When Bad Things Happen When Bad Things Happen To Good Patients: To Good Patients:

Managing The Managing The Complications of TraumaComplications of Trauma

Janice Delgiorno MSN, CCRN, ACNP-BCJanice Delgiorno MSN, CCRN, ACNP-BCAcute Care Nurse PractitionerAcute Care Nurse Practitioner

Department of SurgeryDepartment of SurgeryDivision of Trauma and Surgical Critical Division of Trauma and Surgical Critical

CareCareCooper University Medical CenterCooper University Medical Center

Cooper TraumaCooper Trauma

Typical Trauma PatientTypical Trauma Patient

37 Y/O male37 Y/O male ETOHETOH Intubated, L SC TLC, NGT, Intubated, L SC TLC, NGT,

FlexisealFlexiseal Grade II Liver, Grade III SpleenGrade II Liver, Grade III Spleen L Traumatic AKAL Traumatic AKA R Grade 3-4 C Open Tibia fx with R Grade 3-4 C Open Tibia fx with

external fixatorexternal fixator OR Q Other Day for Wash outsOR Q Other Day for Wash outs

AirwayAirway

Emergent Airways/ Loss of Emergent Airways/ Loss of AirwayAirway

Obstruction from loss of Obstruction from loss of consciousness is the most consciousness is the most common causecommon cause

Facial FracturesFacial Fractures BurnsBurns Laryngeal FractureLaryngeal Fracture

Laryngeal FractureLaryngeal Fracture

CricothyroidotomyCricothyroidotomy

Inappropriate NGTInappropriate NGT

Raccoon eyes Raccoon eyes suggest basilar suggest basilar skull fractureskull fracture

NGT placedNGT placed Could go through Could go through

cribiform plate!!cribiform plate!!

RespiratoryRespiratory

ARDSARDS Pneumonia/ VAPPneumonia/ VAP AtelectasisAtelectasis Respiratory FailureRespiratory Failure Iatrogenic PneumothoraxIatrogenic Pneumothorax EmpyemaEmpyema

EmpyemaEmpyema

Collection of pus in Collection of pus in pleural spacepleural space

Caused by infection in Caused by infection in the lung the lung

Fluid builds up to a Fluid builds up to a pint or more and puts pint or more and puts pressure on the lungpressure on the lung

Causes SOB and painCauses SOB and pain TX: thoracentesisTX: thoracentesis

Iatrogenic PneumothoraxIatrogenic Pneumothorax

Air in the pleural Air in the pleural spacespace

Caused by: Trans-Caused by: Trans-thoracic needle thoracic needle aspiration procedures aspiration procedures (37%), central line (37%), central line insertion, mechanical insertion, mechanical ventilation, ventilation, thoracentesisthoracentesis

Can cause substantial Can cause substantial morbidity: rarely morbidity: rarely deathdeath

ARDSARDS

ARDSARDS Causes: Injury (inhalation, Causes: Injury (inhalation,

trauma), or as a result of MODStrauma), or as a result of MODS Causes lung swelling and fluid Causes lung swelling and fluid

build up in the alveolibuild up in the alveoli Lungs become “stiff” and unable Lungs become “stiff” and unable

to ventilateto ventilate Fluid build up inhibits oxygen Fluid build up inhibits oxygen

passing into the bloodstreampassing into the bloodstream Mechanical ventilation with PEEP, Mechanical ventilation with PEEP,

diureticsdiuretics

Respiratory InfectionRespiratory Infection

Primary loss of defense when Primary loss of defense when patient is intubatedpatient is intubated

Flail Chest, rib fractures, surgical Flail Chest, rib fractures, surgical incisions…can’t cough and deep incisions…can’t cough and deep breathebreathe

Aspiration : Streptococcus most Aspiration : Streptococcus most commoncommon

Respiratory InfectionRespiratory Infection

NG tubes and Nasal-tracheal NG tubes and Nasal-tracheal tubes can obstruct the drainage tubes can obstruct the drainage of the sinuses and result in of the sinuses and result in nosocomial sinusitisnosocomial sinusitis

Can obstruct eustachian tubes Can obstruct eustachian tubes and cause otitis mediaand cause otitis media

Chest tubes have been shown to Chest tubes have been shown to be a factor in developing be a factor in developing nosocomial empyemanosocomial empyema

VAPVAP

ETT/ Trach provide a direct route ETT/ Trach provide a direct route to the lungs for bacteriato the lungs for bacteria

Gram negative bacilli and Staph Gram negative bacilli and Staph aureus are the most common aureus are the most common bacteriabacteria

Compartment SyndromeCompartment Syndrome

ChestChest AbdomenAbdomen ExtremitiesExtremities

Compartment SyndromeCompartment Syndrome

Compartment SyndromeCompartment Syndrome Can affect any body compartmentCan affect any body compartment Most commonly affected are the Most commonly affected are the

lower leg and forearmlower leg and forearm Body has 46 compartments, 36 are Body has 46 compartments, 36 are

found in the extremitiesfound in the extremities Closed spaces containing muscles, Closed spaces containing muscles,

nerves, vascular structures nerves, vascular structures enclosed within bone or fasciaenclosed within bone or fascia

Can result from internal or external Can result from internal or external forces increasing compartment forces increasing compartment pressurespressures

Abdominal Compartment Abdominal Compartment SyndromeSyndrome

Secondary to resuscitation edema, Secondary to resuscitation edema, ileus, bowel obstruction, post op ileus, bowel obstruction, post op hemorrhage or abdominal packinghemorrhage or abdominal packing

Increased abdominal pressure Increased abdominal pressure affects ventilation, urinary output, affects ventilation, urinary output, and the CV system (hypotension, and the CV system (hypotension, decrease CO)decrease CO)

Normal IAP is 0 IAP >20 produces Normal IAP is 0 IAP >20 produces adverse physiologic effectsadverse physiologic effects

Abdominal Compartment Abdominal Compartment SyndromeSyndrome

Compartment SyndromeCompartment Syndrome

Compartment SyndromeCompartment Syndrome

Any injury to an extremity has the Any injury to an extremity has the potential to cause a compartment potential to cause a compartment sydromesydrome

Tibial and forearm fracturesTibial and forearm fractures Severe crush injury to muscleSevere crush injury to muscle Localized, prolonged external Localized, prolonged external

pressure to an extremitypressure to an extremity Increased capillary permeability Increased capillary permeability

secondary to ischemic musclesecondary to ischemic muscle BurnsBurns Excessive exerciseExcessive exercise

Compartment Sydrome: Compartment Sydrome: 6 P’s6 P’s

PainPain ParasthesiaParasthesia PallorPallor ParalysisParalysis Pulse loss (late sign)Pulse loss (late sign) Tissue Pressures >35 to 45 Tissue Pressures >35 to 45

mmHgmmHg

ManagementManagement All constricting dressings, casts, and All constricting dressings, casts, and

splints applied over the affected splints applied over the affected extremity must be releasedextremity must be released

Patient must be carefully monitored Patient must be carefully monitored for the next 30-60minfor the next 30-60min

Anticipate OR for muscle compartment Anticipate OR for muscle compartment pressures greater than 35-45mm Hgpressures greater than 35-45mm Hg

FasciotomyFasciotomy

Compartment SyndromeCompartment Syndrome

Compartment SyndromeCompartment Syndrome

Compartment SyndromeCompartment Syndrome

Compartment SyndromeCompartment Syndrome

RhabdomylosisRhabdomylosis

From crush injuries, electrical From crush injuries, electrical shock, severe burns, excessive shock, severe burns, excessive muscle use, drugs (ethanol, muscle use, drugs (ethanol, cocaine, ecstacy, snake venom, cocaine, ecstacy, snake venom, tetanus)tetanus)

Damaged muscle cells release Damaged muscle cells release potassium and Phosphorus potassium and Phosphorus

High myoglobin levels in the urineHigh myoglobin levels in the urine CK climbs to > 5x normal CK climbs to > 5x normal

RhabdomyolysisRhabdomyolysis

Most common muscles involved Most common muscles involved are the calves and lower backare the calves and lower back

Signs/ Symptoms: Tachycardia, Signs/ Symptoms: Tachycardia, pain, malaise, nausea/ vomiting, pain, malaise, nausea/ vomiting, and feverand fever

RhabdomyolysisRhabdomyolysis

Aggressive IVF administration to Aggressive IVF administration to “flush” kidneys“flush” kidneys

NaHCO3, Insulin, and Glucose to NaHCO3, Insulin, and Glucose to alkalinize urine and push alkalinize urine and push potassium back into cellspotassium back into cells

Maintain urine output by using Maintain urine output by using mannitol or lasixmannitol or lasix

CRRT if necessary CRRT if necessary

InfectionInfection

SepsisSepsis SinusitisSinusitis OsteomylitisOsteomylitis Urinary Tract InfectionUrinary Tract Infection VAPVAP Skin/ Wound InfectionSkin/ Wound Infection

Infection…Infection…

Trauma patients are a breeding Trauma patients are a breeding ground…think of all the tubes…ground…think of all the tubes…tube in every orifice…tube in every orifice…

Sepsis, urinary tract infection, Sepsis, urinary tract infection, blood stream infection, wound/ blood stream infection, wound/ skin infection…skin infection…

Skeevy…Skeevy…

InfectionInfection

Pathogens bypass the first line Pathogens bypass the first line defense, when broken skin and defense, when broken skin and mucosal membranes are mucosal membranes are contaminated during injury and contaminated during injury and later by surgery and debridement later by surgery and debridement

Surgical Drains, external fixators, Surgical Drains, external fixators, IV catheters, ICP monitors, IV catheters, ICP monitors, urinary catheters, woundsurinary catheters, wounds

Nosocomial InfectionsNosocomial Infections

SIRSSIRS

Caused by endogenous Caused by endogenous mediatorsmediators

Overall inflammatory response Overall inflammatory response that effects multiple organs with that effects multiple organs with or without infectionor without infection

SIRS can compromise the SIRS can compromise the function of various organ function of various organ systems resulting in MODSsystems resulting in MODS

SIRS with a confirmed infection is SIRS with a confirmed infection is SepsisSepsis

SIRSSIRS

2 or more of the following:2 or more of the following: Fever >38 c or < 36 cFever >38 c or < 36 c HR >90HR >90 RR >20 or CO2 <32RR >20 or CO2 <32 WBC > 12K or < 4K or > 10% WBC > 12K or < 4K or > 10%

bandsbands

SepsisSepsis

High Mortality Rates: 40% for High Mortality Rates: 40% for uncomplicated sepsis…80% for uncomplicated sepsis…80% for cases of septic shock and MODScases of septic shock and MODS

Severe Sepsis: Sepsis with organ Severe Sepsis: Sepsis with organ hypoperfusionhypoperfusion

Septic Shock: Severe sepsis with Septic Shock: Severe sepsis with hypotension…requires fuids, hypotension…requires fuids, vasopressorsvasopressors

SepsisSepsis

Early, Goal Directed TherapyEarly, Goal Directed Therapy OxygenateOxygenate Central Venous Oximetry monitor and Central Venous Oximetry monitor and

A-lineA-line CVP <8 Crystalloid, ColloidCVP <8 Crystalloid, Colloid MAP <65 or >90 Vasoactive agentsMAP <65 or >90 Vasoactive agents ScVO2 <70% Transfuse PRBC’s to Hct ScVO2 <70% Transfuse PRBC’s to Hct

>30>30 ScVO2 still <70% start DobutamineScVO2 still <70% start Dobutamine Antibiotics within one hourAntibiotics within one hour

SpleenSpleen

SpleenSpleen

Filtration of aging or deformed Filtration of aging or deformed blood cellsblood cells

Antibody synthesisAntibody synthesis Promotion of phagocytosisPromotion of phagocytosis Asplenic patients have Asplenic patients have

significantly decreased levels of significantly decreased levels of IgM, lack the ability to swithch IgM, lack the ability to swithch from IgM to IgG antibody from IgM to IgG antibody productionproduction

SpleenSpleen

The net effect is a decrease in The net effect is a decrease in opsonizationopsonization

Opsonization facilitates the Opsonization facilitates the adherence of a phagocyte to a adherence of a phagocyte to a bacteriabacteria

Important for phagocytosis of Important for phagocytosis of encapsulated bacteria such as encapsulated bacteria such as pneumococci, salmonellae, pneumococci, salmonellae, haemophilus, meningococci and haemophilus, meningococci and staph aureusstaph aureus

Post Splenectomy SepsisPost Splenectomy Sepsis

Well documented in children and Well documented in children and becoming more common in adultsbecoming more common in adults

Fulminant and usually fatalFulminant and usually fatal 1.4% of patients1.4% of patients Early antibiotics and hemodynamic Early antibiotics and hemodynamic

supportsupport Prevention is imperativePrevention is imperative Pneumococcal Vaccine Pneumococcal Vaccine

(Pneumovax) within 72hrs of (Pneumovax) within 72hrs of splenectomysplenectomy

Post Splenectomy Post Splenectomy InfectionInfection

Encapsulated bacteria: Encapsulated bacteria: S. S. pneumoniae, H. influenza, N. pneumoniae, H. influenza, N. meningitidismeningitidis

· · S. aureusS. aureus · Numerous gram negatives · Numerous gram negatives

including including E. coli, K. pneumoniae,E. coli, K. pneumoniae, Salmonella spSalmonella sp. and . and Capnotcytophagia spCapnotcytophagia sp. (the latter . (the latter usually acquired from a dog bite)usually acquired from a dog bite)

Post Splenectomy Post Splenectomy InfectionsInfections

· Malaria· Malaria · Babesia (acquired from ticks in · Babesia (acquired from ticks in

the Eastern seaboard particularly the Eastern seaboard particularly Cape Cod, Martha’s Vineyard, Cape Cod, Martha’s Vineyard, Nantucket, Block Island)Nantucket, Block Island)

VaccinationsVaccinations

PneumococcalPneumococcal MeningococcalMeningococcal H Influenza H Influenza

As soon as possible after As soon as possible after splenectomysplenectomy

OsteomylitisOsteomylitis

Lots of ortho injuries…almost Lots of ortho injuries…almost 80% of trauma patients have an 80% of trauma patients have an ortho injuryortho injury

Open fractures, fixators, Open fractures, fixators, procrastination of amputationprocrastination of amputation

OsteomyelitisOsteomyelitis

Infection involving bone and marrowInfection involving bone and marrow Can occur weeks, months or years Can occur weeks, months or years

after injuryafter injury Infected hardware, overlying wound Infected hardware, overlying wound

infection, inadequate debridement infection, inadequate debridement of a hematoma at the time of injuryof a hematoma at the time of injury

Pain, erythema, heat, tenderness, Pain, erythema, heat, tenderness, drainage drainage

OsteomyelitisOsteomyelitis

Remove infected hardwareRemove infected hardware Surgical debridementSurgical debridement IV antibiotics for a minimum of 4 IV antibiotics for a minimum of 4

weeksweeks

Deep Vein ThrombosisDeep Vein Thrombosis

Approximately 630,000 pts develop Approximately 630,000 pts develop DVT annually resulting in 200,000 DVT annually resulting in 200,000 deathsdeaths

In surgical patients over the age of 40 In surgical patients over the age of 40 DVT occurs in 16%-30% with PE DVT occurs in 16%-30% with PE episodes in 1.6% Fatal PE..1%episodes in 1.6% Fatal PE..1%

20% of young trauma patients develop 20% of young trauma patients develop DVTDVT

More than 40% of elderly trauma More than 40% of elderly trauma patients with hip fractures develop DVT patients with hip fractures develop DVT and 14% have a fatal PE episodeand 14% have a fatal PE episode

Deep Vein ThrombosisDeep Vein Thrombosis

Head and Spinal Cord Patients Head and Spinal Cord Patients 40% and fatal PE of 5%40% and fatal PE of 5%

Prevention is keyPrevention is key Pre disposing factors: Venous Pre disposing factors: Venous

stasis, vascular damage, hyper-stasis, vascular damage, hyper-coagulabilitycoagulability

Examples: Sepsis, bed rest, long Examples: Sepsis, bed rest, long bone or pelvic fractures, spinal bone or pelvic fractures, spinal cord injuries, obesity, age >40, cord injuries, obesity, age >40, previous DVT or PE, prolonged previous DVT or PE, prolonged use of MAST trousersuse of MAST trousers

Deep Vein ThrombosisDeep Vein Thrombosis

Pneumatic Compression DevicePneumatic Compression Device TEDSTEDS Low Molecular Weight HeparinLow Molecular Weight Heparin Vena Cava FilterVena Cava Filter Doppler ScreeningDoppler Screening

Deep Vein ThrombosisDeep Vein Thrombosis

ProphylaxisProphylaxis Sequential Compression DevicesSequential Compression Devices Low Molecular Weight HeparinLow Molecular Weight Heparin TEDSTEDS

Deep Vein ThrombosisDeep Vein Thrombosis

Calf pain on forced dorsiflexion Calf pain on forced dorsiflexion of foot (Homan’s sign)of foot (Homan’s sign)

Subtle to obvious swelling of the Subtle to obvious swelling of the involved areainvolved area

TachycardiaTachycardia FeverFever Distal Skin color and temp. Distal Skin color and temp.

changeschanges

Deep Vein ThrombosisDeep Vein Thrombosis

If a DVT is diagnosed:If a DVT is diagnosed: Bedrest to lower risk of clot Bedrest to lower risk of clot

dislodgmentdislodgment AnticoagulationAnticoagulation ThrombolysisThrombolysis Surgery may be necessary to Surgery may be necessary to

prevent PEprevent PE

DVT TreatmentDVT Treatment

Anticoagulation if Possible: Anticoagulation if Possible: Therapeutic Lovenox: 1mg/kgTherapeutic Lovenox: 1mg/kg

Transition to CoumadinTransition to Coumadin 3 Months of treatment: Needs a 3 Months of treatment: Needs a

new ultrasound before new ultrasound before discontinuing anti-coagulationdiscontinuing anti-coagulation

Pulmonary EmbolusPulmonary Embolus

Embolus lodges in a pulmonary Embolus lodges in a pulmonary artery or smaller pulmonary artery or smaller pulmonary vessel and prevents blood flowvessel and prevents blood flow

Life threatening conditionLife threatening condition

Pulmonary EmbolusPulmonary Embolus

Pulmonary EmbolusPulmonary Embolus

Substernal Chest PainSubsternal Chest Pain Rapid, shallow respirationsRapid, shallow respirations Shortness of breathShortness of breath Pale, dusky or cyanotic skin coloringPale, dusky or cyanotic skin coloring Anxiety, feeling of impending doomAnxiety, feeling of impending doom Altered or decreased level of Altered or decreased level of

consciousnessconsciousness Low grade feverLow grade fever

Pulmonary EmbolusPulmonary Embolus

Cardiopulmonary SupportCardiopulmonary Support Pain ControlPain Control AnticoagulationAnticoagulation Operative intervention may be Operative intervention may be

necessarynecessary 6 months tx6 months tx

Fat EmboliFat Emboli

Can occur with any type of Can occur with any type of fracturefracture especially pelvis and long bonesespecially pelvis and long bones

Fat globules released from bone Fat globules released from bone marrow into injured veinsmarrow into injured veins become trapped in pulmonary become trapped in pulmonary

vasculaturevasculature

Fat EmboliFat Emboli

Signs and Signs and symptomssymptoms DyspneaDyspnea TachypneaTachypnea Altered LOCAltered LOC Decreased PaO2 Decreased PaO2

and SpO2and SpO2 PetechiaePetechiae Retinal Retinal

HemorrhageHemorrhage Chest painChest pain

Normal RetinaNormal Retina

Fat EmboliFat EmboliRetinal HemorrhageRetinal Hemorrhage

Fat EmboliFat EmboliPetechiaePetechiae

Unrelieved Pain/ Chronic Unrelieved Pain/ Chronic PainPain

Pain is under managed in the Pain is under managed in the majority of trauma patientsmajority of trauma patients

Increases morbidity…potentially Increases morbidity…potentially increases mortalityincreases mortality

Can delay and intensify rehabCan delay and intensify rehab

PainPain

Nociception: tissue damage-induced Nociception: tissue damage-induced pain from the peripheral receptor pain from the peripheral receptor through the spinal cord to the brainthrough the spinal cord to the brain

Central Pain: Traumatic amputationsCentral Pain: Traumatic amputations Psychologic Pain: feelings of anxiety Psychologic Pain: feelings of anxiety

or depression mislabeled as painor depression mislabeled as pain Behavioral Pain: For attention, Behavioral Pain: For attention,

sympathy, time off from work…pt c/o sympathy, time off from work…pt c/o painpain

Nerve Pain: Burning, shooting painNerve Pain: Burning, shooting pain

PainPain

Team approach is bestTeam approach is best Aggressive Pain Management to Aggressive Pain Management to

prevent complicationsprevent complications Chronic pain can become the Chronic pain can become the

focal point of a patient’s lifefocal point of a patient’s life Chronic pain often goes hand in Chronic pain often goes hand in

hand with depressionhand with depression

Chronic PainChronic Pain

Secondary Brain InjurySecondary Brain Injury

Lack of oxygen/ perfusion to the Lack of oxygen/ perfusion to the brain after an injurybrain after an injury

Causes: hypotension, hypoxia, Causes: hypotension, hypoxia, hypercapnia, hypocapnia, hypercapnia, hypocapnia, anemia, hyperthermia, anemia, hyperthermia, hypoglycemia, hyperglycemia, hypoglycemia, hyperglycemia, elctrolyte abnormalities, elctrolyte abnormalities, increased ICP, seizures, increased ICP, seizures, vasospasm…vasospasm…

Secondary Brain InjurySecondary Brain Injury

Systemic hypoxia and Systemic hypoxia and hypotension are the most hypotension are the most commoncommon

Contribute significantly to Contribute significantly to morbidity and mortalitymorbidity and mortality

If SBP is <90 or PaO2 <60 on If SBP is <90 or PaO2 <60 on hospital admission a patient’s hospital admission a patient’s mortality doublesmortality doubles

Complications that cause Complications that cause secondary brain injury are secondary brain injury are usually easily treatableusually easily treatable

Acute Acalculous Acute Acalculous CholecystitisCholecystitis

Acute inflammation of the Acute inflammation of the gallbladder in the absence of gallbladder in the absence of gallstonesgallstones

Affected patients are often critically Affected patients are often critically illill

Cause is uncertainCause is uncertain Contributing factors include TPN, Contributing factors include TPN,

lack of oral intake and narcoticslack of oral intake and narcotics Gallbladder ischemia also a cause in Gallbladder ischemia also a cause in

patients who were hypotensive or patients who were hypotensive or had low blood flow during surgeryhad low blood flow during surgery

ACCACC

Does not differ from the calculous type Does not differ from the calculous type except the incidence of gangrene and except the incidence of gangrene and perforation is higherperforation is higher

Fever, N/V, RUQ tendernessFever, N/V, RUQ tenderness Difficult to diagnose in critically ill Difficult to diagnose in critically ill

trauma patient…sedated, intubated, trauma patient…sedated, intubated, associated injuriesassociated injuries

Increased WBC in 70% and increased Increased WBC in 70% and increased AST in 50%AST in 50%

Imaging: Ultrasound and Imaging: Ultrasound and cholescintigraphy cholescintigraphy

Post Traumatic Stress Post Traumatic Stress SyndromeSyndrome

Trauma is a crisis…life changing Trauma is a crisis…life changing event for most patientsevent for most patients

Event itself was probably Event itself was probably terrifyingterrifying

Now lots of life changesNow lots of life changes PTSD is often mis-diagnosedPTSD is often mis-diagnosed Spinal Cord injury and facial Spinal Cord injury and facial

injuries put patients at great risk injuries put patients at great risk for PTSDfor PTSD

PTSDPTSD

Experience sudden, vivid Experience sudden, vivid flashbacks of the eventflashbacks of the event

Emotions such as fear, grief and Emotions such as fear, grief and angeranger

May demonstrate avoidance: May demonstrate avoidance: relationships disintegrate relationships disintegrate

Chronic hyper-arousal and a Chronic hyper-arousal and a biologic alarm reaction ex: GSW biologic alarm reaction ex: GSW victim responds to a car back victim responds to a car back firing firing

PTSDPTSD

GI upset, headaches, irritability, GI upset, headaches, irritability, insomnia, difficulty concentratinginsomnia, difficulty concentrating

Tx with benzos, SSRI’s Tx with benzos, SSRI’s Many patients also benefit from Many patients also benefit from

non-pharmacological therapynon-pharmacological therapy

DeathDeath

DeathDeath

Some patients are not Some patients are not salvageablesalvageable

Some patients die from initial Some patients die from initial injuriesinjuries

Some patients die from Some patients die from complications complications