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Anti-Coagulation for Nursing Critical Care, Lecture notes of Nursing

University of Nevada - Las Vegas (UNLV)Nursing

The complications that arise in trauma patients, particularly related to anticoagulation, pain management, and mobilization. It highlights the risks associated with chronic anticoagulation and antiplatelet drugs, the importance of pain control to prevent complications, and the benefits of early mobilization. The document emphasizes the need for a multidisciplinary team effort to coordinate interventions and improve outcomes.

Typology: Lecture notes

2022/2023

Available from 05/10/2023

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Anticoagulation
Many older patients are admitted with some
type of anticoagulation. Warfarin and various
platelet inhibitors can cause bleeding problems
after trauma. Older patients with falls are often
admitted with intracranial bleeding related to
chronic anticoagulation or antiplatelet drugs.
Bleeding risk in solid organ injury or major
orthopedic injury also increases with elevated
international normalized ratio (INR) or
decreased platelet function. Massive
transfusion protocols may be utilized for
anticoagulated patients who require emergent
surgery and develop DIC. Older patients
requiring reversal of anticoagulation may
require multiple units of fresh frozen plasma
and require close monitoring for fluid overload.
Pain management
Many complications are directly related to pain
control. In trauma patients, pain control is
extremely important to avoid complications
associated with immobility
and hypoventilation. Patients
with chest trauma, including multiple rib
fractures and pulmonary contusions, need
adequate pain control in order
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Anticoagulation

Many older patients are admitted with some type of anticoagulation. Warfarin and various platelet inhibitors can cause bleeding problems after trauma. Older patients with falls are often admitted with intracranial bleeding related to chronic anticoagulation or antiplatelet drugs. Bleeding risk in solid organ injury or major orthopedic injury also increases with elevated international normalized ratio (INR) or decreased platelet function. Massive transfusion protocols may be utilized for anticoagulated patients who require emergent surgery and develop DIC. Older patients requiring reversal of anticoagulation may require multiple units of fresh frozen plasma and require close monitoring for fluid overload.

Pain management

Many complications are directly related to pain control. In trauma patients, pain control is extremely important to avoid complications associated with immobility and hypoventilation. Patients with chest trauma, including multiple rib fractures and pulmonary contusions, need adequate pain control in order

to continue with aggressive pulmonary toilet to prevent pneumonia and lobar collapse. Pneumonia may develop secondary to a combination of factors including hypoventilation, aspiration, inadequate pain management, atelectasis, and pooling of secretions.

Early mobilization

Mobilization is also a key factor in the prevention of complications. While historically the ICU has not been a place where patients spend a lot of time out of bed, new studies support mobilizing even mechanically ventilated patients (Bourdin, 2010; Kress, 2009). This requires a multidisciplinary team effort including nurses, respiratory, physical, and occupational therapies. The improvement in outcomes such as ability of patients to ambulate on discharge and shortened length of stay make the coordination of these interventions essential and worth the effort (Kress, 2009). Bourdin (2010) found that getting the ICU patient into the chair resulted in a decline in heart rate by a mean of 3.5 beats per minute and decreased respiratory rate of 1.4 breaths per minute, while oxygen saturation and arterial blood pressure were not adversely affected. While there can be many barriers to getting trauma patients out of bed, the positive

Thoracic injury management

Rib fractures can easily be underestimated as a major injury. Patients, especially elderly patients, can very quickly decompensate as they take only very shallow inspirations due to pain from multiple rib fractures. The gold standard for pain control in rib fractures is the use of the epidural infusion for analgesia (Simon et al ., 2012). However, this can only be used in patients without exposure to anticoagulation and without spinal injury. When an epidural is not possible, scheduled oral medication or patient-controlled analgesia combined with a continuous infusion of narcotic may be warranted. Patients must be carefully monitored for respiratory depression. The balance between adequate pain relief and neurologic and respiratory depression is a key measure for continuous monitoring. Another risk associated with chest injury is pleural effusion. The patient with rib fractures and/or pulmonary contusion is at risk for effusion 3–5 days post injury. Patients already at risk for respiratory insufficiency may have worsening inspiratory volumes due to the collection of pleural fluid, limiting tidal volume. Drainage with chest tubes or thoracentesis is often required. These patients are followed closely with daily chest X-rays and continuous oxygen saturation monitoring.

Use of narcotics for pain control can contribute to respiratory depression and increasing carbon dioxide levels, not readily apparent in oxygen saturation monitoring. These patients may require alternate modes of both oxygen delivery and ventilation support. Use of bilevel positive airway pressure (BiPAP) for ventilation support or continuous positive airway pressure (CPAP) for oxygenation support may become necessary to prevent progression to respiratory failure Pneumothorax or hemopneumothorax may occur as the primary injury in blunt chest trauma, or can occur as a possible complication from rib fractures or pulmonary contusion. Chest tube thoracotomy is the treatment of choice. Pain control is again important for these patients and monitoring for adequate oxygenation and ventilation is essential. Not only are rib fractures painful, but the insertion of the chest tube adds to the painful experience. Empyema may develop due to inadequately drained hemothorax, infected parapneumonic effusion, trauma, esophageal perforation, or bronchopleural fistula (Ahmed & Zangan, 2012).