Transcript
Chapter 34: Multiple Trauma
Critical Thinking Checkpoint Case Studies
An 82-year-old male unrestrained driver hit another vehicle head-on while driving at 45 miles per hour. He was brought to the ED via helicopter. On arrival to the ED, his vital signs were BP 125/85 mm Hg; HR 110/min.; RR 34/min.; and temperature 98.6°F (37°C). His past medical history includes previous myocardial infarction and hypertension.
This activity contains 5 questions.
1. Given this patient's mechanism of injury, for what injuries is he at risk?
Answer: This patient has sustained blunt trauma. Unrestrained drivers are at risk for head and/or facial injuries, rib fractures, injuries to the sternum, myocardial or pulmonary contusions, cervical spine fractures, laryngotracheal injuries, spleen injuries, liver injuries, small bowl injuries, posterior fracture/dislocation of the hips, and femur fractures.
2. On arrival to the ED, how would you begin to assess this patient?
Answer: Start with the primary survey. The purpose of the primary survey is to identify and treat life-threatening injuries. The primary survey is done using the A, B, C, D, E approach. A: Airway patency is assessed. Actual or potential airway obstruction is treated with a secure airway, which may include chin lift, oropharyngeal or nasopharyngeal airway, endotracheal intubation, or placement of a surgical airway. Cervical spine immobilization is required during airway placement. B: Breathing is assessed by look, listen, and feel parameters. C: Circulation is assessed for signs of impairment indicating a shock state. Aggressive fluid administration is required. Recognition of the source of blood loss is critical. D: Disability evaluates neurologic status using the AVPU method. The final step, E, exposes the patient for examination and to warm the patient to prevent hypothermia.
3. During your secondary survey, the patient becomes hypotensive. You note his blood pressure is lower on expiration than inspiration. His heart sounds are now muffled. What should you do and what is your interpretation of his condition?
Answer: If there are any hemodynamic changes that occur during the secondary survey, the nurse must stop the assessment and repeat the primary survey to identify life-threatening injuries. The patient is demonstrating signs of cardiac tamponade, including pulsus paradoxus and muffled heart sounds. Other signs of cardiac tamponade may include elevated central venous pressure or hypotension. This is a life-threatening condition because blood in the pericardial sac is restricting the heart's ability to pump and impeding venous return, which ultimately results in cardiovascular collapse.
4. Discuss how the client's age impacts his risk factors for trauma.
Answer: The elderly are predisposed to trauma because of age-related changes in reaction time, balance, coordination, and sensory motor function; falls are the leading mechanism of injury in people 65 years and older . Trauma in the elderly is associated with higher mortality and morbidity with less severe injury. This is attributed to pre-existing medical conditions and the older person's diminished ability to compensate for severe injury (known as limited physiological reserve). Limited physiological reserve is the concept of limited organ function in the face of a physiologic challenge. Organ dysfunction may not appear in the resting state, but in a physiological stress situation (such as traumatic injury), the ability of the organs to augment function is compromised. Moreover, the reduced physiological response to traumatic injury may mask the seriousness of the older patient's condition, causing delayed diagnosis and treatment
5. Discuss why it is important to find out a client's past medical history when a client experiences trauma.
Answer: It is extremely important to identify comorbidities or underlying medical conditions when considering the patient's physiological and hemodynamic response to trauma. Chronic conditions such as heart disease, kidney disease, or diabetes and the medications used to control their effects may alter the physiological response to trauma. Eliciting a complete medical history, including comorbidity information, is crucial during the initial assessment. This is especially important in older adults, who are most likely to be admitted with at least one comorbid illness; it is estimated that 80% of people 65 years of age or older have comorbid illnesses.
