Trauma Blunt Abdominal Trauma Situation 35 yo male
Trauma Blunt Abdominal Trauma
Situation • • • 35 y/o male driver involved in MVA Wearing a seat belt but driving at high speed Hit an abutment Initially awake at scene LOC declined on route to ED
Background • MHX noncontributory • FMX negative for heart disease, diabetes, or cancer • Social HX – 15 pack year of cigarette smoking – Drinks socially
Question What are the initial assessment priorities for a patient with blunt abdominal trauma?
Answer Primary Survey ABCs & rapid neurologic assessment Stop and fix what is critical, then move on Life-threatening conditions are managed Secondary Survey Tertiary Survey
Steps to Primary Survey Airway/Breathing • • • Assess for patent airway Assess for facial trauma that could impede airway Patient’s ability to breath spontaneously The presence and quality of breath sounds Check for – – – Deviated trachea Symmetrical chest rise Sucking, open wounds Subcutaneous emphysema If pt is conscious, palpate chest for c/o pain/tenderness • Oxygen saturation can be done quickly and is a good assessment tool, even if pt is anemic from blood loss
Steps to Primary Survey Circulation • HR, rhythm, BP • If BP cannot be read (1999) – Palpable radial pulse; around 80 mm Hg – No radial but you can feel a femoral pulse; around 70 mm Hg – If only the carotid pulse; around 60 mm Hg • Overt signs of bleeding are assessed & controlled with direct pressure
Fluid Resuscitation To achieve circulatory stability • Crystalloids and blood products • Controversy with the use of colloids during initial stabilization – Capillaries begin to leak fluid into the interstitial spaces as a result of increased cap permeability – Regardless of the type of fluid administered, a certain amount will leave the circulation & enter the interstitial spaces • Third spacing • Contributes to edema in the post-resuscitation phase – Colloids may enhance third spacing as a result of increased oncotic pressure
Circulation, cont’d • Assess for cardiac tamponade – Especially with MVA pts • Beck’s triad may not be present due to hemorrhagic shock and hypotension
Primary Neurologic Survey • Cervical spine should have been immobilized in the pre-hospital setting • Flexion & extension of the neck must be avoided even during intubation • Assess GCS • Pupil assessment • Ability to move all 4 extremities
Upon arrival to ED • • Had been intubated Had received 2 L of NS On a backboard with a cervical collar VS – BP – HR – Sao 2 110/80 mm Hg 113 95% on 100% oxygen
Primary ED Survey • Pupils 3 cm & PERL • Trachea midline • Chest was negative for flailing and no SQ emphysema • BS diminished in bilateral LL
Primary ED Assessment, cont’d • Tachycardic with normal S 1 & S 2 and no murmurs, rubs, or gallops • Peripheral pulses were 2+ bilaterally • Moved all 4 extremities spontaneously • Orientation could not be determined d/t sedation
Question What is the purpose of a secondary survey for a patient with blunt abdominal trauma?
Answer • To identify the extent of internal injuries • Mechanism of injury is used to guide the assessment priorities • Need to know – Driver or passenger • Liver vs splenic injuries – Seat belt or air bag – Ejection from the vehicle
Question What other internal structures might be damaged in a patient with blunt abdominal trauma?
Answer • Kidney & Bladder – Hematuria is considered the hallmark of genitourinary injury • The secondary survey also involves a more indepth neurological assessment
Secondary Neurological Survey • Attention to any skull or spinal abnormalities – Usually referred to as step-offs • Rectal tone can indicated integrity of spinal nerves • Assess for signs of basilar skull injury – Raccoon eyes – Battles signs
Secondary ED Survey • Abd was soft & moderately distended with hypoactive BS • No palpable abd masses & no hepatosplenomegaly • No gross hematuria • Rectal tone normal • Stool guaiac negative
Secondary ED Survey, cont’d • • Pelvis was stable Negative Battle’s sign or raccoon eyes TMs clear No step-offs over skull or down spine
Diagnostics • Abd CT – Grade III liver laceration – No splenic or renal injuries noted • CT head – No hematoma • CXR – Bilateral pulmonary contusion with bilateral rib fractures
Blood Count & Coags • • • WBC Crit Platelets PT PTT INR 21. 7 34 217 K 21 41. 9 1. 7
CP • • • Na+ 135 K+ CO 2 Cl. BUN Creatinine 1. 0 Glucose SGOT Bilirubin Albumin 4. 2 22 119 9 170 635 0. 9 1. 8
ABG • • p. H Pa. CO 2 Pa. O 2 Base deficit 7. 1 51 82 14. 4
Tox Screen • Negative for drugs • BA 171 g/dl
Problem List Blunt abdominal trauma No closed head injury Bil pulmonary contusions with bil rib fx Relative hypoxia with a Pa. O 2 value of 80 with inhalation of 100% oxygen • Metabolic acidosis • Hypovolemic shock • •
Question What is a pulmonary contusion?
Answer • Hemorrhage into the alveolar and interstitial spaces • Results in reduced alveolar ventilation and subsequent hypoxemia • Affects 75% of patients who sustain blunt trauma to the chest – Mortality as high as 40% • Hypoxemia from loss of ventilated alveoli • Also reduced pulmonary compliance and an increase in pulmonary vascular resistance • 50% of pts with pulmonary contusions may develop pneumonia
Interventions in Trauma Unit • Synchronized intermittent mechanical ventilation with positive end-expiratory pressure and pressure support • Insertion of a PA, NG tube, & Foley catheter • Fluids changed from NS to LR • Three runs of sodium bicarb
Over the next 12 hours • Abdomen became very firm & distended • < 300 ml of drainage from the NGT • Peak inspiratory pressure rose from 35 -60 mm Hg • Bladder pressure rose to 35 mm Hg
Vital Signs • • BP 100/80 HR 130 Respirations 14 Intra-abdominal pressure 35
DX: Abdominal Compartment Syndrome • Decompression laparotomy • Laceration on the right dome of the liver was assessed & packed • No other injuries were noted in abd but small bowel was edematous & distended • The abd could not be closed d/t the edema • Intestines covered with a sterile towel & a larger sterile transparent dressing over the wound
Question After this patient’s surgery, what additional nursing considerations are there?
Answer • Infection from open surgical wound
Question What is the pathophysiology of abdominal compartment syndrome?
Abdominal compartment syndrome #1 • The increased intra-abdominal pressure is transmitted to the pleural space so that lung compliance decreases • Hypoventilation and alteration of ventilation/perfusion distribution lead to hypoxemia and hypercapnia • When mechanical ventilation is applied, very high inspiratory pressures are often required to deliver tidal volume
Abdominal compartment syndrome #2 • The combined increase in abdominal pressure and pleural pressure leads to a decrease in venous return, direct compression of the heart, and increased afterload
Abdominal compartment syndrome #3 • Perfusion to the intra-abdominal organs can be critically reduced by the combined effects of the decreased cardiac output, increased interstitial pressure, and increased outflow pressure • Can lead to oliguria and renal failure • Perfusion of the abdominal wall may be decreased, so that wound healing may be impaired
Abdominal compartment syndrome #4 • Intracranial pressure may also be increased due to the decrease in cerebral venous return and increased venous pressure
Post-op VS • • PIP BP HR PAP • EF 35 mm Hg 120/64 112 50/27 40% Pulmonary artery pressure
Elevated Peak Inspiratory Pressure (PIP) possibly indicates: • Hyperventilation – Tidal volume to large, Breath stacking • Poor compliance � Lung issues – Bronchospasm, alveolar collapse, consolidation in the lung, edema � Pleural – pneumothorax, effusion � Chest wall – abdominal distention, obesity, burns � Patient ventilator dysynchrony, coughing • Equipment issue – Kinked ETT or vent tubing, ETT displacement, ETT obstruction
Ventilator Settings • • SIMV rate PEEP RR Sa. O 2 14 10 cm H 20 14 97%
Question Besides this patient’s pulmonary contusion, what other condition might be contributing to his poor oxygenation?
Answer • Trauma patients are at risk for developing ARDS – The accumulation of fluid in the interstitial spaces in the lungs from noncardiac causes – Trauma is accompanied by over-activation of the systemic inflammatory immune system • Results in neutrophils & macrophages migrating to the lungs • They can become very destructive • Fluid leaks from the vascular bed into the interstitial lung spaces
Medications • • • Gentamicin Levaquin Fentanyl Pepcid Ativan for conscious sedation
Question Why was conscious sedation used instead of a paralyzing agent?
Answer • ARDS patients often require high levels of PEEP and PS as well as a high Fio 2 – This is uncomfortable – Patient may feel dyspneic • Conscious sedation facilitates ventilation and reduces metabolic needs • Goal is to not “fight” the ventilator
2 days post-op • Returned to OR for re-exploration of his abd & assessment of his liver laceration • When packing was removed, hemostasis had been maintained & there was no necrosis of the liver or any signs of active bleeding
Question What are the nutritional needs of a patient with a blunt abdominal trauma?
Answer • With a stressful event the metabolic demands of the body can be divided into two phases: 1. Ebb phase o o o First 24 -48 hours Characterized by shunting of blood to the heart, lungs, and brain in an effort to maintain perfusion Body’s metabolism is reduced 2. Flow phase o Characterized by an increase in C/O, oxygen consumption, body temperature, and catabolic activity
Answer, cont’d • Nutritional support should be started within 24 -72 hours of admission or at the resolution of the ebb phase • It is important to assess bowel and renal function to determine whether any pancreatic injury is present • Enteral feedings are preferred to maintain the function of the bowel and to prevent translocation of bacteria
Day 3 • Start of enteral feeding with progression to 90 ml/hour by day 5
Day 6 • Returned to OR for closure of the abdominal fascia • Skin was not closed because the wound had been open for 6 days • Wound was packed with sterile wet to dry dressings • Underwent a tracheotomy
Day 8 • Weaning from the ventilator began
Day 19 • Transferred to a rehab facility • Required only supplementary oxygen through the trach collar with minimal suction q 2 hours
Question What do you think the purpose of a tertiary survey is?
Answer • Additional comprehensive assessment that is done either after the patient can talk, when the patient is about to ambulate, or in some institutions, within 24 hours of admission • Focus is to ID previously missed injuries and to prevent possible complications caused by missed injuries
Question • Why would our patient have missed injuries?
Answer • Trauma team was focused on the immediate life-threatening injuries which took days to sort out and treat
Trauma & Missed Injuries • Blunt abdominal trauma pts are at a higher risk for missed injuries than pts with penetrating injuries • The most frequently missed injuries are musculoskeletal – Cervical spine injuries are the most critical • Alterations in LOC d/t injury or alcohol contribute to missed injuries
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