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Preparing for patients with multisystem trauma
Barbara J Lockwood, RN
Preparing for patients with multisystem trauma
Rapid technological growth, improved prehospital care, and sophisticated transport systems are improving the life expectancy of the multisystem trauma patient. Today these patients appear in increasing numbers in our operating rooms. Their outcomes depend on how well medical and nursing personnel meet the challenge of their complex care problems. Multisystem trauma means injuries sustained by two or more body systems. One or more may be life threatening. The predominant symptom that often requires immediate surgery is hypovolemic shock resulting from severe hemorrhage. Major vessel tears; ruptured, torn, or punctured organs; and as-
Barbara J Lockwood, RN, M S , is systems director,nursing services,St Anthony Hospital Systems, Denver. She received baccataureate and master's degrees in nursing from the University of Colorado Health Sciences Center. Denver.
sociated skeletal fractures may be responsible singly or together for hypovolemia. Pulmonary parenchymal injuries, cardiac injuries, brain injury, and spinal cord injury may further complicate the clinical picture. Each injury must be rapidly assessed and ranked. Priorities are established according to which injury poses the gravest danger to the patient. Hemorrhage must be stopped, circulating volume returned to normal, and tissue oxygenation improved before other injuries are treated. For internal hemorrhage, rapid surgical intervention is required. The multisystem trauma patient will probably come to surgery shortly after the accident. He does not have a lot of time. He will die if the operating personnel are not prepared. The patient may arrive amid a great deal of confusion. Many ancillary personnel are involved in the initial care. The activities of the laboratory, radiology, and emergency room personnel must be coordinated and controlled by the operating room nurse. Several surgeons may be operating at one time during the initial surgery. Anticipating the needs of the thoracic, general, orthopedic, and neurosurgeons further complicates the nurse's role. In the early moments, it is extremely difficult for the nurse to establish a quiet, nonstimulating environment for the patient, but this is important. This patient was well until a short time before
AORN Journal, November 1981, Vol34, No 5
829
entering the hospital. He is not prepared for surgery and is probably frightened. The operating room nurse can do much to reassure and calm a conscious patient by explaining what is happening to him. Responding appropriately to this type of emergency surgery requires good knowledge of trauma pathophysiology. Common complications of traumatic injury can be averted if the nurse is aware of the events in surgery that can increase their occurrence. Knowing these will enable the nurse to anticipate the patient’s needs and plan care accordingly. Since this patient arrives with little warning and limited historical information, the nurse must be prepared for anything. All necessary equipment, instruments, and medicine must be readily available (Tables 1 and 2). Hypovolemic shock. For the patient in hypovolemic shock, the surgical team must react as if they were behind and must catch up. In fact, this is often the case. A relative loss of circulating blood volume within the cardiovascular system results in the inability to meet the metabolic tissue demands for oxygenation and waste removal. Left untreated, the condition will lead to cellular anoxia and death. A sudden loss of circulating volume sets off a sympathomimetic response, which causes vasoconstriction of the pnripheral blood vessels, increasing vascular resistance. Cardiac output is also increased initially. In this way, circulating volume is shiRed to the vital organs-the brain and heart. Blood flow consequently decreases to the peripheral limbs, skin, kidneys, and abdominal organs. Simultaneously, interstitial fluid is shifted into capillary beds in an attempt to increase circulating volume. Antidiuretic hormone is secreted by the anterior pituitary, and the adrenals secrete aldosterone to retain water and sodium in the kidneys. This additional fluid is returned to the bloodstream to
830
increase circulating volume. At this stage, shock is termed reversib1e.l As the shock state progresses, the organs and tissues not adequately perfused develop cellular hypoxia. Metabolic waste products increase, causing lactate retention and metabolic acidosis. Eventually, the continual buildup of metabolites will stimulate arterial vasodilatation. Venous vascular resistance to metabolites is higher. The relative difference in pressure between the arterial and venous capillary beds causes fluid in the venous system to reenter interstitial spaces. With this, venous return to the heart decreases, and cardiac output is reduced, ultimately leading to death. This is termed irreversible shock.2 Clinical s i p s of shock in the early stages are often subtle. Increased vasoconstriction causes cool, clammy, and pale skin. Decreased circulating volume with increased cardiac output produces tachycardia and a characteristically “thready” pulse. Respiratory rate increases to compensate for metabolic acidosis. Hyperventilation is the body’s attempt to remove carbon dioxide and keep blood pH within normal limits. As water and salts are shunted away from the kidney, urinary output falls below normal. If hypovolemic shock has been present long, the patient may exhibit signs of confusion and disorientation due to cerebral hypoxia. The patient in reversible shock can maintain a normal blood pressure. Once the pressure falls, the outcome is grave. Diaphoresis, coma, tachypnea, hypothermia, and anuria are the other clinical signs that signal irreversible or decompensated The goal of immediate surgery is to reverse hypovolemic shock while the patient has still compensated for sudden blood loss. T h e circulating nurse. The operating room nurse who circulates for the multisystem trauma patient focuses on intervention in the shock syndrome, anti-
AORN Journal, Nouember 1981, V o l 3 4 , No 5
Table 1
Multiple trauma emergency instruments St Anthony Hospital Systems, Denver, has developed this list of instrumentsthat are always ready for the multisystem trauma patient in a specially designed trauma room. Intravenous fluids, blood warmer, and emergency equipment are also kept in this room.
Freer elevators Nerve hook Probe with eye Uterine packing forceps Internal defibrillation paddles, adult and pediatric Clamps Aortic cross-clamps-2 Hemostats Kelly (6 to 8 inch) Towel clips Tonsil Kidney pedicle Arterial, all types Fogarty with inserts
Exploratory laparotomy set Arterial instrument set Chest instrument set Bowel instrument set Tracheotomy tray with trach tubes Subclavian (arterial)tray Sternal saw with motor Orthopedic special tray Plastic suture set Burr hole with flap tray Disposable skin staplers Tissue forceps, all sizes Arterial forceps, all sizes Scissors, all types and sizes Extra knife handles, all sizes Needle holders, all types and sizes Suction tips, Poole, tonsil, and neurosurgical Lebsche knife with mallet
Specialinstruments Weinberg retractor Instrument magnetic pad Clips and appliers Tibia1 traction tray Deep Balfour retractor Light handles Set of Deaver retractors Pin cutter
cipating problems and taking appropriate action. This patient will develop unnecessary complications if the nurse is not alert. On the patient’s arrival, the nurse concentrates on controlling the environment, reassuring the patient, and planning for proper positioning and padding. It is extremely important to maintain body alignment when moving the patient onto the operating bed. There may be undiagnosed fractured or dislocated vertebrae and other skeletal injuries. Cervical collars, sandbags, and splints should be left in place until x-rays rule out fractures. The anesthesiologist must be told a cervical vertebrae fracture is suspected prior to intubation and
induction. Decreased circulating volume, peripheral vasoconstriction, and subsequent diminished tissue oxygen supply increase the patient’s risk of pressure ulcers and equipment burns. Proper grounding must be assured. The operating room nurse is responsible to check and record peripheral circulation frequently. Particular attention is paid to areas distal to known injuries (eg, pedal and tibia1 pulses below a fractured tibia and fibula). Be sure that no equipment or operating room team member is applying pressure to the body. Improper positioning and pressure can cause brachial and ulnar nerve damage. The patient on a warming blanket must be
AORN Journal, November 1981, V o l 3 4 , No 5
831
Table 2
Multiple trauma emergency drugs Cephalothin (Keflin),1 gm
St Anthony Hospital Systems has the following drugs readily available for the multisystem trauma patient. Most of these drugs are given intravenously.
Adrenergics Dopamine hydrochloride, 200 mg Epinephrine ampul, 1 :lo00 Epinephrine automatic injector,
Quantity 4 2
Epinephrine automatic injector with cardiac needle lsoproterenol hydrochloride (Isuprel) automatic injector, 1 mgi5 cc Levarterenol bitartrate (Levophed),4 mg/4 cc Metaraminol bitartrate (Aramine), 10 mgicc
2 4 4
2
5
4
Atropine sulfate, 0.5 mg/5 cc Lidocaine hydrochloride, 2 gm Lidocaine automatic injector, 100 mgil0 cc Procainamide hydrochloride (Pronestyl),500 mg Propranolol hydrochloride (Inderal),1 mgicc
Cimetidine (Tagamet) Intravenous solution, 300 mg in 200 ml Corticosteroids Dexamethasone (Decadron) Hydrocortisone sodium succinate (Solu-Cortef),500 mg
2 4
2
An tiarrhythmics
4 2
Diuretics Furosemide (Lasix),100 rng 40 mg Mannitol, 12.5 mg 500 cc 20%
1
3 2
3
2 1 2
2 2
adequately protected from burns with sheepskins and bath blankets. At the scene of the injury, hypovolemic shock is treated by rapid infusion of volume expanders and counterpressure (MAST) suits. These inflatable trousers increase the blood circulating to the heart, brain, lungs, and kidneys. External counterpressure redirects venous blood flow away from the lower extremities to the organs above the dia~ h r a g mThe . ~ trousers should not be re-
832
Calcium chloride Automatic injector, 1 gm/lO cc
6
2
1 :I 0,000
Antibiotics Ampicillin, 1 gm Cefazolin (Ancef),1 gm
Antitoxins Tetanus toxoid (equine) Diphtheria (tetanus toxoid) Tetanus immune globulin, human
2
Narcotic antagonists Naloxone (Narcan) Sodium bicarbonate Automatic injector, 44.6 mEqi50 cc Vitamin K (phytonadione)
4
16
2
moved until the surgeon is confident the hemorrhage is controlled. Surgery can be performed by deflating the abdominal section of the trousers. The legs are left inflated to improve circulation to the vital organs. If counterpressure suits are removed prematurely, the patient may die in irreversible shock. Since hypovolemic shock is accompanied by metabolic acidosis, arterial blood gas samples should be taken frequently. The results will determine the
AORN Journal, Nouember 1981, V o l 3 4 , N o 5
0
ne patient received 19,000 cc of whole blood and fluid in 11h hours and survived.
level of acidosis and compensation. Arterial blood gases will also indicate how well therapy is working. Intravenous sodium bicarbonate (NaHC03) is given to reverse metabolic acidosis. Decreased circulating volume causes cellular hypoxia due partially to the loss of hemoglobin. The remaining blood has less oxygen-carrying ability. Hyperventilation compensates for metabolic acidosis and increases the oxygen supply to the available hemoglobin. Trauma patients with associated pulmonary injuries can develop respiratory acidosis caused by decreased ventilation (oxygen and carbon dioxide exchange) at the alveolar level. The brain injured patient also has decreased ventilation due to damage to respiratory drive centers. High-flow oxygen and rapid manual or mechanical ventilation will decrease carbon dioxide levels. This is the preferred treatment for respiratory acidosis. Brain-injured patients usually have vital signs t h a t are the reverse of hypovolemic shock (high blood pressure and slow pulse). When hypovolemic shock is present in the brain-injured patient, these classic signs will not be present. Hypovolemic shock is always treated first, since brain injury is usually not immediately life threatening. Fluid resuscitation. Fluid resuscitation is the most critical phase of care for the multisystem trauma patient. This is begun at the scene and continued until the hemorrhage is surgically stopped,
and circulating volume ,is restored. Volume expanders are started initially. These are crystaloids (lactated Ringer’s, normal saline) and colloids (albumin, plasmate). Whole blood must be started in the operating room immediately. It may be necessary to give type 0,Rh positive (universal donor) blood. When type-specific or complete crossmatched blood is available, it should be administered rapidly. The patient’s oxygen transport problems will not be resolved until he has enough hemoglobin to carry oxygen to the tissue^.^ Constant communication with the blood bank is mandatory throughout this period. I have seen one patient who received 19,000 ce of whole blood and fluid in 1%hours during fluid resuscitation. He survived. Since blood loss can be so large, many operating room teams used autotransfusion to replace volume. Autologousblood is salvaged during surgery, filtered to remove debris, and reinfused through available intravenous lines. The advantages of autotransfusion include decreased risk of transfusion reaction compared with homologous blood and rapid blood replacement in the face of severe blood shortages. This method is particularly valuable if the patient has a rare blood type. Autotransfusion also has disadvantages. Infected or malignant cells in the operative field may be returned to the systemic circulation. Coagulation abnormalities may develop due t o
AORN Journal, Novernber 1981, VoL 34, N o 5
833
hemolysis of red blood cells. The additional step of washing the erythrocytes prior t o reinfusion reduces the likelihood of coagulation disorders.6 Throughout fluid resuscitation, the nurse monitors intravenous intake, central venous pressure, urinary output, and output from other sources, such as suction, chest tubes, and the nasogastric tube. Central venous pressure (CVP) readings indicate the circulating volume returning to the heart and cardiac pump action. A continuously low CVP reading indicates further fluid resuscitation is nece~saryA . ~ rapid increase in CVP could indicate pump failure. If this increase is coupled with sudden rales and rhonchi in the chest, fluid overload should be suspected. Serious, unnoticed fluid overload can increase intracranial pressure and adversely affect the injured brain. Pulmonary complications and acid-base disturbances develop following fluid overload. Excess fluid is absorbed into the interstitial spaces, and oxygen-carbon dioxide gas exchange is altered. Since urinary output is a n indication of improved circulation and perfusion, the amount of urine must be closely monitored. A Foley catheter must be inserted early. The collection system should be calibrated so small amounts of urine can be measured accurately. An accurate record must be kept of all output, including that from suction, chest tubes, and nasogastric tube, so the patient’s volume output can be replaced. Accurate intake and output records greatly improve fluid resuscitation. Fluid resuscitation can lower the body’s core temperature so far that severe hypothermia is produced. Hypothermia is also a late complication of shock. Because of the cool operating room environment, the patient can also experience losses in his core temperature from his open surgical wounds. All fluids given intravenously should be warmed,
834
Motivation and adaptability are the keys to flight nursing, says Dusty €id, RN, flight supervisor. At right, flight nurses and emergency room nurses care for an auto accident patient flown in to St Anthony Hospital, Denver, by the Flight for Life helicopter.
Helicopters fight time to save trauma patients In trauma, the main enemy is time, and helicopters have become a major weapon in the war against the clock. Estimates are that the mortality rate rises 300°/0for every 30 minutes of delay in treating severely injured patients.’ The military learned the value of rapid air evacuation during the Vietnam War and brought it home to civilian hospitals. With its tradition of emergency care and proximity to the stormy and unpredictable Rocky Mountains, St Anthony Hospital Systems, Denver, was one of the first to set up a.helicopter program. Flight for Life began in 1972. This year, t h e program is averaging 7.38 flights a day for a projected yearly total of about 2,700 trips. Turbo-propsand Learjets are available at nearby Stapleton Airport for flights of over 150 miles, and flight crews have traveled
AORN Journal, November 1981, V o l 3 4 , N o 5
as far as Canada and Costa Rica. Flight for Life is more than an air ambulance service. Henry C Cleveland, MD, St Anthony’s medical director, has described it as a “mobile intensive care unit, an extension of the emergency department.” Registered nurses and emergency medical technicians staff the flights. The flight nurses have training and experience in critical care nursing, especially the management of difficult airway problems. The nurses work under physician supervision with written protocols, according to rules and regulations from the state board of nursing. When the program began, RNs were chosen over resident physicians as regular staff because it was felt they would provide continuity. With a total of 16 flight nurses, the flight program is staffed with RNs 24
hours a day. Flight nursing “takes a lot of motivation and adaptability,” Dusty Eid, RN, flight supervisor, said. There’s a lot of overtime, since a call to the flight program might come in toward the end of a shift, and the nurse has to go. Nurses are expected to rotate on all three shifts. But despite the stress, the waiting list is long, because this kind of nursing is hard to beat for challenge, variety, and drama. Note 1. W Robert Felix, Jr, “Metropolitan aeromedical service: State of the art,” Journal of Trauma 16 (November 1976) 873.
AORN Journal, November 1981, V o l 3 4 , No 5
835
ntreated hypothermia will cause circulatory collapse and death.
U
and the patient should be on a warming blanket throughout the surgery. Some surgeons a r e now irrigating open cavities with warmed normal saline to try to counteract heat loss. Ledingham and his associates have treated hypothermia with a modified Sengstaken tube to circulate lactated Ringer’s warmed to 41 C through the gastric and esophageal balloons.8 Untreated hypothermia will cause circulatory collapse and death. Metabolic acidosis develops, compounding the acidosis produced by the traumatic injuries. Hypoxia, cerebral edema, and cardiac arrhythmias can develop. The operating room nurse must monitor core temperature throughout the surgical procedure and communicate changes to the physicians. A temperature monitor with a rectal probe is invaluable. Medications. The multisystem trauma patient requires emergency and prophylactic drug therapy. These medicines must be readily available in or near the surgical suite (Table 2). A large supply of sodium bicarbonate (NaHC03) for intravenous use will be needed. Because the urgency of initial surgery may preclude proper aseptic technique, prophylactic antibiotic therapy is frequently begun during surgery. Many surgeons also s t a r t prophylactic steroid therapy. Cimetidine (Tagamet) may be given to decrease gastric irritation and prevent stress ulcers. Appropriate drugs to treat cardiac arrhythmias should be readily
836
available as well. Cardiac arrhythmias. Arrhythmias may develop due to decreased oxygen supply to the heart. Severe acidosis, either from hypovolemic shock or hypothermia, increases myocardial irritability. These ventricular arrythmias may require defibrillation. Since the primary cause of cardiac failure following multisystem trauma is inadequate circulating volume and tissue hypoxia, defibrillation and drug therapy may not reverse the arrhythmia. If the patient develops a n arrthythmia during surgery, be prepared t o treat it, but realize the outcome at this point is grave. After surgery. Provided the patient does not develop life-threatening arrhythmias and the hemorrhage is stopped, the initial surgery will be completed and plans made to treat the patient’s other injuries. This may be done immediately, or further surgeries will be scheduled later. The patient is now ready to be moved to the recovery room or the intensive care unit. The operating room nurse communicates to the receiving nurse significant events during surgery and plans for the future. The report includes total fluid intake and output; present urinary output rate; and output from chest tubes, nasogastric tube, etc. Vital signs before, during, and after surgery plus the most recent blood pressure, pulse and central venous pressure must be communicated. Medications given before and during
AORN Journal, November 2981, Val 34, No 5
surgery should be brought to the receiving nurse’s attention. It is extremely important to communicate additional injuries that are either diagnosed or suspected. This patient will need intensive support following surgery. He may face a multitude of posttraumatic complications, such as adult respiratory distress syndrome; disseminating intravascular coagulation (DIC); diabetes insipidus, peritonitis, intraabdominal abscess, renal failure, and stress ulcers. The multisystem trauma patient presents complex problems for the operating room nurse. For nurses who circulate on these cases, knowledge of the pathophysiology of shock is mandatory. This prepares them to take measures that can help prevent complications. Many complications will not occur if fluid resuscitation is rapid and accurate. Permanent nerve damage does not occur in patients who are properly positioned and padded. DIC is seen less frequently as the technology and skill in treating hypovolemic shock improve. In the end, the patient’s survival depends on the knowledge and skill of the OR nurse and the entire 0 surgery team. Notes 1. R W Virgilio et al, “Assessment and therapy of the shock syndrome,” Emergency Care: Assessment and lntelvention, 2nd ed, ed. Carmen Warner (St Louis: C V Mosby, 1978) 75-80. 2. Ibid. 3. lbid, 81. 4. J R Hoffman, “External counterpressure and the MAST suit: Current and future roles,” Annals of Emergency Medicine 9 (August 1980) 419-421. 5. Hugh E Stephenson, Jr, Robert S Kimpton, lmmediate Care of the Acutely Illandlnjured, 2nd ed (St Louis: C V Mosby, 1978) 15-17. 6. C L Rice, G S Moss, “Blood and blood substitutes: Current practice,” Advances in Surgery 13 (1979) 94-97. 7. Virgilio et al, “Assessment and therapy of the shock syndrome,” 83. 8. I McA Ledingham et al, “Central rewarming system for treatment of hypothermia,” Lancet 1:8179 (May31, 1980) 1168-1169.
Suggested reading Hardaway, Robert M. “Mechanism of traumatic shock.” Surgery, Gynecologyand Obstetrics 151 (July 1980) 65-69. Kneedler, Julia A. “Planning effective OR nursing care.” AORNJournal19 (June 1974) 1243-1245. Robinson, W A. “Fluid therapy in hemorrhagic shock.” Critical Care Quarterly 2 (March 1980) 1-14. Waeckerle, J F. “Antishock garments.” Critical Care Quarterly 2 (March 1980) 15-26.
Adrena/ecfomy no longer advised in breast cancer Surgical adrenalectomy or h ypoph ysectomy may no longer have a role in treating women with metastatic breast cancer, I Craig Henderson, MD, says in an editorial in the Sept 3 New England Journal of Medicine. Endocrine therapy is more prudent, he believes. Tamoxifen should be the first drug of choice for both premenopausal and postmenopausal patients because it is the least toxic. A relatively new agent-arninoglutethimide-is “a reasonable second therapy,” Dr Henderson writes. Results of a study by Richard J Santen, MD, and associates, reported in t h e same issue, show that aminoglutethimide is as effective as adrenalectomy for breast cancer. It even induced tumor regression in some patients whose cancers had not responded to the surgery. “Considering these results, it is appropriateto consider aminoglutethimide a firstline treatment in the large array of effective therapies already available for breast cancer,”Dr Henderson states. Major advantages of the two newer agents over previous therapies are the higher rates of response and the lower toxicity. Developed as an anticonvulsant about 20 years ago, aminoglutethimide was not effective for that purpose but was observed to suppress adrenal function. It was then tested for use in breast cancer. Tamoxifen is an antiestrogen that works by competing with estrogen for binding sites in cancer cells and then inhibits vital cell processes.
AORN Journal, November 1981, Vo l 3 4 , No 5
837
Preparing for patients with multisystem trauma
Rapid technological growth, improved prehospital care, and sophisticated transport systems are improving the life expectancy of the multisystem trauma patient. Today these patients appear in increasing numbers in our operating rooms. Their outcomes depend on how well medical and nursing personnel meet the challenge of their complex care problems. Multisystem trauma means injuries sustained by two or more body systems. One or more may be life threatening. The predominant symptom that often requires immediate surgery is hypovolemic shock resulting from severe hemorrhage. Major vessel tears; ruptured, torn, or punctured organs; and as-
Barbara J Lockwood, RN, M S , is systems director,nursing services,St Anthony Hospital Systems, Denver. She received baccataureate and master's degrees in nursing from the University of Colorado Health Sciences Center. Denver.
sociated skeletal fractures may be responsible singly or together for hypovolemia. Pulmonary parenchymal injuries, cardiac injuries, brain injury, and spinal cord injury may further complicate the clinical picture. Each injury must be rapidly assessed and ranked. Priorities are established according to which injury poses the gravest danger to the patient. Hemorrhage must be stopped, circulating volume returned to normal, and tissue oxygenation improved before other injuries are treated. For internal hemorrhage, rapid surgical intervention is required. The multisystem trauma patient will probably come to surgery shortly after the accident. He does not have a lot of time. He will die if the operating personnel are not prepared. The patient may arrive amid a great deal of confusion. Many ancillary personnel are involved in the initial care. The activities of the laboratory, radiology, and emergency room personnel must be coordinated and controlled by the operating room nurse. Several surgeons may be operating at one time during the initial surgery. Anticipating the needs of the thoracic, general, orthopedic, and neurosurgeons further complicates the nurse's role. In the early moments, it is extremely difficult for the nurse to establish a quiet, nonstimulating environment for the patient, but this is important. This patient was well until a short time before
AORN Journal, November 1981, Vol34, No 5
829
entering the hospital. He is not prepared for surgery and is probably frightened. The operating room nurse can do much to reassure and calm a conscious patient by explaining what is happening to him. Responding appropriately to this type of emergency surgery requires good knowledge of trauma pathophysiology. Common complications of traumatic injury can be averted if the nurse is aware of the events in surgery that can increase their occurrence. Knowing these will enable the nurse to anticipate the patient’s needs and plan care accordingly. Since this patient arrives with little warning and limited historical information, the nurse must be prepared for anything. All necessary equipment, instruments, and medicine must be readily available (Tables 1 and 2). Hypovolemic shock. For the patient in hypovolemic shock, the surgical team must react as if they were behind and must catch up. In fact, this is often the case. A relative loss of circulating blood volume within the cardiovascular system results in the inability to meet the metabolic tissue demands for oxygenation and waste removal. Left untreated, the condition will lead to cellular anoxia and death. A sudden loss of circulating volume sets off a sympathomimetic response, which causes vasoconstriction of the pnripheral blood vessels, increasing vascular resistance. Cardiac output is also increased initially. In this way, circulating volume is shiRed to the vital organs-the brain and heart. Blood flow consequently decreases to the peripheral limbs, skin, kidneys, and abdominal organs. Simultaneously, interstitial fluid is shifted into capillary beds in an attempt to increase circulating volume. Antidiuretic hormone is secreted by the anterior pituitary, and the adrenals secrete aldosterone to retain water and sodium in the kidneys. This additional fluid is returned to the bloodstream to
830
increase circulating volume. At this stage, shock is termed reversib1e.l As the shock state progresses, the organs and tissues not adequately perfused develop cellular hypoxia. Metabolic waste products increase, causing lactate retention and metabolic acidosis. Eventually, the continual buildup of metabolites will stimulate arterial vasodilatation. Venous vascular resistance to metabolites is higher. The relative difference in pressure between the arterial and venous capillary beds causes fluid in the venous system to reenter interstitial spaces. With this, venous return to the heart decreases, and cardiac output is reduced, ultimately leading to death. This is termed irreversible shock.2 Clinical s i p s of shock in the early stages are often subtle. Increased vasoconstriction causes cool, clammy, and pale skin. Decreased circulating volume with increased cardiac output produces tachycardia and a characteristically “thready” pulse. Respiratory rate increases to compensate for metabolic acidosis. Hyperventilation is the body’s attempt to remove carbon dioxide and keep blood pH within normal limits. As water and salts are shunted away from the kidney, urinary output falls below normal. If hypovolemic shock has been present long, the patient may exhibit signs of confusion and disorientation due to cerebral hypoxia. The patient in reversible shock can maintain a normal blood pressure. Once the pressure falls, the outcome is grave. Diaphoresis, coma, tachypnea, hypothermia, and anuria are the other clinical signs that signal irreversible or decompensated The goal of immediate surgery is to reverse hypovolemic shock while the patient has still compensated for sudden blood loss. T h e circulating nurse. The operating room nurse who circulates for the multisystem trauma patient focuses on intervention in the shock syndrome, anti-
AORN Journal, Nouember 1981, V o l 3 4 , No 5
Table 1
Multiple trauma emergency instruments St Anthony Hospital Systems, Denver, has developed this list of instrumentsthat are always ready for the multisystem trauma patient in a specially designed trauma room. Intravenous fluids, blood warmer, and emergency equipment are also kept in this room.
Freer elevators Nerve hook Probe with eye Uterine packing forceps Internal defibrillation paddles, adult and pediatric Clamps Aortic cross-clamps-2 Hemostats Kelly (6 to 8 inch) Towel clips Tonsil Kidney pedicle Arterial, all types Fogarty with inserts
Exploratory laparotomy set Arterial instrument set Chest instrument set Bowel instrument set Tracheotomy tray with trach tubes Subclavian (arterial)tray Sternal saw with motor Orthopedic special tray Plastic suture set Burr hole with flap tray Disposable skin staplers Tissue forceps, all sizes Arterial forceps, all sizes Scissors, all types and sizes Extra knife handles, all sizes Needle holders, all types and sizes Suction tips, Poole, tonsil, and neurosurgical Lebsche knife with mallet
Specialinstruments Weinberg retractor Instrument magnetic pad Clips and appliers Tibia1 traction tray Deep Balfour retractor Light handles Set of Deaver retractors Pin cutter
cipating problems and taking appropriate action. This patient will develop unnecessary complications if the nurse is not alert. On the patient’s arrival, the nurse concentrates on controlling the environment, reassuring the patient, and planning for proper positioning and padding. It is extremely important to maintain body alignment when moving the patient onto the operating bed. There may be undiagnosed fractured or dislocated vertebrae and other skeletal injuries. Cervical collars, sandbags, and splints should be left in place until x-rays rule out fractures. The anesthesiologist must be told a cervical vertebrae fracture is suspected prior to intubation and
induction. Decreased circulating volume, peripheral vasoconstriction, and subsequent diminished tissue oxygen supply increase the patient’s risk of pressure ulcers and equipment burns. Proper grounding must be assured. The operating room nurse is responsible to check and record peripheral circulation frequently. Particular attention is paid to areas distal to known injuries (eg, pedal and tibia1 pulses below a fractured tibia and fibula). Be sure that no equipment or operating room team member is applying pressure to the body. Improper positioning and pressure can cause brachial and ulnar nerve damage. The patient on a warming blanket must be
AORN Journal, November 1981, V o l 3 4 , No 5
831
Table 2
Multiple trauma emergency drugs Cephalothin (Keflin),1 gm
St Anthony Hospital Systems has the following drugs readily available for the multisystem trauma patient. Most of these drugs are given intravenously.
Adrenergics Dopamine hydrochloride, 200 mg Epinephrine ampul, 1 :lo00 Epinephrine automatic injector,
Quantity 4 2
Epinephrine automatic injector with cardiac needle lsoproterenol hydrochloride (Isuprel) automatic injector, 1 mgi5 cc Levarterenol bitartrate (Levophed),4 mg/4 cc Metaraminol bitartrate (Aramine), 10 mgicc
2 4 4
2
5
4
Atropine sulfate, 0.5 mg/5 cc Lidocaine hydrochloride, 2 gm Lidocaine automatic injector, 100 mgil0 cc Procainamide hydrochloride (Pronestyl),500 mg Propranolol hydrochloride (Inderal),1 mgicc
Cimetidine (Tagamet) Intravenous solution, 300 mg in 200 ml Corticosteroids Dexamethasone (Decadron) Hydrocortisone sodium succinate (Solu-Cortef),500 mg
2 4
2
An tiarrhythmics
4 2
Diuretics Furosemide (Lasix),100 rng 40 mg Mannitol, 12.5 mg 500 cc 20%
1
3 2
3
2 1 2
2 2
adequately protected from burns with sheepskins and bath blankets. At the scene of the injury, hypovolemic shock is treated by rapid infusion of volume expanders and counterpressure (MAST) suits. These inflatable trousers increase the blood circulating to the heart, brain, lungs, and kidneys. External counterpressure redirects venous blood flow away from the lower extremities to the organs above the dia~ h r a g mThe . ~ trousers should not be re-
832
Calcium chloride Automatic injector, 1 gm/lO cc
6
2
1 :I 0,000
Antibiotics Ampicillin, 1 gm Cefazolin (Ancef),1 gm
Antitoxins Tetanus toxoid (equine) Diphtheria (tetanus toxoid) Tetanus immune globulin, human
2
Narcotic antagonists Naloxone (Narcan) Sodium bicarbonate Automatic injector, 44.6 mEqi50 cc Vitamin K (phytonadione)
4
16
2
moved until the surgeon is confident the hemorrhage is controlled. Surgery can be performed by deflating the abdominal section of the trousers. The legs are left inflated to improve circulation to the vital organs. If counterpressure suits are removed prematurely, the patient may die in irreversible shock. Since hypovolemic shock is accompanied by metabolic acidosis, arterial blood gas samples should be taken frequently. The results will determine the
AORN Journal, Nouember 1981, V o l 3 4 , N o 5
0
ne patient received 19,000 cc of whole blood and fluid in 11h hours and survived.
level of acidosis and compensation. Arterial blood gases will also indicate how well therapy is working. Intravenous sodium bicarbonate (NaHC03) is given to reverse metabolic acidosis. Decreased circulating volume causes cellular hypoxia due partially to the loss of hemoglobin. The remaining blood has less oxygen-carrying ability. Hyperventilation compensates for metabolic acidosis and increases the oxygen supply to the available hemoglobin. Trauma patients with associated pulmonary injuries can develop respiratory acidosis caused by decreased ventilation (oxygen and carbon dioxide exchange) at the alveolar level. The brain injured patient also has decreased ventilation due to damage to respiratory drive centers. High-flow oxygen and rapid manual or mechanical ventilation will decrease carbon dioxide levels. This is the preferred treatment for respiratory acidosis. Brain-injured patients usually have vital signs t h a t are the reverse of hypovolemic shock (high blood pressure and slow pulse). When hypovolemic shock is present in the brain-injured patient, these classic signs will not be present. Hypovolemic shock is always treated first, since brain injury is usually not immediately life threatening. Fluid resuscitation. Fluid resuscitation is the most critical phase of care for the multisystem trauma patient. This is begun at the scene and continued until the hemorrhage is surgically stopped,
and circulating volume ,is restored. Volume expanders are started initially. These are crystaloids (lactated Ringer’s, normal saline) and colloids (albumin, plasmate). Whole blood must be started in the operating room immediately. It may be necessary to give type 0,Rh positive (universal donor) blood. When type-specific or complete crossmatched blood is available, it should be administered rapidly. The patient’s oxygen transport problems will not be resolved until he has enough hemoglobin to carry oxygen to the tissue^.^ Constant communication with the blood bank is mandatory throughout this period. I have seen one patient who received 19,000 ce of whole blood and fluid in 1%hours during fluid resuscitation. He survived. Since blood loss can be so large, many operating room teams used autotransfusion to replace volume. Autologousblood is salvaged during surgery, filtered to remove debris, and reinfused through available intravenous lines. The advantages of autotransfusion include decreased risk of transfusion reaction compared with homologous blood and rapid blood replacement in the face of severe blood shortages. This method is particularly valuable if the patient has a rare blood type. Autotransfusion also has disadvantages. Infected or malignant cells in the operative field may be returned to the systemic circulation. Coagulation abnormalities may develop due t o
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hemolysis of red blood cells. The additional step of washing the erythrocytes prior t o reinfusion reduces the likelihood of coagulation disorders.6 Throughout fluid resuscitation, the nurse monitors intravenous intake, central venous pressure, urinary output, and output from other sources, such as suction, chest tubes, and the nasogastric tube. Central venous pressure (CVP) readings indicate the circulating volume returning to the heart and cardiac pump action. A continuously low CVP reading indicates further fluid resuscitation is nece~saryA . ~ rapid increase in CVP could indicate pump failure. If this increase is coupled with sudden rales and rhonchi in the chest, fluid overload should be suspected. Serious, unnoticed fluid overload can increase intracranial pressure and adversely affect the injured brain. Pulmonary complications and acid-base disturbances develop following fluid overload. Excess fluid is absorbed into the interstitial spaces, and oxygen-carbon dioxide gas exchange is altered. Since urinary output is a n indication of improved circulation and perfusion, the amount of urine must be closely monitored. A Foley catheter must be inserted early. The collection system should be calibrated so small amounts of urine can be measured accurately. An accurate record must be kept of all output, including that from suction, chest tubes, and nasogastric tube, so the patient’s volume output can be replaced. Accurate intake and output records greatly improve fluid resuscitation. Fluid resuscitation can lower the body’s core temperature so far that severe hypothermia is produced. Hypothermia is also a late complication of shock. Because of the cool operating room environment, the patient can also experience losses in his core temperature from his open surgical wounds. All fluids given intravenously should be warmed,
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Motivation and adaptability are the keys to flight nursing, says Dusty €id, RN, flight supervisor. At right, flight nurses and emergency room nurses care for an auto accident patient flown in to St Anthony Hospital, Denver, by the Flight for Life helicopter.
Helicopters fight time to save trauma patients In trauma, the main enemy is time, and helicopters have become a major weapon in the war against the clock. Estimates are that the mortality rate rises 300°/0for every 30 minutes of delay in treating severely injured patients.’ The military learned the value of rapid air evacuation during the Vietnam War and brought it home to civilian hospitals. With its tradition of emergency care and proximity to the stormy and unpredictable Rocky Mountains, St Anthony Hospital Systems, Denver, was one of the first to set up a.helicopter program. Flight for Life began in 1972. This year, t h e program is averaging 7.38 flights a day for a projected yearly total of about 2,700 trips. Turbo-propsand Learjets are available at nearby Stapleton Airport for flights of over 150 miles, and flight crews have traveled
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as far as Canada and Costa Rica. Flight for Life is more than an air ambulance service. Henry C Cleveland, MD, St Anthony’s medical director, has described it as a “mobile intensive care unit, an extension of the emergency department.” Registered nurses and emergency medical technicians staff the flights. The flight nurses have training and experience in critical care nursing, especially the management of difficult airway problems. The nurses work under physician supervision with written protocols, according to rules and regulations from the state board of nursing. When the program began, RNs were chosen over resident physicians as regular staff because it was felt they would provide continuity. With a total of 16 flight nurses, the flight program is staffed with RNs 24
hours a day. Flight nursing “takes a lot of motivation and adaptability,” Dusty Eid, RN, flight supervisor, said. There’s a lot of overtime, since a call to the flight program might come in toward the end of a shift, and the nurse has to go. Nurses are expected to rotate on all three shifts. But despite the stress, the waiting list is long, because this kind of nursing is hard to beat for challenge, variety, and drama. Note 1. W Robert Felix, Jr, “Metropolitan aeromedical service: State of the art,” Journal of Trauma 16 (November 1976) 873.
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ntreated hypothermia will cause circulatory collapse and death.
U
and the patient should be on a warming blanket throughout the surgery. Some surgeons a r e now irrigating open cavities with warmed normal saline to try to counteract heat loss. Ledingham and his associates have treated hypothermia with a modified Sengstaken tube to circulate lactated Ringer’s warmed to 41 C through the gastric and esophageal balloons.8 Untreated hypothermia will cause circulatory collapse and death. Metabolic acidosis develops, compounding the acidosis produced by the traumatic injuries. Hypoxia, cerebral edema, and cardiac arrhythmias can develop. The operating room nurse must monitor core temperature throughout the surgical procedure and communicate changes to the physicians. A temperature monitor with a rectal probe is invaluable. Medications. The multisystem trauma patient requires emergency and prophylactic drug therapy. These medicines must be readily available in or near the surgical suite (Table 2). A large supply of sodium bicarbonate (NaHC03) for intravenous use will be needed. Because the urgency of initial surgery may preclude proper aseptic technique, prophylactic antibiotic therapy is frequently begun during surgery. Many surgeons also s t a r t prophylactic steroid therapy. Cimetidine (Tagamet) may be given to decrease gastric irritation and prevent stress ulcers. Appropriate drugs to treat cardiac arrhythmias should be readily
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available as well. Cardiac arrhythmias. Arrhythmias may develop due to decreased oxygen supply to the heart. Severe acidosis, either from hypovolemic shock or hypothermia, increases myocardial irritability. These ventricular arrythmias may require defibrillation. Since the primary cause of cardiac failure following multisystem trauma is inadequate circulating volume and tissue hypoxia, defibrillation and drug therapy may not reverse the arrhythmia. If the patient develops a n arrthythmia during surgery, be prepared t o treat it, but realize the outcome at this point is grave. After surgery. Provided the patient does not develop life-threatening arrhythmias and the hemorrhage is stopped, the initial surgery will be completed and plans made to treat the patient’s other injuries. This may be done immediately, or further surgeries will be scheduled later. The patient is now ready to be moved to the recovery room or the intensive care unit. The operating room nurse communicates to the receiving nurse significant events during surgery and plans for the future. The report includes total fluid intake and output; present urinary output rate; and output from chest tubes, nasogastric tube, etc. Vital signs before, during, and after surgery plus the most recent blood pressure, pulse and central venous pressure must be communicated. Medications given before and during
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surgery should be brought to the receiving nurse’s attention. It is extremely important to communicate additional injuries that are either diagnosed or suspected. This patient will need intensive support following surgery. He may face a multitude of posttraumatic complications, such as adult respiratory distress syndrome; disseminating intravascular coagulation (DIC); diabetes insipidus, peritonitis, intraabdominal abscess, renal failure, and stress ulcers. The multisystem trauma patient presents complex problems for the operating room nurse. For nurses who circulate on these cases, knowledge of the pathophysiology of shock is mandatory. This prepares them to take measures that can help prevent complications. Many complications will not occur if fluid resuscitation is rapid and accurate. Permanent nerve damage does not occur in patients who are properly positioned and padded. DIC is seen less frequently as the technology and skill in treating hypovolemic shock improve. In the end, the patient’s survival depends on the knowledge and skill of the OR nurse and the entire 0 surgery team. Notes 1. R W Virgilio et al, “Assessment and therapy of the shock syndrome,” Emergency Care: Assessment and lntelvention, 2nd ed, ed. Carmen Warner (St Louis: C V Mosby, 1978) 75-80. 2. Ibid. 3. lbid, 81. 4. J R Hoffman, “External counterpressure and the MAST suit: Current and future roles,” Annals of Emergency Medicine 9 (August 1980) 419-421. 5. Hugh E Stephenson, Jr, Robert S Kimpton, lmmediate Care of the Acutely Illandlnjured, 2nd ed (St Louis: C V Mosby, 1978) 15-17. 6. C L Rice, G S Moss, “Blood and blood substitutes: Current practice,” Advances in Surgery 13 (1979) 94-97. 7. Virgilio et al, “Assessment and therapy of the shock syndrome,” 83. 8. I McA Ledingham et al, “Central rewarming system for treatment of hypothermia,” Lancet 1:8179 (May31, 1980) 1168-1169.
Suggested reading Hardaway, Robert M. “Mechanism of traumatic shock.” Surgery, Gynecologyand Obstetrics 151 (July 1980) 65-69. Kneedler, Julia A. “Planning effective OR nursing care.” AORNJournal19 (June 1974) 1243-1245. Robinson, W A. “Fluid therapy in hemorrhagic shock.” Critical Care Quarterly 2 (March 1980) 1-14. Waeckerle, J F. “Antishock garments.” Critical Care Quarterly 2 (March 1980) 15-26.
Adrena/ecfomy no longer advised in breast cancer Surgical adrenalectomy or h ypoph ysectomy may no longer have a role in treating women with metastatic breast cancer, I Craig Henderson, MD, says in an editorial in the Sept 3 New England Journal of Medicine. Endocrine therapy is more prudent, he believes. Tamoxifen should be the first drug of choice for both premenopausal and postmenopausal patients because it is the least toxic. A relatively new agent-arninoglutethimide-is “a reasonable second therapy,” Dr Henderson writes. Results of a study by Richard J Santen, MD, and associates, reported in t h e same issue, show that aminoglutethimide is as effective as adrenalectomy for breast cancer. It even induced tumor regression in some patients whose cancers had not responded to the surgery. “Considering these results, it is appropriateto consider aminoglutethimide a firstline treatment in the large array of effective therapies already available for breast cancer,”Dr Henderson states. Major advantages of the two newer agents over previous therapies are the higher rates of response and the lower toxicity. Developed as an anticonvulsant about 20 years ago, aminoglutethimide was not effective for that purpose but was observed to suppress adrenal function. It was then tested for use in breast cancer. Tamoxifen is an antiestrogen that works by competing with estrogen for binding sites in cancer cells and then inhibits vital cell processes.
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