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Define central or transtentorial herniation. - ansA downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium.
Define Hemothorax. - ansAccumulation of blood in the pleural space.
Define Minor Head Trauma. - ansGCS 13-
Define Moderate Head Trauma - ansPostresuscitative state with GCS 9-13.
Define Pneumothorax. - ansResults when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue.
An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea.
Define Severe Head Trauma. - ansPostresuscitative state with GCS score of 8 or less.
Define tension pneumothorax. - ansLife-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results.
Immediate decompression should be performed. Treatment should not be delayed.
Define uncal herniation. - ansThe uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes.
Disruptions of the bony structures of the skull can result in what? - ansDisplaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF.
CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess
Explain adrenal gland response. - ansWhen adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase.
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Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion.
Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol.
Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar.
Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water.
Explain Cardiogenic Shock. - ansSyndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle.
Some causes:
- MI
- Blunt cardiac injury
- Mitral valve insufficiency
- dysrhythmias
- Cardiac Failure
Explain Distributive Shock. - ansResults from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region.
Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock.
Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities.
Explain Hepatic Response. - ansLiver can store excess glucose as glycogen.
As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose.
In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas.
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- GCS
- PERRL?
- Determine presence of lateralizing signs including:
- Unilateral deterioration in motor movements or unequal pupils
- Symptoms that help to locate area of injury in brain
How do you confirm ET Tube/Alternative Airway Placement? - ans- Visualization of the chords
- Using bronchoscope to confirm placement
- Listening to breath sounds over the epigastrum and chest walls while ventilating the pt
- CO2 detector
- Esophageal detection device
- Chest x-ray
How do you inspect the chest for adequate ventilation? - ansObserve:
- mental status
- RR and pattern
- chest wall symmetry
- any injuries
- patient's skin color (cyanosis?)
- JVD or tracheal deviation? (Tension pneumothorax)
How would you assess a patient with ocular, maxillofacial and neck trauma? - ans(Initial assessment) HISTORY
- MOI?
- Acceleration/Deceleration?
- What was it caused by?
- Pt restrained? Airbags deployed? Etc.
- What are the pt's complaints?
- Pt normally wear glasses or contacts?
- Pt have hx of eye problems?
- Pt ever have eye surgery?
- Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION:
- Inspect eye, orbits, face and neck
- Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas
- Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents
- Determine whether lid lac's
- Assess pupil's (PERRL)
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- Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome
- Bilateral fixed and pinpoint pupils = pontine lesion or drugs
- Mildly dilated pupil w/sluggish response may early sign of herniation syndrome
- Widely dilated pupil occasionally occurs w/direct trauma to globe of eye
- Assess for consensual response
- Assess redness, eye watering, blepharospasm
- Assess extraocular movement, except when an open globe injury is known or suspected.
- Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle
- Perform visual acuity exam
- Use Snellen or handheld chart. Check uninjured eye first
- Assess for blurred or double vision with injured eye and then with both eyes open
- Inspect for rhinorrhea or otorrhea
- If drng present, may indicate CSF leak
- Observe for impaled objects
- Assess occlusion of mandible and maxilla
- Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx
- Observe for uncontrolled bleeding PALPATION
- Palpate periorbital area, face and neck for:
- Tenderness
- Edema
- Step-off de
How would you assess a pt with a cranial injury? - ans(Initial assessment) INSPECTION:
- Assess airway
- RR, pattern and effort
- Assess pupil size and response to light
- Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP
- Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates
- Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome
- Widely dilated pupil occasionally occurs w/direct trauma to globe of eye
- Determine if pt uses eye meds
- Abnormal posturing?
- Inspect craniofacial area for ecchymosis/contusions
- Periorbital ecchymosis
- Mastoid's process ecchymosis
- Blood behind tympanic membrane
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Palpation:
- Palpate chest wall, clavicles and neck for:
- Tenderness
- Swelling or hematoma
- Subcutaneous emphysema
- Note presence of bony crepitus
- Palpate central and peripheral pulses and compare quality between:
- Right and left extremities
- Upper and lower extremities
- Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax)
- Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury). Auscultation:
- Auscultate compare BP in both UE's and LE's
- Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain).
- Auscultate chest for presence of BS (diaphragmatic rupture)
- Auscultate Heart sounds (muffled = pericardial tamponade)
- Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures:
- Xrays
- Arteriography
- Bronchoscopy and laryngoscopy
- CT's
- FAST
- Labs (cardiac enzymes)
- ECG, CVP
How would you assess someone in hypovolemic shock? - ans(Use Initial Assessment) and then: Inspect:
- LOC
- Rate and quality of respirations
- External bleeding?
- Skin color and moisture
- Assess jugular veins and peripheral veins Auscultate:
- BP
- Pulse pressure
- Breath sounds
- Heart sounds
- Bowel sounds
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Percuss:
- Chest and abdomen Palpate:
- Central pulse (carotid or femoral)
- Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse
- Palpate peripheral pulses
- Palpate skin temp and moisture Diagnostic Procedures:
- Xrays and other studies
- Labs Planning and Implementation
- Oxygen
- IV's with warmed replacement fluids
- Control external bleeding with direct pressure
- Elevate LE's
- NGT
- Foley
- Monitor and pulse oximeter
- Monitor for development of coagulopathies
- Surgery?
ICP is a reflection of what three volumes? What happens when one increases? - ans1. Brain
- CSF
- Blood within the nonexpansible cranial vault
As volume of one increases, the volume of another decreases to maintain ICP within normal range.
As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful.
Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP.
Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - ansA tight-fitting nonrebreather mask at 12-15 lpm.
What are aortic injuries S/S? - ans- Hypotension
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- Dysphagia (difficulty swallowing)
What are S/S of a rib fracture? - ans- Dyspnea
- Localized pain on movement, palpation, or inspiration
- Pt assumes position intended to splint chest wall to reduce pain
- Chest wall ecchymosis or sternal contusion
- Bony crepitus or deformity
What are S/S of a ruptured diaphragm? - ans(Anything below the nipple line and should be evaluated for potential diaphragmatic injury).
- Dyspnea or orthopnea
- Dysphagia
- Abdominal pain
- Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign)
- Bowel sounds heard in lower middle chest
- Decreased breath sounds on injured side
What are s/s of chemical burns to the eye? - ansChemical injuries require immediate intervention if it is to be preserved. S/S:
- Pain
- Corneal Opacification
- Coexisting chemical burn and swelling of lids
What are S/S of penetrating trauma/open or ruptured globe? - ans- Marked visual impairments
- Extrusion of intraocular contents
- Flattened or shallow anterior chamber
- Subconjunctival hemorrhage, hyphema
- Decreased intraocular pressure
- Restriction of extraocular movements
What are S/S with blunt cardiac injury? - ans"Cardiac contusion" or "concussion." Common with MVC or falls from heights.
- ECG (sinus tach, PVC's, AV blocks)
- Chest pain
- Chest wall ecchymosis
What are S/S with tracheobronchial injury? - ansBlunt trauma. "Clothesline-type" injuries.
- Dyspnea, tachypnea
- Hoarseness
- Hemoptysis
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- Subcutaneous emphysema in neck, face, or suprasternal area
- Decreased or absent breath sounds
- S/S of airway obstruction
What are signs of a serious eye injury? - ans- Visual disturbances
- Pain
- Redness and ecchymosis of the eye
- Periorbital ecchymosis
- Increased intraocular pressure
What are signs of ineffective breathing? - ans- AMS
- Cyanosis, especially around the mouth
- Asymmetric expansion of chest wall
- Paradoxical movement of the chest wall during inspiration and expiration
- Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
- Sucking chest wounds
- Absent or diminished breath sounds
- Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
- Anticipate definitive airway management to support ventilation.
What are signs of ineffective circulation? - ans- Tachycardia
- AMS
- Uncontrolled external bleeding
- Pale, cool, moist skin
- Distended or abnormally flattened external jugular veins
- Distant heart sounds
What are the early signs and symptoms of increased ICP? - ans- Headache
- N/V
- Amnesia regarding events around the injury
- Altered LOC
- Restlessness, drowsiness, changes in speech, or loss of judgement
What are the interventions for Disability? - ans- If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments
- If pt is not alert or verbal, continue to monitor for any compromise to ABC's
- If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation.
What are the interventions for Effective/Ineffective Circulation? - ans- Control any uncontrolled external bleeding by:
- Applying direct pressure over bleeding site
- Elevating bleeding extremity
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- Prepare for intubation, PRN.
- Cannulate 2 large IV's, initiate isotonic crystalloid IV solution
- Control external bleeding w/direct pressure
- Monitor for continued bleeding + expanding hematomas
- Apply cold compresses to face to minimize edema
- Assist w/repair of oral lac's, PRN
- Admin antibiotics
- Stabilize impaled objects
- Admin analgesic meds
What are the nursing interventions for a pt with an ocular injury? - ans- Assess visual acuity & reassess
- Elevate HOB to minimize intraocular pressure
- Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure
- Assist w/removal of foreign bodies as indicated; stabilize impaled objects
- Apply cool packs to decrease pain + periorbital swelling
- Admin medications
- Instill prescribed topical anesthetic drops for pain
- Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration
- Antibiotics topically or systemically
- Admin tetanus prophylactically
- Use an eye patch to affected eye
- Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries
- Patch, shield or cover w/cool pack
- Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe.
- Provide psychosocial support
- Obtain an ophthalmology consultation
- Provide d/c instructions:
- Importance of protective eyewear
- No driving w/eye patch on
- Wear sunglasses to prevent tearing, aid photophobia
- Prepare for admission, OR or transfer
What are the Rapid Sequence Intubation Steps? - ansPREPARATION:
- gather equipment, staffing, etc. PREOXYGENATION:
- Use 100% O2 (prevent risk of aspiration). PRETREATMENT:
- Decrease S/E's of intubation PARALYSIS WITH INDUCTION:
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- Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING:
- Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF
- Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30- seconds between attempts.
- After intubation, inflate the cuff
- Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT:
- Secure ET tube
- Set ventilator settings
- Obtain Chest x-ray
- Continue to medicate
- Recheck VS and pulse oxtimetry
What are the S/S of a basilar skull fx? - ans- H/A
- Altered LOC
- Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum)
- Facial nerve (VII) palsy
- CSF rhinorrhea or otorrhea
What are the S/S of a depressed skull fx? - ans- H/A
- Possible decreased LOC
- Possible open fx
- Palpable depression of skull over the fx site
What are the S/S of a linear skull fx? - ans- H/A
What are the S/S of a pneumothorax? - ans- Dyspnea, tachypnea
- Tachycardia
- Hyerresonance (increased echo produced by percussion over the lung field) on the injured side
- Decreased or absent breath sounds on the injured side
- Chest pain
- Open, sucking wound on inspiration (open pneumothorax)
What are the S/S of a tension pneumothorax? - ans- Severe respiratory distress
- Markedly diminished or absent breath sounds on affected side
- hypotension
- Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present
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- Memory impairment
- Attention deficit
- Irritability
- Insomnia
- Impaired judgement
- Loss of libido
- Anxiety
- Depression
What are the two types of herniation that occurs with ICP? - ans1. Uncal herniation
- Central or transtentorial herniation
What are you looking for when auscultating lung sounds? - ansAbsence of BS:
- Pneumothorax
- Hemothorax
- Airway Obstruction Diminished BS:
- Splinting or shallow BS may be a result of pain
What are you looking for when palpating the chest wall, clavicles and neck? - ans- Tenderness
- Swelling
- subcutaneous emphysema
- step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax.
What are you looking for when percussing the chest? - ansDullness:
- hemothorax Hyperresonance
- Pneumothorax
What could a flail chest be associated with? - ans- Ineffective ventilation
- Pulmonary contusion
- Lacerated lung parenchyma
What happens to a ruptured diaphragm? - ansPotentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver.
- Herniation of abdominal contents
- Respiratory compromise b/c impaired lung capacity + displacement of normal tissue.
- Mediastinal structures may shift to opposite side of injury
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What intervention should be done if a pt presents with effective circulation? - ans- Insert 2 large caliber IV's
- Administer warmed isotonic crystalloid solution at an appropriate rate
What is a cerebral contusion and its S/S? - ansA common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18-36 post injury. S/S:
- Alteration in LOC
- Behavior, motor or speech deficits
- Abnormal motor posturing
- Signs of increased ICP
What is a Combitube? - ansA dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult.
What is a concussion and its signs and symptoms? - ansA temporary change in neurologic function that may occur as a result of minor head trauma. S/S:
- Transient LOC
- H/A
- Confusion and disorientation
- Dizziness
- N/V
- Loss of memory
- Difficulty with concentration
- Irritability
- Fatigue
What is a flail chest? - ansA fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum.
Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases.
What is a Laryngeal Mask Airway? - ansLooks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area.
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What is assessed and intervened for Expose/Environmental Controls? - ans- Remove clothing
- Ensure appropriate decontamination if exposed to hazardous material
- Keep pt warm
- Keep clothing for evidence
What is assessed under the Mnemonic "H"? - ansHISTORY / HEAD-TO-TOE ASSESSMENT
- MIVT
- M = Mechanism of injury
- I = Injuries sustained
- V = Vital Signs
- T = Treatment
- Pt generated information
- PMH
- Head-to-toe assessment
What is assessed under the Mnemonic "I"? - ansINSPECT POSTERIOR SURFACES
- While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs.
- Palpate vertebral column for deformity and areas of tenderness
- Assess rectum for presence/absence of tone, presence of blood
What is Cushing's phenomenon or Cushing's Reflex? - ansTriad of progressive HTN, bradycardia and diminished respiratory effort.
What is diffuse axonal injury and its signs and symptoms? - ans(DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S:
- Immediate unconsciousness
- mild DAI, coma = 6-24 hrs
- severe DAI, coma = weeks/months or persistent vegetative state
- Elevated ICP
- Abnormal posturing
- HTN
- Hyperthermia
- Excessive sweating because of autonomic dysfunction
- Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits
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What is hyphema and its S/S? - ansAccumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S:
- Blood in anterior chamber
- Deep, aching pain
- Mild to severe diminished visual acuity
- Increased intraocular pressure
What is kinematics? - ansA branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body.
What is kinetic energy (KE)? - ansKE equals 1/2 the mass (M) multiplied by the velocity squared.
What is LeFort I fracture and its S/S? - ansTransverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S:
- Slight swelling of maxillary area
- Possible lip lac's or fractured teeth
- Independent movement of the maxilla from rest of face
- Malocclusion
What is LeFort II fracture and its S/S? - ansPyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S:
- Massive facial edema
- Nasal swelling w/obvious fx of nasal bones
- Malocclusion
- CSF rhinorrhea
What is LeFort III fracture and its S/S? - ansComplete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S:
- Massive facial edema
- Mobility and depression of zygomatic bones
- Ecchymosis
- Anesthesia of the cheek
