CARE OF PATIENT

WITH TRAUMA
Prepared By:
NES of FMIC
Head trauma
◦ Definition:
◦ Head trauma refers to any
damage to the scalp, skull or
brain caused by injury. Head
injury may be classified in various
different ways according to the
type of injury, which structures in
the head are damaged or how
severe the trauma is
Layers of skull and brain
• Scalp
• Skull
• Dura mater
• Arachnoid
• Sub arachnoid and
space with CSF
• Pia mater
• Brain
Anatomy and physiology of brain:
◦ Cortex-Thinking and voluntary movements
◦ Brain stem - breathing and sleep are controlled here.
◦ The basal ganglia - coordinate messages between
multiple other brain areas.
◦ Cerebellum - responsible for coordination and balance.
◦ The brain is also divided into several lobes:
◦ The frontal lobes are responsible for problem solving and
judgment and motor function.
◦ The parietal lobes manage sensation, handwriting, and
body position.
◦ The temporal lobes are involved with memory and
hearing.
◦ The occipital lobes contain the brain's visual processing
system.
◦ The brain is surrounded by a layer of tissue called the
meninges. The skull (cranium) helps protect the brain
from injury.
Spinal cord
• Cervical
• C1: Atlas
• C2: Axes
• C3-C7
• Thoracic
• T1-T
• Lumber
• L1-L5
• Sacral
• S1-S5
• Coccygeal
• Coccyx 1-4
Primary brain injury:
◦ direct mechanical damage at the time of
trauma.
◦ The pathophysiology = focal and diffuse
lesions.
◦ Focal = with blows to the head= cerebral
contusions and hematomas. Primary head injuries
◦ Focal injuries impact morbidity and
mortality based on their location, size, and include:
overall progression. Skull fracture
◦ Diffuse axonal injury = motor vehicle Epidural Hematoma
accidents. Subdural Hematoma
◦ In clinical practice, diffuse axonal injury and Intracerebral Hematoma
focal brain lesions frequently coexist.
Diffuse Axonal Injuries
 Secondary brain injury:
◦ Secondary brain injury occurs after the initial trauma and is defined as the
damage to neurons due to the systemic physiologic responses to the initial
injury
Traumatic Brain Injury

A number of biochemical substances releases (such as amino acids

glutamate and aspartate, cytokines, and free radicals and hypoxia or
hypotension

Dangerous cascade of continued cell membrane breakdown and ionic shifts

further harms the injured brain.

Neural Injury
 Types of Injury
• Concussion
• a type of traumatic brain injury—or TBI—
caused by a bump, blow, or jolt to the head or by
a hit to the body that causes the head and brain
to move rapidly back and forth.
• Contusion
• caused by a direct blow to the body that can
cause damage to the surface of the skin and to
deeper tissues as well depending on the severity
of the blow.
• Hemorrhagic injury
◦ Is the collection of blood within the
skull.
Characteristics of Concussion
• Immediate temporary altered or loss of consciousness resulting
from a violent blow or motion to the head lasting less than 30
minutes
• May or may not report this LOC
• Headache*
• Confusion
• Dizziness
• Visual, gait disturbances
• Memory issues* - around the time of injury
 Role of intracranial pressure and cerebral
perfusion:
◦ The cranial vault is a fixed space (closed box).It contains:
◦ brain tissue
◦ cerebrospinal fluid (CSF)
◦ extracellular fluid
◦ Blood
◦ Any changes in above four can cause increase in intracranial pressure.
Types of Injury
Open head injury- penetrating trauma
• is a head injury in which the dura mater, the outer
layer of the meninges, is breached.
Closed head injury
• a type of traumatic brain injury in which the skull and
dura mater remain intact.
Can be focal or diffuse
• The damage can be focal (confined to one area of the
brain) or diffuse (happens in more than one area of the
brain).
Traumatic Brain Injury (TBI)
• An outside force that impacts the head
hard enough to cause the brain to move
within the skull which creates damage to
the brain
• Examples: motor vehicle collisions,
falls, gun-shot wounds, sports, physical
violence, etc.
• Closed Head Injury vs. Open Head
Injury.
Mechanism of injury: Motor vehicle accident

◦ Frontal impact: Associated injuries ◦Rear impact auto collision

◦ -Cervical spine fracture ◦-Cervical Spine Injury
◦ -Anterior flail chest ◦ Ejection from vehicle
◦ -Myocardial contusion ◦-Significantly increased risk of
◦ -Pneumothorax multiple injury
◦ -Traumatic aortic rupture or transection ◦ -Significantly increased mortality
◦ -Spleen or liver Injury
◦ -Hip or knee dislocation
Traumatic Brain Injury (TBI)
Closed Head Injury vs. Open Head Injury.
◦ open injuries penetrate the skull while
closed injuries do not
Mechanism of Injury
• Penetrating
• a head injury in which the dura mater, the
outer layer of the meninges, is breached.
• Coup and Cont recoup
• Coup: Laceration or contusion at sight
of impact
• Cont recoup: Injury occurs at the
opposite side due to movement of the brain
Penetrating trauma
-Bullets
-Knives
-Impaling object
◦ Burn injury or cold injury
◦ Hazardous environment
Hemorrhagic Injury
• Any injury causing bleeding into
the central nervous system
• Subdural hematoma
• Epidural hematoma
• Intra-cerebral hemorrhage
• Subarachnoid hemorrhage

+-
Epidural Hematoma
• Arterial bleed
• Initially lucid then
rapidly declines
• Rapid onset of symptoms
• Risk of herniation
• Symptoms: LOC; dilated,
nonreactive ipsilateral
(same side) pupil
Subdural Hematoma
◦ Bleeding between
dura & arachnoid
layer
Intracerebral Hemorrhage
Intracerebral Hematoma
•Note the midline
shift
Severity of head injury:
◦ The severity of the head injury is classified clinically by the
Glasgow Coma Scale.
◦ GCS score of 13 to 15 mild head injury.
◦ GCS of 9 to 12 moderate.
◦ GCS score of 8 as severe.
 Diagnostic study:
◦ CT scan =evaluating acute head trauma.
◦ CT scanning= intracranial injury.
◦ Abnormalities noted on CT imaging:
◦ subdural hematomas,
◦ subarachnoid hemorrhage,
◦ intra-cerebral hematomas,
◦ cerebral infarcts,
◦ diffuse brain injury,
◦ and generalized cerebral edema often with shift of midline structures.
◦ Normal initial CT scan does not exclude significant intracranial hypertension.
 Surgical management:
◦ Once stabilized, neurosurgical consultation is
required.
◦ Critical factors evacuation of an intracranial
hematoma
◦ Surgical evacuation= intra-cerebral
hematomas 20 ml with mass effect.
◦ Surgical repair is also required in patients
with:
◦ depressed,
◦ open, and compound skull fractures.
Measures to prevent ICP:
◦ Prevent the following conditions:
◦ Hypotension
◦ -Administer ringer lactate or N/S.
◦ -Hypotonic solution should be avoided.
◦ -Hypertonic saline shown positive
results
◦ Hypoxia
◦ Hydrogen ion balance (PC02 in normal
ranges)
◦ Hyperthermia
◦ Hypoglycemia
 Goals of management of trauma patient:
◦To maintain patent airway.
◦To prevent cervical spine injury and further damage to spine.
◦To remove airway obstruction by foreign matter (e.g. blood)
or by tongue fall back.
◦To provide adequate fluid resuscitation in head injured.
◦To recognize and treat internal hemorrhage.
 How to manage patient with trauma?
Primary survey:
◦ A= Airway maintenance with C-spine
control
◦ B= Breathing and ventilation
◦ C= Circulation with hemorrhage
control
◦ D= Disability: neurologic status
◦ E= Exposure and environmental
control
◦ Trauma diagnostic testing
Guidelines for emergency care:
Check for responsiveness

Maintain airway by jaw thrust method if cervical injury is suspected

Check for breathing

Yes No

Watch for impending risk of Check for pulse

respiratory failure
Pulse present, no breathing No pulse

Start rescue breathing Start CPR

A. Airway maintenance:
Emergent airway management is a key for
survival.
Evaluation:
◦ Signs of impending airway compromise
◦ Tongue (tongue fall back)
◦ Evaluate for trauma that can compromise
airway: maxillofacial trauma, neck trauma,
laryngeal trauma.
◦ Hoarseness (harshness, unnatural rough
quality of voice).
◦ Subcutaneous Emphysema.
Management:
◦ Assume cervical spine injury
◦ Maintain inline cervical spine
stabilization
◦ Consider SCIWORA (Spinal
Cord Injury Without
Radiographic Abnormal) in
pediatric patients.
 Approach:
◦ Assume cervical spine injury ◦ Open airway:
present: ◦ Head tilt-chin lift
◦ All children with multiple injuries ◦ Jaw thrust (if cervical spine injury is
◦ Fall less than 5 feet rarely cause C- suspected)
Spine Injury ◦ Airway suction:
◦ X-Ray not needed if C-Spine ROM ◦ Blood
normal and no pain
◦ Mucus
◦ X-Ray cannot rule out Pediatric C-
◦ Dental fragments
Spine Injury
◦ Maintain C-Spine control until full ◦ Maintain airway:
clinical evaluation ◦ Oropharyngeal airway
◦ Nasopharyngeal airway
Indication of immobilization:
◦ Loss of consciousness with trauma
◦ Significant multi-system trauma or high
energy injury
◦ Severe head or facial trauma
◦ Neurologic deficit
◦ Extremity numbness
◦ Extremity weakness
◦ Neck pain or neck tenderness
◦ Multiple painful injuries (distracting injuries)
◦ No history available
Techniques of immobilization: Safe log roll step 1

◦ For complete immobilization of spine, cervical collar is

required.
◦ Do not place patient until adequate support.
◦ With the help of 3-4 trained person log roll should be
done to change patient position.
◦ One person is assigned to stabilize the neck.
Safe log roll step 2
◦ Do not move patient until complete immobilization.
◦ Special circumstances such as football injury, immobilize
head and neck with helmet and pads in place.
◦ Leave both helmet and shoulder pads in place.
◦ Cervical spine can be misaligned if one of the 2 is
removed.
◦ Face mask may be removed if face access is needed.
Complication:
◦ Foreign body in airway
◦ Cervical spine injury
◦ Mandibular or maxillofacial fracture
◦ Trachea or larynx disruption
◦ Aspiration of gastric contents
B. Breathing and ventilation:
◦ Assess:
Signs of impending
◦ Breathing (look, listen and feel)
respiratory failure:
◦ Ventilation
 Increased respiratory rate
◦ Oxygenation  Nasal flaring
 Use of accessory muscles
 Cyanosis
 Management:
◦ If patient awake with spontaneous breathing
◦ Give supplemental oxygen delivery
◦ Use oxy-hood for infants less than 1 year old
◦ Use non-re-breather mask with reservoir for
children/adults
◦ If patient is conscious with difficulty in breathing
◦ Give ventilation through bag valve mask with 100%
oxygen
◦ Ventilation rate
◦ -Adult: 12 breaths per minute
◦ -Child: 15 breaths per minute
◦ -Infant: 20 breaths per minute
◦ Prevent acidosis (keep PC02 between 30-35mmHg)
◦ If patient is unresponsive with respiratory failure
◦ Arrange oro-tracheal intubation
◦ Give chest compression with bag valve mask ventilation
Complication:
◦ Tension pneumothorax
◦ Rib fractures
◦ High risk injury if fractured ribs 1 through 3
◦ -Associated with significant cardiopulmonary injury
◦ -Flail chest
◦ -Pulmonary contusion
◦ Open pneumothorax
◦ Massive haemothorax
 Circulation management:
◦ Guidelines for emergency cardiovascular care
◦ If pulse absent (or >60bpm and signs of poor perfusion in infant) Start
CPR
◦ If pulse present evaluate for organ perfusion
Evaluation:
◦ Assess organ perfusion:
◦ Level of consciousness (lethargy, drowsy or
unresponsive)
◦ Skin color
◦ Central pulse
◦ Child or adult: carotid pulse or femoral pulse
◦ Infant: brachial pulse
◦ Sites of rapid blood loss
◦ Chest injury
◦ Abdominal injury (especially retroperitoneal)
◦ Pelvic injury
◦ Extremity injury (especially femur)
 Evaluation:
◦ Mnemonic: IV-O2-Monitor ◦ Too fast (tachycardia)
◦ Intravenous access ◦ -Too slow (bradycardia)
◦ Oxygen delivery ◦ Correct hypovolemia: fluid replacement in
◦ Monitor and 12 lead EKG trauma
◦ Vital signs, history and exam ◦ Two large bore IVs (14 or 16 gauge)

◦ Assess for suspected cause ◦ -Shorter tubing provides faster IV rate

◦ Hypotension ◦ Replace fluid deficit

◦ -Hemorrhagic shock ◦ -Infuse lactated ringers 2-3 liters until

response
◦ -Intra-abdominal blood loss
◦ -Consider blood transfusion
◦ -Closed head injury ◦ Hemorrhage evaluation
◦ Shock ◦ Avoid potentially harmful measures
◦ Acute pulmonary edema
◦ -Vasopressors
◦ Acute myocardial
infarction ◦ -Steroids
◦ Arrhythmia ◦ -Sodium bicarbonate
◦ -
 Cont…
Complications: Disability evaluation:
◦ Inadequate correction of ◦ Evaluation: neurological status
hypovolemia ◦ Level of consciousness:
◦ Intra-abdominal or intra-thoracic (Glasgow coma scale)
injury ◦ Pupil response
◦ Femur fracture or pelvic Fracture
◦ Penetrating injuries with large
vessel involved
◦ External hemorrhage
◦
Glasgow coma scale for infant and children
Area Assessed Infants Children Adult score

Eye opening Open spontaneously Open spontaneously Open spontaneously 4

Open in response to Open in response to Open in response to 3

verbal stimuli verbal stimuli verbal stimuli

Open in response to Open in response to Open in response to 2

pain stimuli pain stimuli pain stimuli

Dose not response/ Dose not response/ Dose not response/ 1

open eye open eye open eye
 Cont…
Area Infants Children Adult score
Assessed

Verbal Smile, Orientated to sound, Oriented, Oriented 5

follows objects, interact appropriate
Response
Irritable, cries Confused Confused 4
conversations

Cries in response to pain Inappropriate Inappropriate 3

words words

Moans in response to pain Incomprehensible Incomprehensible 2

words or words or
nonspecific sound nonspecific sound
No response No response No response 1
 Cont…
Area Infants Children Adult score
Assessed
Motor Moves spontaneously Obeys commands Obeys commands 6
and purposefully
Response
Withdraws to touch Localize pain stimulus Localize pain stimulus 5

Withdraws in response to Withdraws in response to Withdraws in response to 4

pain pain pain
Response to pain with Response to pain with Response to pain with 3
decorticate posturing decorticate posturing decorticate posturing
(abnormal flexion) (abnormal flexion) (abnormal flexion)

Response to pain with Response to pain with Response to pain with 2

decerebration posturing decerebration posturing decerebration posturing
(abnormal extension) (abnormal extension) (abnormal extension)

No response No response No response 1

Conscious Level
Secondary survey:
◦ Obtain trauma history
◦ Perform trauma secondary
survey
Trauma history:
◦ History
◦ Allergies
◦ Medications
◦ Past illness
◦ Last Meal
◦ Events or environment related to injury
Head evaluation:
Assess eyes early (may be difficult after face ◦

edema) Maxillofacial injury:

◦ Visual acuity ◦ Pending airway obstruction or airway status changes
◦ Pupil size and pupil reactivity
◦ Cervical spine injury
◦ Conjunctival hemorrhage
◦ Retinal hemorrhage ◦ Lacrimal duct laceration
◦ Penetrating injury ◦ Facial nerve injury
◦ Contact lenses ◦ Cervical spine evaluation:
◦ Lens dislocation ◦ Assess for cervical spine injury
Neurological assessment: ◦ X-Ray
◦ Assign Glasgow coma scale score
Chest evaluation:
◦ Increased intracranial pressure
◦ Tension pneumothorax
◦ Subdural hematoma
◦ Open chest wound
◦ Epidural hematoma
◦ Flail chest
◦ Depressed skull fracture
◦ Spine injury ◦ Cardiac Tamponade
◦ Aortic Rupture
Abdomen and genitourinary Musculoskeletal evaluation:
evaluation: ◦ Spine fracture
◦ Liver, spleen, kidney, or pancreas ◦ Pelvic fracture
injury ◦ Digital fracture
◦ Hollow viscus or lumbar spine injury ◦ Fracture with vascular compromise
◦ Seat belt ◦ Compartment syndrome
◦ Deceleration injury ◦ Observe for paresthesia's (altered
◦ Pelvic fracture sensation such as tingling, numbness
or burning) or pain on passive ROM
◦ Urethral injury
◦ Measure tissue pressure (over
◦ Rectal injury 25mmHg is abnormal)
◦ Vaginal injury ◦ Nerve injury
◦ Bladder injury
 Nursing responsibilities:
◦ Maintain airway
◦ Check for ventilation and oxygenation status and intervene accordingly.
◦ Check for organ perfusion and hydration status of patients
◦ Perform neurological assessment using Glasgow coma scale as required (every hourly in
head trauma patients).
◦ Immobilize neck and spine of patient with cervical spinal Injury
◦ Assess patient’s pain with pain scale and administer analgesics as ordered.
Nursing responsibilities:
◦ Perform dressing daily or as required and prevent the surgical site infections.
◦ Assess the site of drains per shift for skin condition, and signs of infection.
◦ Record the amount, color, consistency of the drain and manage it using aseptic
techniques to reduce the risk of infections.
◦ Position the patients to prevent skin breakdown (Log roll only with spinal
injury patients)
 Other nursing care:
◦ Check patient GCS and pupil hourly and inform the doctor immediately in case of any fluctuations.
◦ Seizure prophylaxis is currently recommended for 7 days following the injury in patients with severe TBI.
◦ Keep patient head in midline position to avoid jugular venous outflow obstruction. Do not flex patients legs
◦ Elevate patient head side at 30 degree.
◦ Avoid stimulating activities such as suctioning.
◦ If suctioning is required, take out suction catheter with in 10 second.
◦ Watch patients for sign of raised ICP, and stop the activity immediately in case of raised ICP.
◦ Electrolyte Imbalances: Prevent hyponatremia and hypomagnesemia as it decrease the threshold for
seizures
◦ Nutrition care: Traumatic brain injury results in a generalized hyper-metabolic and
catabolic state. Early enteral nutrition maintains the integrity of the GI mucosa and
has beneficial effects on immune competence.
◦ Management of established intracranial hypertension:
◦ If the ICP remains 20 mm Hg, despite adequate sedation and elevation of the head
of the bed (to 30°), additional measures are required to lower the ICP.
◦ CSF drainage should be done.
◦ If CSF drainage is ineffective, a hyper-osmotic agent such as mannitol should be
used next.