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Trauma - Coggle Diagram

- - - - Temp: cool indicates arterial insufficiency due to pressure or damage to artery. Warm and cyanosis indicates poor or congested venous return.
        Pulse: diminished or absent pulse distal injury indicates vascular dysfunction and insufficiency due to pressure from swelling or direct damage from trauma. Pitting oedema may present with severe injury
        Sensation: loss of sensation is a late sign of neurovascular damage.
        Pain: if pain is out of proportion to the severity of injury -> indication of compartment syndrome.
- - - - Infants: bulging of fontanelles
    - - Munro-kellie: Cranial cavity is a closed space where, CPP=MAP-ICP (0-15mmHg). Change in one of blood, brain or CSF volume results in reciprocal changes of one or two of the other components. e.g. oedema, tumour and ruptured vessel can increase one of these components. Does not apply in open skull injury.
        MAP=SBP+2(SDP)/3. 2 SDPs because most of cardiac cycle is spent in diastole.
      - determinants of CPP
        
        Factors that influence ICP: arterial and venous pressure, intrabdominal and intrathoracic pressure, posture, temperature, CO2.
      - mechanisms maintaining CPP
        
        -<60mmHg CPP brain hypoxia will occur
        -CSF absorption and production is altered and is displaced into spinal subarachnoid space.
        -Blood volume compensated by constriction or dilation.
        -Brain volume compensated through distension of the dura or compression of brain tissue.
        -Between 70mmhg and 150mmhg of MAP is where autoregulation of cerebral blood flow is effective.
  - - - flexor - internal rotation, adduction of arms and flexion of elbows, wrists and fingers. Results from interruption of voluntary motor tracts in cerebral cortex
    - - more serious damage. Disruption of motor fibres in midbrain and brain stem. Arms are stiffly extended, adducted and hyperpronated.
- - - - -extradural haematoma
        -between dura and the skull
        -closed head trauma
        -requires surgery to stop bleed and remove clot
        -causes midline shift of the brain
      - -subdural haematoma
        -between dura and arachnoid layers
        -common in elderly and alcoholics, (increased dural space as brain shrinks)
      - -subarachnoid haemorrhage
        -associated with aneurysmal bleeds. 'Thunderclap' headaches.
        -higher presentation in females
        -graded depending on severity
      - -Cushing's triad=brain herniation through foramen magnum
        -HTN, brady, hypoventilation
      - -skull fracture
        -linear: low risk of CSF leak
        -comminuted/depressed: direct brain injury, raccoon's eyes
        -basilar: high risk CSF leak, battle's sign
        
        Basilar
        
        -clear fluid from ears or nose (rhinnorhea)
        -CSF with presence of glucose, check with dipstick
        -all interventions e.g. suctioning need to be reviewed before actioning
  - - - Hyperosmolar therapy
        -indicated in oedmea
        -hypertronic solutions to cause diuretic effect removing excess fluid from brain
        -mannitol-reduces viscosity and osmotic diuretic effect
        -3-10% normal saline
        -monitor Na levels with ABG and fluid balance and ICP. Can adversely cause demyelination
      - CSF drainage
        -external ventricular drain (EVD)
        -used to monitor ICP, CSF. And drain it to control ICP precisely.
        -potential for infection, sterility at all times. 20mls/hour max.
      - Pain management
        -fentanyl is preferred due to less risk of respiratory depression
    - - parameters
        -MAP 70-90, SBP=90<>140
        -CPP 60<>90
        -CO2 35-45
        -rest are as per normal
      - Manipulate the physiological mechanisms as temporary fix
        -cool body to hypothermia (~35degrees) to reduce ICP. But paralyse muscles to prevent shivering
        -decrease CO2 levels via ventilator to cause vasoconstriction (increased MAP)
        -supplementary O2
      - Control ICP
        -reduce noise and interactions via cluster care
        -education and support family
        -sedating and analgesics, but consider haemodynamics
        Control cerebral oedema
        -elevate head to 30 degrees
    - - -social work - sudden changes to life
        -OT - movement and functional deficits
        -physio - build strength and new muscle memory
        -dietician - brain is big consumer of energy
        -pharm - risk of seizures post TBI
        -speech therapy - if speech centres are affected
- - - - External fixation
        -quickly stabilise fracture
        -pelvic fracture used commonly
        -can be adjusted as healing occurs
        -regular cleaning of insertion sites and pain management
        -PAC is difficult, positioning is crucial
  - - - -blunt force
        -penetrating
        -thermal
        -electrical or poisoning
      - Injuries
        
        Thoracic
        
        -seatbelt, crush, penetration
        -heart, lungs, great vessels, trachea
        -assess with visual inspection, auscultation, percussion, palpation, x-ray, ultrasound, CT, MRI
        
        haemo/pneumo thorax=air or blood in pleural space. Prevents full expansion.
        Tension pneumo=one way valve effect. Compression on heart and great vessels
        
        Intercostal catheter (ICC) and underwater sealed drainage (UWSD)
        -allows air and fluid to escape on expiration. Water trap acts as one way valve (opposite principle to tension pneumo)
        -Obs=swinging (fluid moving up and down the tube) represents breathing. Bubbling is escape of air. Draining of fluid.
        
        Nursing responsbilities
        
        -ensure tubing is secure, maintain airtight dressing
        -keep UWSD upright and below level of chest
        -monitor large and sudden increase in drainage
        -ensure swing is stable
        -maintain pt comfort and educate
        
        Intraabdominal
        
        -easily missed. Intraabdominal sepsis due to faecal matter leakage
        -retroperitoneal haematoma
        
        FAST scan
        -functional assessment sonography in trauma
        -detect free fluid in abdominal cavity or pericardium
        -if positive, proceed to laparotomy
        -does not exclude injury
        
        Orthopaedic
        
        -open, closed, comminuted (broken into pieces), greenstick
        -long bones=significant blood loss
        -bone injury can cause damage to surrounding structures
        
        Rib fractures
        -may penetrate lungs and very painful. impairs airway clearance=risk of pneumonia. Need Physio intervention.
        -flail chest=2 or more rib fractures in 2 or more locations, 'free floating' ribs.
        
        Pelvic fractures
        -requires great deal of force
        -hypovolaemia
        -NO movement if not stabilised