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Trauma and the elderly: A case study
T R A U M A AND THE ELDERLY: A CASE S T U D Y
Kate McCarthy C.N.S., G. Dip Critical Care
1930hrs
2031hrs Hospital Emergency
Patient: An 87 year old female front seat passenger involved in a head on motor vehicle accident at approximately 80kph with major deformation to the front of the car.
Department
1950hrs At scene - Ambulance arrived - not trapped and wearing seat belt - alert, orientated, nil reported loss of consciousness complaining of mild dyspnoea, pain on inspiration relieved by high flow oxygen - SaO2 99%, GCS = 15, pupils equal and reactive. - Hard collar applied - Haemaccel 500mls stat commenced - Morphine 2.5mg and Maxalon 10mg I.V. - Temp 36.3, Pulse not recorded, BP 140 systolic, RR 18 - Haemodynamically stable en route according to ambulance report.
~
i~i~iiii!i~iii@~:@i ~
Primary Survey Airway: patent, cervical spine immobilised with hard collar. Breathing: spontaneous, high flow oxygen insitu, symmetrical chest expansion. Breath sounds slightly diminished on left side. Mild pain and extensive bruising noted on chest. Patient pale, SaO2 98%. Circulation: Pulse- strong, regular 80 bpm. BP 141/86, skin peripherally cool and clammy, capillary refill less than 2 secs. Further large bore Intravenous cannula inserted. Cardiac monitor sinus rhythm. Neuro: Pupils equal and reactive, size 4, GCS = 15. Patient's clothes removed during primary survey. XRAYS: Lateral C Spine, Supine chest BLOODS: FBC/EUC/LFT's/BSL/
Amylase/ABG's/G+H. 16g IVC inserted - total of 3 peripheral IVC's. Haemaccel 500mls and 1L hartmans star.
SecondarySurvey Head to toe examination conducted. Head; no abnormalities detected. Neck; irregular abrasion across anterior and lateral lower left neck. Trunk; Diffuse bruising extending from the antero lateral right chest just below the clavicle down lateral to the right breast. Diffuse bruising also involving lateral aspect of right abdomen and upper thigh extending into the right groin with sparing of the perineal area, abdomen soft. Pain on movement. Marked pain on springing of pelvis. On the left side, similar bruising which extended onto the anterior upper left thigh. Superficial lacerations present over anterior aspect of the left groin.
~U
J
~.. Haemaccel 100mls stat Packed cells- 4 stat Fresh frozen plasma- 6 stat Alert, pain free, cold peripheries, increasingly hardening abdomen Awaiting surgical review.
2345hrs
.... /
J5
Patient transferred to CT for pelvic, chest and abdomen scans without chest xray being reviewed.
2235hrs
Upper limbs; Irregular bruising extending from the left antecubital fossa onto the flexor aspect of the upper and middle thirds of the left forearm. Laceration on dorsum of right hand, dressing attended. Lower limbs; Irregular bruises covering both left and right knees and shins. A log roll was not done. Investigations: Xrays: later c-spine, erect chest, abdo, pelvis CT: Requests for abdo, chest and pelvis ECG: sinus tachycardia IDC inserted Past medical history: Nil significant. Nil known allergies. Medications: Feldene.
21 ! Ohrs BP 93/53, HR 100, stat haemaccel 500mls Penicillin 600mg IV Flucloxacillin lg IV Tet tox and TIG IMI
Returned to ED BP 77/45, HR 120, given haemaccel 1000mls, resulting in slight increase in BE No documented observations in CT Chest Xray: fractured right 1-6 ribs and left 1-2 ribs anteriorly left haemothorax.
2250hrs BP 79/40, packed cells 1 unit stat Level of consciousness decreased with increasing tachycardia, pale, cool and clammy skin. Patient refusing analgesia, states she has no pain. Abdomen becoming distended. ICU registrar paged IDC drainage decreased to < 25 mls/hour. CT report: head: NAD chest: left haemothorax and multiple fractured ribs pelvis: multiple fractures and haemorrhage.
Patient remains unstable, BP 92/56, P 82, extremely pale, alert at times, responsive to verbal and gentle physical stimuli, cooperative, refusing offers of analgesia. Patient's fluid resuscitation thus far: 2600mls haemaccel 1000mls Hartmans 5 units packed cells 6 units of FFP
O030hrs Patient is maintaining her airway, breathing is shallow and slow, very cold peripherally, fluctuating level of conscious, urine output > 20ml/hr. BP 63/35, P 116. ICU and surgical registrars do not provide any suggestions re management. Further 2 units of packed cells 2 units of haemaccel 4 units of FFP 0123hrs Patient is unconscious, unresponsive, no pulse. BP 40/35 CPR commenced, given atropine and adrenaline Patient's relative, a doctor, enters and says " Let her go, she's had enough" CPR ceased, time of death 0125hrs.
2310hrs Insertion of ICC between the 5th and 6th ribs by ED registrar BP 65/36, P 40
23
ii....
~ 17 ~!~i'~~ 7
LDERLY
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j
,¸
ii
PATHOPHYSIOLOGICAL RESPONSE TO TRAUMA Hypovolemicshock Initially cardiac output (CO) is decreased and compensatory neural and hormonal mechanisms are activated to successfully restore CO and tissue perfusion to the vital organsJ ~) As shock progresses, physiologic changes commenced in the compensatory stage of shock that aided in shunting blood to vital organs become ineffective, leading to hypoperfusion and multiple system organ failure./4) Loss of auto regulation in the micro circulation and increased capillary permeability reduce cardiac preload and thus CO. Decreased CO reduces arterial BP, lessening coronary artery perfusion and the myocardial muscle oxygen supply/4). The rising muscle oxygen demands are unable to be met resulting in arrhythmias, muscle ischaemia and cell death. These further depress cardiac function, preload and CO, creating a vicious cycle of decreased CO and cardiac failure develops leading to the deterioration of the circulatory system and inadequate perfusion of other organ systems 14'5).For example: ischaemic induced acute renal failure, which is a result of a significant decrease in renal perfusion. Current opinions of the causal mechanisms of tubular cell damage include cellular adenosine triphosphate (ATP) depletion, oxygen free radicals,
~i!!i!~!!i{{!ii!~ 24
loss of epithelial cell polarity and increased intra cellular calcium levels% Hypothermia frequently occurs in trauma and centrally administered warm fluids assist in maintaining normothermia, preventing decreasing arterial pressure, arrhythmias and cardiovascular and cerebral depression. ~z°~
Pulmonarycomplicationsof trauma Chest injuries occur in more than one third of MVA victims, and age has considerable effect on the extent of damage the mechanism of injury will cause, considering frail bones, underlying disease processes and decreased suppleness of cartilage. 16'7) Normal ventilation requires a clear airway, an intact chest wall, a functioning diaphragm and normal pulmonary parenchyma. <6'1~)Problems associated with increased physiological dead space are V/Q imbalances, impaired gas exchange and hypoxemia. In response to hypoxemia, the rate and depth of ventilation increases, and generally the exhalation of large amounts of carbon dioxide resulting in respiratory alkalosis. ~4'8/The combination of decreased arterial oxygen and carbon dioxide pressures and alkalosis adversely affects the level of consciousness, generating restlessness, confusion, lethargy and mental cloudiness. 14'16~ The patient has 1st rib fractures, which are signs of severe traumatic injury. The 1st ribs are connected to the shoulder, sternum, dorsal vertebrae and cervical spine by numerous ligaments and muscles, thus substantial force was required to break these ribs and alerts us to the probability of associated injuries, such as pneumothorax, lung contusions, flail chest atelectasis, haemothorax and aortic injury. " ' ~) The fractured lower ribs and marked bruising anatomically place
the spleen and liver at risk of injury. Pulmonary contusions occur in nearly 75 % of patients with blunt trauma to the chest, with the mortality rate being 40%. Patients at greatest risk are the thin chested and the elderly, a'6'8) The compression and sheer forces of the chest trauma are transmitted to the lungs causing rupture of lung tissue, alveoli and tiny airways. The initial response is haemorrhage into alveolar and interstitial spaces. An inflammatory response will gradually spread to surrounding tissue. ~2'6'8) Alveolar ventilation as reduced in the involved parenchyma leading to a reduced V/Q ratio. Hypoxic vasoconstriction occurs locally in an attempt to decrease hypoxemia, but despite this the net result is an increased V/Q mismatch causing hypoxemia, increasing pulmonary vascular resistance, decreased lung compliance and hypercapnia. Is) Pleural cavity injury can be caused by chest wall injuries and penetrating chest trauma. Disruption of the pleural cavity can result in a pneumothorax, tension pneumothorax or haemothorax. Pneumothorax is the accumulation of air as a result in either the visceral or parietal pleura. (6'~The normal intrapleural negative pressure is compromised and air escapes into the cavity until the pressures become equal, causing the lung to collapse. ~9~As a result, there is a restrictive ventilation impairment with the reduced total lung capacity causing hypoxemia by shunting of blood through non ventilated lung tissue. ~9)The life threatening tension pneumothorax develops when air enters the pleural space during inspiration but trapped during expiration, the accumulating air causes a marked positive pleural pressure, compressing and deviati.ng the mediastinal structures and functional lung. Hypoxemia results from decreased
venous return and CO and impaired gas exchange, tracheal deviation and raised JVP ultimately leading to death.(9)
Multiple Pelvic Fractures The patient sustained fractures to the crest and wing of both ilea, consistent with a large crushing force as mechanism of injury. The implications of multiple pelvic fractures reach far beyond the mechanical stability of the pelvis, intraperitoneal injuries and retroperitoneal haemorrhage become a major concern./~°) Research reviewed by Rosen & Barkin (1992) indicates a 50% mortality rate associated with multiple pelvic injuries, and this increases with age. Haemorrhage from pelvic injuries result from lacerations to the rich vascular network supplying the pelvis and collects in the retroperitoneal cavity. Pelvic fractures can result in over 2500mls of blood loss. (*' Considerable bleeding may also occur from marrow vessels ruptured at fracture sites, coagulopathy may be another contributor31°~ Major arteries supplying the pelvis are the left and right iliac, superior gluteal and pudendal branches of the ileac, all in close proximity to the posterior pelvic arch and commonly injured due to lack of muscle protection. (1°a21The venous system also has many collateral branches; is without valves, allowing bidirectional flow, and is thin wailed, preventing constrictionY ,12)Without performing angiography, it is impossible to know clinically where the bleeding is originating.~1°) Most pelvic haematomas derive venously and tamponade retroperitoneally by the intact peritoneum. Both arterial and venous haematomas may dissect retroperitoneally to eventually spread into the leaves of the intestinal mesentery and produce clinical signs of an acute abdomen - rigidity and
distention. They may also dissect anteriorly into the anterior abdominal wall.,0,11.12/ In the emergency department, objectives of the care of patients with pelvic fractures are to; 1) Recognise the patient who is in haemorrhagic shock and to initiate blood transfusion early in resuscitation (10). 2) Realise that patients with posterior arch fractures may have a retroperitoneal haematoma contributing to their hypovolemic state. 3) Identify by diagnostic peritoneal lavage (DPL) the patient who has intra abdominal bleeding that necessitates laparotomy. However, the use of DPL in the presence of pelvic fracture is controversial amongst clinicians. (1°) 4) Minimise movement of bone at the fracture sites so as not to disturb the haemostatic processesY I 5) understand the role and timing of angiography in managing the patient31°~ A simple and effective method of immobilising the pelvis is to fold a sheet length ways until it is approximately 1 foot wide. Place the folded sheet under the patient, twist the ends and tie or pin around the patient.
Trauma and the elderly Trauma patients over the age of 60 are at a greater risk of sustaining injury due to the effect of the aging process. Research conducted by Morris et al (1990) found that 59% of trauma patient deaths were among those aged over 55 years of age (2~.The body has less protection from trauma because of changes in the musculoskeletal system such as decreased bone mass, muscle atrophy and loss of subcutaneous tissue. 65% of elderly trauma patients present with one or more preexisting medical
conditions3 =) Functional changes affecting response to injury enables the elderly to deteriorate rapidly with few warning signs. The earliest physiologic responses to shock are directed at restoring and maintaining adequate perfusion to vital organs. Aging reduces the response of the sympathetic nervous system to stimulation and catecholamine release (z2,237Thickened heart valves and blood vessels, and weaker veins are less able to adjust to increase venous return and thus inhibit the shunting of blood flow to vital organs. Atherosclerotic arteries and a reduced number of functioning cardiac conducting ceils effect the responsiveness to adrenergic stimulation and myocardial contractility.(2z) Age related changes in the biochemical structure of cell membranes significantly reduce beta receptor activity resulting in a limited chronotropic and inotropic response to beta stimulation3 z4/ Systolic hypertension is common among the aged, which generally results in poor toleration of acute hypotension, also resulting in poor perfusion to vital organs. It is important to understand the altered physiological responses of the potentially shocked aged patient as they tend not to present with the tachycardia, increased myocardial contractility and vasoconstriction associated with stimulation of the sympathetic n e r v o u s s y s t e m . 122'24)Many elderly patients take medication such as antihypertensives, beta and calcium channel blockers, diuretics, antiarrythmics, non steroidals, narcotics, insulin and steroids, bronchodialtors, anticonvulsants which all affect the stress response321~ Pulmonary function is also affected by many structural and functional changes in the aging process. A
® 25
....
LDERLY \4!
NURSING INTERVEHTIONS AND TRAUMA MANAGEMENT.
present
-
Initial assessment- the primarysurvey
i/f
Airway + c spine Breathing + ventilation Circulation + control of bleeding Disability - neurologic A i r w a y
decreased number and size of alveoli and decreased surfactant production weakens the ability of the lungs to respond to hypoxia, hypercarbia and acidosis (=~Chronic diseases such as chronic airways limitations and asthma add to the risk of pulmonary failure(21) Atrophy of respiratory muscles, decreased vital capacity and chest wall compliance increases the work of breathing in the elderly patient, and fatigue occurs quickly.(21~ Factors that contribute to improved survival are early invasive monitoring, aggressive volume resuscitation, early mechanical ventilation, the severity of injury, time between injury and treatment, past medical history, the quality of care and prevention of complications(=, z3.247
i:i
flail:: ¸ ¸i¸¸ ! i?iiii
The process of aging is extremely individual, and no assumptions regarding management should be based on age. However, it is important to consult the patient, private doctors and family members, collect information about the patient such as mechanism of injury, past medical history and level of independent function early on to direct resuscitative efforts. (=,23~
patient obstructed
- control bleeding - 2 large bore IVC's fluid infusion (warm) - send bloods including cross match
Neurologic Assess level of consciousness, pupil size and reaction, Glasgow Coma Score. If patient has a decreased level of consciousness also consider traumatic causes such as hypoglycemia, hypovolaemia and drug induced coma. Other initial observations and interventions include - temperature urinary catheter, naso/orogastric tube, CVP line - documentation communication with trauma team, family and patient Nursing staff can anticipate the equipment, drugs and resources which may be used to aid in smooth, rapid trauma management. Immediate intervention to correct any life threatening deviation of the above must occur before proceeding to the secondary survey. (17,,8) n o n
stabilise c-spine with a rigid collar and tape jaw thrust without hyperextension - remove debris (suction, blood, mucous, vomit) - oral nasopharyngeal airway intubation or crycothyrotomy -
-
-
B r e a t h i n g
present absent
- high flow oxygen - bag valve device with high flow oxygen intubation/ crycothyrotomy positive pressure ventilation Also assess for decreased level of consciousness, respiratory rate and characteristics, oxygen saturation, tracheal and mediastinal shift, diminished breath sounds, asymmetrical and paradoxical chest expansion, cyanosis, sucking chest wounds. Tension p n e u m o t h o r a x - needle thorocostomy and prepare for a chest tube Sucking chest w o u n d - 3 sided porous dressing Flail chest - Prepare for assisted ventilation H e m o t h o r a x - chest tube -
-
-
-
MANAGEMENT ISSUES • The function of the trauma team includes follow up, communication among medical, nursing and allied health staff, and providing a management plan. Communication between team members and a definitive case plan were suboptimal in this case.
n o n
Circulation
® 26
Assess pulse rate and quality, location, blood pressure, capillary refill, bleeding, skin colour and feel, level of consciousness, cardiac monitor.
• The lack of senior medical staff involvement early in the case resulted in less experienced staff underestimating the seriousness of the patient's injuries. • The need for senior medical staff involvement in decision making and consultation with the patient and family early in the resuscitation phase should be reinforced.
Fluid resuscitation: Overall, the patient had 4500mls of colloids, 7 units of packed cells and 10 units of fresh frozen plasma and did not maintain normotension. This is an indication for the need to identify the source of bleeding and appropriately intervene. • The decision to transfer an unstable patient within the hospital to diagnostic areas.
The importance of documentation can not be emphasised enough. • Documentation provides a record of care and condition during the patients movements through different departments. There were no vital signs documented in the CT scanner in this case, which meant the team had no record of the patients' deterioration or the duration of hypotension.
• Organising debriefing of staff involved in a trauma is important to supply feedback, voice complaints and suggestions, offer reassurance and just talk! • Emotional support for the family should always be made an option. Social workers and chaplains can be made available, if the family does not want any immediate support, give them a phone number or notify the hospital social work service who should follow the family up with a phone call and offers of counselling. • There is nothing worse than not knowing what is happening to a loved one, doubt, assumption and panic can occur. It is important to have continual communication with the family, so that they remain informed and can be involved in decision making.
SUMMARY This case highlights the role of the trauma team and the importance of communication between the team members, senior medical staff, the patient and their family. Trauma care in the elderly poses a myriad of problems and dilemmas, both physiological and ethical. Each of these issues needs to be considered in the context of trauma. Other issues of importance illustrated by this case include the importance of documentation and early consultation with the patient and family regarding care. Also emphasised is the need for debriefing of staff involved in the incident and the option of consulting senior raedical staff after hours. Auditing cases such as this identifies management deficits and problems that can be used as an educational tool and
i
!ii!iiiiiiiii i i!iii
to effect a change in practice.
• The documentation of fluids given to the patient aids in determining accurate fluid deficits/overload. A record of administered drugs and coinciding patient condition can indicate the extent of patient pain and sedation. For example, too much morphine depresses respiratory function. • Patient records may be required as evidence in court, whether for civil or criminal proceedings, and will be subject to close and careful scrutiny. Documentation should be legible, accurate and objective (19). • If a nurse feels that patient management is not appropriate and has expressed this to the attending medical officer and nurse manager, the nurse should not hesitate to contact and inform senior medical staff, whether it be the trauma or emergency registrar or consultant. The nurse should also document the rationale and actions taken.
15
® 27
Kate McCarthy C.N.S., G. Dip Critical Care
1930hrs
2031hrs Hospital Emergency
Patient: An 87 year old female front seat passenger involved in a head on motor vehicle accident at approximately 80kph with major deformation to the front of the car.
Department
1950hrs At scene - Ambulance arrived - not trapped and wearing seat belt - alert, orientated, nil reported loss of consciousness complaining of mild dyspnoea, pain on inspiration relieved by high flow oxygen - SaO2 99%, GCS = 15, pupils equal and reactive. - Hard collar applied - Haemaccel 500mls stat commenced - Morphine 2.5mg and Maxalon 10mg I.V. - Temp 36.3, Pulse not recorded, BP 140 systolic, RR 18 - Haemodynamically stable en route according to ambulance report.
~
i~i~iiii!i~iii@~:@i ~
Primary Survey Airway: patent, cervical spine immobilised with hard collar. Breathing: spontaneous, high flow oxygen insitu, symmetrical chest expansion. Breath sounds slightly diminished on left side. Mild pain and extensive bruising noted on chest. Patient pale, SaO2 98%. Circulation: Pulse- strong, regular 80 bpm. BP 141/86, skin peripherally cool and clammy, capillary refill less than 2 secs. Further large bore Intravenous cannula inserted. Cardiac monitor sinus rhythm. Neuro: Pupils equal and reactive, size 4, GCS = 15. Patient's clothes removed during primary survey. XRAYS: Lateral C Spine, Supine chest BLOODS: FBC/EUC/LFT's/BSL/
Amylase/ABG's/G+H. 16g IVC inserted - total of 3 peripheral IVC's. Haemaccel 500mls and 1L hartmans star.
SecondarySurvey Head to toe examination conducted. Head; no abnormalities detected. Neck; irregular abrasion across anterior and lateral lower left neck. Trunk; Diffuse bruising extending from the antero lateral right chest just below the clavicle down lateral to the right breast. Diffuse bruising also involving lateral aspect of right abdomen and upper thigh extending into the right groin with sparing of the perineal area, abdomen soft. Pain on movement. Marked pain on springing of pelvis. On the left side, similar bruising which extended onto the anterior upper left thigh. Superficial lacerations present over anterior aspect of the left groin.
~U
J
~.. Haemaccel 100mls stat Packed cells- 4 stat Fresh frozen plasma- 6 stat Alert, pain free, cold peripheries, increasingly hardening abdomen Awaiting surgical review.
2345hrs
.... /
J5
Patient transferred to CT for pelvic, chest and abdomen scans without chest xray being reviewed.
2235hrs
Upper limbs; Irregular bruising extending from the left antecubital fossa onto the flexor aspect of the upper and middle thirds of the left forearm. Laceration on dorsum of right hand, dressing attended. Lower limbs; Irregular bruises covering both left and right knees and shins. A log roll was not done. Investigations: Xrays: later c-spine, erect chest, abdo, pelvis CT: Requests for abdo, chest and pelvis ECG: sinus tachycardia IDC inserted Past medical history: Nil significant. Nil known allergies. Medications: Feldene.
21 ! Ohrs BP 93/53, HR 100, stat haemaccel 500mls Penicillin 600mg IV Flucloxacillin lg IV Tet tox and TIG IMI
Returned to ED BP 77/45, HR 120, given haemaccel 1000mls, resulting in slight increase in BE No documented observations in CT Chest Xray: fractured right 1-6 ribs and left 1-2 ribs anteriorly left haemothorax.
2250hrs BP 79/40, packed cells 1 unit stat Level of consciousness decreased with increasing tachycardia, pale, cool and clammy skin. Patient refusing analgesia, states she has no pain. Abdomen becoming distended. ICU registrar paged IDC drainage decreased to < 25 mls/hour. CT report: head: NAD chest: left haemothorax and multiple fractured ribs pelvis: multiple fractures and haemorrhage.
Patient remains unstable, BP 92/56, P 82, extremely pale, alert at times, responsive to verbal and gentle physical stimuli, cooperative, refusing offers of analgesia. Patient's fluid resuscitation thus far: 2600mls haemaccel 1000mls Hartmans 5 units packed cells 6 units of FFP
O030hrs Patient is maintaining her airway, breathing is shallow and slow, very cold peripherally, fluctuating level of conscious, urine output > 20ml/hr. BP 63/35, P 116. ICU and surgical registrars do not provide any suggestions re management. Further 2 units of packed cells 2 units of haemaccel 4 units of FFP 0123hrs Patient is unconscious, unresponsive, no pulse. BP 40/35 CPR commenced, given atropine and adrenaline Patient's relative, a doctor, enters and says " Let her go, she's had enough" CPR ceased, time of death 0125hrs.
2310hrs Insertion of ICC between the 5th and 6th ribs by ED registrar BP 65/36, P 40
23
ii....
~ 17 ~!~i'~~ 7
LDERLY
'\
j
,¸
ii
PATHOPHYSIOLOGICAL RESPONSE TO TRAUMA Hypovolemicshock Initially cardiac output (CO) is decreased and compensatory neural and hormonal mechanisms are activated to successfully restore CO and tissue perfusion to the vital organsJ ~) As shock progresses, physiologic changes commenced in the compensatory stage of shock that aided in shunting blood to vital organs become ineffective, leading to hypoperfusion and multiple system organ failure./4) Loss of auto regulation in the micro circulation and increased capillary permeability reduce cardiac preload and thus CO. Decreased CO reduces arterial BP, lessening coronary artery perfusion and the myocardial muscle oxygen supply/4). The rising muscle oxygen demands are unable to be met resulting in arrhythmias, muscle ischaemia and cell death. These further depress cardiac function, preload and CO, creating a vicious cycle of decreased CO and cardiac failure develops leading to the deterioration of the circulatory system and inadequate perfusion of other organ systems 14'5).For example: ischaemic induced acute renal failure, which is a result of a significant decrease in renal perfusion. Current opinions of the causal mechanisms of tubular cell damage include cellular adenosine triphosphate (ATP) depletion, oxygen free radicals,
~i!!i!~!!i{{!ii!~ 24
loss of epithelial cell polarity and increased intra cellular calcium levels% Hypothermia frequently occurs in trauma and centrally administered warm fluids assist in maintaining normothermia, preventing decreasing arterial pressure, arrhythmias and cardiovascular and cerebral depression. ~z°~
Pulmonarycomplicationsof trauma Chest injuries occur in more than one third of MVA victims, and age has considerable effect on the extent of damage the mechanism of injury will cause, considering frail bones, underlying disease processes and decreased suppleness of cartilage. 16'7) Normal ventilation requires a clear airway, an intact chest wall, a functioning diaphragm and normal pulmonary parenchyma. <6'1~)Problems associated with increased physiological dead space are V/Q imbalances, impaired gas exchange and hypoxemia. In response to hypoxemia, the rate and depth of ventilation increases, and generally the exhalation of large amounts of carbon dioxide resulting in respiratory alkalosis. ~4'8/The combination of decreased arterial oxygen and carbon dioxide pressures and alkalosis adversely affects the level of consciousness, generating restlessness, confusion, lethargy and mental cloudiness. 14'16~ The patient has 1st rib fractures, which are signs of severe traumatic injury. The 1st ribs are connected to the shoulder, sternum, dorsal vertebrae and cervical spine by numerous ligaments and muscles, thus substantial force was required to break these ribs and alerts us to the probability of associated injuries, such as pneumothorax, lung contusions, flail chest atelectasis, haemothorax and aortic injury. " ' ~) The fractured lower ribs and marked bruising anatomically place
the spleen and liver at risk of injury. Pulmonary contusions occur in nearly 75 % of patients with blunt trauma to the chest, with the mortality rate being 40%. Patients at greatest risk are the thin chested and the elderly, a'6'8) The compression and sheer forces of the chest trauma are transmitted to the lungs causing rupture of lung tissue, alveoli and tiny airways. The initial response is haemorrhage into alveolar and interstitial spaces. An inflammatory response will gradually spread to surrounding tissue. ~2'6'8) Alveolar ventilation as reduced in the involved parenchyma leading to a reduced V/Q ratio. Hypoxic vasoconstriction occurs locally in an attempt to decrease hypoxemia, but despite this the net result is an increased V/Q mismatch causing hypoxemia, increasing pulmonary vascular resistance, decreased lung compliance and hypercapnia. Is) Pleural cavity injury can be caused by chest wall injuries and penetrating chest trauma. Disruption of the pleural cavity can result in a pneumothorax, tension pneumothorax or haemothorax. Pneumothorax is the accumulation of air as a result in either the visceral or parietal pleura. (6'~The normal intrapleural negative pressure is compromised and air escapes into the cavity until the pressures become equal, causing the lung to collapse. ~9~As a result, there is a restrictive ventilation impairment with the reduced total lung capacity causing hypoxemia by shunting of blood through non ventilated lung tissue. ~9)The life threatening tension pneumothorax develops when air enters the pleural space during inspiration but trapped during expiration, the accumulating air causes a marked positive pleural pressure, compressing and deviati.ng the mediastinal structures and functional lung. Hypoxemia results from decreased
venous return and CO and impaired gas exchange, tracheal deviation and raised JVP ultimately leading to death.(9)
Multiple Pelvic Fractures The patient sustained fractures to the crest and wing of both ilea, consistent with a large crushing force as mechanism of injury. The implications of multiple pelvic fractures reach far beyond the mechanical stability of the pelvis, intraperitoneal injuries and retroperitoneal haemorrhage become a major concern./~°) Research reviewed by Rosen & Barkin (1992) indicates a 50% mortality rate associated with multiple pelvic injuries, and this increases with age. Haemorrhage from pelvic injuries result from lacerations to the rich vascular network supplying the pelvis and collects in the retroperitoneal cavity. Pelvic fractures can result in over 2500mls of blood loss. (*' Considerable bleeding may also occur from marrow vessels ruptured at fracture sites, coagulopathy may be another contributor31°~ Major arteries supplying the pelvis are the left and right iliac, superior gluteal and pudendal branches of the ileac, all in close proximity to the posterior pelvic arch and commonly injured due to lack of muscle protection. (1°a21The venous system also has many collateral branches; is without valves, allowing bidirectional flow, and is thin wailed, preventing constrictionY ,12)Without performing angiography, it is impossible to know clinically where the bleeding is originating.~1°) Most pelvic haematomas derive venously and tamponade retroperitoneally by the intact peritoneum. Both arterial and venous haematomas may dissect retroperitoneally to eventually spread into the leaves of the intestinal mesentery and produce clinical signs of an acute abdomen - rigidity and
distention. They may also dissect anteriorly into the anterior abdominal wall.,0,11.12/ In the emergency department, objectives of the care of patients with pelvic fractures are to; 1) Recognise the patient who is in haemorrhagic shock and to initiate blood transfusion early in resuscitation (10). 2) Realise that patients with posterior arch fractures may have a retroperitoneal haematoma contributing to their hypovolemic state. 3) Identify by diagnostic peritoneal lavage (DPL) the patient who has intra abdominal bleeding that necessitates laparotomy. However, the use of DPL in the presence of pelvic fracture is controversial amongst clinicians. (1°) 4) Minimise movement of bone at the fracture sites so as not to disturb the haemostatic processesY I 5) understand the role and timing of angiography in managing the patient31°~ A simple and effective method of immobilising the pelvis is to fold a sheet length ways until it is approximately 1 foot wide. Place the folded sheet under the patient, twist the ends and tie or pin around the patient.
Trauma and the elderly Trauma patients over the age of 60 are at a greater risk of sustaining injury due to the effect of the aging process. Research conducted by Morris et al (1990) found that 59% of trauma patient deaths were among those aged over 55 years of age (2~.The body has less protection from trauma because of changes in the musculoskeletal system such as decreased bone mass, muscle atrophy and loss of subcutaneous tissue. 65% of elderly trauma patients present with one or more preexisting medical
conditions3 =) Functional changes affecting response to injury enables the elderly to deteriorate rapidly with few warning signs. The earliest physiologic responses to shock are directed at restoring and maintaining adequate perfusion to vital organs. Aging reduces the response of the sympathetic nervous system to stimulation and catecholamine release (z2,237Thickened heart valves and blood vessels, and weaker veins are less able to adjust to increase venous return and thus inhibit the shunting of blood flow to vital organs. Atherosclerotic arteries and a reduced number of functioning cardiac conducting ceils effect the responsiveness to adrenergic stimulation and myocardial contractility.(2z) Age related changes in the biochemical structure of cell membranes significantly reduce beta receptor activity resulting in a limited chronotropic and inotropic response to beta stimulation3 z4/ Systolic hypertension is common among the aged, which generally results in poor toleration of acute hypotension, also resulting in poor perfusion to vital organs. It is important to understand the altered physiological responses of the potentially shocked aged patient as they tend not to present with the tachycardia, increased myocardial contractility and vasoconstriction associated with stimulation of the sympathetic n e r v o u s s y s t e m . 122'24)Many elderly patients take medication such as antihypertensives, beta and calcium channel blockers, diuretics, antiarrythmics, non steroidals, narcotics, insulin and steroids, bronchodialtors, anticonvulsants which all affect the stress response321~ Pulmonary function is also affected by many structural and functional changes in the aging process. A
® 25
....
LDERLY \4!
NURSING INTERVEHTIONS AND TRAUMA MANAGEMENT.
present
-
Initial assessment- the primarysurvey
i/f
Airway + c spine Breathing + ventilation Circulation + control of bleeding Disability - neurologic A i r w a y
decreased number and size of alveoli and decreased surfactant production weakens the ability of the lungs to respond to hypoxia, hypercarbia and acidosis (=~Chronic diseases such as chronic airways limitations and asthma add to the risk of pulmonary failure(21) Atrophy of respiratory muscles, decreased vital capacity and chest wall compliance increases the work of breathing in the elderly patient, and fatigue occurs quickly.(21~ Factors that contribute to improved survival are early invasive monitoring, aggressive volume resuscitation, early mechanical ventilation, the severity of injury, time between injury and treatment, past medical history, the quality of care and prevention of complications(=, z3.247
i:i
flail:: ¸ ¸i¸¸ ! i?iiii
The process of aging is extremely individual, and no assumptions regarding management should be based on age. However, it is important to consult the patient, private doctors and family members, collect information about the patient such as mechanism of injury, past medical history and level of independent function early on to direct resuscitative efforts. (=,23~
patient obstructed
- control bleeding - 2 large bore IVC's fluid infusion (warm) - send bloods including cross match
Neurologic Assess level of consciousness, pupil size and reaction, Glasgow Coma Score. If patient has a decreased level of consciousness also consider traumatic causes such as hypoglycemia, hypovolaemia and drug induced coma. Other initial observations and interventions include - temperature urinary catheter, naso/orogastric tube, CVP line - documentation communication with trauma team, family and patient Nursing staff can anticipate the equipment, drugs and resources which may be used to aid in smooth, rapid trauma management. Immediate intervention to correct any life threatening deviation of the above must occur before proceeding to the secondary survey. (17,,8) n o n
stabilise c-spine with a rigid collar and tape jaw thrust without hyperextension - remove debris (suction, blood, mucous, vomit) - oral nasopharyngeal airway intubation or crycothyrotomy -
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B r e a t h i n g
present absent
- high flow oxygen - bag valve device with high flow oxygen intubation/ crycothyrotomy positive pressure ventilation Also assess for decreased level of consciousness, respiratory rate and characteristics, oxygen saturation, tracheal and mediastinal shift, diminished breath sounds, asymmetrical and paradoxical chest expansion, cyanosis, sucking chest wounds. Tension p n e u m o t h o r a x - needle thorocostomy and prepare for a chest tube Sucking chest w o u n d - 3 sided porous dressing Flail chest - Prepare for assisted ventilation H e m o t h o r a x - chest tube -
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MANAGEMENT ISSUES • The function of the trauma team includes follow up, communication among medical, nursing and allied health staff, and providing a management plan. Communication between team members and a definitive case plan were suboptimal in this case.
n o n
Circulation
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Assess pulse rate and quality, location, blood pressure, capillary refill, bleeding, skin colour and feel, level of consciousness, cardiac monitor.
• The lack of senior medical staff involvement early in the case resulted in less experienced staff underestimating the seriousness of the patient's injuries. • The need for senior medical staff involvement in decision making and consultation with the patient and family early in the resuscitation phase should be reinforced.
Fluid resuscitation: Overall, the patient had 4500mls of colloids, 7 units of packed cells and 10 units of fresh frozen plasma and did not maintain normotension. This is an indication for the need to identify the source of bleeding and appropriately intervene. • The decision to transfer an unstable patient within the hospital to diagnostic areas.
The importance of documentation can not be emphasised enough. • Documentation provides a record of care and condition during the patients movements through different departments. There were no vital signs documented in the CT scanner in this case, which meant the team had no record of the patients' deterioration or the duration of hypotension.
• Organising debriefing of staff involved in a trauma is important to supply feedback, voice complaints and suggestions, offer reassurance and just talk! • Emotional support for the family should always be made an option. Social workers and chaplains can be made available, if the family does not want any immediate support, give them a phone number or notify the hospital social work service who should follow the family up with a phone call and offers of counselling. • There is nothing worse than not knowing what is happening to a loved one, doubt, assumption and panic can occur. It is important to have continual communication with the family, so that they remain informed and can be involved in decision making.
SUMMARY This case highlights the role of the trauma team and the importance of communication between the team members, senior medical staff, the patient and their family. Trauma care in the elderly poses a myriad of problems and dilemmas, both physiological and ethical. Each of these issues needs to be considered in the context of trauma. Other issues of importance illustrated by this case include the importance of documentation and early consultation with the patient and family regarding care. Also emphasised is the need for debriefing of staff involved in the incident and the option of consulting senior raedical staff after hours. Auditing cases such as this identifies management deficits and problems that can be used as an educational tool and
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to effect a change in practice.
• The documentation of fluids given to the patient aids in determining accurate fluid deficits/overload. A record of administered drugs and coinciding patient condition can indicate the extent of patient pain and sedation. For example, too much morphine depresses respiratory function. • Patient records may be required as evidence in court, whether for civil or criminal proceedings, and will be subject to close and careful scrutiny. Documentation should be legible, accurate and objective (19). • If a nurse feels that patient management is not appropriate and has expressed this to the attending medical officer and nurse manager, the nurse should not hesitate to contact and inform senior medical staff, whether it be the trauma or emergency registrar or consultant. The nurse should also document the rationale and actions taken.
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