ER/Trauma
What technique is used to open the airway of an unresponsive patient with a suspected cervical injury?
What is jaw thrust technique?
What components are required to transfer a patient according to EMTALA?
An accepting physician
An available bed and resources to care for the patient
Appropriate mode of transfer based on the patient's injury and needs
Name the components of the primary survey of the trauma patient. Must list ALL components.
B: breathing
C: circulation
D: disability
E: exposure, environmental controls
Describe components for the assessment of airway and breathing in a trauma patient.
Vocalization, can the patient talk? moaning? crying?
tongue obstructing airway?
loose teeth, foreign objects, blood, vomitus, other secretions? carbonaceous sputum? edema?
equal rise and fall of chest cavity, bilateral clear breath sounds to auscultation, nasal flaring? accessory muscle use? SPO2? respiratory rate? spontaneous breathing, rate and pattern of breathing, skin color, cyanosis?, bruising to chest wall? bony structures of chest wall? chest deformities? JVD? tracheal deviation? AMS, restless, signs of hypoxia, paradoxical movement, subcutaneous emphysema, sucking chest wounds
ABGs?
What two items should you always keep at the bedside of a patient with a pneumothorax?
bottle of normal saline and an occlusive dressing
Describe the function of a chest tube drainage system and identify troubleshooting for complications.
Prevents air and fluid from reentering the pleural space.
Creates negative intrapleural pressure to reinflate the lung
chest tube tubing becomes disconnected from water seal system, place the tubing in a bottle of sterile saline to provide a water seal
chest tube becomes dislodged from patient, place occlusive dressing at wound taped at 3 sides
water seal chamber- rise and fall with breathing (tidaling), if none then system may not be working properly or pt's lung may have reexpanded, continuous bubbling- leak
suction chamber- continuous bubbling
keep system below the pt's chest at all times
initial output > 1000 ml or > 200 in 3-4 hours, report to physician
Dont clamp or milk
What do priapism and absent rectal tone indicate in a trauma patient?
Name the components of the secondary survey for a trauma patient. Must list ALL components.
F- full set of vital signs, focused adjuncts, family presence
G- give comfort measures
H- head to toe assessment, history
I- inspect posterior surfaces
Name components for the assessment of the circulation and disability primary survey.
circulation- ams, signs of decreased perfusion, skin color, pulses, central and peripheral, tachycardia, hypotension, decreased cardiac output, pale, cool moist skin, uncontrolled bleeding, distended or flat jugular veins, distant heart sounds
disability- avpu- alert, verbal, pain, unresponsive
GCS
pupils PERRLA, lateralizing signs (hemiparesis, hemiplegia, pupil changes, facial droop)
abnormal posturing, decorticate, decerebrate
paradoxical movement of the chest wall, the unsupported chest wall move paradoxically or opposite from the rest of the chest wall during inspiration and expiration
leads to hyoventilation and atelectasis
treatment- 100% oxygen, pain management, deep breathing, coughing, incentive spirometry
What is flail chest?
Name the indication, contraindications, advantage, disadvantage, insertion technique, and measurement for a nasopharyngeal airway
Indication- airway adjunct used to maintain or open a patient's airway
Contraindications- coagulopathies, facial trauma, basilar skull fracture
Advantage- can provide suction through device
Disadvantages- doesn't protect against aspiration
Measurement- from tip of nose to tragus of ear
Insertion technique- insert along floor of nasopharyngeal cavity, rotate 90 degrees
Complication of blunt trauma/MVC
pts found DOA usually cause
pt describes as "ripping or tearing" in chest
chest pain, jaw and neck pain, shoulder pain
no pain 10% of patients
dyspnea, syncope, flank pain, abdominal pain
This is why trauma patients should have chest x-ray, chest CT performed to rule out this life-threatening injury
What is a dissecting aorta?
Name at least 3 measures to verify endotracheal tube placement.
bilateral breath sounds to auscultation
equal rise and fall of chest cavity
waveform capnography- CO2 35-45 mm Hg
exhaled co2 detector- "go for the gold"
esophageal detection device- inflated if in trachea, deflated if in esophagus
stat portable chest x-ray
Describe assessment, interventions for the expose, environmental controls, focused adjuncts, family presence, full set of vital signs of the primary and secondary survey
remove pt's clothing so that all injuries can be quickly identified, carefully remove weapons, glass, needles, objects that could harm staff, document decontamination if performed, follow protocol for collecting evidence (rape kit), use bear hugger, warmed fluids, cold fluids, tepid sponge bath, cold packs to groin/axillae depending on dx,
urinary catheter, cardiac telemetry, ng tube insertion, diagnostics, chest x-ray etc,
accumulation of blood in the pericardial sac, 120-150 ml of blood compresses the atria and ventricles
occurs most often with penetrating injury, also blunt trauma
decreased venous return, decreased preload, decreased cardiac output
s/s- hypotension, tachycardia, dyspnea, cyanosis
tx- pericardiocentesis
What is cardiac tamponade?
Name 3 indications for endotracheal intubation.
1. failure to ventilate
2. failure to oxygenate
3. inability to protect the airway against aspiration
4. Anticipate deteriorating course that will eventually lead to respiratory failure
5. inability to maintain airway patency
What does free air in the abdomen on x-ray indicate?
What is perforation of the bowels/peritonitis?
Give the indication, contraindication, disadvantage, insertion technique, and measurement for an oropharyngeal airway.
Indication- airway adjunct used to open or maintain a patient's airway
Measurement- from corner of mouth to angle of jaw
Contraindication- the patient has a gag reflex
Disadvantage- Does not protect against aspiration
Insertion technique- insert upside down and rotate 180 degrees
Describe the components for assessment/interventions for give comfort measures, history, head to toe assessment, inspect posterior surfaces
nonverbal pain cues, grimacing, muscle tension, tachycardia, elevated BP, tachypnea, diaphoresis,guarding, splinting, clenched fist/teeth
If pain is not treated what can occur? increased heart rate and force of hear contraction, increase work on the heart, tachypnea ,anorexia, nausea, vomiting, release of catecholamines epi and norepi causing increased BP, cardiac afterload, and myocardial oxygen consumption
What pain medications should be avoided in patients with neurological symptoms?
preexisting medical conditions, current medications, allergies, tetanus immunization hx, previous hospitalizations and surgeries, recent use of drugs or alcohol, last normal menstrual period, mechanism of injury, tx received prior to arrival,▪History of smoking, substance abuse, age > 55 or < 5, cardiovascular disease, respiratory disease, diabetes, hemophilia or other blood disorders, morbid obesity, pregnancy, immunosuppression, use of anticoagulants
absence of rectal tone, abrasions, lacerations, etc
Name the 3 components of Beck's Triad?
What disorder is it seen in?
What are muffled heart sounds, hypotension, and jugular venous distention?
Cardiac tamponade
Name all types of pneumothorax, describe symptoms for each, risk factors if noted, and treatment
s/s- subcutaneous emphysema, dyspnea, chest pain, tachypnea, tachycardia, hyperresonance, decreased breath sounds on affected side (pneumothorax), or decreased breath sounds on opposite side (tension pneumothorax), open sucking wound (open pneumothorax), blood present (hemothorax)
tx pneumothorax/hemothorax- greater than 15% chest tube
open pneumothorax- occlusive dressing taped on 3 sides
tension pneumothorax- immediate needle decompression followed by chest tube insertion
tension pneumothorax- trachea deviation to opposite side, decreased cardiac output, hypotension, distended neck veins, chest pain, dyspnea, severe respiratory distress, cyanosis
Name s/s of a basilar skull fracture
What other complication could this injury cause?
What nursing interventions are contraindicated with basilar skull fracture?
How is basilar skull fracture diagnosed?
battle's sign (bruising behind ear), racoon eyes (periorbital ecchymosis), rhinorrhea, otorrhea, cranial nerve VII palsy, (facial droop)
bacterial meningitis
ng tube insertion, nasopharyngeal airway insertion
CT of the brain, halo test- concentric ring indicates the presence of glucose (CSF)
Name and describe the five levels of triage.
Must list ALL components and give accurate definitions.
2. Emergent- high-risk situation, unstable, severe pain or distress, tx within 10 minutes
3. Urgent- require treatment within 20-30 minutes
4. Semi-urgent- require treatment within 1-2 hours
5. Nonurgent- wait is indefinite
What are Cullen's sign, Grey Turner's sign, and Kehr's sign?
What disorder is specifically associated with Cullen's sign and Grey Turner's sign?
What do each indicate?
Cullen's sign- bruising around the umbilicus, indicates bleeding in the abdominal cavity (retroperitoneum)
pancreatitis
Grey Turner's sign- bruising at flanks, indicates bleeding in the abdominal cavity
Kehrs sign- acute pain in the tip of the shoulder , can indicate blood in the peritoneal cavity, kehr's sign in the left shoulder is a classic symptom of a ruptured spleen, what disorder does kehr's sign in the right shoulder typically indicate? cholecystitis
What three components does the GCS measure?
A GCS < 8 indicates ?
This posturing is characterized by abnormal extension of the extremities and indicates damage to the cortical spine tract (nerve pathway between the brain and the spinal cord)
This posturing is characterized by abnormal flexion of the extremities and indicates damage to the brainstem
verbal, motor, eye response
coma
decorticate
decerebrate