RONNIE M.

AMAZONA, RN, MAN

What is Emergency?

 a situation, often dangerous, which arises

suddenly and calls for prompt action
What is Disaster?

 an event causing great loss, hardship or

suffering to many people
 a great or sudden misfortune
Trauma Assessment
ATLS methodology "ATLS"

 Primary survey and resuscitation

– A = Airway and cervical spine
– B = Breathing
– C = Circulation and hemorrhage control
– D = Dysfunction of the central nervous system
– E = Exposure
Airway and cervical spine

 Always assume that patient has cervical spine injury

 Place in hard collar and keep on until cervical spine has been
'cleared'
 If patient can talk then he is able to maintain own airway
 If airway compromised initially attempt a chin lift and clear
airway of foreign bodies
 If gag reflex present insert nasopharyngeal airway
 If no gag reflex patient will need endotracheal intubation
 If unable to intubate will require a cricothyroidotomy
 Give 100% oxygen through a mask
Breathing

 Check position of trachea, respiratory rate

and air entry
 If clinical evidence of tension pneumothorax
will need immediate relief
 If open chest wound seal with occlusive
dressing
Circulation and hemorrhage control

 Assess pulse, capillary return and state of

neck veins
 Take venous blood for CBC and Cross match
 Take sample for arterial blood gasses
 Give intravenous fluids
 Crystalloid or colloid in adequate volume
 Attach patient to ECG monitor
Dysfunction

 Assess level of consciousness using AVPU

method
– A = alert
– V = responding to voice
– P = responding to pain
– U = unresponsive
 Assess pupil size, equality and
responsiveness
Exposure

 Fully undress patients

 Avoid hypothermia
Nursing Diagnoses

1. Ineffective airway clearance

2. Impaired physical mobility related to severe
burn
3. Parental fear related to outcome after head
injury
4. Interrupted family processes related to
accident
5. Anxiety related to apprehension and lack of
knowledge regarding medical treatment
I. HEAD INJURY

 Head injury is a general term used to

describe any trauma to the head, and most
specifically to the brain itself.
Causes

 All types of head injuries can be caused by

trauma.
 In adults such injuries commonly result from
motor vehicle accidents, assaults, and falls.
 In children falls are the most common cause
followed by recreational activities such as
biking, skating, or skateboarding.
 A small but significant number of head injuries
in children are from abuse.
Classification of Head Trauma

 Penetrating trauma: Missiles such as bullets or

sharp instruments (also knives, screwdrivers, ice
picks) may penetrate the skull.
– The result is called a penetrating head injury.
– Penetrating injuries often require surgery to remove
debris from the brain tissue.
 Blunt head trauma: These injuries may be from
direct blow (a club or large missile) or from a
rapid deceleration force (a fall or striking the
windshield in a car accident).
Types of Head Injuries
Different Types of Head Injuries

a. Traumatic Brain Injury

– Open injuries
– Closed injuries
b. Temporal Bone Fractures
c. Fractures of the Nose
d. Fractures of the Jaw and Contiguous
Structures
e. External Ear Trauma
a. Traumatic Brain Injury

 is physical injury to brain tissue that temporarily or

permanently impairs brain function
TYPES
 Open injuries
 Closed injuries
1. Concussion
2. Diffuse axonal injury
3. Brain contusions
4. Hematomas
5. Skull Fracture
a. Traumatic Brain Injury

Open injuries
 involve penetration of the scalp and skull (and usually the
meninges and underlying brain tissue)
 typically involve bullets or sharp objects, but a skull fracture
with overlying laceration due to severe blunt force is also
considered an open injury.
Closed injuries
 typically occur when the head is struck, strikes an object, or is
shaken violently, causing rapid brain acceleration and
deceleration
 acceleration or deceleration can injure tissue at the point of
impact (coup), at its opposite pole (contrecoup), or diffusely; the
frontal and temporal lobes are particularly vulnerable
1. Concussion

 transient and reversible post traumatic

alteration in mental status (eg, loss of
consciousness or memory) lasting from
seconds to minutes.
 no gross structural brain lesions
 no serious neurologic residua, although
temporary disability can be considerable
2. Diffuse axonal injury
 diffuse axonal injury (DAI) occurs when deceleration
causes shear-type forces that result in generalized,
widespread disruption of axonal fibers and myelin
sheaths (although DAI may also result from minor head
injury)
 no gross structural lesions, but small petechial
hemorrhages in the white matter are often observed on
CT scan
 sometimes defined clinically as a loss of consciousness
lasting > 6 h in the absence of a specific focal lesion.
 Edema from the injury often increases intracranial
pressure (ICP), leading to various manifestations
 typically the underlying injury in shaken baby syndrome.
3. Brain contusions

 Contusions (bruises of the brain) can occur

with open (including penetrating) or closed
injuries and can impair a wide range of brain
functions, depending on contusion size and
location.
 Larger contusions may cause widespread
brain edema and increase ICP.
4. Hematomas

Hematomas (collections of blood in or around

the brain) can occur with penetrating or
closed injuries and may be
 Subdural hematoma
 Intra parenchymal hemorrhage/cerebral
contusion
 Epidural hematoma
5. Skull fracture

 is a break in the bone surrounding the brain

and other structures within the skull
b. Temporal Bone Fractures

Temporal bone fractures can occur after severe

blunt trauma to the head and sometimes
involve structures of the ear causing
 hearing loss
 vertigo
 balance disturbance
 facial paralysis
ASSESSMENT FINDINGS
a. Traumatic Brain Injury

 Initially, most patients with TBI lose consciousness

(usually for seconds or minutes), although with minor
injuries, some have only confusion or amnesia (amnesia
is usually retrograde and lasts for seconds to a few
hours).
 Young children may simply become irritable.
 Some patients have seizures, often within the 1st hour or
day.
 After these initial symptoms, patients may be fully awake
and alert, or consciousness and function may be altered
to some degree, from mild confusion to stupor to coma.
a. Traumatic Brain Injury

 Markedly increased ICP classically manifests as

a combination of hypertension, bradycardia, and
respiratory depression (Cushing's triad).
 Vomiting may occur but is nonspecific.
 Severe diffuse brain injury or markedly increased
ICP may produce decorticate or decerebrate
posturing.
a. Traumatic Brain Injury

The Glasgow Coma Scale

 is a quick, reproducible scoring system to be used during the
initial examination to estimate severity of TBI.
 it is based on alertness as evidenced by eye opening and best
motor and best verbal responses.
 A score of 3 indicates potentially fatal damage, especially if
both pupils fail to respond to light and oculovestibular
responses are absent.
 Higher initial scores tend to predict better recovery.
 By convention, the severity of head injury is initially defined by
the GCS
– GCS score of 14 or 15 is mild TB
– GCS score of 9 to 13 is moderate TBI
– GCS score of 3 to 8 is severe TBI
a. Traumatic Brain Injury
Glasgow Coma Scale

Spontaneous 4
To Voice 3
Eye Opening
To Pain 2
None 1
Oriented 5
Confused 4
Best Verbal Inappropriate Words 3
Incomprehensible Sounds 2
None 1
Obeys Commands 6
Localizes Pain 5
Withdraws to Pain 4
Best Motor
Flexion to Pain 3
Extension to Pain 2
None 1
a. Traumatic Brain Injury
Area Assessed Infants Children Score*

Eye opening Open spontaneously Open spontaneously 4

Open in response to verbal Open in response to verbal 3

stimuli stimuli
Open in response to pain only Open in response to pain only 2

No response No response 1
Verbal Coos and babbles Oriented, appropriate 5
response
Irritable cries Confused 4
Cries in response to pain Inappropriate words 3
Moans in response to pain Incomprehensible words or 2
nonspecific sounds
No response No response 1
a. Traumatic Brain Injury

Motor response† Moves spontaneously Obeys commands 6

and purposefully
Withdraws to touch Localizes painful stimulus 5

Withdraws in response Withdraws in response to 4

to pain pain
Responds to pain with Responds to pain with 3
decorticate posturing flexion
(abnormal flexion)
Responds to pain with Responds to pain with 2
decerebrate posturing extension
(abnormal extension)
No response No response 1
b. Temporal Bone Fractures

 suggested by Battle's sign (postauricular ecchymosis)

and bleeding from the ear.
 bleeding may come from the middle ear
(hemotympanum) through a ruptured tympanic
membrane or from a fracture line in the ear canal
 a hemotympanum makes the tympanic membrane
appear blue-black
 CSF otorrhea indicates a communication between the
middle ear and the subarachnoid space
DIAGNOSTIC TEST
RESULTS
a. Traumatic Brain Injury

 Despite the availability of modern diagnostic

tools, following are often the most important
information the doctor uses to make treatment
decisions
– physical examination
– history of the exact details of the injury,
– past medical history
– symptoms
a. Traumatic Brain Injury

 Skull x-rays:
– It may be order to look for a fracture (break) in the skull bone.
– The presence of a skull fracture on x-ray does not mean there
has been an injury to the brain, and the absence of a fracture
does not exclude a brain injury.
– Skull x-rays are not taken as frequently now as in the past.

 CT scan:
– Is the test used most often to evaluate acute head injuries.
– The CT is essentially an x-ray machine that takes multiple x-
rays from many angles around the head.
– A computer uses these x-ray images to make a picture of the
brain and other structures inside the skull.
– The details on a CT scan are very good, and even small spots
of blood may be seen as little white dots.
a. Traumatic Brain Injury

 MRI scans:
– These are rarely used immediately after head injuries.
– The MRI may be used later for additional information about a
brain injury.
 In some cases of bleeding in or around the brain,
angiography may be performed to visualize the blood
vessels.
– This test involves injecting dye into the arteries of the head.
– X-rays are taken that show the blood vessels and may show
exactly where bleeding is occurring.
– In some cases it is possible to stop the bleeding during
angiography. This involves injecting special materials, which are
released into the bleeding blood vessel and cause a clot to form.
If this procedure is successful, the bleeding is stopped without
the need for surgery.
a. Traumatic Brain Injury

 Obtain x-rays of the skull if CT scanning is

either not indicated, or cannot be done.
 If a CT scan is planned, skull x-rays are
unnecessary. The fracture will be seen on
CT.
b. Temporal Bone Fractures

 If a temporal bone fracture is suspected, immediate

CT of the head with special attention to the temporal
bone is done.
 The Weber and Rinne tuning fork tests can be done
during the initial physical examination in conscious
patients to help differentiate between conductive and
sensorineural hearing loss. However, formal
audiometric examination is required for all patients
with temporal bone fractures.
 If facial paralysis is present, electrical testing of the
facial nerve is warranted.
TREATMENT
a. Traumatic Brain Injury

Treatment varies widely depending on the type and

severity of injuries.
 Minor head injuries are often treated at home as long
as someone is available to watch the person.
– Bed rest, fluids, and a mild pain reliever such as
acetaminophen (Tylenol, for example) may be prescribed. Ice
may be applied to the scalp for pain relief and to decrease
swelling.
– Cuts will be numbed with a medication usually given by
injection. They will then be cleansed. The doctor will then look
for foreign matter and hidden injuries. The wound usually is
closed with skin staples, stitches (sutures), or a special skin
glue. An immunization to prevent tetanus will be given if
needed.
a. Traumatic Brain Injury

 A simple skull fracture requires only

observation for neurological injury.
 Any neurological abnormality, or abnormal
finding on CT scan, requires neurosurgical
consultation.
 Depressed skull fractures, if more than about
1/2 the skull thickness, are usually elevated in
the operating room.
 Open skull fractures require consultation to rule
out intracranial contamination.
a. Traumatic Brain Injury

Rehabilitation:
 When neurologic deficits persist, rehabilitation is needed.
 Occurrence and duration of coma after a TBI are strong predictors
of rehabilitation needs; of patients whose coma exceeds 24 h, 50%
have major persistent neurologic sequelae, and 2 to 6% remain in
a persistent vegetative state at 6 mo.
 For patients who survive the initial hospitalization, a prolonged
period of rehabilitation, particularly in cognitive and emotional
areas, is often required, and rehabilitation services should be
planned early.
 Rehabilitation is best provided through a team approach that
combines physical, occupational, and speech therapy; skill-building
activities; and counseling to meet the patient's social and
emotional needs.
b. Temporal Bone Fractures

 Treatment is based on managing facial nerve injury, hearing

loss, vestibular dysfunction, and CSF leakage.
 If immediate facial nerve paralysis occurs with loss of
electrical response, surgical exploration may be warranted.
Delayed-onset or incomplete facial paralysis almost always
resolves with conservative management, including use of
corticosteroids, which are gradually tapered.
 Conductive hearing loss requires ossicular chain
reconstruction several weeks to months after the injury.
 Sensorineural hearing is typically permanent and there are
no medical or surgical therapies available to improve hearing.
However, in the rare case of fluctuating sensorineural hearing
loss, an exploratory tympanotomy to search for a perilymph
fistula may be indicated.
II. ABDOMINAL TRAUMA

 Trauma in between diaphragm and pelvis

 Injury, illness very difficult to assess because of
large variety of structures
 Most survive to reach hospital
 Most common factors leading to death
– Failure to adequately evaluate
– Delayed resuscitation
– Inadequate volume
– Inadequate diagnosis
– Delayed surgery
Types of Abdominal Trauma

 Liver Injury
 Spleen Injury
 Kidney Injury
 Bowel Rupture
 Pancreas Injury
Assessment of abdominal trauma

 Assessment of patients with abdominal

trauma can be difficult due to
– Altered sensorium (head injury, alcohol)
– Altered sensation (spinal cord injury)
– Injury to adjacent structures (pelvis, chest)
 Pattern of injury will be different between
penetrating and blunt trauma
Assessment of abdominal trauma

 The initial evaluation of the injured abdomen

looks for hemorrhage or spillage of bowel
content. Despite the multitude of intra
abdominal organs, and the wide variation of
presentation of injured patients, the question is:
"Is there blood or peritoneal
contamination?"
 Evaluate the abdomen during the secondary
survey.
 The primary goal is to decide if surgery is
necessary.
Approaches on the injured abdomen in a
simplistic fashion

 If the abdomen is tender or if the patient has a

decreased level of consciousness, assume
significant injury.
 If the patient is hypotensive or will undergo
urgent surgery for a non-abdominal problem,
perform peritoneal lavage.
 If the patient is sufficiently stable and other
problems are not emergent, order a CT scan of
the abdomen.
Assessment and Diagnostic Findings

 The patient who has free air on abdominal x-ray needs

rapid laparotomy, rather than an attempt to localize the
organ rupture.
 The patient with hypotension, left upper quadrant pain,
and a positive peritoneal lavage needs surgery now.
Assume a ruptured spleen.
 The exam notes the location and relative severity of
tenderness and seeks any clues such as broken ribs, or
a steering wheel mark across the abdomen.
 All gunshot wounds will require surgical exploration.
 Some knife wounds are managed conservatively.
 X-rays and peritoneal lavage may be used to screen for
bowel laceration or major bleeding.
Assessment and Diagnostic Findings

Imaging
 Either CT or ultrasound can be used for the
assessment of abdominal trauma
 CT scanning is preferred method but
requires patient to be cardiovascularly stable
 Ultrasound has high specificity but low
sensitivity for the detection of:
– Free fluid
– Visceral damage
Assessment and Diagnostic Findings

FAST
 Focused assessment for the sonographic assessment
of trauma
 Is the use of ultrasound to rapidly assess for
intraperitoneal fluid
 Probe is placed on the:
– Right upper quadrant
– Left upper quadrant
– Suprapubic region
 Fluid in subphrenic, subhepatic spaces or Pouch of
Douglas in hypotensive patient
 Confirms likely need for emergency laparotomy
Assessment and Diagnostic Findings

Peritoneal lavage
– Indications
 Equivocal clinical examination
 Difficulty in assessing patient
 Persistent hypotension despite adequate
resuscitation
 Multiple injuries
 Stab wounds where the peritoneum has been
breached
Assessment and Diagnostic Findings

Peritoneal lavage
– Method
 Ensure that a catheter and nasogastric tube is in place
 Incise peritoneum and insert peritoneal dialysis catheter
 Aspirate any free blood or gastric content
 If no blood seen - infuse 1litre of normal saline an allow 3
min. to equilibrate
 Place drainage bag on floor and allow to drain
 Send 20 ml to laboratory for measurement of RBC, WBC
and microbiological examination
Assessment and Diagnostic Findings

Peritoneal lavage
– Positive result
 Red cell count more than 100,000 /
mm3
 White cell count more than 500 / mm3
 Presence of bile, bacteria or fecal
material
Nursing/ Medical Management

Stabilization of Abdominal Injury

 Complete the primary (ABC) survey.
 Infuse fluid rapidly for the patient with evidence of shock.
 Examine the abdomen during the secondary survey.
 Place an NG tube and foley catheter.
 Cover any open wounds to protect the viscera.
 Rupture of the diaphragm is more common than realized. It
should be anticipated with any patient with a penetrating
wound of the upper abdomen or lower chest.
Nursing/ Medical Management

Initial operation
 Early management of major abdominal
trauma surgery should aim to:
– Control hemorrhage with ligation of vessels and
packing
– Remove dead tissue
– Control contamination with clamps and stapling
devices
– Lavage the abdominal cavity
– Close the abdomen without tension
Nursing/ Medical Management

 Options for temporary wound closure include

– Skin-closure only
– Plastic abdominoplasty
– Absorbable mesh
– Non-absorbable mesh with protection of
underlying viscera
– Vacuum pack
– Vacuum-assisted wound management
 A plastic sheet or 'Bogata bag' may be useful
'Bogata bag'
III. DENTAL TRAUMA

 Definition
Dental trauma is injury to the mouth, including
teeth, lips, gums, tongue, and jawbones. The most
common dental trauma is a broken or lost tooth.
 Description
– Dental trauma may be inflicted in a number of ways:
contact sports, motor vehicle accidents, fights, falls,
eating hard foods, drinking hot liquids, and other
such mishaps.
– As oral tissues are highly sensitive, injuries to the
mouth are typically very painful. Dental trauma
should receive prompt treatment from a dentist.
III. DENTAL TRAUMA
III. DENTAL TRAUMA

 Causes & symptoms

– Soft tissue injuries, such as a "fat lip," a burned tongue, or a
cut inside the cheek, are characterized by pain, redness, and
swelling with or without bleeding.
– A broken tooth often has a sharp edge that may cut the tongue
and cheek. Depending on the position of the fracture, the tooth
may or may not cause toothache pain.
– When a tooth is knocked out (evulsed), the socket is swollen,
painful, and bloody. A jawbone may be broken if the upper and
lower teeth no longer fit together properly (malocclusion), or if
the jaws have pain with limited ability to open and close
(mobility), especially around the temporomandibular joint
(TMJ).
III. DENTAL TRAUMA

 Diagnosis
– Dental trauma is readily apparent upon
examination.
– Dental x rays may be taken to determine
the extent of the damage to broken teeth.
More comprehensive x rays are needed to
diagnose a broken jaw.
III. DENTAL TRAUMA

 Treatment
– Soft tissue injuries may require only cold
compresses to reduce swelling.
– Bleeding may be controlled with direct pressure
applied with clean gauze.
– Deep lacerations and punctures may require
stitches.
– Pain may be managed with aspirin or
acetaminophen (Tylenol, Aspirin Free Excedrin)
or ibuprofen (Motrin, Advil).
III. DENTAL TRAUMA

When a permanent tooth has been knocked out, it

may be saved with prompt action.
 The tooth must be found immediately after it has
been lost. It should be picked up by the natural
crown (the top part covered by hard enamel).
 It must not be handled by the root.
– If the tooth is dirty, it may be gently rinsed under
running water.
– It should never be scrubbed, and it should never be
washed with soap, toothpaste, mouthwash, or other
chemicals.
III. DENTAL TRAUMA

 The tooth should not be dried or wrapped in a tissue

or cloth. It must be kept moist at all times.
 The tooth may be placed in a clean container of milk,
cool water with or without a pinch of salt, or in saliva.
 If possible, the patient and the tooth should be
brought to the dentist within 30 minutes of the tooth
loss.
 Rapid action improves the chances of successful re-
implantation; however, it is possible to save a tooth
after 30 minutes, if the tooth has been kept moist
and handled properly.
III. DENTAL TRAUMA

 A broken jaw must be set back into its proper

position and stabilized with wires while it
heals.
 Healing may take six weeks or longer,
depending on the patient's age and the
severity of the fracture.
III. DENTAL TRAUMA

Are all dental fractures to be considered as an

emergency?
 Not all fractures of the teeth may be considered as a
dental emergency.
 Fractures can occur in a number of places in the teeth.
 Fractures that involve only the enamel or enamel and
dentin may not pose much problems for the health and
recovery of the teeth. These are called uncomplicated
fractures.
 Complicated fractures of the teeth are those where the
pulp tissue is exposed to the exterior. These fractures are
to be treated as an emergency and may require
endodontic treatment