• Trauma is defined as a physical injury caused by external forces or violence.

• Fifth leading cause of death in the United States.

• Deaths related to trauma are primarily from motor vehicle crashes (MVCs), homicide, poisoning (e.g.,
prescription drug overdose), and falls.
• Use of alcohol, drugs, or other substance abuse is often involved in traumatic events.
• Trauma is frequently referred to as the disease of the young, because the majority of injured persons
range in age from 16 to 54 years.
• MVCs are the leading cause of death in teens; approximately 11 teens die in an MVC every day on U.S.
roads. Programs such as Graduated Drivers Licensing (GDL) are aimed at reducing teen MVC-related
deaths through better driver safety education.
• The incidence of trauma in the United States is a major health care and economic concern because of
the loss of life, the societal burden in terms of lost productivity and increased disability of injured
persons, and the consumption of health care resources.
•
• A model trauma system provides an organized approach to trauma care that includes components of
prevention, rapid access, acute hospital care, rehabilitation, and research activities.
• Regional and state trauma systems provide comprehensive processes to deliver optimal care through
an established trauma system network that matches a patient’s medical needs to the level of trauma
hospital with the resources necessary to provide the best possible care for the type and severity of
traumatic injury.
• A trauma system combines levels of designated trauma centers that coexist with other acute-care
facilities. Levels of a trauma system are a differentiation of medical care but are defined by resources
available within the specific hospital.
•
A coordinated team effort is essential in trauma management. Box 20-1 reviews roles of the team.
Box 20-1 Interprofessional Trauma Team
• Emergency medical services (EMS) response team
• Trauma surgeon (team leader)
• Emergency physician
• Anesthesiologist
• Trauma nurse team leader (coordinates and directs nursing care)
• Trauma resuscitation nurse (hangs fluids, blood, and medications; assists physicians)
• Trauma scribe (records all interventions on the trauma flow sheet)
• Laboratory phlebotomist
• Radiologic technologist
• Respiratory therapist
• Social worker/pastoral services
• Hospital security officer
• Physician specialists (neurosurgeon, orthopedic surgeon, urological surgeon)
•
• Triage means sorting the patients to determine which patients need specialized care for actual or
potential injuries.
• Triage decisions are often made by prehospital personnel based on knowledge of the mechanisms of
injury and rapid assessment of the patient’s clinical status.
• The ultimate goal of any EMS system is to get the patient to the right level of hospital care in the
shortest span of time to optimize patients’ outcomes.
• Additional lifesaving prehospital interventions that may be required include spinal precautions,
occlusive dressings on open chest wounds, airway management and ventilation assistance, and needle
thoracotomy to relieve tension pneumothorax.
• Ground or air transport is appropriate to move the trauma patient from the scene of the injury to the
trauma center. Considerations in the choice of transport include travel time, terrain, availability of air
and ground units, capabilities of transport personnel, and weather conditions.
• A disaster is a sudden event in which local EMS services, hospitals, and community resources are
overwhelmed by the demands placed on them; many different causes.
• Disasters are classified by the number of victims involved: multiple patient incident refers to fewer
than 10 victims; multiple casualty incident refers to 10 to 100 victims; mass casualty incident refers to
more than 100 victims. Disasters may also be classified as an institutional-based, internal disaster,
occurring within a hospital and rendering the facility partially or totally inoperable.
• Command control centers and communication stations are established at the event site when possible
and maintain contact with the lead hospital to facilitate efficient transport of patients. Effective,
consistent, and accurate communication of the activities at the disaster site and effective
management of the severity and volume of incoming victims at the hospitals are critical to successful
disaster and mass casualty management.
• Disaster plans outline the roles and responsibilities of all health care providers, including hospital
administrators, physicians, nurses, pharmacists, respiratory therapists, and security personnel. All
personnel are required to be familiar with the disaster response policy.
• Disasters cause significant psychological stress during the event and after the situation has been
stabilized; debriefing of health care professionals is warranted.
•
• Mechanism of injury refers to how a traumatic event occurred, the injuring agent, and information
about the type and amount of energy exchanged during the event. Guides assessment and treatment.
• Energy may be kinetic (e.g., crashes, falls, blast injuries, penetrating injuries), thermal, electrical,
chemical, or from radiation exposure.
• Kinetic energy is defined as mass multiplied by velocity squared, divided by 2; the greater the mass
and velocity (speed) are, the more significant the displacement of kinetic energy will be to the body
structures, resulting in severe injury.
• The effects of the energy released and the resultant injuries depend on the force of impact, the
duration of impact, the body part involved, the injuring agent, and the presence of associated risk
factors.
•
• Blunt trauma is the most common mechanism of injury. It most often results from MVCs, but it also
occurs from assaults with blunt objects, falls from heights, sports-related activities, and pedestrians
struck by a motor vehicle. The severity of injury varies.
• Blunt trauma may be caused by accelerating, decelerating, shearing, crushing, or compressing forces.
• Organ injury from blunt trauma may not be immediately visible. Knowledge of the mechanism of
injury and the effects of blunt trauma forces is vital in the care of the blunt trauma patient.
•
• Potential injuries to an unrestrained driver in an MVC.
Review each of these patterns and discuss possible related injuries.

• Penetrating trauma results from the impalement of foreign objects (e.g., knives, bullets, debris) into
the body.
• Low or high velocity:
• Stab wounds are low-velocity injuries because the velocity is equal only to the speed with
which the object is thrust into the body.
• Ballistic trauma is categorized as either medium- or high-velocity injuries.
• Assessment of penetrating injury includes examination of the entrance and exit wounds (if present).
• The entrance wound is usually smaller than the exit wound; however, forensic experts rather than the
trauma team determine the direction of the bullet entrance and exit.
• Penetrating injuries are monitored closely for subsequent complications, including organ damage,
hemorrhage, and infection.
• Blast injuries are forms of blunt and penetrating trauma, including debris impalement. Energy
exchanged from the blast causes tissue and organ damage.
• Classified as primary, secondary, tertiary, and quaternary.
• The primary explosive blast generates shock waves that create changes in air pressure,
causing tissue damage.
• Secondary injuries occur from increased negative pressure from the shock wave, causing
debris to impale the body, creating organ and tissue damage.
• Tertiary blast injuries are the result of the body being thrown by the force of the explosion,
resulting in blunt tissue trauma, including closed head injuries, fractures, and visceral organ
injury.
• Quaternary blast injuries occur from chemical, thermal, and biological exposure.
•
• Rapid assessment in the field by prehospital personnel is important, as is immediate transport of the
trauma patient to an appropriate trauma care facility.
• Treatment of life-threatening problems is provided at the scene, with careful attention given to the
airway with cervical spine immobilization, breathing, and circulation (ABCs).
• Interventions include establishing an airway, providing ventilation, applying pressure to control
hemorrhage, immobilizing the complete spine, and stabilizing fractures.
•
Emergency Care Phase
• Information obtained during the prehospital phase provides essential data to ensure a coordinated,
lifesaving approach in the management of trauma patients.
• Most traumatic events are considered “scoop and run” situations with short transport times, but
other patients may come to the hospital by private car.
• Emergency departments in trauma centers designate resuscitation rooms, providing a central location
for the team facilitating a quick initial assessment, stabilization, and determination of the immediate
medical needs of the patient.
• The resuscitation room must always be in a state of readiness for the next trauma patient.
• Equipment needed for management of the airway with cervical spine immobilization, breathing,
circulatory support, and hemorrhage control must be immediately available and easily accessible.
• Procedures exist within hospitals to activate the trauma team, including the operating room team, for
emergent surgical interventions.
•
• The secondary survey is a methodical head-to-toe evaluation of the patient, using the assessment
techniques of inspection, palpation, percussion, and auscultation to identify all injuries.
• The secondary survey is initiated after the primary survey has been completed and all actual or
potential life-threatening injuries have been identified and addressed. A full set of vital signs is
obtained as a baseline for analysis of trends during the resuscitation phase, comfort measures are
implemented, patient history is taken, and inspection of posterior surfaces is completed (FGHI).
See Table 20-3.
• From the time of initial injury until the patient is stabilized in the emergency department or operating
room, the trauma team resuscitates the patient.
• Resuscitation in trauma refers to reestablishing an effective circulatory volume and a stable
hemodynamic status in the patient.
• During the emergency care phase, effective resuscitation is a central component of the primary and
secondary survey.
• The ABCDEs of this phase include airway, breathing, circulation, disability (neurological), and
exposure, and treating life-threatening injuries (e.g., pneumothorax, cardiac tamponade) emergently.
Maintain airway patency
• Endotracheal intubation is the definitive nonsurgical airway management technique and allows for
complete control of the airway.
• Rapid sequence intubation (sequential administration of a sedative or anesthetic, and a
neuromuscular blocking agent) may be used to facilitate endotracheal intubation, followed by
mechanical ventilation.
• An alternative airway device, a laryngeal mask airway (LMA) may be used when endotracheal
intubation is not feasible.
• In rare circumstances it may be difficult to intubate the trauma patient. In this event, a surgical
intervention (cricothyrotomy) is performed to establish an effective airway. Conditions that may
require cricothyrotomy are maxillofacial trauma, laryngeal fractures, facial or upper airway burns,
airway edema, and severe oropharyngeal hemorrhage.
•
Ineffective breathing
• Interventions to restore normal breathing patterns are directed toward the specific injury or
underlying cause of respiratory distress, with the goal of improving ventilation and oxygenation.
• Basic nursing interventions include application of supplemental oxygen with ventilatory assistance (if
applicable), effective positioning, and evaluation of specific interventions.
• The patient is assessed frequently for respiratory rate and effort, heart rate and rhythm, breath
sounds, sensorium, skin color, temperature, tracheal position, and jugular venous distension.
• Assessment is ongoing, and the nurse must be prepared to assist with intubation and subsequent
mechanical ventilation, needle thoracostomy, chest tube insertion, and restoration of circulating blood
volume.
•
• Impaired gas exchange can result from ineffective ventilation, an inability to exchange gases at the
alveoli, or both.
• Possible causes include a decrease in inspired air, retained secretions, lung collapse or compression,
atelectasis, or accumulation of blood in the thoracic cavity.
• Any patient presenting with multiple systemic injuries, hemorrhagic shock, chest trauma, and/or
central nervous system trauma must be assessed for impaired gas exchange.
• Assessment is ongoing, and the nurse must be prepared to assist with intubation and subsequent
mechanical ventilation, needle thoracostomy, chest tube insertion, and restoration of circulating blood
volume.
•
• The most common cause of hypotension and impaired cardiac output in the trauma patient is
hypovolemic shock from acute blood loss.
• Initial interventions include applying pressure to control the bleeding, replacing circulatory volume
with crystalloid and blood products, and determining definitive treatment. In the face of hypovolemic
shock from hemorrhage, early, rapid surgical intervention is lifesaving and limb saving.
•
Tx of hypovolaemia
• Venous access and infusion of volume are required for optimal fluid resuscitation in the patient with
hypovolemic shock.
• At least two large-caliber peripheral IV lines are necessary. The preferred sites are the forearm or
antecubital veins.
• As an alternative, intraosseous (IO) needles may be used for access in the sternum, legs, arms, or
pelvis if the patient’s injuries do not interfere with the procedure (Figure 20-3).
•
Interosseous procedure
• As an alternative, intraosseous (IO) needles may be used for access in the sternum, legs, arms, or
pelvis if the patient’s injuries do not interfere with the procedure (Figure 20-3).
• The IO may be placed in the field by EMS personnel or in the emergency department.
 • Resuscitation fluids, medications, and blood products can be administered through an IO device.
• Potential complications with IO access include pain on instillation of fluids, extravasation of fluids, and
compartment syndrome.
• Isotonic electrolyte solutions (e.g., lactated Ringer’s solution or normal saline) are used for initial fluid
resuscitation.
• A rapid infuser device may be used to facilitate rapid infusion of warm IV fluids.
• The ACS recommends administration of 3 mL of crystalloid solution for each milliliter of blood loss (3:1
rule).
• The decision to administer blood is based on the patient’s response to initial fluid therapy and the
amount of blood lost; autotransfusion is another option.
•
• Rapid responders react quickly to the initial bolus and remain hemodynamically stable after
administration of the initial fluid bolus. Fluids are then slowed to maintenance rates.
• Transient responders improve in response to the initial fluid bolus. However, these patients begin to
show deterioration in perfusion when fluids are slowed to maintenance rates. This finding indicates
ongoing blood loss or inadequate resuscitation. Continued fluid administration and blood transfusion
are indicated. If the patient continues to respond in a transient manner, the patient is probably
bleeding and requires rapid surgical intervention.
• Minimal or no responders fail to respond to crystalloid and blood administration in the emergency
department, and surgical intervention is needed immediately to control hemorrhage.
•
Ongoing sx n symps of shock
• Sympathetic compensatory mechanisms in the body respond to states of hypoperfusion through
tachycardia, narrowing pulse pressure, tachypnea, and decreased urine output. These signs and
symptoms may not be obvious until the patient is in a later stage of hypovolemic shock.
• The serum arterial lactate level and base deficit are markers of effective tissue perfusion. The higher
the lactate level and base deficit are, the more severe the tissue underperfusion will be and the higher
the morbidity and mortality.
•
Massive fluid resus/massive blood transfusion
• If blood loss and coagulopathy are life-threatening, massive blood transfusion may be required—
administering 10 or more units of packed red blood cells in 24 hours.
• In this situation, it is necessary to administer platelets and fresh frozen plasma in addition to packed
RBCs to improve patient outcomes.
• Blood products are given in a [Link] ratio when massive blood transfusions are required—1 unit of
packed RBCs, 1 unit of platelets, and 1 unit of fresh frozen plasma.
• During fluid resuscitation, the patient is monitored for electrolyte imbalances, dilutional
coagulopathies, and consequences of excessive third-spacing of IV fluids.
• Electrolyte imbalances that may develop include hypocalcemia, hypomagnesemia, and hyperkalemia
or hypokalemia
•
Complications of massive fluid resuscitation
• Electrolyte imbalances that may develop include hypocalcemia, hypomagnesemia, and hyperkalemia
or hypokalemia. These imbalances may lead to changes in myocardial function, laryngeal spasm, and
neuromuscular and central nervous system hyperirritability.
• Hypothermia may result from IV and blood products; warm fluids and patient.
• Dilutional coagulopathy may occur with excessive IV fluid resuscitation and extensive blood loss;
banked blood products have high levels of citrate, which may induce transient hypocalcemia.
• Decreased serum calcium levels may lead to ineffective coagulation because calcium is a
necessary cofactor in the coagulation cascade.
• Further inhibition of the clotting cascade is observed when platelet dysfunction develops
secondary to hypothermia or metabolic acidosis.
 • Third-spacing can pose a significant problem during and within hours of aggressive fluid resuscitation.
• During states of hypoperfusion and acidosis, inflammation occurs and vessels become more
permeable to fluid and molecules.
• With aggressive fluid resuscitation, this change in permeability allows the movement of fluid
from the intravascular space into the interstitial spaces (third-spacing). Hypovolemia thus
occurs in the intravascular space, and patients require a larger volume of fluid replacement.
• This creates a vicious cycle; as more IV fluids are given to support systemic circulation, fluids
continue to migrate into the interstitial space, causing excessive edema and predisposing the
patient to additional complications such as abdominal compartment syndrome, ARDS, acute
kidney injury, and MODS.
FAST
• Diagnostic testing is completed early to determine injuries and potential sources of bleeding. Potential
injuries to the chest, pelvis, abdomen, and suspected extremity fractures are assessed.
• Diagnostic studies include x-rays and focused assessment with sonography for trauma (FAST).
• FAST provides a rapid, noninvasive means to diagnose accumulation of blood or free fluid in the
peritoneal cavity or pericardial sac.
• If free fluid or hemorrhage is found, a CT may be obtained and/or surgical interventions initiated as
appropriate.
•
Neurological TBI
• Primary injury:
• Insult directly to the head (blunt and or penetrating trauma). Primary head injury from blunt
trauma typically occurs in the presence of acceleration, deceleration, or rotational forces.
Injury may be focal or diffuse.
• Rapid assessment of patients with neurological injury, along with early intervention, is a vital
element of the primary survey.
• Assessment of neurological disabilities includes evaluation of the patient’s level of
consciousness, pupillary size and reaction, and spontaneous and reflexive spinal movement,
as well as consideration of possible neurological injuries based on the history of the injury
(e.g., ejection from motor vehicle, fall, or diving accident).
• Evaluate substance abuse (drugs or alcohol use) that may interfere with neurological exam.
• Secondary injury:
• Secondary head injury refers to the systemic (hypotension, hypoxia, anemia, hyperthermia)
or intracranial changes (edema, intracranial hypertension, seizures) that result in alterations
in the nervous system tissue.
• Patients with secondary injury often have poor outcomes, including death.
• Nursing interventions focus on ensuring an adequate blood pressure to meet cerebral
perfusion needs (mean arterial pressure greater than 50 mm Hg), maximizing ventilation and
oxygenation through effective airway management, maintaining the head in a midline
position to enhance cerebral blood flow, administering sedatives to address agitation and
increased intracranial pressure, and conducting frequent neurological assessments.
• The key to neurological assessments is to recognize subtle changes and notify the physician for
prompt intervention (see Chapter 14).
• Nursing interventions focus on ensuring an adequate blood pressure to meet cerebral perfusion needs
(mean arterial pressure greater than 50 mm Hg), maximizing ventilation and oxygenation through
effective airway management, maintaining the head in a midline position to enhance cerebral blood
flow, administering sedatives to address agitation and increased intracranial pressure, and conducting
frequent neurological assessments.
• The key to neurological assessments is to recognize subtle changes and to notify the physician for
prompt intervention (see Chapter 14).
SCI
• Mechanisms of injuries that may result in SCI include hyperflexion, hyperextension, axial loading,
rotation, and penetrating trauma.
• The initial treatment of a patient with suspected SCI includes the ABCs of resuscitation, spinal
immobilization, and prevention of further injury through surgical stabilization of the spine.
• A complete sensory and motor neurological examination is performed, and x-ray studies of the
cervical spine are obtained.
• A spinal CT scan may be performed to rule out occult injury. It is important to determine the
approximate level of SCI because higher cervical spine injuries may result in the loss of phrenic nerve
innervations, compromising the patient’s ability to breathe spontaneously.
• SCI causes a loss of sympathetic output, resulting in distributive shock with hypotension and
bradycardia.
• Blood pressure may respond to IV fluids, but vasopressor therapy is often required to
compensate for the loss of sympathetic innervation and resultant vasodilation.
Refer to Chapter 14 for greater detail.

Basilar skull #
• Fractures of the skull may be linear, basilar, closed depressed, open depressed, or comminuted.
• Underlying brain injury may occur with skull fractures. Basilar skull fractures are located at the base of
the cranium and potentially involve the five bones that form the skull base.
• The diagnosis is based on the presence of cerebrospinal fluid in the nose (rhinorrhea), in the ears
(otorrhea), or in both; ecchymosis over the mastoid area (Battle’s sign); or hemotympanum (blood in
the middle ear).
• Raccoon eyes or periorbital ecchymoses are present after a cribriform plate fracture (see Chapter 14).
•
• Cardiac tamponade is a life-threatening condition caused by rapid accumulation of fluid (usually
blood) in the pericardial sac.
• As the intrapericardial pressure increases, cardiac output is impaired because of decreased venous
return.
• The development of pulsus paradoxus may occur with a decrease in systolic blood pressure during
spontaneous inspiration.
• Blood, if unable to flow into the right side of the heart, causes increased right atrial pressure and
distended neck veins.
• Classic signs of this injury are hypotension, muffled or distant heart sounds, and elevated venous
pressure (Beck’s triad).
• Beck’s triad may not be present until late in the development of tamponade.

• Blunt trauma to the chest is the most frequent cause of cardiac contusion.
• The force of the traumatic event bruises the heart muscle and can compromise effective heart
functioning.
• Dysrhythmias are the most significant concern with cardiac contusion.
• Ongoing monitoring for symptomatic cardiac dysrhythmias via continuous monitoring of the
electrocardiogram (ECG) is frequently indicated for up to 48 to 72 hours.
• In the event of significant anterior chest trauma, a 12-lead ECG and serum levels of cardiac
isoenzymes and troponin are obtained to rule out ischemia or infarction. With severe cardiac
contusion injuries, inotropic agents are occasionally needed to support myocardial function.
•
• Aortic disruption is produced by blunt trauma to the chest, frequently resulting in death at the scene
of the traumatic event.
• Rapid deceleration forces contribute to injury.
• Signs of aortic disruption include weak femoral pulses, dysphagia, dyspnea, hoarseness, and pain.
• A chest x-ray study may demonstrate a widened mediastinum, tracheal deviation to the right,
depressed left mainstem bronchus, first and second rib fractures, and left hemothorax.
• The diagnosis is confirmed by an aortogram.
• Definitive, emergent surgical resection and repair are necessary with this injury.
•
• Tension pneumothorax is a rapidly fatal emergency that is easily resolved with early recognition and
intervention.
• It occurs when an injury to the chest allows air to enter the pleural cavity without a route for
escape.
• With each inspiration, additional air accumulates in the pleural space, increasing intrathoracic
pressure and leading to lung collapse.
• The increased pressure causes compression of the heart and great vessels toward the
unaffected side, as evidenced by mediastinal shift and distended neck veins.
• The resulting decreased cardiac output and alterations in gas exchange are manifested by
severe respiratory distress, chest pain, hypotension, tachycardia, absence of breath sounds
on the affected side, and tracheal deviation.
• Cyanosis is a late manifestation of this life-threatening clinical situation.
• The diagnosis of tension pneumothorax is based on the patient’s clinical presentation; treatment is
never delayed to confirm the diagnosis with a chest x-ray study.
• Immediate decompression of the intrathoracic pressure is accomplished by needle thoracostomy.
• The physician inserts a 14-gauge needle into the second intercostal space at the midclavicular
line on the injured side.
• Subsequent definitive treatment is required with placement of a chest tube.
•
• Hemothorax is a collection of blood in the pleural space resulting from injuries to the heart, great
vessels, or the pulmonary parenchyma.
• Bleeding can be moderate (from intercostal vessels) or massive (from the aorta or from subclavian or
pulmonary vessels).
• Decreased breath sounds, dullness to percussion on the affected side, hypotension, and respiratory
distress may be seen.
• Placement of a chest tube facilitates removal of blood from the pleural space with resolution of
ventilation and gas exchange abnormalities.
•
• Open pneumothorax results from penetrating trauma that allows air to pass in and out of the pleural
space.
• The normal pressure gradient between the atmosphere and intrathoracic space no longer exists.
• Patients present with hypoxia and hemodynamic instability.
• Management of the open wound is accomplished with a three-sided occlusive dressing. The fourth
side is left open to allow for exhalation of air within the pleural cavity.
• If the dressing becomes completely occlusive on all sides, a tension pneumothorax may occur.
• A chest tube is inserted on the affected side.
•
• Pulmonary contusion occurs as a result of blunt or penetrating trauma to the chest; it is one of the
most common causes of death after chest trauma, and it predisposes the patient to pneumonia or
acute lung injury.
• A contusion is a parenchymal injury to the lung that often results in some degree of hemorrhage and
edema with a subsequent inflammatory process extending beyond the site of injury.
• Difficult to detect because the initial chest x-ray study may be normal.
• The clinical presentation includes chest wall abrasions, ecchymosis, bloody secretions, and a partial
pressure of arterial oxygen (PaO2) of less than 60 mm Hg while breathing room air. The bruised lung
tissue becomes edematous, resulting in hypoxia and respiratory distress.
• Ventilatory support is needed to promote healing of the lungs. Fluids must be administered cautiously
to avoid further lung edema.
• Adequate pain relief with IV narcotics is essential to optimize lung expansion and respiratory effort
and to prevent complications, including atelectasis and pneumonia.
•
• Rib fractures are the most common injury associated with chest trauma.
• May lead to significant respiratory dysfunction and may indicate a serious injury to organs
and structures below and near the rib cage.
• Diagnosis of rib fractures is frequently made after a chest x-ray study.
• Injury to the liver, spleen, or kidney may accompany fractures of ribs 10 through 12.
• A flail chest occurs when two or more adjacent ribs are broken in two or more places, creating a free-
floating segment of the rib cage.
• The flail segment results in paradoxical chest movement; it contracts inward with inhalation
and expands outward with exhalation.
• Normal respiratory mechanics depend on a rigid chest wall to generate negative intrathoracic
pressure for effective ventilation.
• The uncoordinated chest movement with flail chest impairs the ability of the body to
generate effective changes in intrathoracic pressure for ventilation.
• Clinical presentation includes paradoxical chest movement, increased work of breathing,
tachypnea, and eventually signs and symptoms of hypoxemia.
• The management of rib fractures is dependent on the number of ribs fractured, the degree of
underlying injury, and the age of the patient.
• Interventions focus on assessing the patient’s ventilation and oxygenation, preventing
pneumonia, and managing pain effectively.
• Nurses should provide education on pillow splinting, incentive spirometry, coughing and
deep-breathing exercises, the benefits of early ambulation, and pain management. Effective
pain management enables the patient to maximally participate in pulmonary exercises.
• Pneumonia is the primary complication associated with rib fractures.
•
• Abdominal injuries are often difficult to diagnose.
• A normal initial examination does not necessarily rule out intraabdominal injury.
• FAST is short for “focused assessment with sonography for trauma”; CT may also be used to evaluate
abdominal bleeding.
• The classic sign of abdominal injury is pain; pain cannot be used as an assessment tool if the patient
has an altered sensorium, drug intoxication, or SCI with impaired sensation.
• The liver is the most commonly injured organ after blunt or penetrating trauma, and hemorrhage is
the primary cause of death after injury.
• Presentation: history of right lower thoracic trauma, fractured lower right ribs, right upper quadrant
ecchymosis, right upper quadrant tenderness, and hypotension.
• The diagnosis is confirmed with the use of FAST and/or abdominal CT.
• The degree of liver injury is graded on a scale of I to VI, with I representing a nonexpanding
subcapsular hematoma and VI signifying hepatic avulsion. Grades I through III injuries are treated with
close monitoring (regular abdominal assessment and serial hemoglobin and hematocrit
measurements) and bed rest for 5 days. Angiographic embolization or surgical management is
indicated for grades IV through VI in which there is expansion of the hemorrhage, a large laceration, or
complete avulsion of the liver from its vascular supply.
• Splenic injury occurs most often as a result of blunt trauma to the abdomen.
• Penetrating trauma to the left upper quadrant of the abdomen or fracture of the anterior left lower
ribs also contributes to splenic injuries.
• The patient may present with left upper quadrant tenderness, peritoneal irritation, referred pain to
the left shoulder (Kehr’s sign), and hypotension or signs of hypovolemic shock.
• An encapsulated hemorrhage of the spleen produces no immediate signs of bleeding.
• The degree of splenic injury is graded on a scale from I to V. Grade I is a subcapsular, nonexpanding
hematoma, and a grade V injury results when the spleen is shattered and devascularized.
Management of splenic injury is similar to that of liver injuries.
• Close monitoring of the patient is vital. This includes assessment of the patient’s hemodynamic status;
the presence of guarding, rebound tenderness, rigidity, or distension of the abdomen; and alterations
in the patient’s hemoglobin and hematocrit values. Bed rest for 5 days may be appropriate for grades I
to III splenic injuries.
• Operative intervention is often necessary for grade IV and V injuries.
• Splenic injuries may continue to bleed slowly, and the spleen may ultimately rupture days to weeks
after the initial injury. A ruptured spleen is a life-threatening event that requires immediate surgical
intervention.
• Every effort is made to preserve splenic tissue because of its role in immune function. Overwhelming
infection has been seen after removal of the spleen.
• Patients undergoing splenectomy are very susceptible to pneumococcal infections, and administration
of the pneumococcal vaccine within the first few days postoperatively is recommended.
•
• Musculoskeletal trauma rarely is a priority in the emergent management of the patient unless the
injuries result in significant hemodynamic instability (e.g., pelvic fractures and traumatic amputations).
• The injuries may be blunt or penetrating, and may involve bone, soft tissue, muscle, nerves, and/or
blood vessels.
• Injuries are classified as fractures, fracture-dislocations, amputations, and tissue trauma (crushing
injuries of the soft tissue, nerves, vessels, or tendons).
• Knowing the mechanism of injury is important in evaluating musculoskeletal injuries because kinetic
energy can be distributed from the bony impact to other areas of the body.
• Fractures involve a disruption of bony continuity.
• X-ray studies are taken to diagnose fractures, and the extremity is immobilized.
• Traumatic soft tissue injuries are categorized as contusions, abrasions, lacerations, puncture wounds,
crush injuries, amputations, or avulsion injuries. Injury to the skin and soft tissues predisposes the
individual to secondary complications, including localized and systemic infection, hypoproteinemia,
and hypothermia.
• Assessment of soft tissue injury is part of the secondary survey unless the loss of tissue (e.g.,
amputation) is hemodynamically compromising the patient.
• Traumatic amputation produces a well-defined wound edge with localized injury to soft
tissue, nerves, and vessels.
• These wounds usually require debridement and surgical closure.
• Avulsion injuries result in stretching and tearing of the soft tissue and may tear nerves and
vessels at different levels other than the actual site of bone and tissue trauma.
• A crush injury may produce local soft tissue trauma or extensive damage distant from the site of
injury. Crush injuries of the pelvis and/or both lower extremities or a prolonged entrapment may be
life-threatening.
• Prolonged compression produces ischemia and anoxia of the affected muscle tissue.
• Third-spacing of fluid, localized edema, and increased compartment pressures cause secondary
ischemia. Without aggressive intervention, these injuries can result in irreversible complications.
• Contusions do not cause a break in the skin, but localized edema, ecchymosis, and pain occur.
• Abrasions (“road rash”) occur when the skin experiences friction. Traumatic abrasions are frequently
contaminated with debris implanted into the skin, resulting in traumatic tattooing. It can take hours to
days to effectively remove the debris from the wound.
• Lacerations are usually caused by sharp objects, and they are treated with cleansing and suturing.
• Puncture wounds carry a heightened risk of infection.
• Although they do not cause vast soft tissue destruction or lacerations, puncture wounds can cause an
aggressive infection because they deliver bacteria or foreign inoculums deep into the body. Puncture
 wounds should not be surgically closed until treatment for infection with local and systemic antibiotics
has been completed. Animal bites are notorious causes of puncture wounds.
• All traumatic wounds are considered contaminated.
• Wounds must be cleansed and debrided to reduce the risk of infection.
• Ongoing assessment of the wound includes evaluating healing and investigating any local and systemic
signs and symptoms of infection (e.g., increased wound pain, swelling, fever, elevated white blood cell
count, increased wound drainage) that arise.
• Tetanus toxoid administration and antibiotic therapy are also considered.
• Common types of fractures (Figure 20-4).
• If the skin is open at the fracture site, it is called an open fracture; if the skin is intact, it is called a
closed fracture.
• Fractures are further classified into grades based on the degree of bony, soft, and vascular tissue and
nerve damage.
• Early treatment of a fracture involves immobilization with splints or application of traction.
• Once the patient is hemodynamically stable, surgical management for open fractures (open reduction
and internal fixation) is performed to restabilize the bone for effective healing.
• During the secondary survey, limb swelling, ecchymosis, and deformity are assessed.
• Extremity assessment is often described by the five Ps: pain, pallor, pulses, paresthesia, and paralysis.
• This process of assessment describes the neurovascular status of the injured extremity and is critical in
assessing circulation in the extremity.
• Loss of pulses is considered a late sign of diminished perfusion. Increased pain, pallor, and paresthesia
supersede loss of pulses and should be reported immediately to the trauma team.
•
• Compartment syndrome occurs when a fascia-enclosed muscle compartment, such as an extremity,
experiences increased pressure from internal and external sources. Internal sources include edema,
hemorrhage, or both; external forces include splints, immobilizers, or dressings.
• The closed muscle compartment of an extremity contains neurovascular bundles that are tightly
covered by fascia.
• If the pressure is not relieved, compression of nerves, blood vessels, and muscle occurs, with resulting
ischemia and necrosis of muscle and nerve tissue.
• Patients with compartment syndrome complain of increasing throbbing pain disproportionate to the
injury; narcotic administration does not relieve the pain. The pain is localized to the involved
compartment and increases with passive muscle stretching.
• The area affected is firm.
• Paresthesia distal to the compartment, pulselessness, and paralysis are late signs and must be
reported immediately to prevent loss of the extremity.
• The affected limb is elevated to heart level to promote venous outflow and to prevent further
swelling.
• Compartmental pressure monitoring may be performed for definitive diagnosis.
• Treatment of compartment syndrome is immediate surgical fasciotomy, in which the fascial
compartment is opened to relieve the pressure.
•
• Rhabdomyolysis is a syndrome of hypoperfusion and ischemia, followed by reperfusion, in which
injured muscle tissue releases myoglobin into the circulation, compromising renal blood flow.
• Causes of rhabdomyolysis include crush injuries, compartment syndrome, burns, and injuries from
being struck by lightning.
• Myloglobinuria (the excretion of myoglobin through the urine) is an effective marker of
rhabdomyolysis and causes the urine to be a dark tea color.
• Ultimately, the myoglobin is toxic to the renal tubule, causing acute tubular necrosis, electrolyte and
acid-base imbalances, and eventually acute kidney injury (AKI).
• Treatment of rhabdomyolysis consists of aggressive fluid resuscitation to flush the myoglobin from the
renal tubules.
• A common protocol includes the titration of IV fluids to achieve a urine output of 100 to 200 mL/hr.
• Administering osmotic diuretics and adding sodium bicarbonate to IV fluids may be used to protect
the renal tubules in patients with myoglobinuria.
•
• The risk of VTE in trauma patients is dependent on the severity of injury, the type of injury (e.g.,
musculoskeletal injuries), the presence of shock, recent surgeries, vascular injury, and immobility.
• VTE usually occurs from a deep vein thromobosis (DVT) in the lower extremities.
• Thrombus formation is enhanced in the presence of Virchow’s triad: vessel damage, venous stasis, and
hypercoagulability.
• If the thrombus dislodges, it becomes an embolus and travels through the body’s vasculature until it
lodges in either the pulmonary artery or its smaller branches (pulmonary embolism).
• Once the embolus becomes lodged, blood flow is obstructed distally and the tissues distal to the
obstruction become hypoxic.
• Pulmonary vessels constrict in response to the hypoxia, resulting in ventilation-perfusion mismatches
and hypoxemia.
• Prevention of VTE is essential in the management of trauma patients. If not medically contraindicated,
patients should receive pharmacological prophylaxis.
• Nurses encourage ambulation, evaluate the patient’s overall hydration, and ensure that sequential
compression devices are used properly.
•
• Fat embolism syndrome is a potential complication that accompanies traumatic injury of the long
bones and pelvis that results in multiple skeletal fractures.
• Typically, the syndrome develops between 24 and 48 hours after injury.
• Long-bone injury may release fat globules into torn vessels and the systemic circulation.
• The fat particles act as an embolus, traveling through the great vessels and pulmonary system,
obstructing flow and causing hypoxia.
• Hallmark clinical signs that accompany fat embolism syndrome begin with the development of a low-
grade fever followed by a new-onset tachycardia, dyspnea, an increased respiratory rate and effort,
hypoxemia (PaO2 ≤ 60 mm Hg), sudden thrombocytopenia, and a petechial rash.
• Late signs and symptoms include ECG changes, lipuria (fat in the urine), and changes in the level of
consciousness progressing to coma.
• Prevention of fat embolism is the best treatment.
• Stabilization of extremity fractures to minimize both bone movement and the release of fatty
products from the bone marrow must be accomplished as early as possible. Treatment of fat
embolism syndrome is directed toward the preservation of pulmonary function and
maintenance of cardiovascular stability.
• Administration of supplemental oxygen and intubation with mechanical ventilation and
positive end-expiratory pressure may be required to restore or maintain pulmonary function.
• Monitoring the patient’s cardiovascular stability is continued throughout the critical care
phase, with particular attention to ECG and hemodynamic changes.
•
• DIC is a syndrome that can be chronic or severe.
• Primary trigger is thought to be systemic inflammation.
• Triggers trauma, rhabdomyolysis, massive blood transfusions, fat emboli, shock state, sepsis, and
prolonged hypothermia.
• Presentation is prolonged PT and PTT, decreased fibrinogen, decreased platelets, and elevated fibrin
split products.
• Bleeding is the threat.
 • The critical care phase for the patient with multisystem traumatic injuries requires the skills and
collaboration of a variety of health care professionals.
• The patient experiences additional physiological stressors from the traumatic injury and subsequent
surgeries, psychological stressors, and often disruption of the social or family unit.
• The nurse is central to the critical care phase, continually assessing the patient’s progress, anticipating
and evaluating for possible complications, encouraging family-centered care, and acting as the
patient’s advocate.
• Interventions that were initiated in the emergent phase to treat and manage the traumatic injuries
continue into the critical care phase.
•
Damage control surgery
• Emergent surgical management of traumatically injured patients is the gold standard to stop
hemorrhage and stabilize life-threatening injuries; definitive surgical interventions may require several
surgeries to effectively manage traumatic injuries.
• The initial surgery focuses on cessation of the cause of bleeding; however, long, extensive surgeries
can lead to severe complications that contribute to the patient’s ultimate death. These complications,
now recognized as the leading cause of death in patients who sustain multisystem traumatic injuries,
include the triad of hypothermia, acidosis, and coagulopathy.
• These complications and resultant mortality have changed the current surgical focus to an approach
known as damage-control surgery or a staged surgical repair; this strategy sacrifices the completeness
of immediate repair, yet provides early surgical stabilization and management of active hemorrhage
associated with injuries.
• The first stage includes the operative repair of life-threatening injuries only.
• Patients are then returned to the critical care unit (second stage) for aggressive rewarming,
ongoing resuscitation, and attainment of hemodynamic stability.
• The third stage occurs usually within 24 to 48 hours after the initial operation. This involves
the return to the operating room for definitive repair of intraabdominal injuries.
•
Post op management
• Preparation for admission of the patient provides a smooth transition in care from the operative phase
to the critical care phase.
• The room temperature may be increased to manage anticipated hypothermia, IV infusion pumps are
accessed, respiratory therapy is contacted for a ventilator, and the monitoring equipment and room
supplies are double-checked to minimize the need to find necessary supplies once the patient is
admitted.
• The bed scale is “zeroed” to obtain a quick admission weight of the patient.
• Receiving the patient
• Handoff communication: the nurse receives a report from the emergency department nurse
before the patient goes to surgery; however, a thorough report from the anesthesiologist as
part of handoff communication between health care providers is essential for continuity of
care.
• Elements of the handoff communication include a review of systems, past medical history,
description of the injury, description of the intraoperative procedures, the patient’s tolerance
of the procedures, vital signs during the surgery and current vital signs, total intake (i.e.,
crystalloids, colloids, blood products) and output (i.e., urine output, chest tube output, and
estimated blood loss), medications administered (i.e., sedation, analgesia, neuromuscular
blockade reversal agents, antibiotics, and vasoactive agents), IV access, and location of chest
tubes and other drains.
• Rapid assessment of airway, breathing, and circulation.
• The nurse quickly connects the patient to the bedside monitor and ventilator, and completes
an assessment of vital signs, cardiac rhythm, pulse oximetry reading, level of consciousness,
and pupil reactivity.
 • Hypothermia is a concern postoperatively; thus the nurse keeps the patient covered while
assessing the body for surgical incisions, dressings, other injuries, and location and function
of drainage devices (e.g., chest tubes, hemovacs). It is important to inspect the posterior
surface of the patient, so a quick turn to assess and remove soiled linens is completed early.
• The nurse reassesses IV access and evaluates the patency of IV catheters, as they may have
become dislodged during transport. All IV infusions are traced from the IV fluid, to the
infusion pump, and to the IV access in the patient.
• Calculation of medication dosages and rates is completed as part of the initial assessment.
• All drainage devices are emptied, such as hemovacs and the urinary drainage bag, and the
volume of output is recorded.
• If a chest tube is in place, the amount of existing drainage is marked on the external
collection system.
• Admission laboratory studies are obtained.
• Finally the patient is weighed. The admission weight is important for ongoing assessment of
the patient’s fluid status and medication administration throughout the critical care unit
admission.
• Nutritional needs of the patient are addressed early in the postoperative phase (within 24 to
48 hours) to assist with healing and meeting the body’s needs related to an elevated
metabolic demand.
• The route of administration (oral, enteral, or parenteral), type of nutritional replacement, and
rate of administration are dependent on the severity of illness or injury and the expected
recovery period. A nutritional consult is placed to evaluate the metabolic needs of the patient
and determine the optimal feeding formula and rate of administration (see Chapter 6).
• Variations in electrolytes and hormonal regulation, specifically hyperglycemia and increased
gluconeogenesis, are often seen in critically ill patients.
• Elevations in serum glucose levels are aggressively treated with IV insulin infusions; however,
current guidelines suggest maintaining serum glucose between 140 and 180 mg/dL.
•
Complications
Patients with multisystem injuries are at high risk of developing myriad complications associated with the
overwhelming stressors of the injury, prolonged immobility, and consequences of inadequate tissue perfusion.
Even with optimal care, the stressors and overwhelming inflammatory responses to injury influence the risk of
secondary complications.
• Even with optimal care, the stressors and overwhelming inflammatory responses to injury influence
the risk of secondary complications.
• These include respiratory impairment (abdominal compartment syndrome, acute lung injury, ARDS,
pneumonia), infection (catheter infection, sepsis), acute kidney injury, high nutritional demands, and
MODS.
• A full discussion of these secondary complications is found in other chapters within this text.
•
Alcohol and Drug abuse
• Up to 40% of all traumatic events involve alcohol, and an additional 20% include drug intoxicants.
• Overall complications, morbidity, and mortality are higher in traumatically injured patients
who test positive for alcohol, drugs, or both, at the time of admission. Most trauma patients
who have high blood alcohol concentration on admission meet criteria that indicate an
alcohol problem.
• Trauma centers need to have alcohol and drug intervention programs that can be implemented at the
time of admission and maintained throughout the hospitalization to reduce the high correlation of
alcohol abuse and serious traumatic injury.
• Because addiction is associated with physiological dependence, when the patient no longer consumes
these agents, serious or life-threatening withdrawal occurs.
 • The nurse must closely monitor the patient’s physiological status while a patient is experiencing
withdrawal.
• Implementation of protocols to address withdrawal provides preemptive treatment.
Common signs and symptoms include increased agitation, anxiety, auditory and visual hallucinations,
disorientation, headache, nausea and vomiting, paroxysmal diaphoresis, and tremors (Box 20-3).