Care of Clients in Cellular Aberrations, Acute Biologic Crisis (ABC), Emergency and Disaster Nursing (NCM106) Acute Biologic

Crisis II
Topics Discussed Here Are: 1. Head Injuries 2. Cervical Spinal Injuries 3. Maxillofacial Trauma 4. Abdominal Injuries 5. Injury to Bones and Joints 6. Soft Tissue Injury

LOOKY HERE

Head Injuries

Definition: - Fractures to the skull and face, direct injury to the brain (as from a bullet) and indirect injury to the brain (such as concussion, contusion, or intracranial hemorrhage). Head injury commonly occurs from motor vehicular accidents, assaults / falls

Specific Head Injuries

1. 2. 3. Concussion: A temporary loss that results from a transient interruption of the brains normal function Contusion: A bruising of the brain tissue. Actual small amounts of bleeding into the brain tissue Intracranial Hemorrhage: Bleeding into a space / a potential space between the skull and the brain Complications of a head injury are; rising intracranial pressure and brain herniation Can be classified as epidural hematomas, subdural hematomas or subarachnoid hemorrhage, depending on the site of bleeding

Primary Assessment
1. 2. Airway: Assess for vomitus, bleeding, and foreign objects. Ensure cervical spine immobilization Breathing: Assess for abnormally shallow or slow respiration. An elevated carbon dioxide partial pressure can worsen cerebral edema Circulation: Assess pulse and bleeding Disability: Assess the patients neurologic status

Nursing ALERT!
Assume a cervical spine fracture for any patient with a significant head injury until proved otherwise

3. 4.

Primary Intervention
1. 2. 3. 4. 5. Airway Use jaw-thrust technique without head tilt. Suction heavy vomitus. Do not stimulate the gag reflex as this can ICP Breathing Administer high flow O2. The most common cause of death from head injury is cerebral anoxia Assist inadequate respiration with a bag valve mask as necessary. Prophylactic hyperventilation is not indicated Control bleeding Apply a bulky loose dressing with no pressure to all head injuries. Do not attempt to stop the flow of bleed / CSF from the nose / ears Initiate 2 IV lines. The rate of flow should be determined by the patients hemodynamic status (Based on VS of patient)

Subsequent Assessment 1. History a. Mechanism of injury b. Duration of loss of consciousness c. Memory of the event d. Position found 2. LOC (Level of Consciousness) a. Change in the LOC is the most sensitive indicator of a change in the patients condition b. Glasgow Coma Scale 3. VS a. Hypertension and bradycardia are late signs of ICP

jcmendiola_Achievers2013

Nursing ALERT! 4. Head injury patients may have If basilar fracture / severe mid-face associated cardiac dysrhythmias fractures are suspected. An NGT is noted by an irregular pulse CONTRAINDICATED. An 5. Elevated temperature - OROGASTRIC TUBE may be Temperature may be associated with considered for insertion head injury 6. Unequal / Unresponsive pupils 7. Confusion / Personality changes 8. Impaired vision 9. One / both eyes appear sunken 10. Seizure activity 11. Periaucilar ecchymosis (Battles Sign) 12. Rhinorrhea / Otorrhea (Indicative of leakage of CSF) 13. Periorbital ecchymosis (Indicates anterior basilar fracture)
General Interventions
1. 2. 3. 4. 5. Keep the neck in a neutral position with the cervical spine immobilized Establish an IV line of normal saline / Lactated Ringers fluid volume should be restricted Be prepared to manage seizures If seizures occur, they should be controlled immediately Maintain normothermia Pharmacologic Interventions include: Anticonvulsants To control seizures Mannitol (Osmitol) To reduce cerebral edema and ICP Antibiotics Antipyretics to control hyperthermia

Cervical Spine Injuries

Definition: - Serious injuries, because the crushing, stretching sand rotational shear forces exerted on the cord at the time of trauma can produce edema and cord swelling - Edema and cord swelling contribute further to the loss of spinal cord function - Any person with a head, neck or back injury or fractures to the upper leg, bones / to the pelvis should be suspected of having a potential spinal cord injury until proved otherwise

Primary Assessment
1. 2. 3. Provide immediate immobilization of the spine while performing assessment Airway Breathing Intercostal paralysis with diaphragmatic breathing SOB produces respiratory rate and difficulty in speaking Circulation Disability Assess neurologic status

4. 5.

Primary Interventions
1. 2. 3. 4. Immobilize the cervical spine Open the airway using the jaw-thrust technique without head tilt If the patient needs to be intubated, it may be done nasally If respirations are shallow, assist with a bag-valve mask

Subsequent Assessment
Assess the position of the patient when found, this may indicate the type of injury incurred o Forearms flexed across the chest CG Injury o Arms Stretched out above the head Cervical injury

jcmendiola_Achievers2013

Hypotension and bradycardia accompanied by warm, dry skin suggests SPINAL SHOCK Neck and back pain / extremity pain / burning sensation to the skin History of unconsciousness Nursing ALERT! Total sensory loss and motor paralysis below level of injury SCI can be made worse during the acute Loss of bowel and bladder control; usually phase of injury, resulting in permanent urinary retention and bladder distention neurologic damage. Proper handling is Loss of sweating and vasomotor tone an immediate priority below level of cord lesion Priaprism Persistent erection of penis Hypothermia Due to the inability to constrict peripheral blood vessels and conserve body heat Loss of rectal tone

Maxillofacial Trauma
Definition: - Injury to the head frequently result in facial lacerations and fractures to the facial bones (i.e. nasal fractures, orbital fractures, maxillary fractures, and mandibular fractures)

Primary Assessment
1. 2. 3. 4. 5. Initiate immobilization of the spine while performing assessment Airway obstruction can occur due to tongue swelling (Fractured jaw), bleeding / broken / missing teeth Breathing may be impaired / due to an obstructed airway Circulation control bleeding Disability

Primary Intervention
1. Establish and maintain an airway This includes having high-flow O2 Inserting an oral airway / assisting with intubation A nasopharyngeal airway should be used ONLY if there is no evidence of nasal fractures or CSF leakages from the nose Control bleeding DO NOT APPLY PRESSURE to the injury site Apply a bulky, loose dressing Do not attempt to stop the flow of blood / CSF from the nose or ears, apply a loose dressing if needed

2.

Subsequent Assessment
1. 2. 3. 4. 5. 6. 7. 8. 9. Examine the mouth for broken / missing teeth Assess for a potential eye injury, vision loss, double vision or pain in the eye Examine the eye for dysconjugate gaze incoordination of eye movement Nursing ALERT! Paralysis of the upward gaze = Indicative of an DO NOT APPLY PRESSURE ON AN INFERIOR ORBIT FRACTURE (Blowout fracture) INJURED EYE!! Crepitus or a crackling feeling on palpation around the nose = Indicates NASAL FRACTURE Malocclusion of the teeth = Indicative of a MAXILLA or MANDIBLE FRACTURE Zygoma (Cheekbone) Fracture A palpable flattening of the cheek and a loss of sensation below the orbit Spasms of the Jaw (Trismus) and mobility of the jaw = Indicate a MAXILLA FRACTURE Rhinorrhea or Otorrhea = Indicative of LEAKAGE OF CSF

General Interventions
1. Gently apply ice to areas of swelling / ecchymosis This may reduce further swelling and pain However, if you suspect an injury to the eye itself, DO NOT APPLY ICE

jcmendiola_Achievers2013

2.

If other injuries permit, elevate the HEAD OF THE BED

NURSING TIP Do not use chemical ice packs near a victims eyes, chemical ice packs could leak and burn the eyes Possible pharmacological interventions MSO4 (Duramorph) Pain Management Diazepam (Valium) Sedation With the potential for a CSF leak, the patient should be instructed NOT TO BLOW THE NOSE, COUGH, OR SNEEZE because of the potential for transmitting infection to the brain / eyes

Abdominal Injuries
Definition: - Abdominal injuries account for a large percentage of trauma-related injuries and deaths - The visceral organs contained within the abdomen can be classified as either hollow / solid - Damage to a hollow organ can result in acute peritonitis leading to shock within a few hours - Damage to solid organs can result in a lethal hemorrhage - Abdominal injuries may be classified as either; penetrating or blunt o Penetrating Abdominal Injury Usually, the result of gunshot wounds / stab wounds The mechanism that caused the penetrating abdominal trauma may cross the diaphragm and enter the chest. The opposite can also occur o Blunt Abdominal Injury Usually caused by MVA / falls Trauma to the abdomen is frequently associated with extra abdominal injury (i.e. Chest, head and extremity injuries) and severe concomitant trauma to multiple intraperitoneal organs - Causes more delayed complication, especially if there is injury to liver, spleen / blood vessels which can lead to substantial blood loss into the peritoneal cavity

Primary Assessment and Intervention

Assess for Airway, Breathing and Circulation Initiate resuscitation as indicated Control bleeding and prepare to treat shock If there is an impaled object in the abdomen, leave it there o Stabilize the object in place with BULKY DRESSINGS along the sides of the object

Subsequent Assessment
Obtain a history of the mechanism of the injury, type of weapon and estimated amount of blood loss o If the patient was stabbed, how long was the blade? o Was the person who stabbed the patient a MAN or a WOMAN? Men usually hold a knife underhand and stab thrust upward Women usually will stab / thrust down-ward with an overhand motion Obtain a History o If the patient sustained a gun-shot and range at which it was shot o Time of onset of symptoms o Passenger location (Drivers frequently sustain spleen / liver rupture) Were safety belts worn? Did the airbag deploy? Inspect the abdomen for obvious signs of injury (penetrating injury, bruises) Evaluation for signs and symptoms of hemorrhage o Frequently accompanies abdominal injury, especially if the liver and spleen have been traumatized

jcmendiola_Achievers2013

NOTE tenderness, rebound tenderness, guarding, rigidity and spasms (Peritoneal IRRITATION) o Press the area of maximal tenderness (let the patient point to the area) Remove the fingers quickly to check for rebound tenderness o Pain at suspected points indicates peritoneal irritation Ask about referred pain: Kehrs Sign o Pain radiating to the LEFT SHOULDER may be a sign of BLOOD BENEATH the LEFT DIAPHRAGM o Pain in the RIGHT SHOULDER can result from LACERATION of the LIVER Look for Abdominal Distention o Measure abdominal girth at the umbilical level early in assessment Serves as a baseline from which changes can be determined Auscultate for BOWEL SOUNDS o A silent abdomen accompany peritoneal irritation Auscultate for loss of dullness over solid organs (Liver, spleen) o Indicate presence of free air: Dullness over regions normally containing gas may indicate presence of blood Look for chest injury which frequently accompany intra-abdominal injuries Cullens Sign o A slight bluish discoloration around the navel is a sign of hemoperitoneum Pain is a poor indicator of the extent of the abdominal injury o Rebound tenderness and board-like rigidity are indicative of a significant intra-abdominal injury A rectal examination and examination of the perineum should be done on all patients o The presence of blood may be indicative of trauma Continually assess o VS o UO o CVP Reading o Hematocrit Values o Tachypnea o Tachycardia o Hypotension May be clues to intra-abdominal bleeding

General Intervention
1. 2. Goals are to control bleeding, maintain blood volume and prevent infection Keep the patient quiet and on the stretcher Because movement may fragment and dislodge a clot in a large vessel and produce massive hemorrhage 3. Cur the clothing away from the wound DO NOT CUT THROUGH bullet holes / stab marks These will be needed by law enforcement authorities as forensic evidence 4. Count the number of wounds 5. Look for entrance and exit wounds 6. If the patient is comatose, immobilize the cervical spine until after cervical films are taken and cleared 7. Apply compression to external bleeding 8. Insert 2 large bore IV lines and infuse Ringers Lactate If possible, one of the lines should be in a Central Venous location 9. Insert NGT to decompress the abdomen This will serve to empty the stomach, relieve gastric distention and facilitate abdomen assessment If blood is found, it may indicate stomach injury or esophageal injury 10. Cover protruding abdominal viscera Do not attempt to replace the protruding organs into the abdomen Use sterile saline dressing to protect viscera from drying Cover open wounds with dry dressing 11. Withhold oral fluids to prevent peristalsis and vomiting

jcmendiola_Achievers2013

12. Insert an indwelling urethral catheter to ascertain the presence of hematuria and monitor UO If a fracture of the pelvis is suspected, a catheter SHOULD NOT BE PLACED until the integrity of the urethra is ensured 13. Pharmacologic Interventions: Tetanus Prophylaxis Broad-spectrum Antibiotics Because bacterial contamination is a frequent complication (Depending on history and nature of the wound) 14. Prepare for performing lavage when there is uncertainty about intraperitoneal bleeding 15. Prepare for surgery if the patient shows evidence of: Unexplained shock Unstable VS Peritoneal irritation Bowel protrusion / evisceration Significant penetrating injury Significant GI Bleeding Peritoneal air 16. Prepare the patient for diagnostic procedures Catheterization and urinalysis As a guide to possible urinary tract injury and to monitor urine output Type and Cross-match and serum hemoglobin and hematocrit levels Their trend reflects presence / absence of bleeding Complete Blood Count (CBC) White blood cell count is generally in trauma Serum Amylase Elevation Indicates pancreatic injury or perforation of GIT Computer Topographic Scan (CT-Scan) Permit detailed evaluation of abdominal and retroperitoneal injury Abdominal and Chest X-Rays

Injury to Bones and Joints (Boints) lol

Definition: - Common - Usually an obvious injury and may be dramatic in nature - Rarely are these injuries life-threatening - Fractures may be caused by; Direct Trauma, Indirect Trauma and Pathologic Reasons o Direct Trauma Projectiles, crush injuries o Indirect Trauma Bones being pulled apart or rotational forces o Pathologic Reasons Weakness in the bone secondary to a disease process such as metastatic cancer - Other injuries include: Dislocation, Sublaxation, Sprains, Strains o Dislocation Complete displacement or separation of a bone from its normal place of articulation It may be associated with a tearing of the ligaments The shoulder, elbow, fingers, hips and ankles are the joints most frequently affected o Sublaxation Partial disruption of the articulating surfaces o Sprains Injuries in which ligaments are partially torn / stretched Usually caused by a twisting of a joint beyond its normal range of motion The severity can range from mild to severe The more serious is the injured ligaments, it may resemble a fracture o Strains Stretching or tearing of muscle and tendon fibers

jcmendiola_Achievers2013

Usually caused by overexertion or overextension Hamstring Muscle tear

Primary Assessment
1. 2. 3. 4. Always ensure the adequacy of Airway, Breathing and Circulation before initiating treatment Occult blood loss into a closed space from the fracture may be significant enough to produce hypovolemic shock Death by exsanguination can occur from pelvic and femoral fractures Estimated blood loss from closed fractures in liters Tibia = 1.5 L Femur = 2 L Pelvis = 6 L Humerus = 2 L A fractured cervical spine, pelvic fracture / fractured femur may produce life-threatening injuries Posterior dislocation of the hip are life-and limb-threatening emergencies due to the potential for blood loss and the disruption in blood supply to the head of the femur The patient may develop avascular necrosis of the femoral head and subsequently may require a hip replacement

5. 6. 7.

Primary Interventions
1. 2. 3. Support/supply Airway, Breathing, and Circulation if compromised Initiate IV line and treatment for shock if evident Protect injured part from movement or further trauma. Splinting in position found may be helpful

Subsequent Assessment
1. Seek information on the mechanism of injury How did the injury occur? In what position was the limb after the injury Did the person fall? How many feet did the person fall? What was the direction and amount of force? Certain musculoskeletal **commonly occur together Assess for the presence of concomitant injury A fractured calcaneus as the result of a fall from a great height may also include a compressed fracture of the spine A person with a fractured patella from a motor vehicular accident may also have a fracture or dislocated femur A fractured pelvis may occur with lumbo-sacral spine fracture and injury Perform a neurovascular assessment to include the area above and below the injury Assess for ischemia to the extremity Pallor = Poor arterial perfusion Cyanosis = Venous congestion Capillary Refill Time of less than 2 seconds = Poor arterial capillary perfusion Palpate the pulse distal to the extremity Loss of a pulse / coldness of the extremity distal to the injury may require Assess neurologic supply of the injured extremity to determine peripheral nerve insult. Damage to a peripheral nerve can be the result of a direct injury, compression or edema Test sensory function Indication may require immediate intervention Test motor function Numbness / paralysis Examine the bones and joints adjacent to the injury If there was enough force to produce one injury, there may be other injuries Sign and Symptoms of FRACTURE Pain and tenderness over the fracture site A grating / Crepitus over the fracture Swelling due to internal bleeding and edema

2.

3.

4.

5. 6.

jcmendiola_Achievers2013

7.

8.

9.

Deformity, unnatural position, or movement where there is no joint Use of guarding Discoloration due to bleeding into the surrounding tissue Shortening of an extremity or rotation of the extremity Signs and Symptoms of DISLOCATION Loss of joint motion The joint may appear frozen Obvious deformity Lump, ridge or excavation Severe pain Signs and Symptoms of SPRAINS Pain in the joint area Swelling Limited use / movement Discoloration Closely monitor VS

General Interventions
Interventions for the SEVERELY INJURED PATIENTS Initiate 2 IV lines and volume replacement with Ringers Lactate This will prevent further damage and will hep to relieve the pain Prepare the patient for the Operating Room (OR), for open reduction, closed internal fixation / wound care Antibiotics may be started Other Interventions: Elevate to prevent / limit swelling Apply ice packs / cold compress; ice should not be placed directly on the skin Cover open fracture with a sterile dressing Splint the extremity in a good alignment as possible until definitive care is complete Immobilize the joint above and below the fracture Handle the part gently as little as possible Provide pain management Assess for Compartment Syndrome Pressure with an extremity resulting from bleeding and swelling into a closed space, causing pressure on vital structures The 6 Ps (Signs and Symptoms) of Compartment Syndrome 1. Pain 2. Pallor Nursing ALERT! 3. Pulselessness If compartment syndrome is suspected, DO 4. Paresthesia NOT ELECATE LIMB ABOVE THE 5. Paralysis Late LEVEL OF THE HEART, this may sign perfusion to the compromised extremity 6. Puffiness Late sign

Soft Tissue Injury

Definition: Soft Tissue Injury involves the skin and underlying subcutaneous tissue and muscles They can be classified as open / closed injury A CLOSED WOUND: Is an injury to the soft tissues but WITHOUT A BREAK IN THE SKIN Includes: 1. CONTUSION Bleeding beneath the skin into the soft tissue. The bleeding can be minor / extensive. Extensive bleeding can cause severe pain and swelling, leading to a compromise of vital structures

jcmendiola_Achievers2013

2. HEMATOMA Well-defined pocket of blood and fluid beneath the skin AN OPEN WOUND: Is an injury to soft tissue with a break in the skin. Generally they are more serious than closed injuries due to the potential for blood loss and infection Includes: 1. ABRASION Superficial loss of skin resulting from rubbing /scraping the skin over a rough / uneven surface 2. LACERATION Tear in the skin. Can be a partial / full thickness wound. Can be defined as incisional / jagged 3. PUNCTURE Occurs when the skin is penetrated by a pointed object. Can be penetrating (Entrance wound only) or Perforating (Entrance and Exit wound) Generally, puncture wounds do not cause serious external bleeding, but these may be significant internal bleeding and damage to vital organs 4. AVULSION Tearing off or loss of a flap of skin 5. AMPUTATION Traumatic cutting / tearing off of a finger, toe, arm / leg

Primary Assessment
Always ensure the adequacy of Airway, Breathing and Circulation before initiating treatment If the bleeding from the injury has been significant. Be aware of the clinical symptoms and signs of shock Clinical Signs and Symptoms of SHOCK related to soft tissue injury Skin is pale, mottled, cold and diaphoretic Tachycardia (Rapid, weak pulse) Nursing ALERT! Tachypnea (Rapid, shallow breathing) Wounds that result in severe Hypotension (Falling blood pressure is a late arterial bleeding should be sign of shock) considered LIFE Restlessness, confusion and anxiety THREATENING, and treatment is Assess for arterial / venous bleeding: second only to CPR Arterial Blood is BRIGHT RED and usually spurts from the wound Venous Blood is DARKER RED and will flow steadily from a wound

Primary Intervention
The primary goal and nursing interventions are to control severe bleeding o Direct pressure Most external bleeding can be controlled by direct pressure o Cover the injury with sterile dressings o Apply firm direct pressure to the site of injury o Pressure should be maintained until the bleeding stops, a pressure dressing is applied or definite treatment is undertaken o If the dressing becomes saturated, reinforce the dressing; DO NOT REMOVE THE DRESSING After bleeding has stopped, apply a pressure dressing o A pressure bandage is made by securing several gauzes pads over the injury with a rolled gauze bandage o A pressure dressing allows the nurse freedom to continue assessing the patient or attend to other injuries o After applying pressure dressing, always ensure that the*** Elevation o Elevating the injured area while applying direct pressure helps to control bleeding. This measure uses gravity to slow the blood flow o If possible, the injured area should be elevated ABOVE THE LEVEL OF THE HEART o DO NOT RAISE A LIMB if a FRACTURE is suspected or if elevating causes the patient pain / discomfort Pressure Points

jcmendiola_Achievers2013

Pressure points are used when direct pressure and elevation cannot control bleeding alone / when direct pressure cannot be applied to a bleeding site due to a protruding bone / an embedded object o Pressure points are located between the sites of injury and the heart where a main artery passes over a bone / underlying muscle mass o Locate the patients pressure points and apply firm, steady pressure with the fingers / the heel of the hand o If heavy bleeding still cannot be controlled and the patient may exsanguinate, tourniquet may be used or a vascular clamp can be applied to the artery o Application of a tourniquet is ONLY A LAST RESORT Expose the wound; cut away clothing if necessary, do not remove any impaled object Assess for the presence of concomitant injury Assess vascular status distal to the injury and compare it to the uninjured extremity o Color of the injured extremity Pallor = Poor arterial perfusion Cyanosis = Venous congestion o Capillary Refill Time A capillary refill time of greater than 2 3 seconds = Arterial capillary perfusion o Test Pulses distal to the injury They should be STRONG Perform a neurologic assessment of the injured extremity to determine peripheral nerve insult, possible caused by direct injury, compression / edema o Sensory Function While the patients eyes are closed, lightly touch*** Determine Tetanus Immunization status History of the injury, including when an how the wound occurred o Any wound that is greater than 6 hours old is considered AT RISK for INFECTION and closure by suture may not be an option Allergy to local anesthesia, epinephrine and antibiotics o

Wound Preparation
o o o Shave the area surrounding the wound, but shave only what is necessary. Eye brows are never shaved Irrigate gently and copiously with isolate sterile saline solution, sterile water to remove dirt and debris A catheter tip syringe may be used to create a hydraulic action o General Rule: Irrigate with 50 ml per inch of wound per hour of age of wound, use more irrigant for grossly contaminated wounds If the wound is grossly contaminated, the wound may need to be cleaned with a surgical scrub sponge and then irrigate The wound may be anesthetized first if the patient cannot tolerate the wound irrigation and cleaning The wound is infiltrated with local anesthesia intradermally through the wound margins / by regional nerve block Devitalized tissue and foreign materials are removed Devitalizing tissue inhibits wound healing*** Wound closure o Closure by primary intent: Wound is repaired without delay after the injury; yields the fasting healing Primary closure may be with sutures, skin tapes, staples / tissue adhesives Wound is allowed to granulate on its own without surgical closure Wound is cleaned and covered with a sterile dressing o Closure by secondary intent with delayed closure: Wound is cleaned and dressed Patient returns in 3 4 days for definitive closure o Dressing should be applied in 3 layers The first layer is the contact layer. This should consist of a non absorbent hydrophilic dressing***

o o o

jcmendiola_Achievers2013

The second layer is the absorbent layer and is usually constructed of surgical dressing pads or a 4x4 gauze The third layer is the outer wrap that holds the dressing in place. The outer wrap may consist of rolled gauze and tape Pharmacologic Interventions - Give antimicrobial treatment as directed, depends on infection potential o How the injury occurred o Age f wound o Presence of soil - Give Tetanus Prophylaxis as indicated; based on patients immunization status wound o For inadequate Tetanus Toxoid (with diphtheria, Td) and Tetanus Immunoglobulin (TIg) are given Patient Education - Inform the patient that the pain should subside in 24 hours - Acetaminophen (Tylenol) or prescribed analgesia to be taken for the 1st 24 hours after a simple laceration - If pain reappears, a wound infection may be suspected - Recommend that the wound be elicited to limit accumulation of fluid in the wounds interstitial spaces o Elevate extremities for 1st 48 hours o Sleep with the head elevated if facial lacerations are present o Advise that health care provider be contacted if there is sudden or persistent pain.

jcmendiola_Achievers2013