Chapter 5: Other Trauma
Learning objectives for this chapter
By the end of this chapter, we would like you:
-To explain how to rapidly and accurately assess a variety of traumatic injuries affecting the thoracic, abdominal, genitourinary and maxillofacial regions in the emergency care setting.
-To describe the common mechanisms of injury and presentation of traumatic injuries affecting the thoracic, abdominal, genitourinary and maxillofacial regions in the emergency care setting.
-To explain how to effectively manage a variety of traumatic injuries affecting the thoracic, abdominal, genitourinary and maxillofacial regions in the emergency care setting.
-To discuss the management of traumatic injuries in children and in obstetric patients.
The term 'thoracic trauma' is used to describe any traumatic injury affecting the chest area. Typically, traumatic thoracic injuries are caused by blunt forces and, though less commonly, penetrating injuries. Although they are less common, patients with penetrating chest injuries tend to deteriorate more rapidly and dramatically than those with blunt force injuries; therefore, rapid assessment and management is particularly important in these patients. Traumatic thoracic injuries account for a significant proportion of pre-hospital deaths in the UK, primarily due to the major disruption of the airway, impairments to breathing and / or problems with circulation they cause. Patients who arrive in emergency care settings with traumatic thoracic injuries are often considerably unwell, and require intensive nursing care.
The assessment of patients with actual or potential thoracic injuries focuses on the identification of the two main problems associated with these injuries: (1) hypoxia, and (2) hypoventilation. During assessment, there must be a particular focus on the patient's breathing; indeed, the nurse should pay particular attention to the rate, depth and effort of the patient's breathing, auscultate breath sounds, and the integrity and symmetry of the chest wall. There is also a focus on a patient's cardiac function, and continuous monitoring of the cardiac rhythm is often undertaken. A rapid assessment of the patient's circulation is also completed. Assessment usually also includes imaging studies - such as X-rays or CT scans - to formally diagnose internal injuries.
During assessment, a nurse may identify one or more of a variety of injuries related to thoracic trauma. The most common injuries, and their management in the emergency care setting, are described following:
- Rib fractures - these may involve a single rib or multiple ribs, and most often occur in the fourth to the tenth rib. Severe rib fractures, those involving eight or more ribs, may result in a flail injury, where a section of the ribcage moves independently from the main ribcage during breathing.
- Pneumothorax - this involves an accumulation of air in the pleural space around the lung/s, and the resultant 'collapse' of the lung/s. Patients with a pneumothorax typically present with chest pain, dyspnoea and tachycardia; auscultation of the chest will demonstrate decreased or absent chest sounds on the side/s of the collapsed lung/s.
- Cardiac tamponade - this occurs when there is a rapid accumulation of the blood in the pericardial sac. As the pericardial sac is a closed space with a definite volume, blood in this space places pressure on the ventricles and prevents them from filling to capacity. This results in acute circulatory dysfunction, including cerebral hypoxia. Patients with cardiac tamponade present with a suite of symptoms referred to as 'Beck's triad': (1) hypotension, (2) muffled or indistinct heart sounds, and (3) distended neck veins; if untreated, the condition results in increasing dyspnoea, decreased level of consciousness (LOC) and eventual death.
The administration of high-flow oxygen via a non-rebreather mask is crucial in the management of the traumatic thoracic injuries described above. The management of pain is also important, as uncontrolled pain can result in disruptions to a patient's respiratory effort; most commonly in the emergency care setting, intravenous opioid analgesics are used.
Abdominal and genitourinary trauma
Traumatic abdominal injuries are often associated with injuries to the genitourinary region. Most often, these injuries are caused by blunt force trauma; however, injuries involving penetrating forces may also be seen.
Traumatic injuries to the abdominal and / or genitourinary regions are divided into two types: (1) injuries to the solid organs and (2) injuries to the hollow organs. The most significant injuries tend to be those to the solid organs as it is these injuries which may result in haemorrhage and rapid death.
The assessment of the abdominal and genitourinary systems can be complex, because any injuries usually occur internally and are not immediately obvious on visual inspection. Severe bruising, lacerations or distention are all indications that a traumatic abdominal and / or genitourinary injury may be present. Percussion and palpation of all four abdominal quadrants, following the administration of an appropriate level of analgesia, may be useful in detecting the presence of free fluid in the abdomen - and, subsequently, of abdominal haemorrhage. However, these assessments are not diagnostic, therefore assessment usually also includes imaging studies to formally diagnose internal injuries.
During assessment, a nurse may identify one or more of a variety of injuries related to abdominal and / or genitourinary trauma. The most common injuries, and their management in the emergency care setting, are described following:
- Lacerations to the solid organs - the liver and spleen are common sites of traumatic abdominal injuries. Because the liver holds up to 25% of the body's circulating blood at any given time, injuries to the liver are particularly significant, often resulting in major haemorrhage.
- Renal injuries - the kidneys are another solid organ which are commonly affected by traumatic abdominal injury. The majority of renal injuries are due to blunt force trauma. Typical signs of renal injury include ecchymosis on the flank/s, a palpable mass in the region of the kidneys, and haematuria.
- Bladder injuries - as one of the largest hollow organs, the bladder is the most common site of traumatic genitourinary injury. A patient with a traumatic bladder injury may present with a range of non-specific signs - for example, gross haematuria, pain in the suprapubic area, difficulty voiding and abdominal tenderness; however, only imaging studies can definitively diagnose a bladder injury.
The administration of analgesic medication for pain is crucial in the management of the traumatic abdominal and genitourinary injuries described above; most commonly in the emergency care setting, intravenous opioid analgesics are used.
Maxillofacial trauma involves injury of the bones, neurovascular structures, skin, subcutaneous tissues, muscles and glands of the face and upper neck. Not only do maxillofacial injuries have the potential to cause significant problems with the function of the airway, they may also affect a person's physical appearance, and this can be a significant source of distress for some.
Ensuring patency of the patient's airway is particularly important; displacement of the mandible, avulsed teeth, naso-orbital haemorrhage and swollen tongue associated with maxillofacial may all occlude the airway. Suctioning to remove foreign objects, control of haemorrhage, and the administration of supplemental oxygen are particularly important; however, if the airway cannot be managed, sedation and the insertion of an artificial airway - usually a nasopharyngeal airway - may be required.
Once the patient's airway, breathing and circulation are stable, the assessment of the maxillofacial region itself can commence. Inspection and subsequent palpation, following the administration of an appropriate level of analgesia, of the facial bones can be important in identifying maxillofacial fractures; depressed irregularities in the bone and crepitus are both key indicators of maxillofacial fractures. However, these assessments are not diagnostic, therefore assessment usually also includes imaging studies to formally diagnose internal injuries. If the patient is conscious, they may be asked about jaw pain, their ability to completely open their jaw, and the extent to which their teeth meet normally; problems in any of these areas may indicate a jaw fracture specifically. The patient's visual acuity should also be assessed, as well as the facial nerve and its branches.
Traumatic maxillofacial injuries are a type of traumatic head injury. For this reason, assessment of a traumatic maxillofacial injury must include a comprehensive assessment of a patient's neurological function using a tool such as the Glasgow Coma Scale (GCS).
During assessment, a nurse may identify one or more of a variety of injuries related to maxillofacial trauma. The most common injuries, and their management in the emergency care setting, are described following:
- Soft tissue injuries - these include injuries to the skin, subcutaneous tissues, intra-oral tissues, the eye and / or the ear. Although painful, these injuries do not usually require urgent care.
- Fractures - the maxillary structures, the mandible and the orbital region are common fracture sites. Maxillary fractures are particularly significant, as they may result in significant changes to normal anatomic structure of, and subsequent impairments to, airway functioning. Occasionally, maxillary fractures are so severe that oropharyngeal airways cannot be inserted; in such cases, a patient will be given a tracheostomy.
The administration of high-flow oxygen via a non-rebreather mask is important if a traumatic maxillofacial injury compromises the patient's airway. Although it is a fundamental aspect of nursing care in all settings, the psychosocial care of a patient with a maxillofacial is particularly important; as described earlier in this section, these injuries may significantly affect a person's physical appearance, and this can be a significant source of distress for some.
Trauma in children
There are a number of important considerations in the management of traumatic injuries in children. Children differ from adults developmentally, anatomically and physiologically, and these differences impact on how children are assessed and managed in the emergency care setting. Key considerations include:
- A child's airway is comparatively short and narrow, and can be easily obstructed.
- A child's ribs tend to be pliable, and contusion is seen more often than rib fracture.
- When a child is in respiratory distress, retractions of the tissue in the intercostal, substernal and supraclavicular spaces are more likely to be observed.
- A child has a thin chest wall which transmits breath sounds easily.
- A child's absolute blood volume is small.
- Hypotension is not common in children.
- Bradycardia is also uncommon.
- Prior to the age of 18 months, the natural 'sutures' in a child's skull have not fused and the skull is pliable.
- A child's head is disproportionately large and the muscles of their neck underdeveloped, increasing their vulnerability to flexion-extension injuries.
- A child's abdominal organs are comparatively larger, increasing their risk of injury.
- A child's periosteum is thicker than that of an adult.
- Children have a large body surface-to-weight ratio, and are prone to hypothermia.
Children of all ages in the emergency care setting are often very frightened of the strange and painful things that are happening to them. Providing comfort measures - including explaining the situation to the child at their level of understanding, holding the child's hand or rubbing their back, and allowing a child to communicate their distress - are all important strategies for nurses to consider.
Trauma in obstetric patients
The management of trauma in pregnant women is very complex; nurses are essentially caring for two patients, the mother and the foetus, and both have very different needs.
Pregnant women differ from other adults anatomically and physiologically, and these differences impact how they and their foetuses are assessed and managed in the emergency care setting. Key considerations include:
- By the third trimester, the uterus is large and prone to injury and haemorrhage.
- If a woman in the third trimester lays supine, the uterus and foetus may suppress the great vessels.
- In response to traumatic injury, the maternal body releases catecholamines.
- Cardiovascular changes on electrocardiogram (ECG) may be normal in pregnancy.
- Maternal blood volume, heart rate and cardiac output increase significantly by the second trimester.
- Maternal assessment must include foetal assessment.
In some situations where a pregnant woman sustains particularly severe traumatic injuries, her foetus may be delivered early in an attempt to save its life. Also, occasionally in emergency care settings, traumatic injuries will result in the onset of labour, and babies may be born very rapidly. If a baby is born unexpectedly in the emergency care setting, it is important that nurses attempt to resuscitate the child. In most cases, foetuses above the age of 24 weeks gestation are considered 'viable'.
This chapter has introduced the knowledge and skills required to accurately and rapidly assess, and effectively manage, a variety of traumatic injuries affecting the thoracic, abdominal, genitourinary and maxillofacial regions in the emergency care setting. This chapter has also considered the most common mechanisms of injury, and typical emergency presentation, of traumatic injuries in the thoracic, abdominal, genitourinary and maxillofacial regions. Finally, this chapter had discussed the principles of managing traumatic injuries in children and in obstetric patients - two populations which are particularly susceptible to trauma, and which require specialised nursing care.
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