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Trauma 

Chapter:
Trauma
Author(s):

Heather Baid

, Fiona Creed

, and Jessica Hargreaves

DOI:
10.1093/med/9780198701071.003.0018
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date: 08 May 2021

Introduction

Trauma is the leading cause of death in children and in adults under 44 years of age, and results in significant long-term physical and psychological effects for those surviving from major injuries.1,2 The assessment and management of trauma patients are complex due to the following:

  • the individual nature of each patient’s injuries, including internal injuries which may initially be missed

  • the potential for rapid deterioration due to either life-threatening injuries or secondary clinical problems

  • the potential for various types of shock to develop, such as hypovolaemic, distributive, or traumatic shock (see Trauma p. [link]), each of which requires a different type of approach to the clinical management

  • the need for involvement of a variety of different types of healthcare professionals while the patient is in critical care which, depending on the type of injury, may include specific surgical teams, physiotherapists, occupational therapists, psychological counsellors, and specialist trauma practitioners.

Trauma assessment and management

In order to immediately identify and treat life-threatening problems while following up ongoing clinical issues, a systematic and structured approach to the assessment and management of the patient with trauma should be adopted. The assessment and management stages are typically undertaken simultaneously, and may involve a variety of healthcare professionals. This chapter will provide an overview of the trauma primary survey (see Trauma p. [link]), secondary survey (see Trauma p. [link]), tertiary survey (see Trauma p. [link]), and a trauma-focused nursing assessment (see Trauma p. [link]).

While assessing and caring for a patient with trauma, it is useful to consider the underpinning nature of any injuries, including the following:

Type of injury

  • Unintentional.

  • Self-inflicted.

  • Assault.

Mechanism of injury

  • Road traffic accident—car, motorcycle, bicycle, or pedestrian.

  • Fall—consider the height and how the patient landed.

  • Penetrating (e.g. stabbing, gunshot, other objects).

  • Blunt force trauma.

  • Blast injuries.

  • Other types of injury (e.g. shearing, crushing, compression, chemical, thermal, electric).

Areas of the body affected

  • Head.

  • Spine.

  • Chest.

  • Abdomen.

  • Pelvis.

  • Limbs.

  • Internal organs.

References

1 National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Trauma: who cares?(2007). Traumawww.ncepod.org.uk/2007t.htm

2 Trauma Audit and Research Network (TARN). Trauma Care. Traumawww.tarn.ac.uk

Further reading

Alzghoul MM. The experience of nurses working with trauma patients in critical care and emergency settings: a qualitative study from Scottish nurses’ perspective. International Journal of Orthopaedic and Trauma Nursing 2014; 18: 13–22.Find this resource:

Christie RJ. Therapeutic positioning of the multiply-injured trauma patient in ICU. British Journal of Nursing 2008; 17: 638–42.Find this resource:

Smith J, Greaves I and Porter K (eds). Oxford Desk Reference: major trauma. Oxford University Press: Oxford, 2011.Find this resource:

Tisherman SA and Forsythe RM. Trauma Intensive Care. Oxford University Press: New York, 2013.Find this resource:

Trauma.Org Traumawww.trauma.org/index.php

Initial management

The primary survey is conducted at the scene of the trauma by pre-hospital staff, and then continues in the Emergency Department. It is concerned with the identification and management of life-threatening injuries using an ABCDE approach. For trauma patients with serious injuries, each section of the ABCDE model should be assessed simultaneously in an efficient manner, which can be achieved by a trauma team whose members have pre-determined roles. Box 18.1 summarizes the key immediate actions to be taken while resuscitating a patient during the primary survey.

Primary survey

Airway maintenance and cervical spine control

  • Establish a patent airway by chin-lift or jaw-thrust manoeuvres.

  • Remove debris, blood clots, and loose-fitting false teeth.

  • Use airway adjuncts or suction.

  • Use endotracheal intubation, cricothyroidotomy, or tracheostomy as required.

  • Consider cervical spine injuries—do not hyperextend the neck.

Breathing and ventilation

  • Give manual ventilation as required (apnoea, reduced respiratory rate).

  • Give high-concentration oxygen therapy and monitor SpO2.

  • Expose the chest to assess respiratory movements (look, listen, and feel).

  • Consider the possibility of tension or open pneumothorax, or flail chest with pulmonary contusions.

Circulation and haemorrhage control

  • Assess haemodynamic status (ECG, blood pressure, heart rate, temperature, capillary refill time, skin colour).

  • Control external haemorrhage by direct pressure or pneumatic splints.

Disability and dysfunction

  • Assess neurological status (GCS, AVPU, pupillary reaction).

  • Consider potential reversible causes of abnormal neurological findings (hypoxia, hypoglycaemia, toxins).

Exposure and environmental control

  • Undress the patient so that a rapid assessment can be made of injuries to the trunk and limbs.

Secondary survey

This begins after life-threatening conditions have been identified and treated and shock therapy has begun. It involves a thorough head-to-toe assessment in which each region of the body is examined in detail. Laboratory studies, X-rays, scans, and special investigations (e.g. peritoneal lavage) are undertaken.

Definitive care phase

All injuries are managed comprehensively. Fractures are stabilized, and the patient is transferred to the operating theatre if immediate surgery is necessary, or stabilized in preparation for transfer to the critical care unit or other specialist area.

Arrival on the critical care unit

Equipment should be prepared and tested prior to the patient’s arrival. Depending on the patient’s injuries, an appropriate bed or pressure-relieving mattress may be required (e.g. Stryker frame for spinal injuries). Ensure that any traction can be affixed to the particular bed used.

Checklist for equipment preparation

  • Humidified oxygen mask and delivery system/ventilator.

  • Rebreathing circuit/Ambu bag.

  • Suctioning equipment.

  • Volumetric pumps and syringe drivers.

  • Pressure bags for rapid IV infusion.

  • Stethoscope.

  • Continual monitoring equipment—ECG, temperature, pulse oximeter.

  • Non-invasive blood-pressure-measuring device.

  • Primed transducers for invasive monitoring.

  • Trolley for central venous/arterial cannulation.

  • Nasogastric tube.

  • Blood- and body-warming devices.

  • Chest drain sets.

  • Ensure that alarm limits are set on monitoring equipment.

Immediate assessment

  • Temperature, pulse, respiratory rate, blood pressure.

  • If the patient is intubated, mechanical ventilator settings and monitoring.

  • ECG rhythm.

  • Central venous pressure.

  • Neurological status.

  • Drainage volumes (urine, wound, chest).

  • Chest drain checks—unclamped, patent, and appropriate position.

  • Infusion checks—ensure the correct rate for all IV fluids and drugs.

  • Patient positioning—ensure that this is appropriate, depending upon injuries.

  • Ensure that fractured limbs are supported and traction is fitted properly.

If the patient is stable at this stage, a full trauma-focused nursing assessment (see Trauma p. [link]) should be carried out. If the patient is haemodynamically unstable, ventilatory support is inadequate, or the patient is in pain, these aspects must be corrected first.

Trauma-focused nursing assessment

Respiratory assessment

  • Airway assessment (patient should be intubated if GCS score is < 8).

  • Assess respiratory rate, rhythm, depth, effort, SpO2, and ABG.

  • Particular patterns are characteristic of head injuries in spontaneously breathing patients. Cheyne–Stokes respiration (irregular breathing of fast, deep breaths alternated with slower, shallow breaths and periods of apnea) is seen in bilateral cerebral hemisphere damage, hyperventilation in midbrain injuries, apneustic respiration (prolonged inspiration) in pontine injuries, and ataxic (random) respiration in medullary injuries.

  • Observe whether the chest is moving symmetrically with each respiration, and auscultate breath sounds to all lung regions.

  • If chest movement is unilateral, the trachea is displaced, or the breath sounds are diminished in any region, consider intraluminal obstruction (e.g. blood clot, tooth), malposition of the endotracheal tube (if intubated), pneumothorax, haemothorax, rupture of a bronchus, or pulmonary contusions.

  • If the patient has multiple rib fractures or a flail segment, this will impede movement of the chest wall, and (if the patient is breathing spontaneously) paradoxical chest wall movement may be evident over the flail segment.

  • For chest drains, note the type (blood, haemoserous fluid, air) and amounts of drainage, and observe whether the drains swing with respiration or are bubbling.

  • Consider underlying respiratory disease, such as asthma or COPD.

Cardiovascular assessment

  • Use continuous ECG monitoring and 12-lead ECG.

  • Assess trends with regard to vital signs—blood pressure, heart rate, respiratory rate, O2 saturations, and temperature.

  • The frequency of blood pressure recording will depend on the extent of the injuries.

    • Continuous blood pressure monitoring allows blood pressure changes to be detected immediately—this is essential in shocked patients and those with multiple injury .

    • Changes in blood pressure should not be considered in isolation but related to other changes, such as those in heart rate, CVP, and stroke volume.

    • Consider the effects of drug therapy (e.g. sedation, analgesia) as a potential cause of blood pressure changes.

  • If haemodynamic monitoring is being used, assess for trends in cardiac output, systemic vascular resistance, stroke volume, etc.

  • Assess the presence and strength of central pulses and rhythm.

  • Assess for cardiac tamponade (Beck’s triad—lowered blood pressure, distended jugular veins, and muffled heart sounds).

Neurological assessment

  • A full neurological assessment must be made to provide a baseline for sequential appraisal and detection of deterioration (see Trauma p. [link]).

  • The frequency of recordings will depend on the patient’s injuries, and the presence of or potential for head injury.

  • The scalp should be examined for lacerations, bruising, and obvious deformity. Bruising behind the ears may indicate bleeding into the mastoid space, which is a late sign of basal skull fracture. Otorrhoea, rhinorrhoea, and bilateral black eyes (panda/raccoon) are also suggestive of basal skull fracture.

Skin

  • Examine the skin for bruising, lacerations, and abrasions, and consider whether any of these may indicate underlying injuries (e.g. seat-belt marks).

  • Feel for subcutaneous emphysema, which may arise from external (e.g. stab wound) or from internal (e.g. rib fractures lacerating the underlying lung) injuries.

  • Observe for cyanosis, which can occur if there is rapid deterioration (e.g. due to a tension pneumothorax).

Limbs

  • Note any bruising, lacerations, swelling, or compartment syndrome.

  • Assess skin colour, warmth, and capillary refill time in each limb.

  • Check the strength of distal pulses and ensure that dressings, splints, plaster casts, or traction on limbs are not impeding circulation.

  • Ensure that pressure is not exerted on healthy skin by plaster casts or traction devices (observe for tissue swelling and breaks in the skin).

Renal assessment

  • Use a urethral urinary catheter to monitor urine output.

  • If there is trauma to the urethra, a suprapubic catheter is used.

  • Perform routine urinalysis—observe for frank haematuria, myoglobinuria (black urine), debris, and clots.

  • Examine the genitalia for bruising, lacerations, and oedema.

  • Raised blood creatine kinase levels increase the risk of AKI.

Gastrointestinal assessment

  • All ventilated patients should have a nasogastric tube inserted unless contraindicated (e.g. due to nasal or basal skull injuries, in which case an orogastric tube should be inserted). The tube should be left to drain freely and aspirated regularly—observe and test for blood.

  • Examine the abdomen for bruising and lacerations, rigidity, pain on palpation, distension, and raised intra-abdominal pressure.

  • Note any rectal bleeding.

Pain

  • Determine whether there is pain or tenderness over a particular area of the chest, or on inspiration, which may limit chest movement.

  • Assess for pain or discomfort in any other areas of the body.

Investigations

  • FBC, LFTs, clotting, U&E, lactate, glucose, creatine kinase.

  • Review radiology reports.

Psychosocial assessment

  • Assess the impact of the trauma on the patient’s mental well-being, and provide reassurance and support.

  • Provide the family with reassurance and support as required.

  • Refer the patient to other relevant services (e.g. specialist trauma team, critical care outreach, social services, mental health services).

Tertiary survey

The primary and secondary surveys for trauma patients focus on the initial identification and management of life-threatening injuries, and less serious injuries may be missed. In addition, the primary and secondary surveys may be interrupted to address critical abnormalities. The purpose of the tertiary survey is to review all of the clinical information to ensure that all injuries and potential complications are addressed and a holistic plan of care can be planned for ongoing rehabilitation.

Missed injuries

  • Factors that increase the risk of missed injuries include a high Injury Severity Score, severe traumatic brain injury, emergency interventions, and primary intensive care unit admission.

  • Body areas to consider for a missed injury are the head and neck, extremities, chest, spine, abdomen, soft tissues, and pelvis.

Timing of the tertiary survey

The tertiary survey of a trauma patient in the critical care setting may be performed by a doctor or an advanced nurse practitioner, although the bedside nurses can also contribute valuable clinical information based on their ongoing assessment while nursing the patient. The timing of the tertiary survey will depend on how long it takes to manage any life-threatening injuries, and the clinical context in which the patient is managed. Suggestions as to when to undertake the tertiary survey include the following:

  • after the patient has been stabilized

  • within 24 h of the patient’s admission to critical care

  • once the patient is awake, extubated, and/or ambulatory

  • prior to discharging the patient from critical care if the survey has not yet been completed.

The tertiary survey should be repeated for patients who previously had a reduced level of consciousness or who were not fully mobilizing when the initial tertiary survey was undertaken.

Tertiary survey process

  • Confirm the mechanism of injury and the patient’s background history.

  • Confirm the assessment findings and diagnoses from primary and secondary surveys.

  • Conduct a comprehensive, full head-to-toe physical assessment.

  • Review reports from all laboratory and radiology investigations.

  • Review reports from all medical and surgical interventions.

Further reading

Giannakopoulos GF et al. Missed injuries during the initial assessment in a cohort of 1124 level-1 trauma patients. Injury 2012; 43: 1517–21.Find this resource:

Mirhadi S, Ashwood N and Karagkevrekis B. A review of tertiary survey and its impact. Trauma 2014; 16: 79–86.Find this resource:

Traumatic brain injury

Patients with suspected traumatic brain injury should have a CT scan of the head performed and be referred to specialist neurological services as needed (for the assessment and management of trauma patients with brain injury, see Trauma p. [link]).

Traumatic haemorrhage

Uncontrolled haemorrhage with trauma shock can cause a deadly combination of coagulopathy, hypothermia, and acidosis, with each of these exacerbating the others (see Figure 18.1). The influence of inflammation and fibrinolysis, which are both triggered after trauma, also enhances the tissue hypoxia and acidosis from shock, leading to even further coagulopathy. Resuscitation of trauma patients requires the addressing of all three aspects of the lethal triad (see Table 18.1).


Figure 18.1 The lethal triad of trauma.

Figure 18.1 The lethal triad of trauma.

Table 18.1 Traumatic haemorrhage pathway checklist

Initial assessment and management

  • Extent of traumatic haemorrhage assessed

  • Patient in shock with identified source of bleeding treated immediately

  • Patient in shock with unidentified source of bleeding sent for further investigation

  • Coagulation, haematocrit, serum lactate levels, and base deficit assessed

  • Antifibrinolytic treatment initiated

  • Patient history of anticoagulant therapy assessed (vitamin K antagonists, antiplatelet agents, oral anticoagulants)

Resuscitation

  • Systolic blood pressure of 80–100 mmHg achieved in absence of traumatic brain injury

  • Measures to achieve normothermia implemented

  • Target Hb level of 7–9 g/dL achieved

Surgical interventions

  • Abdominal bleeding controlled

  • Pelvic ring closed and stabilized

  • Peritoneal packing, angiographic embolization, or surgical bleeding control completed in haemodynamically unstable patient

  • Damage-control surgery performed in haemodynamically unstable patient

  • Local haemostatic measures applied

  • Thromboprophylactic therapy recommended

Coagulation management

  • Coagulation, haematocrit, serum lactate levels, base deficit, and calcium levels reassessed

  • Target fibrinogen level of 1.5–2 g/L achieved

  • Target platelet level achieved

  • Prothrombin complex concentrate administered if indicated due to vitamin K antagonist or viscoelastic monitoring

Source: Spahn DR et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Critical Care 2013; 17: R76. (Reproduced with permission from BioMed Central.)

Principles of damage-control resuscitation

  • Permissive hypotension aiming for a systolic blood pressure of 90 mmHg:

    • prevents renewed bleeding in damaged blood vessels which have just clotted as part of the repair process.

  • Minimal crystalloids:

    • prevents dilution coagulopathy.

  • Haemostatic resuscitation:

    • transfusion of blood products aiming to resemble whole blood

    • fresh frozen plasma, packed red blood cells, and platelets given in a ratio of 1:1:1

    • recombinant factor VIIa, cryoprecipitate, and tranexamic acid may also be considered

    • for further information on massive blood transfusions, see Trauma pp. [link] and [link].

  • Warm the patient to correct hypothermia.

  • Damage-control surgery should be postponed until hypothermia, acidosis, and coagulopathy have been resolved.

Further reading

Jansen JO et al. Damage control resuscitation for patients with major trauma. British Medical Journal 2009; 338: b1778.Find this resource:

Pearson JD, Round JA and Ingram M. Management of shock in trauma. Anaesthesia and Intensive Care Medicine 2011; 12: 387–9.Find this resource:

Sweeney J. Mass transfusion to combat trauma’s lethal triad. Journal of Emergency Nursing 2013; 39: 37–9.Find this resource:

Spinal cord injuries

Spinal cord injuries are often associated with other injuries, particularly to the head and chest. Any unconscious, multiply injured patient must be assumed to have spinal injuries until these have been excluded by expert opinion. The management of the airway, breathing, and circulation must take priority, although precautions should also be taken to prevent exacerbation of any neurological damage.

Airway maintenance with cervical spine control

  • In high cervical spine injuries, intubation may be required to protect the airway and/or provide a means of ventilatory support. Vertebral fractures above C5 lead to loss of diaphragmatic function, and those above C8 cause loss of intercostal function.

  • A difficult intubation should be anticipated. Endotracheal intubation should be performed by an experienced anaesthetist with an assistant responsible for controlling the head and neck and minimizing spinal movement.

  • A fibre-optic laryngoscope or bronchoscope should be available.

  • Pharyngeal stimulation may provoke a vagal reflex, causing severe bradycardia (this can be prevented by administering atropine or glycopyrronium bromide prior to the procedure).

  • The neck must be stabilized at all times using a rigid collar of appropriate size with sand bags on each side of the head.

  • Stabilization of the neck must be continued throughout all procedures (e.g. X-rays, CVP line insertion).

  • If X-rays confirm spinal damage, more definitive stabilization may be considered (e.g. skull tongs, halo-pelvic traction, spinal fusion).

Breathing

  • Careful observation is required in a patient with a spinal injury who is breathing spontaneously. Ascending oedema of the traumatized cervical cord may lead to deterioration in respiratory status.

  • Equipment for manual ventilation must be at the bedside at all times.

  • Arterial blood gas analysis and pulse oximetry should be used to identify hypoxaemia as early as possible.

  • Vital capacity should be monitored, particularly in patients with fractures above C8 (a forced vital capacity of < 10–15 mL/kg body weight may indicate the need for ventilatory support).

  • The patient should be nursed on a bed capable of lateral tilting and longitudinal elevation, while keeping the spine straight.

  • Keep the head tilted up and the feet down at 30° if possible to increase functional capacity and help to prevent atelectasis.

  • Regular physiotherapy and assisted coughing (supporting the diaphragm) is essential to help to remove chest secretions.

Circulation

  • Neurogenic shock—reduced sympathetic outflow between T1 and T12 may cause hypotension and bradycardia (see Trauma p. [link]).

  • Neurogenic shock must be distinguished from hypovolaemic shock (hypotension and tachycardia), as aggressive fluid replacement is detrimental and may precipitate pulmonary oedema.

  • Atropine or glycopyrronium bromide may be needed if the heart rate is < 50 beats/min with associated hypotension (< 80 mmHg systolic).

  • Fluid challenges may be needed if the patient is hypotensive and bradycardic, but with careful ongoing assessment to avoid over-resuscitation.

  • Hypotension and inadequate tissue perfusion may lead to irreversible neurological damage, and frequent monitoring of vital signs is required—noradrenaline may be needed to maintain sufficient MAP.

  • ECG monitoring is required due to the increased risk of arrhythmias.

  • Temperature may be fluctuating due to loss of sympathetic control.

  • Abdominal or other occult trauma may not be recognized because the abdominal wall is anaesthetized and flaccid. Signs of visceral perforation and haemorrhage may not be readily apparent.

  • Peritoneal lavage, ultrasound, and X-ray procedures may be necessary if abdominal trauma is suspected.

  • Prophylaxis of venous thromboembolism is required.

  • Autonomic dysreflexia—excessive uncontrolled sympathetic output is triggered by a stimulus (e.g. full bladder or bowel) and results in extremely severe hypertension. It is treated by removing the stimulus and administering an antihypertensive drug as necessary to prevent stroke or cerebral haemorrhage.

  • Spinal shock—this is loss of reflexes, sensation, and movement below the level of the spinal cord injury due to swelling (it can last from hours to several weeks, and resolves once the swelling around the injury subsides).

Specific nursing management

  • Cervical spine immobilization and log rolling until the cervical spine is cleared.

  • Nasogastric tube insertion (unless contraindicated) and regular aspiration. Paralytic ileus and gastric dilatation are common in spinal cord trauma. The patient should be nil by mouth for 48 h.

  • Urethral catheter (unless contraindicated), as urinary retention may develop. Urine output should be monitored regularly.

  • Regular urinalysis should be performed (and the colour observed) and body temperature recorded to detect urinary tract infections.

  • Regular administration of laxative and enemas as per unit protocol.

  • Prevention of pressure sores and limb deformities by correct positioning of limbs and joints.

  • Physiotherapy and passive limb movements to preserve joint motion and stimulate the circulation.

  • Adequate nutrition to prevent hypoalbuminaemia.

  • Psychosocial care for the patient and their family.

Further reading

Jia X et al. Critical care of traumatic spinal cord injury. Journal of Intensive Care Medicine 2013; 28: 12–23.Find this resource:

Pellatt GC. Spinal surgery for acute traumatic spinal cord injury: implications for nursing. British Journal of Neuroscience Nursing 2010; 6: 271–5.Find this resource:

Chest injuries

Airway and breathing

  • A patent airway must be secured—endotracheal intubation or tracheostomy may be required.

  • Chest X-ray is needed to identify the specific location of injuries.

  • Mechanical ventilation, CPAP, non-invasive ventilation, or oxygen therapy should be instituted according to the patient’s condition.

  • Any pneumothorax must be identified and drained.

  • Continuous pulse oximetry and regular arterial blood gas analysis should be performed in conjunction with respiratory observations to monitor respiratory function.

  • The self-ventilating patient requires careful and continuous observation in order to detect respiratory distress and the need for further intervention.

Circulation

  • Continuous ECG and monitoring of vital signs are essential.

  • Observe for signs of hypovolaemia (tachycardia, hypotension) and frank blood loss via drains and wounds.

  • Monitor haemoglobin levels.

  • Myocardial contusions may give rise to tachyarrhythmias and conduction abnormalities.

  • Large blood losses may result from tearing of thoracic vessels and haemothoraces.

  • Major cardiac or vascular lacerations may have had haemorrhage arrested by a tamponade effect. Rapid transfusion and the subsequent rise in arterial pressure may result in uncontrollable bleeding.

Specific chest injuries

Pulmonary contusions

Shearing and crushing forces within the thoracic cage cause disruption of the microcirculation. Extravasation of red cells and plasma occurs, and these fluids fill the alveoli. Interstitial haemorrhage and alveolar collapse result, impairing gas exchange. Perfusion is maintained in the unventilated lung segments, causing intrapulmonary shunting and hypoxaemia. Management involves treating hypoxia (with mechanical ventilation, non-invasive ventilation, or O2 therapy), ensuring that there is adequate pain control, and providing physiotherapy.

Rib fractures

Sharp edges of fractured rib may lacerate the underlying lung or blood vessels. If several ribs are fractured in more than one place, or the broken ribs are combined with fracture dislocation of the costochondrial junctions or sternum, a flail segment can move independently of the rib cage. Management is the same as for pulmonary contusions.

Pneumo/haemothoraces

  • Simple pneumothorax—air in the pleural cavity is caused by damage to lung tissue.

  • Open pneumothorax—air enters the pleural cavity from a penetrating injury.

  • Tension pneumothorax—air enters the pleural cavity and increases with each respiration. The affected lung is compressed and collapses, pushing the mediastinal structures to the unaffected side. Cardiovascular collapse will ensue unless immediate decompression is undertaken.

  • Haemothorax—blood is present in the pleural cavity.

  • Pneumo/haemothoraces impair ventilation and may result in hypoxaemia. A chest drain is usually inserted, particularly if mechanical ventilation is necessary, as the likelihood of tension pneumothorax is greatly increased.

Pericardial tamponade

Penetrating or blunt trauma causes the pericardium to fill with blood. This condition is characterized by:

  • Beck’s triad—lowered blood pressure, jugular venous distension, and muffled heart sounds

  • tachycardia

  • increased CVP

  • reduced cardiac output and other signs of obstructive shock (see Trauma p. [link])

  • pulsus paradoxus (a fall in blood pressure during inspiration)

  • ST-segment changes and low-voltage QRS complexes on ECG

  • arrhythmias.

Treatment is by pericardiocentesis.

Myocardial contusions

These are caused by blunt trauma to the chest or by deceleration trauma. They are characterized by:

  • non-specific ST-segment and T-wave changes on ECG

  • arrhythmias

  • elevated cardiac enzymes.

Diaphragmatic rupture

This is caused by blunt or penetrating injuries. The abdominal contents may be pushed through the laceration. Surgical repair is usually necessary.

Aortic rupture

This is characterized by persistent or recurrent hypovolaemia despite fluid replacement. It is frequently fatal.

Major airway injuries

These are characterized by:

  • surgical emphysema

  • stridor

  • aphonia

  • haemoptysis

  • respiratory distress.

They are often accompanied by injuries to the oesophagus, carotid artery, and jugular vein, and may be associated with pneumo/haemothoraces.

Abdominal injuries

Initial priorities are the maintenance of airway, breathing, and circulation. Specific treatment of abdominal injury should not delay correction of hypoxaemia and tissue hypoperfusion. Urgent laparotomy may be indicated if hypovolaemia persists after adequate fluid replacement and the cause cannot be attributed to other injuries.

Blunt abdominal trauma can result in significant internal injuries without obvious external physical signs, and abdominal organs may rupture and/or haemorrhage several hours or days after the traumatic incident. Causes of blunt abdominal trauma include road traffic accidents (including seat-belt injuries), falls, physical fights, and sports injuries. Penetrating abdominal injuries may be due to gunshots, knives, or stabbing with any other type of object inserted into the abdomen.

Assessment

  • ABCDE assessment, observing for signs of hypovolaemic shock (see Trauma p. [link]).

  • Presence of increasing abdominal pain, rigidity, or distension.

  • Presence of bruising, lesions, or wounds to the abdomen or flanks (see Table 18.2).

  • For penetrating trauma, check the groin, buttocks, and armpits.

  • Urine output, volume, and colour, and presence of blood in the urine.

  • Abdominal pressure (for the assessment and management of intra-abdominal hypertension, see Trauma pp. [link] and [link]).

  • Haemoglobin and coagulation profile to assess whether these indicate ongoing internal bleeding.

  • LFTs, U&E, and glucose levels to assess liver and kidney function.

Table 18.2 Abdominal signs

Name

Assessment

Causes

Grey Turner’s sign

Bruising to lower abdomen and back

Acute pancreatitis, retroperitoneal bleeding, ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy

Cullen’s sign

Bruising and oedema near the umbilical area

Acute pancreatitis, retroperitoneal bleeding, ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy

Ballance’s sign

  • Left upper quadrant percussion—dullness

  • Right upper quadrant percussion—shifting dullness

Splenic rupture or injury (coagulated blood around splenic area and free blood in peritoneum)

Kehr’s sign

Acute pain in shoulder tip, which increases while lying down with feet up

Referred pain from diaphragmatic irritation due to intraperitoneal blood, clots, or air (e.g. splenic injury, ruptured ectopic pregnancy)

Specific nursing management

  • Closely monitor vital signs and haemoglobin levels.

  • Provide IV fluids and/or blood products as required.

  • Insert a nasogastric tube (unless contraindicated) in order to:

    • decompress the stomach

    • reduce the risk of aspiration pneumonia

    • detect the presence of upper gastrointestinal injury (indicated by blood in the nasogastric aspirate).

  • Closely monitor temperature, peritonism (see Table 18.3), and purulent discharge from wounds or drains.

    • Patients with abdominal injuries are particularly at risk of local infection, septicaemia, and multi-organ dysfunction syndrome (MODS), so must be regularly monitored for potential infection.

    • If the spleen has been removed, there is an increased risk of overwhelming bacterial sepsis due to reduced humoral immunity.

Table 18.3 Peritonism*

Peritoneal sign

Assessment

Acute abdominal pain

Pain to the abdomen increases with movement of the peritoneum (e.g. ask patient to cough, flex and rotate hip, lie on their side and hyperextend hip)

Guarding

Voluntary contraction of abdominal muscle upon palpation (may decrease if the patient is reassured or distracted)

Rigidity

Involuntary reflex in which abdominal muscles contract upon palpation; it persists on repeat examinations

Rebound tenderness

Increased pain when the fingers are quickly withdrawn after firmly palpating into the abdomen

*Peritonism refers to an acute abdomen which is probably due to peritonitis and presents with the peritoneal signs listed above.

Pelvic fractures

Causes of a fractured pelvis include falls from standing (patients with osteoporosis are particularly at risk), falls from a considerable height, road traffic accidents, and crush injuries. The following are specific examples of different types of pelvic injuries:

  • lateral compression fracture (see Figure 18.2)

  • anterior–posterior compression fracture (open book) (see Figure 18.3)

  • vertical sheer fracture (see Figure 18.4).


Figure 18.2 Pelvic injury: lateral compression (LC) fracture.

Figure 18.2 Pelvic injury: lateral compression (LC) fracture.

(Reproduced from Bulstrode C et al., Oxford Textbook of Trauma and Orthopaedics, 2011. By permission from Oxford University Press.)


Figure 18.3 Pelvic injury: anterior–posterior compression (APC) fracture (open book).

Figure 18.3 Pelvic injury: anterior–posterior compression (APC) fracture (open book).

(Reproduced from Bulstrode C et al., Oxford Textbook of Trauma and Orthopaedics, 2011. By permission from Oxford University Press.)


Figure 18.4 Pelvic injury: vertical sheer fracture.

Figure 18.4 Pelvic injury: vertical sheer fracture.

(Reproduced from Bulstrode C et al., Oxford Textbook of Trauma and Orthopaedics, 2011. By permission from Oxford University Press.)

Injury to the pelvis can result in severe and uncontrollable haemorrhage. Therefore continuous recording of vital signs is essential, and fluid resuscitation should be given as necessary. Immobilization and external fixation can help to control bleeding, but surgical repair of torn vessels or angiography and embolization may be required.

Care of pressure areas may pose particular problems, and clear instructions must be given by the surgeon as to the degree of mobility the patient is allowed. A pressure-relieving mattress is essential, as movement remains limited even after external/internal fixation.

Further reading

Bodden J. Treatment options in the hemodynamically unstable patient with a pelvic fracture. Orthopedic Nursing 2009; 28: 109–16.Find this resource:

McMaster J. Pelvic ring fractures: assessment, associated injuries, and acute management. In: C Bulstrode et al. (eds) Oxford Textbook of Trauma and Orthopaedics, 2nd edn. Oxford University Press: Oxford, 2011. pp. 1253–64.Find this resource:

Walker J. Pelvic factures: classification and nursing management. Nursing Standard 2011; 26: 49–58.Find this resource:

Genito-urinary injuries

The initial management of a patient with genito-urinary injury is to stabilize airway, breathing, and circulation before specific investigations are undertaken to diagnose the injury. A urethral catheter must not be inserted in a patient with suspected trauma or major pelvic fractures until advised by the urologist.

Upper genito-urinary injuries

Renal trauma can be categorized as follows:

  • minor—parenchymal damage, contusions, superficial lacerations

  • major—deep lacerations involving the pelvicalyceal system and/or tears of the capsule

  • critical—renal fragmentation and pedical injuries (renal artery thrombosis, pelvi-ureteric rupture, avulsion of renal vessels); these can cause major blood loss and hypovolaemic shock.

Specific nursing observations

  • Vital signs and haemoglobin levels.

  • Urinary output.

  • Haematuria.

  • Evidence of bruising or swelling over the lower thoracic, loin, or upper abdominal areas.

  • Pain.

  • Rigidity of the abdominal wall on the affected side.

  • Ureteric colic if blood clots are passed through the ureter.

Lower genito-urinary injuries

Specific nursing observations

  • Vital signs and haemoglobin levels.

  • Urinary output.

  • Haematuria.

  • Inspect the urethral meatus for blood.

  • Evidence of bruising, particularly of the perineum.

  • Abdominal pain or rigidity.

Musculoskeletal injuries

Management is secondary to resuscitation and control of the airway, breathing, and circulation. Life-threatening conditions include:

  • traumatic amputations

  • severe crush injuries to the pelvis and abdomen

  • multiple long bone fractures

  • vascular injuries

  • open fractures

  • haemorrhagic shock (see Trauma pp. [link] and [link]), which must be identified and treated before definitive treatment of the injury.

Specific observation of limbs

  • Temperature.

  • Colour.

  • Capillary refill time.

  • Pulses.

  • Sensation and pain.

  • Local compression (plaster of Paris, splints, bandages).

Specific nursing management

This depends on the extent of the injuries and degree of immobility.

Traction

  • Frequent and meticulous attention to pressure areas, and use of a pressure-relieving mattress.

  • Inspect pin sites, and keep them clean and dry.

  • Passive/active limb exercises for non-immobilized joints.

  • Traction weights should hang free, with the knots secure.

  • Retain traction when moving the patient, and support the weights.

Plaster cast

  • For a description of specific observation of limbs, see Trauma p. [link].

  • Check for constriction due to swelling.

  • Check for pain under the plaster cast.

  • Check skin integrity around the plaster edge.

  • Elevate the limb to alleviate swelling.

Potential complications

  • Haemorrhage—monitor vital signs and haemoglobin levels, and observe wounds and drains.

  • Compartment syndrome—monitor the area affected by trauma for swelling and signs of poor perfusion (report suspected compartment syndrome to the doctor immediately because of the need for urgent surgical intervention).

  • Infection—monitor temperature, and observe wounds, cannulae, and pin sites.

  • Deep vein thrombosis—inspect the calves for swelling and pain, and consider anti-embolic stockings/prophylactic anticoagulation.

  • Rhabdomyolysis—monitor creatine kinase and renal function.

  • Fat embolism syndrome:

    • This is associated with fractures to the long bones and pelvis, polytrauma, and after orthopaedic surgery

    • Fat macroglobules released from the bone damage the endothelium, leading to respiratory failure, cerebral dysfunction, and skin petechiae (although the patient may be asymptomatic).

    • It is difficult to diagnose (so is often diagnosed by exclusion of other causes), and management includes respiratory support and fluid resuscitation.

Flaps

Free or pedical flaps are used to correct an anatomical defect. Post- operative survival of the flap depends on adequate perfusion. Close and frequent observation of the flap is essential in order to detect changes as soon as possible. Assess and document the flap condition according to local protocol, and report any changes immediately. Factors that are detrimental to flap survival include:

  • hypotension

  • vasopressors

  • hypovolaemia

  • poor positioning.

Specific flap observations

  • Temperature—core, peripheral, and flap.

  • Colour.

  • Capillary refill time.

  • Turgidity.

  • Pulse.

Specific flap management to maintain core–flap temperature difference of < 1.5°C

  • Keep the flap warm—use a body-warming device if necessary.

  • Keep the vessels dilated—use IV glyceryl trinitrate.

  • Keep Hb < 10 g/dL to reduce blood viscosity.

  • Maintain blood pressure and CVP within set parameters.

Blast injuries

Victims of blast injuries experience trauma from a number of sources. The initial source of trauma is the blast wave (primary injury), and this is often accompanied by blunt or penetrating trauma associated with projectile debris from the explosive device or the surrounding area (secondary injury). Further injury can be caused by being thrown against stationary objects, or by building collapse (tertiary injury). There may also be exposure to toxic or radioactive substances (quaternary injury).

The predominant injuries seen after bomb blasts are pulmonary, abdominal, orthopaedic (including soft tissue), neurological, and ontological.

Blast wave or primary injury

Injuries are caused by the slamming impact of the high-pressure energy wave on the body. This causes injuries to hollow organs, such as the ears, respiratory tract, and abdominal viscera. These injuries may manifest little in the way of external evidence of trauma, so patients require careful assessment for any clinical manifestations (see Table 18.4).

Table 18.4 Impact of blast injuries

Pathology

Clinical signs

Blast lung (alveolar rupture, pneumothorax, pulmonary contusion, and haemorrhage)

  • Tachypnoea

  • Hypoxaemia

  • Cyanosis

  • Wheezing

  • Decreased breath sounds

  • Haemoptysis

  • Cough

  • Chest pain

  • Dyspnoea

  • Haemodynamic instability

Tympanic membrane rupture and damage

  • Deafness

  • Bleeding from the ear

Abdominal haemorrhage and perforation

  • Abdominal pain and rectal bleeding

  • Liver or spleen lacerations

  • Rebound tenderness

  • Guarding

  • Absent bowel sounds

  • Signs of hypovolaemia

  • Nausea and vomiting

Traumatic brain injury

  • Loss of consciousness

  • Headache

  • Fatigue

  • Poor concentration

  • Lethargy

  • Amnesia

Blast-wave-related traumatic brain injury is also frequent, and has the hallmark of diffuse brain injury. This is thought to be related to transfer of the kinetic energy of the blast pressure to the central nervous system.

Secondary injuries

These are commonly multiple, involving shrapnel wounds, traumatic amputations, fractures, and internal injuries. Victims may also receive extensive burns from the blast energy and blast-related fire. These injuries can rapidly lead to haemorrhagic shock and a severe systemic inflammatory response syndrome, and require immediate and effective treatment.

Management of blast injuries

  • Immediate management will follow the ABCDE priorities of any acute trauma. A primary assessment is needed to ensure that airway, breathing, and circulation are supported, followed by a thorough secondary assessment.

  • Airway—should be secured by endotracheal intubation if there are signs of compromise, upper airway burns or smoke inhalation, or impending respiratory failure.

  • Breathing—adequate arterial oxygen saturations should be maintained with additional inspired oxygen plus mechanical ventilation. If there are concerns about pulmonary blast injury, care should be taken not to deliver too much fluid during resuscitation.

  • Circulation—an adequate circulating intravascular volume and organ perfusion should be maintained by filling against markers such as blood pressure, CVP, urine output, and metabolic acidosis. Hypotension usually requires correction with whole blood, clear fluids (colloid/crystalloid), and blood products to maintain haemostasis.

Major burns

Expert advice for patients with major burn injuries should be sought from a specialist burns unit or centre. While the patient is waiting to be transferred to a specialist unit, protective isolation in an environment with humidity and temperature control should be provided if possible. Initial history taking and rapid assessment should identify the causative factor (e.g. flame, electrical, chemical, explosion, radiation, or cold), and the depth, size, and location of the burn.

Airway

  • Early intubation may be needed before laryngeal oedema and facial swelling increase over time.

  • Do not cut the oral endotracheal tube (OETT) prior to intubation. Do assess the tie tapes frequently because of facial swelling.

Breathing

  • Give humidified O2 and mechanical respiratory assistance as required.

  • Mechanical ventilation should follow protective lung strategies (see Trauma p. [link]) due to the high risk of ARDS.

  • Use regular suctioning and nebulizers—bronchial lavage may also be required to clear secretions.

  • Monitor ABG, lactate, and carboxyhaemoglobin levels.

Smoke inhalation

  • Chemicals in smoke cause inflammation and damage to the airway and lungs, leading to mucosal dysfunction, airway coagulopathy, laryngospasm, bronchospasm, pulmonary oedema, and ARDS.

  • There is an increased risk with fire in a confined space or prolonged exposure to smoke—bronchoscopy is required to confirm the diagnosis.

  • Do not rely on O2 saturation readings (see Trauma p. [link] for an overview of the effects of carboxyhaemoglobin on pulse oximetry).

  • Use nebulized agents according to local protocol (e.g. normal saline, salbutamol, bicarbonate, acetylcysteine, anticoagulant).

Circulation

Burn shock

  • Poor tissue perfusion results from combined hypovolaemic, distributive, and cardiogenic shock due to a reduced effective circulating blood volume, SIRS, and decreased myocardial contractility.

Fluid resuscitation

  • Massive intravascular fluid deficit can occur due to direct fluid loss at the burn site and third spacing (fluids shift to the interstitial space as a result of decreased albumin and increased capillary permeability).

  • Formulae exist for IV fluid replacement regimes, but should be used as a guide only—seek expert advice from the specialist burns unit and use end points of resuscitation goals (e.g. heart rate, blood pressure, urinary output, haemoglobin, lactate, and base deficit) to prevent under- or over-resuscitation.

    • Fluid creep—fluid overload from over-resuscitation with excessive administration of IV fluids.

  • Inotropes and/or vasoconstrictor may be required if low blood pressure and low cardiac output persist despite fluid resuscitation.

  • Close monitoring of blood electrolytes, clotting, and full blood count is required.

  • Blood components (e.g. packed red blood cells, fresh frozen plasma) should be given as required.

Renal monitoring

  • Close monitoring of urine output is needed, aiming for 0.5 mL/kg/h.

  • Acute kidney injury may result from:

    • lowered blood pressure due to decreased intravascular volume and/or vasodilation

    • myohaemoglobinuria, which occurs with electrical burns or deep dermal/full-thickness burns and causes rhabdomyolysis—use a urine output goal of 1–2 mL/kg/h to flush out the kidneys.

Hypothermia

  • Prolonged SIRS and hypermetabolism that occur with major burns result in the body resetting its ‘normal’ baseline temperature to 38°C. A temperature of 36–38°C is considered to be relative hypothermia.

  • Warm the room, and provide inspired air, blankets, and IV fluids as needed.

Infection

  • Raised temperature can persist for several days, but may be due to SIRS and not necessarily caused by infection.

  • Scrupulous attention to infection prevention and control is essential.

  • Observe wounds and discharge for signs of infection.

  • Appropriate antibiotics should be given if indicated.

Disability

  • Monitor neurological status, sedation level, and pain.

  • Provide analgesia, particularly before and during dressing changes.

  • Provide blood glucose control according to local protocol.

Exposure

  • Liaise with the specialist burns unit with regard to wound management.

  • Monitor the abdomen and limbs for signs of compartment syndrome.

Other considerations

  • Avoid suxamethonium from 5 to 150 days post-burn, as there is a risk of rapid and severe hyperkalaemia.

  • Early enteral nutrition should follow specific guidance from a dietitian.

  • A bowel management system should be used if burns affect the buttocks or upper legs.

  • Physiotherapy and occupational therapy referral should be arranged.

  • Psychological support should be provided for the patient, their family, and staff members.

Further reading

Bishop S and Maguire S. Anaesthesia and intensive care for major burns. Continuing Education in Anaesthesia, Critical Care & Pain 2012; 12: 118–22.Find this resource:

Miller AC, Elamin EM and Suffredini AF. Inhaled anticoagulation regimens for the treatment of smoke inhalation-associated acute lung injury: a systematic review. Critical Care Medicine 2014; 42: 413–19.Find this resource:

Maxillofacial injuries

Many patients with severe maxillofacial injuries will have other associated injuries, and cervical spine trauma must always be suspected. Extreme care is needed while stabilizing the neck when the airway is being secured. Injuries to the face and neck can be life-threatening because they may compromise the airway and cause major haemorrhage.

Specific fractures

  • Mandible—may cause airway obstruction if it is a bilateral fracture. Often causes haematoma and swelling of the neck and floor of the mouth. Treatment is by internal wiring or plating.

  • Maxilla—Le Fort I, II, or III. Le Fort II and III fractures are associated with basal skull fracture and may lead to CSF leakage. Nasal intubation must never be performed. Treatment involves internal wiring and plating and intermaxillary fixation. External fixation is often required.

  • Zygoma and orbit—fracture and displacement of the zygoma can disrupt the lateral wall and floor of the orbit. Subconjunctival ecchymosis and peri-orbital swelling may be present. Unstable fractures require internal or external fixation, whereas stable fractures can be surgically reduced. Fractures of the orbital walls may tear or compress the optic nerve, and blindness is immediate and permanent. Avoid supra-orbital pressure during neurological assessment of patients with suspected facial fracture.

  • Nasal—haemorrhage may be severe and may require nasal packing. Closed reduction and external splinting may be required.

  • Larynx—fracture may severely compromise the airway and necessitate immediate tracheostomy. Surgical exploration and repair are usually necessary.

Specific management

Airway and breathing

  • Soft tissue swelling and oedema can increase insidiously.

  • A patient without tracheal intubation is at risk of developing airway problems.

  • Ensure that oxygen face masks are not tight-fitting if the patient has facial injuries.

  • Never use nasal cannulae if there is evidence of rhinorrhoea.

  • Observe for increasing difficulty in breathing, stridor, and oedema of the face, neck, and mouth.

  • Keep the head of the bed elevated if possible to encourage drainage of blood, saliva, and CSF away from the airway and reduce venous pressure.

Circulation

Significant haemorrhage can occur from closed fractures to the maxilla, nose, and ethmoids, and can cause profound swelling.

  • Obtain clear guidelines from the medical staff with regard to specific wound management.

  • Check all wounds for foreign bodies such as glass.

  • Observe for haemorrhage, haematoma, and infection.

  • Ensure that pin sites of external fixation are kept clean and dry.

Mouth

  • Mouth care can be difficult, but is essential in patients who have had major oral surgery and have sutures or skin grafts within the oral cavity, have their jaws wired together, or cannot take oral fluids.

  • A pair of wire cutters must be available at the bedside if the patient’s jaws are wired (in order to cut the wires if the patient vomits and the airway is compromised).

  • Regular anti-emetics should be given if the patient is experiencing nausea, as vomiting must be prevented.

Eyes

  • Observe for peri-orbital swelling and subconjunctival haemorrhage.

  • Pooling of tears may indicate damage to the lacrimal apparatus.

  • Proptosis or exophthalmos (bulging of the eye) suggests haemorrhage within the orbital walls.

  • Foreign bodies (grit or glass) can penetrate the eye and cause pyrogenic infection.

Nose

  • Observe for bleeding.

  • Rhinorrhoea suggests a cribriform plate fracture. Do not pass a nasogastric tube in this case or the cranial cavity may be intubated.

Ears

  • Observe for bleeding or otorrhoea.

  • Look behind the ears for bruising over the mastoid process (Battle’s sign), which can indicate a basal skull fracture.

Drowning

Definition

The International Liaison Committee on Resuscitation defines drowning as a ‘process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. Implicit in this definition is that a liquid–air interface is present at the entrance of the victim’s airway, preventing the victim from breathing air. The victim may live or die after this process, but whatever the outcome, he or she has been involved in a drowning incident.’3 Hypothermia usually accompanies a drowning incident, and although it has a protective effect against organ damage, it causes loss of consciousness and haemodynamic changes.

Causes

Traditionally, freshwater drowning was thought to lead to rapid absorption of water into the circulation, causing haemolysis, hypo-osmolality, and electrolyte disturbances, whereas inhalation of salt water was believed to cause mucosal injury and osmotic pulmonary oedema. In practice there is little difference between them, as both cause loss of surfactant and severe inflammatory disruption of the alveolar–capillary membrane, leading to ARDS.

Assessment findings

  • Hypoxia.

  • ARDS.

  • Multi-organ dysfunction syndrome.

  • Sepsis.

  • Pneumonia.

  • Circulatory failure.

  • Electrolyte imbalance.

  • Dysrhythmias.

  • Acute kidney injury.

  • Neurological damage.

  • Gastric dilatation.

  • Metabolic acidosis.

Management

  • Cardiopulmonary resuscitation is often required initially.

  • Airway management and high-concentration O2 by mask if self-ventilating, or intubation and mechanical ventilation as needed. Early CPAP/PEEP is useful, and high inflation pressures may be required.

  • Nebulized β‎-agonists if bronchospasm is present.

  • Haemodynamic monitoring.

  • Vasopressors if the patient is hypotensive.

  • Treatment of dysrhythmias (secondary to hypoxaemia, electrolyte imbalance, acidosis, and hypothermia).

  • Monitoring of blood electrolytes and glucose levels.

  • Fluid replacement guided by appropriate monitoring.

  • Haemolysis may require blood transfusion.

  • Monitor the core temperature, and rewarm as necessary (see Table 18.6, Trauma p. [link]).

  • Monitor urine output—haemolysis may cause haemoglobinuria and consequent acute kidney injury.

  • Neurological observations—ischaemic cerebral damage and cerebral oedema may occur. Raised intracranial pressure should be reduced to maintain cerebral perfusion, and the patient should be closely monitored for seizures, with subsequent seizure management implemented (see Trauma p. [link]).

  • Insert a nasogastric tube for gastric decompression and to avoid aspiration.

  • Antibiotic therapy is required if there is evidence of aspiration (e.g. mud, sand, or particulate matter on suction). Otherwise take specimens and treat as indicated.

  • Metabolic acidosis may develop following intense peripheral vasoconstriction and hypoxaemia. Lactate levels rise as oxygen delivery to the tissues falls, but should improve as the patient is rewarmed and hypoxia is corrected.

  • Physiotherapy.

Table 18.6 Rewarming

Passive

Mild hypothermia

  • Rewarm slowly (0.5–1°C/h)

  • Warm environment

  • Reflective space blanket/warm air blanket

  • Extra blankets

  • Cover exposed skin (e.g. scalp)

  • Remove wet clothes

Active

Moderate hypothermia

  • Heated humidified respiratory gases

  • Warmed IV fluids

  • Electrically heated mattress or pads

Core warming

Severe hypothermia

  • Rapid rewarming techniques (1–5°C/h)

  • Gastric and bladder lavage with warmed fluids

  • Peritoneal/haemodialysis

  • Extracorporeal circuits

Reference

3 Idris AH et al. Recommended guidelines for uniform reporting of data from drowning: the “Utstein style”. Resuscitation 2003; 59: 45–57.Find this resource:

Further reading

Soar J et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010; 81: 1400–33.Find this resource:

Hypothermia

Definition

A patient is considered to be hypothermic if they have a sustained core temperature below 35°C (mild, 32–35°C; moderate, 28–32°C; severe, < 28°C).

Causes

Environmental causes

  • Immobility (e.g. due to coma, spinal injury, or in elderly).

  • Submersion or immersion in cold water.

  • Exposure or poor living conditions.

Secondary hypothermia

  • Reduced metabolic rate caused by a primary metabolic disorder (e.g. hypothyroidism, hypopituitarism, malnutrition).

  • Sepsis.

  • Immediate post-operative.

  • Erythroderma (generalized erythema and exfoliation).

Therapeutic

  • Targeted temperature management following cardiac arrest (see Trauma p. [link]) or traumatic brain injury (see Trauma p. [link]).

Assessment findings

  • Table 18.5 summarizes the features of hypothermia.

Table 18.5 Features of hypothermia

Temperature

Assessment

> 33°C

Thermoregulatory mechanisms usually intact, marked shivering

< 33°C

Slowness and dysarthria

< 31°C

Loss of consciousness, pupillary dilatation, hypertonicity, life-threatening cardiovascular dysfunction

< 28°C

Rigor mortis-like appearance, impalpable arterial pulse, cessation of respiration

  • ECG changes—as the body temperature decreases, sinus bradycardia is followed by atrial flutter and fibrillation. The PR interval, QRS, and QT interval are prolonged. Atrial activity then ceases, and ventricular fibrillation is common at < 30°C, leading to asystole at < 28°C.

  • Decreased cardiac output and blood pressure.

  • Hypoxaemia due to hypoventilation and ventilation–perfusion mismatch.

  • Respiratory acidosis due to increased CO2 levels.

  • Polyuria and electrolyte imbalance due to impaired tubular function and reduced responsiveness to antidiuretic hormone (ADH).

  • Cerebral depression due to decreased cerebral blood flow.

  • Metabolic acidosis due to increased levels of lactate and other metabolites.

  • Hyperglycaemia due to decreased insulin release, glucose metabolized from liver glycogen, or pancreatitis which may develop.

  • Coagulopathy.

Management

  • Airway management and oxygenation.

  • Monitor core temperature.

    • Assess for ongoing hypothermia and impact of rewarming techniques to return patient to normothermia.

    • Consider targeted temperature management, maintaining therapeutic hypothermia if there has been a return to spontaneous circulation following cardiac arrest (see Trauma p. [link]).

    • Ensure that the patient does not become hyperthermic as a result of rewarming therapy.

  • Rewarming (see Table 18.6).

  • ECG monitoring and detection of dysrhythmias.

    • In the event of cardiac arrest (and no evidence of other fatal disease), full resuscitation should continue until the patient is normothermic.

    • VF is resistant to defibrillation in the temperature range 28–30°C.

  • Haemodynamic monitoring.

    • Vasodilation occurs as the patient is rewarmed, which may require large amounts IV fluids and vasoconstrictor.

  • Monitor fluid status and provide warm IV fluids as required.

  • Monitor urine output.

  • Monitor blood glucose levels, electrolytes, and clotting profile.

  • Neurological observations, including assessment of and treatment for seizures.

Complications following trauma

Hypovolaemic shock

See Trauma p. [link].

Compartment syndrome

This results from swelling, bleeding, or ischaemia within the fascial compartments of the limbs. The interstitial tissue pressure rises as the compartments are unable to expand. When this pressure exceeds that of the capillary bed, local ischaemia of nerve and muscle occurs. Rhabdomyolysis (see Trauma p. [link]), permanent paralysis, or gangrene may result.

Features

  • Pain.

  • Tense swelling of the fascial compartment(s).

  • Reduced sensation over the dermatomes supplied by the affected nerves.

  • Absence of distal pulses (a late sign—may be irreversible damage).

Management

  • Monitor the limbs for swelling, abnormal perfusion, temperature differences, and pain.

  • Remove restrictive dressings.

  • Needle manometry (pressures of > 20mmHg are abnormal).

  • Fasciotomy.

Fat embolism

Fat macroglobules and marrow enter the systemic circulation from bone fractures (usually of the long bones and pelvis) and cause mechanical obstruction of vessels.

Features

  • Hypoxaemia.

  • Tachypnoea, tachycardia, and pyrexia.

  • Hypotension and decreased cardiac output.

  • Oliguria.

  • Petechiae.

  • Confusion, drowsiness, decerebrate signs, convulsions, or coma.

Management

  • Supportive treatment.

  • Supplementary oxygen or mechanical respiratory assistance to correct hypoxaemia.

  • Maintain circulatory volume.

  • Inotropic support.

  • Renal support—CVVHD/dialysis.

Air embolism

This occurs when air leaks from the lungs directly into the pulmonary circulation and into the left side of the heart. It can occur in severe lung injury due to a bronchopulmonary vein fistula or from direct penetrating injury to the pulmonary veins. Major cardiovascular collapse follows, with associated hypoxaemia. Treatment consists of turning the patient on their left side in a head-down, feet-up position, and the air is aspirated from the left ventricle, followed by thoracotomy of the injured side.

Post-traumatic stress disorder (PTSD)

In addition to the physiological impact of trauma on the body, traumatic injury can significantly influence the mental well-being of the patient who has experienced the trauma, as well as that of their family. For the assessment and management of PTSD, see Trauma pp. [link] and [link].

Further reading

Aitken LM et al. Health status of critically ill trauma patients. Journal of Clinical Nursing 2014; 23: 704–15.Find this resource: