the Catheter into the trach until resistance is met and pull back 1 cm  ____ Apply intermittent suction and slowly withdraw while rotating it back and forth

14. You are the triage nurse coming on duty. The following patients come in to be seen. This is all the info you have. How would you triage them and why?  54/m c/o chest pain 2/10 had a CABG 6 months ago. Hr 92 BP 140/90 RR32 SAO2 95% on 4 liters  7 /F mom states has been vomiting and diarrhea x 2 days. She has not voided for 12 hours and can not keep fluids down. HR 112 RR24 lips and mouth dry, skin cool  70/m with general weakness and unable to due ADL. He is SOB and c/o abd pain. Bibasilar crackles, HR 123 irregular BP 150/72 sat 88% RA

15. Hyperthermia  Acute Medical Emergency  Failure of heat regulating mechanisms  Elderly and young at risk  Exceptional heat exhaustion  Stems from heavy perspiration  Need to stay hydrated!  Causes thermal injury at cellular level

16. Treatment  Lower temp as quickly as possible(102 and lower) How can this be done?  ABC’s  Give 02, Start large bore IV  Insert foley  Labs:  Lytes, CBC, myoglobin. Cardiac enzymes

17. Assessment  Mental status… Seizure may occur  Monitor vitals frequently  Renal status  Monitor temp continuously  EKG, Neuro status  Hypermetabolism due to increased body temp  Increases 02 demand  Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

18. Heat  Exhaustion  Stroke

19. Heat Exhaustion  Caused by dehydration  Stems from heavy perspiration  Poor electrolyte consumption  Signs/Symptoms  Normal mental status  Flu like  Headache  Weakness  N/V  Orthostatic hypotension  Tachycardia

20. Heat Exhaustion  Treatment  Outside hospital  Stop activity  Move to cool place  Cold packs  Remove constrictive clothing  Re-hydrate (water, sports drinks)  If remains call 911  In hospital  IV 0.9% saline  Frequent vitals  Draw serum electrolyte level

21. Heat Stroke Assessment Monitor mental status Monitor vitals Monitor renal status Treatment At site ensure patent airway Move to cool environment Pour water on scalp and body Fan the client Ice the client Call 911 At hospital O2 Start IV Administer normal saline Use cooling blanket DO NOT give ASA Monitor rectal temp q15 minutes Insert foley to monitor I/Os closely and measure specific gravity of urine Check CBC, Cardiac enzymes, serum electrolytes, liver enzymes ASAP Assess ABGs Monitor vitals q 15 minutes Administer muscle relaxants if the client shivers Slow interventions when core temp is 102 degrees or less

22. Management of Patients With Heat Stroke  Remember ABCs (decrease temp to 39° C as quickly as possible  Cooling methods  Cooling blankets, cool sheets, towels, or sponging with cool water  Apply ice to neck, groin, chest, and axillae  Iced lavage of the stomach or colon  Immersion in cold water bath  Monitor temp, VS, ECG, CVP, LOC, urine output  Use IVs to replace fluid losses – Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

23. Patient teaching  Ensure adequate fluid and foods intake  Prevent overexposure to sun  Use sunscreen with at least SPF 30  Rest frequently when in hot environment  Gradually expose self to heat  Wear light weight, light colored, loose clothing  Pay attention to personal limitations: modify accordingly

24. Cold Injuries  Most common  Hypothermia  Frostbite  Synthetic clothing is best because it wicks away moisture and dries fast  “cotton kills” it holds moisture and promotes frostbite  A hat is essential to prevent heat loss though head  Keep water, extra clothing, and food in car in case of break down

25. Hypothermia  Internal core temperate is 35° C or less  Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk  Alcohol ingestion increases susceptibility  Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence  Physiologic changes in all organ systems  Monitor continuously

26. Assessment  Apathy, drowsiness, pulmonary edema, coagulopathies  Weak HR and BP  Hypoxemia  Continuous temperature and EKG  Watch for dysrhythmias

30. Frost Bite  Inadequate insulation is the culprit  3 stages  Superficial (frost nip)  Mild  Severe  Frostnip produces mild pain, numbness, pallor of affected skin

31.  NOW for the Bugs and Creatures

32. Snake Bites  Most species non venomous and harmless  Poisonous snakes found in each state except Maine, Alaska, and Hawaii  Fatalities are few  Children 1-9 yrs old victims during daylight hours  AWARENESS is KEY  Most bites between April and October  Peak in July and August  2 main types in North America are  pit vipers (look for warm blooded prey)  Water moccasins, copperheads, rattlesnakes  Most of bites  Coral snakes  From North Carolina to Florida and in the Gulf states, Arizona, and Texas

33.  Pit Vipers  Depression between eye and nostril  Triangular head indicative of venom  Venom function is to immbolize, kill and aid in digestion of prey (systemic effects happen with in 8 hours of puncture)  impairs blood clotting  Breaks down tissue protein  Alters membrane integrity  Necrosis of tissues  Swelling  Hypovolemic shock  Pulmonary edema, renal failure  DIC  2 retractable curved fangs with canals  Rattlers have horny rings in tail that vibrates as a warning

34.  Treatment  At site  Move person to safe area  Encourage rest to decrease venom circulation  Remove jewelry and restrictive clothing  Splint limb below level of heart  Be calm and reassuring  No alcohol or caffeine 2 nd to speed of venom absorption  At hospital  Constrict extremity but not to tight  Do NOT incise or suck wound  Do NOT apply ice  Use Sawyer extractor if available if used within 3 minutes of bite and leave for 30 minutes in place  At hospital continued  O2  2 large bore IV sites  Crystalloid fluids (NS or LR)  Continuous tele and bp monitoring  Opiod pain management  Tetanus shot  Broad spectrum antibx  Lab draw (coagulation studies, CBC, creatinine kinase, T and C, UA)  ECG  Obtain history of wound and pre-hospital tx  measure circumference of bite every 15-30 minutes  Possibly give antivenom if ordered (see page 177)  Monitor for anaphylaxis  Notify poison control

35.  Coral Snakes  Corals burrow in the ground  Bands of black, red, yellow  “red on yellow can kill a fellow”  “red on black venom lack”  Are generally non aggressive  Ability to inject venom is less efficient  Maxillary fangs are small and fixed  Use chewing motion to inject  Venom is neurotoxic and myotoxic  Enough in adult coral to kill human

36.  Action of venom  Blocks binding of acetylcholine at post synaptic junction  S/S  pain mild and transient  Fang marks may be hard to see  Effects may be delayed 12 hours but then act rapidly after  N/V  Headache  Pallor, abd pain  Late stage: parathesias, numbness, mental status change, crainal and peripheral nerve deficit, flaccid, difficulty speaking, swallowing, breathing  elevated creatinine kinase

37.  Coral Treatment  At site  Try to ID snake  Same as pit viper without concern of necrosis  At Hospital  Continuous tele  Continuous bp and pulse ox  Provide airway management (possible ET tube)  Provide antivenom treatment as ordered  Monitor for anaphylaxis from antivenom  Notify poison control

38. Patient teaching Avoid venomous snakes as pets Be cautious in areas that harbour snakes like tall grass, rock piles, ledges, crevices, caaves, swamps Don protective attire like boots, heavy pants and leather gloves. Use a walking stick Inspect areas before placing hands or feet in them Do not harass snakes….striking distance is the length of the snake Snakes can bite even 20—60 minutes after death due to bite reflex Use caution when transporting snake with victim to hospital…make sure it is in a sealed container.

39. Arthropod Bites and Stings  Spiders: carnivorous  Almost all are venomous  Most not harmful to humans  Brown recluse, black widow, and tarantula are dangerous for example  Scorpions: not in Midwest or New England  Sting with tail  Bark scorpion is most dangerous  Bees and Wasps  Wide range of reactions  African or killer bees are very aggressive found in southwest states http://www.videojug.com/film/how-to-treat-an-insect-bite

40. Brown recluse spider  Bites result in ulcerative lesions  Cytotoxic effect to tissue  Medium in size  Light brown color with dark brown fiddle shaped mark from eyes  Shy in nature..hide in boxes, closets, basements, sheds, garages, luggage, shoes, clothing, bedsheets, clothes

41.  Over 1-3 days lesion becomes dark and necrotic…eschar even forms, and sloughs  Surgery is often needed  Skin grafting  Rare: Malaise, Joint pain, Petechaie, N/V Fever, Chills  Pruritis  Erythema  Extreme: hemolytic, renal failure, death

42.  Treatment  At site  Cold compress initially and intermittently over 4 days (may limit necrosis)  Rest  Elevation of extremity  NEVER use heat  At hospital  Topical antiseptic  Sterile dressing changes  Antibx  Dapsone: polymorphonuclear leukocyte inhibitor: 50mg twice/day  Monitor lab work closely  Surgery consult  Debridment and skin grafting

43. Black Widow  Found in every state but Alaska  Prefers cool, damp, environment  Black in color with red hourglass pattern on abd  Male are smaller and lighter color that females  Carry neurotoxic venom  Bites to humans are defensive in nature  Main prey other bugs, snakes, and lizards  Bite is can be painful, local reactions  Systemic reactions can happen in 1 hour and involve the neuromuscular system

44.  Causes lactrodectism  Venom causes neurotransmitters to release from nerve terminals  s/s  Abd pain  Peritonitis like symptoms  N/V  Hypertension  Muscle rigidity  Muscle spasms  Facial edema  Pytosis  Diaphoresis  Weakness  Increased salavation  Priapism  Respiratory difficulty  Faciculations  parathesias

45.  At site  Apply an ice pack  Monitor for systemic involvement  ABCs  At hospital  Monitor vitals  Pain meds  Muscle relaxants  Tentanus  Monitor for seizures  Antihypertensives  Anti venom if needed  Call poison control

46. Tarantulas  Largest spider  Found mostly in tropical and subtropical parts of USA  Some are in dry arid states like New Mexico and Arizona  Can live 25 years  Venom paralyzes prey and causes muscle necrosis  Most human bites have local effects  Have urticating hairs in dorsal abd area that can be launched for a defensive technique landing in skin and causing an inflammatory response

47.  USA trantulas don’t produce systemic reactions  Worldly ones do  S/S  Pain at site  Swelling  Redness  Numbness  Lymphangitis  Intense pruritis  Severe ophthalmic reactions if hairs come in contact with eyes

48.  Treatment  Pain meds  Immobolize extremity  Elevate site  Remove hairs with sticky tape followed by irrigation  For eyes: irrigation with saline  Antihistamines and steroids for pruritis

49. Scorpions  Found in many states  Not usual in midwest or new england unless pet, or transported in baggage  Venom in stinger located on the tail  s/s  Localized pain  Inflammation  Mild symptoms  Treatment: pain meds, wound care, supportive management

50. Bark scorpion  Deadly  Has a fatal sting  Found in tress, wood piles, and around debris  Humans stung when it gets in clothing, shoes, blankets, and items left on ground  Solid yellow, brown, or tan in color  Have thin pinchers, thin tail, and a tubercle  Found in Arizona, New Mexico, Texas, Nevada, and California  Has neurotoxic venom

51.  s/s  Involve cranial nerves  May be symptom free  Pain  Respiratory failure  Pancreatitis  Musculoskeletal dysfunction  Gentle tap at possible sting site while client not looking greatly increases pain, and is confirmation of bite  Symptoms begin immediately and reach maximum intensity in 5 hours  Most symptoms resolve in 9- 30 hours  Pain and parathesia can last 2 weeks

52.  Treatment  Monitor vitals  May need intubation  Supply O2  IV Fluids  Ice pack to sting site  Pain meds and sedatives with caution in non intubated client  Wound care  Call poison control  Atropine gtts to help with hypersalavation  Antivenom if needed

53. Bees/Wasps  Stings cause wide array of reactions  S/S  Anaphylaxis most severe  Respiratory failure  Hypotension  Decrease in LOC  Dysrhythmias  Cardiac arrest  Pain  Local reaction  Swelling  N/V  Diarrhea  Pruritis  Urticaria  Lip swelling

54. treatment  At site  Remove stinger  Ice pack  Epipen if allergy to bees  Call 911 if needed  In hospital  ABCs  Check history for allergy  Epinephrine  Antihistamine  O2  NS 0.9%  corticosteroids

55. Patient Education  Wear protective clothing when working in areas with known venomous athropods (bees, scorpions, wasps)  Cover garbage cans  Use screens in windows and doors  Inspect clothing and, shoes and gear before putting on  Shake out clothing and gear that is on ground  Exterminate the exterior house  Do not place hands where eyes can not see  Do not keep insects as pets  Epi pen if allergy to bee/wasp

56. POP QUIZ  If someone collapsed at the boston marathon. Core temp reflects 106 degree. Urine is tea colored. What does this mean?  If antivenom is not available what do you do??

57. Poisoning  According to your book, Poison is any substance that when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relativity small amounts injures the body by its chemical action  Treatment goals:  Remove or inactivate the poison before it is absorbed  Provide supportive care in maintaining vital organ systems  Administer specific antidotes  Implement treatment to hasten the elimination of the poison

58. Assessment of Patients With Ingested Poisons  Remember ABCs  Monitor VS, LOC, ECG, and UO  Assess lab values  Determine what, when, and how much substance was ingested  Assess signs and symptoms of poisoning and tissue damage  Assess health history  Determine age and weight

59. Interventions for those with Ingested Poisons  remove the toxin or decrease its absorption  Use emetics  Gastric lavage  Activated charcoal  Cathartic when appropriate  Administration of specific antagonist as early as possible  Other measures may include diuresis, dialysis, or hemoperfusion

60. Management of Carbon Monoxide Poisoning  Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen  Manifestations: CNS symptoms predominate  Skin color is not a reliable sign  pulse oximetry is not valid  Treatment  Get to fresh air immediately  Perform CPR as necessary  Administer oxygen: 100% or oxygen under hyperbaric pressure  Monitor patient continuously  Draw blood levels  May need HBO

61. Management of Food Poisoning  A sudden illness due to the ingestion of contaminated food or drink  Food poisoning has the ability to result in respiratory paralysis and death depending on the cause  ABCs and supportive measures are key  Treatment  correct fluid and electrolyte imbalances  Control nausea and vomiting  Provide clear liquid diet and progression of diet after nausea and vomiting subside

62. Patients With Substance Abuse  Acute alcohol intoxication  Alcohol poisoning may result in death  Maintain airway  Observe for CNS depression and hypotension  Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated  Use a nonjudgmental, calm manner  Patient may need sedation if noisy or belligerent  Examine for withdrawal delirium, injuries, and evidence of other disorders  Commonly abused substances: ???  see Table 71-1

63. Lightning  Year round problem  Most common in summer  Caused by electrical charge in cloud  Large energy with small duration  High voltage is 1000 volts  Lighting is 1 million volts  Cloud to ground is most dangerous  Flash over phenomenon: force powerful enough to blow off or damage the victims clothing  Injury is by:  Direct strike  Spashing or side flash off of near by structure  Through the ground

64. Lightning  Best remedy: AVOIDANCE  Education  Observe forecasts  Seek shelter when your hear thunder  DO NOT stand under tree  DO NOT stand in an open area  Isolated sheds and caves are dangerous  Leave water immediately  Avoid metal objects  If camping stay away from metal tent poles and wet walls  Stay away from open doors, windows, fireplaces  Turn off electrical equipment  Stay off of telephone  Move to valley area and huddle in ball if in open area (this minimizes target area)

65. Interventions  At site  Spinal immobilization  Monitor ABCs  CPR  Sterile dressings for burns  Hospital care  ACLS  Telemetry  ABC support  Ventilator prn  Creatinine kinase level to determine muscle damage  Monitor for kidney failure  Monitor for rhabdomyolosis (muscle destruction)  Burn precautions  Tetanus  Xfer to burn center

66. Altitude related Illness  High altitude is elevations above 5000 feet  most ski resorts  As altitude increases  barametric pressure decrease  This means less o2 the higher you go  Oxygen is 21% of the barametric pressure  Acclimatization  the process of adapting to high altitudes  Increased RR  Decrease in CO2  Respiratory alkalosis  Impaired REM  Excess bicarb excretion through the kidneys  Cerebral blood flow increases

67. 3 most common altitude illnesses Acute Mountain Sickness (AMS) Precursor for HACE/HAPE Throbbing headache, anorexia, N/V Chilled, irritable Similar symptoms to alcohol hangover VS variable DOE or at rest High altitude cerebral edema (HACE) Unable to perform ADLs Ataxia w/o focal signs (decreased motor coordination) Confusion, impaired judgment, seizures Stupor, Coma, Death from brain swelling Increased ICP over 1-3 days High altitude pulmonary edema (HAPE) Most frequent cause of death Poor exercise intolerance and recovery Fatigue and weakness Tachycardia and tachypnea, rales, pneumonia Increased pulmonary artery pressure

68. Altitude Illness Site Descent to lower altitude Monitor for symptom progression Rest O2 if available Hospital Acetazolamide Acts as bicarb diuretic Sulfa drug Take 24 hours before ascent and take for 1 st 2 days of the trip 125mg-250mg po BID or 500mg SR cap daily Dexamethazone: 4mg – 8mg po or IM initially then 4mg q6hours during descent O2 Monitor airway Lasix Critical care

69. Altitude Education  Plan a slow descent  Avoid overexertion and over exposure to cold  Avoid alcohol and sleeping pills  Stay hydrated and have adequate nutrition  If symptoms develop descend immediately  O2 if able  Wear protective gear  Wear sunscreen

70. Near Drowning

71.  Rip currents are powerful currents of water moving away from shore.  More people die every year from rip currents than from shark attacks, tornadoes, lightning or hurricanes.  According to the United States Lifesaving Association, 80 percent of surf beach rescues are attributed to rip currents, and more than 100 people die annually from drowning when they are unable to escape a rip current.  Rip currents can attain speeds as high as 8 feet per second Some rip currents last for a few hours; others are permanent.  Rip currents range from 50 to 100 feet or more in width. They can extend up to 1000 feet offshore.

72.  If caught in a rip current:  Remain calm to conserve energy and think clearly.  Never fight against the current.  Think of it like a treadmill that cannot be turned off, which you need to step to the side of.  Swim out of the current in a direction following the shoreline. When out of the current, swim at an angle--away from the current--towards shore.  If you are unable to swim out of the rip current, float or calmly tread water. When out of the current, swim towards shore.  If you are still unable to reach shore, draw attention to yourself by waving your arm and yelling for help.

73. POP QUIZ  What does salt do to the body?

74. Causes Leaving small children unattended around bathtubs and pools Drinking alcohol while boating or swimming Inability to swim or panic while swimming Falling through thin ice Blows to the head or seizures while in the water Attempted suicide Symptoms Symptoms can vary, but may include: Abdominal distention Bluish skinBluish skin of the face, especially around the lips Cold skin and pale appearance Confusion CoughCough with pink, frothy sputum Irritability Lethargy No breathing Restlessness Shallow or gasping respirations Chest pain Unconsciousness Vomiting

77.  Prevention  Avoid drinking alcohol whenever swimming or boating.  Observe water safety rules.  Take a water safety course.  Never allow children to swim alone or unsupervised regardless of their ability to swim.  Never leave children alone for any period of time, or let them leave your line of sight around any pool or body of water. Drowning have occurred when parents left "for just a minute" to answer the phone or door.  Drowning can occur in any container of water. Do not leave any standing water (in empty basins, buckets, ice chests, kiddy pools, or bathtubs). Secure the toilet seat cover with a child safety device.  Fence all pools and spas. Secure all the doors to the outside, and install pool and door alarms.  If your child is missing, check the pool immediately.

78. Spinal Cord Injuries (SCI)  tetraplegia (quadriplegia): paralysis from neck down  Loss of bowel and bladder control  Loss of motor function  Loss of reflex activity  Loss of sensation  Coping issues *Christopher Reeve is example of this injury*

79.  Complete: spinal cord severed and no nerve impulses below level of injury  Incomplete: allow some function and movement below level of injury

80. Causes of SCI  Primary  Hyperflexion (moved forward excessively)  Hyperextension (MVA)  Axial loading (blow at top of head causes shattering)  Excessive rotation (turning beyond normal range)  Penetrating (knife, bullet)  Secondary  Neurogenic shock  Vascular insult  Hemorrhage  Ischemia  Electrolyte imbalance

82. Cervical Injuries  Anterior cord syndrome  Damage to anterior portion of gray and white matter as a result of decreased blood supply..pt will have a loss of motor function, pain, and temperature sensation but touch, vibration, and position remain intact  Posterior cord lesion  Damage to posterior white and gray matter..pt has intact motor function but loss of vibratory sense, crude touch, and position sensation  Brown Sequard syndrome  Result of penetrating injury that causes hemisection of spinal cord.  Motor function, proprioseption, vibration, and deep touch are lost on the same side as injury (ipsilateral)  On the other side (contralateral) the sensation of pain, temperature and light touch are affected  Central cord syndrome  Loss of motor function in upper extremities and varying degrees of sensation remain

83. Assessment Of SCI  1 st assess respiratory status  ET tube may be necessary if compromised  2 nd assess for intra-abdominal hemorrhage (hypotension, tachycardia, weak and thready pulse)  3 rd assess motor function  C4-5 apply downward pressure while the client shrugs  C5-6 apply resistance while client pulls up arms  C7 apply resistance while pt straightens flexed arms  C8 check hand grasp  L2-4 apply resistance while the client lifts legs from bed  L5 apply resistance while client dorsiflexes feet  S1 apply resistance while client plantar flexes feet

84. Emergency Care of SCI  Observe for signs of autonomic dysreflexia  Sever HTN, bradycardia, sever headache, nasal stuffiness, and flushing  Caused by noxious stimuli like distended bladder or constipation  Immediate interventions  Place in sitting position  Call doctor  Loosen tight clothes  Check foley tubing if present  Check for impaction  Check room temp  Monitor BP q10-15 minutes  Give nitrates or hydralazine per md order

85. Treatment of SCI  Immobilize fx  Proper body alignment  Traction is possible  Monitor vs q4 hours or more  Neuro checks q4 hours or more  Monitor for neurogenic shock (hypotension and bradycardia)  Prepare for possible surgery  Teach skin care, ADLs, wound prevention techniques, bowel and bladder training, medications, and sexuality

86. Brain Injuries (TBI)  Open- skull fx or when skull is pierced by penetrating object  Linear fx- simple clean break  Depressed fx- bone pressed in towards tissue  Open fx-lacerated scalp that creates opening to brain tissue  Comminuted fx- bone fragments and depresses into brain tissue  Basilar- unique fx at base of skull with CSF leaking though the ear or nose  Closed- blunt trauma  Mild concussion-brief LOC  Diffuse axonal injury- usually from MVA  May go into coma  Contusion-bruising of brain  Site of impact (coupe)  Opposite side of impact (contrecoupe)  Laceration-tearing of cortical surface vessels that leads to hemorrhage edema and inflammation

88. Motor Vehicle Collisions  Frontal  Front of car stops and driver keeps going  Injuries: Seatbelt, Steering wheel, TBI, cspine, flail chest, myocardial contusion  Side  Injuries: Cspine, flail chest, pneumothorax  Rear  Hyperextension, cspine  Rollover  Multiple injuries

89. POP QUIZ  A front end collision with airbags and seatbelts in place and working may break ribs. If this occurs what do we need to monitor for?

90. Figure 74.2 Unrestrained frontal impact.

91. Other types of multiple injuries  Motorcyle  Tib/fib, chest, abd, TBI, cspine, femur  Pedestrian  Femur, chest, lower extremities  Falls  Calcaneous, compression, wrist, TBI

93. Blunt Trauma by Force  Acceleration-caused by external force contacting head  Deceleration- when head suddenly stops or hits a stationary object

95. Interventions for musculoskeletal trauma  Fractures  Open  Closed  Spontaneous  Stress  Compression  Greenstick  Spiral  Oblique  Impacted  Displaced  Non-displaced  fragmented

96. Stages of healing  48-72 hours after injury hematoma forms at break site  Area of bone necrosis forms secondary to diminished blood flow  Fibroblasts and osteoblasts come to site  Fibrocartilage forms =new foundation  Callus forms 2-6 weeks after initial break  3 weeks to 6 months later new bone is formed

97. Musculoskeletal assessment  Assess for life threatening complications  Skin color and temp  Movement  Sensation  Pulses especially distal to the injury  Cap refill  Pain  Listen for crepitation-grating sound  Look for ecchymosis  Assess for subcutaneous emphysema-bubbles under skin (like bubble wrap when pushed)  Assess clients feeling of situation  Some fractures can causes internal injury- hemorrhage

98. diagnostics  No special lab tests except maybe D-Dimer for clots  H/H could be low due to bleeding  CT  Bone scan  MRI  X-rays  Affected extremity

99. interventions  Inspect fx site  Palpate area lightly  Assess motor function  Immobilize extremity  Realignment  Cast  Traction  Surgery  open reduction with internal fixation

100. education  Provide education regarding medication  Instruct the client on s/s of infection (foul discharge, purulent drainage, fever, lethargy, etc)  Instruct on dressing changes and importance of them  Instruct about pressure ulcer prevention  Instruct on use of crutches or walker if needed  Instruct about HHC and other available resources

101. Specific fractures

102.  Fx of clavicle usually from a fall  Fx of scapula not common and caused by direct impact  Fx of humerus common in older adult  Fx of olecrenon usually from fall directly onto elbow  Fx of radius and ulna usually Fx together  Fx of wrist and hand most common site is the carpal scaphoid bone in young adult men..one of the most misdiagnosed Fx b/c of poor visibility on x-ray  Fx of hip caused by falls  Fx of femur caused from trauma  Fx of patella result from direct impact  Fx of tibia and fibula usually break together  Fx of ankle and foot difficult to heal because of instability of ankle bone

103.  Fx of ribs and sternum caused by chest trauma and potentially can puncture lungs, heart and arteries  Fx of pelvis can also cause major internal damage because of the vascular structure present  Compression Fx of the spine usually caused by osteoporosis. This causes pain, deformity, neurologic compromise

104. Femur and Pelvic Fractures  High incidence of hemmorage  Femur fx-cast, brace, splint, traction  Fat embolism: fat from bone released into blood and into heart, lungs, etc  Pelvic- girdle, assess for stability  Large amount of force  Rectal exam

105. Figure 56.10 Vascular anatomy of the pelvis.

106. Dislocations  Painful  Needs to be reduced ASAP  Can cause nerve damage  Avascular Necrosis  Dislocation occludes blood supply

107. complications  Acute compartment syndrome: increase pressure compromises circulation to are. Most common in lower leg and forearm.  Fat embolism: fat from bone released into blood and into heart, lungs, etc. Most common with long bone fx  DVT  PE  INFECTION: from break or from implanted hardware..bone infection most common with open fx  Fracture blisters: associated with twisting injury..fluid moves into vacant spaces..leads to infection  Ischemic necrosis: blood flow to bone is disrupted  Delayed union: unhealed after 6 months  Nonunion:never completely heal  Malunion: heal incorrectly

108. CRUSH SYNDROME  CAUSES  Wringer type injuries  Natural disasters  Work related injuries  Drug or alcohol overdose  CHARACTERISTICS  Acute compartment syndrome  Hyperkalemia  Rhabdomyolosis – myoglobin released into blood  S/S  Hypovolemia, hyperkalemia, compartment syndrome  TX  IVF, diuretics, low dose dopamine, sodium bicarb, kayexelate, hemodialysis is possible.

109. Complex regional pain syndrome  s/s: debilitating pain, atrophy, autonomic dysfunction (excessive sweating, vascular changes), and motor impairment (muscle paresis)  Caused by hyperactive sympathetic nervous system  Results from trauma  Common in feet and hands  3 stages:  1: lasts 1-3 months; local severe burning pain, edema, vasospasm, muscle spasms  2: 3-6 months; pain, edema, muscle atrophy, spotty osteoporosis  3: marked muscle atrophy, intractable pain, severely limited mobility, contractures, osteoporosis

110. Sports related injuries  Tears  Lock knee  Torn ACL  Tendon rupture  Dislocation  Subluxation  Strains  Sprains  Torn rotator cuff

111. Interventions for musculoskeletal trauma  Casts  Braces  Splints  Traction  Surgery  Reduction (realignment)

112. amputations  Removal of part of the body  Types  Surgical-example digit  Traumatic- example digit  Levels  Lower extremity: digits, bka, aka, midfoot  Upper extremity: hands, fingers, arms  Complications  Hemorrhage  Infection  Phantom limb pain: perceive pain in the amputated limb  Immobility  Neuroma: sensitive tumor consisting of nerve cells found at several nerve endings  Contractures

113. assessments  Skin color  Temp  Sensation  Pulses  Cap refill  Assess feelings r/t amputation  Young: bitter, hostile, uncooperative, loss of job, loss of hobbies, altered self concept, feeling a loss of independence  Assess families perceptions also  Routine preop xrays done  BP done in all extremities  Angiography to look at layout of vessels

115. Stab wounds  4 types of wounds  Incised = Sharp cut like injuries (knives, glass)  Slash wounds= more longer than deep  Stab wound= depth longer than length  Defense wound= warding wounds (like on hand)

116. Defense Wound Stab Wound w/ single edge blade

117. Gun shot wounds  4 types  Close contact= illustrates a patternized abrasion around the wound  Contact= barrel has contacted the skin and the gases have passed into SQ tissues faint abrasion ring and sone grey/black discoloration  Intermediate wound= powder tatooing  Exit wound= slit like exit wound…no powder or soot

119. Wound Care Treatment (at Site) Bleeding can usually be stopped by applying direct pressure to the wound. Very large foreign objects stuck in a wound should be stabilized. Do not remove them. All wounds require immediate thorough cleansing with fresh tap water. Gently scrub the wound with soap and water to remove foreign material. If a syringe is available, it should be used to provide high-pressure irrigation. Remove dead tissue from the wound with a sterile scissors or scalpel. After cleaning the wound, a topical antibiotic ointment (bacitracin) should be applied 3 times per day. Wounded extremities should be immobilized and elevated. Puncture wounds are usually not sutured (stitched) unless they involve the face.

120.  If the wound is clean, the edges can be drawn together with tape.  (Do not cover wounds inflicted by animals or that occurred in seawater with tape.)  Oral antibiotics are usually recommended to prevent infection.  If infection develops, continue antibiotics for at least 5 days after all signs of infection have cleared.  Inform the doctor of any drug allergy prior to starting any antibiotic. The doctor will prescribe the appropriate antibiotic. Some may cause sensitivity to the sun, so sunscreen (at least SPF 15) is mandatory while taking these antibiotics.  Pain may be relieved with 1-2 acetaminophen (Tylenol) every 4 hours, 1-2 ibuprofen (Motrin, Advil) every 6-8 hours, or both.  Call 911 or get to ER immediately if stab or gunshot wound.

121. Sexual Abuse Sexual abuse (also referred to as molestation ) is defined as the forcing of undesired sexual acts by one person to another. The term incest is defined as sexual abuse between family members, and the euphemism "bad touch" is sometimes used to describe such abuse. (Renvoizé 1982) incest(Renvoizé 1982) Different types of sexual abuse involve: Non-consensual, forced physical sexual behavior such as rape or sexual assault rape sexual assault Psychological forms of abuse, such as verbal sexual behavior or stalking. stalking The use of a position of trust for sexual purposes.position of trust Acquaintance rape - forced sexual intercourse between individuals who know each other - is a crime that is widespread on many college and university campuses. Usually, both parties involved in acquaintance rape have been drinking - often to excess. Research has not yet explained how and why alcohol is related to aggression in general or to acquaintance rape in particular http://www.youtube.com/watch?v=PvXxzZUuIn0

122. Sexual Abuse  Signs of sexual abuse  Unexplained injuries (especially to parts of the female body that can be covered by a two- piece swimsuit)  Torn or stained clothing or underwear  Pregnancy  Sexually transmitted diseases (STDs)  Unexplained behavioral problems  Depression  Self abuse and/or suicidal behavior  Drug and/or alcohol abuse  Sudden loss of interest in sexual activity  Sudden increase of sexual behavior

123.  The doctor in the emergency room will examine the victim for injuries and collect evidence.  The attacker may have left behind pieces of evidence such as clothing fibers, hairs, saliva or semen that may help identify him.  In most hospitals, a "rape kit" is used to help collect evidence.  A rape kit is a standard kit with little boxes, microscope slides and plastic bags for collecting and storing evidence. Samples of evidence may be used in court.  Next, the doctor will need to do a blood test. Women will be checked for pregnancy and all rape victims are tested for diseases that can be passed through sex.  Cultures of the cervix may be sent to a lab to check for disease, too. The results of these tests will come back in several days or a few weeks.  It's important for the client to see their own doctor in 1 or 2 weeks to review the results of these tests. If any of the tests are positive, the victim will need to talk with your doctor about treatment.

124. Rape  Classified as assault  Primary cause is an aggressive desire to dominate according to experts  Difficult to prosecute b/c of lack of evidence  Statistics  Women by men: 90-91% most frequent  Male by male: 9-10% less common  Little to no research on women offenders  Definition  Intercourse, is attempted or happens without consent of one of the parties involved (penetration with penis or objects etc)

125. Effects of rape  Unpredictable emotions  Feeling numb and detached  Memory problems  Avoidance of things  anxiety  PTSD can occur  Relive the rape over and over  Disturbed sleeping patterns  Eating habits affected

126. More stats  If reported to police 50% chance an arrest will be made  If arrest made, 80% chance of prosecution  If prosecuted, 58% chance of felony conviction  If felony conviction, 69% chance of jail time

127. Mandatory reporting  If abuse suspected  Child  Domestic  Any type