NFN 108 TRAUMA EMERGENCIES AND FIRST AID

Expected learning outcomes

By the end of the unit, the learner will be able to:
1. Define terminologies in first aid
2. State the principles of first aid
3. Manage common injuries and emergencies
4. Describe causes, clinical features and the first aid measures for an unconscious client
5. Demonstrate ability to lift and transport an injured or patients with various injuries
6. Demonstrate methods of bandaging and immobilization of various injured body parts
7. Demonstrate the procedure for lifting and carrying injured patients in a simulated situation
8. Explain preparation necessary to prevent and respond to accidental fire
9. Demonstrate the assembly of equipment and application of bandages and dressing in a simulated
situation
10. Demonstrate the methods of immobilization fractured fractured body parts in a simulated
situation

FIRST AID
Definition of First Aid:
First Aid is an emergency care and treatment of a sick or injured person before more advanced medical
assistance, in the form of the emergency medical services (EMS) arrives.

Philosophy of First Aid:

In the pre-hospital setting, the key contributors to survival and recovery from illness and injury are
prompt and effective maintenance of the body’s primary functions:
Airway
Breathing
Circulation
Bleeding control (life threatening)
Responsibilities of a first aider:

Preserve life and provide initial emergency care and treatment to sick or injured people
Protect the unconscious
Prevent a casualty’s condition from becoming worse
Promote the recovery of the casualty

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PRINCIPLES OF FIRST AID
 Preserve life
 Prevent deterioration
 Promote recovery
 Taking immediate action
 Calming down the situation
 Calling for medical assistance
 Apply relevant treatment
o Check for consciousness
o Open airway
o Check for breathing follow airway, breathing and resuscitation -CPR if needed
o Check for circulation
o Check for bleeding, controlling any major bleeding

Look the situation over and make a careful assessment:

• Determine the cause of the injury, accident, or illness.
• Do not become a casualty yourself

Call for help:

• If you are not alone designate someone to call for help immediately
• If you are alone you will need to determine the seriousness of the injury and may need to provide
immediate first aid then leave the victim to call for help

Do not move the victim if:

• Chance of spine, back, or neck injury is apparent
• Possibility exists of aggravating the injuries
Special Note: Victims of spine, back, and neck injuries should only be moved if the victim is in greater
danger by not being moved
If needed, clear the airway:
• Lack of oxygen can cause brain damage and may kill a person within a few minutes
• If a person cannot speak, cough, or breathe, the airway may be obstructed

Control heavy bleeding:

• Use clean dressing to control excess blood loss by applying constant direct pressure
• If possible, elevate the injury above the heart or nearest pressure point
• Avoid use of a tourniquet unless the person is in danger of bleeding to death and you have been trained
to apply one

Treat for shock:

• Signs include: Cold pale skin; nausea; a rapid, faint pulse; rapid breathing or panting; and weakness.
• Keep the victim lying down and covered up only enough to maintain body heat.
• Do not move the victim unless absolutely necessary and get him immediate medical attention
• Do not become a casualty yourself

Special Note: A quick, calm response to any emergency situation is imperative. Good first aid skills are
needed to prevent further
injury and to keep any injury from getting worse and possibly even saving a co-worker’s life. However,
when providing first aid care, one should never exceed the level of training.

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Review these principles:
• Know your limitations – Give only the first aid you are qualified to perform.
• In a medical emergency, always get qualified medical attention to the victim promptly.
• In any emergency, give urgent care first.
• Don’t ever give anyone CPR unless you are trained to do so.
• Always bring help to the victim; do not move an injured person unless absolutely necessary.
• Always know the location of your first aid kits.

Conclusion: Knowing how to properly respond to serious injury accidents requires skills developed
through study and training.
The effort you expend to learn first aid skills is worthwhile because someday they may help you to save a
life.

Emergency Nursing

 “Emergency!” The very event that is linked to drama and hysteria.

 The word emerge in emergency, and an emergency suddenly emerges — it happens all of a sudden,
at any time to anyone, and anywhere.

 The person, specifically the nurse who responds at the scene in the emergency department or on the
medical-surgical unit, faces the ultimate challenge of their nursing skills.

 In this medical setting, you plan a solution for a short period of time, and there is no room for error.

Emergency

 Any trauma or sudden illness that requires immediate intervention to prevent imminent severe
damage or death.
 Any condition that — in the opinion of the patient, his family, or whoever assumes the responsibility
of bringing the patient to the hospital — requires immediate medical intervention.
 This condition continues until the determination has been made that the patient’s life or wellbeing is
not threatened.
Emergency nursing

 It is a nursing specialty that focuses on the care of patients who require prompt medical attention to
avoid long-term disability or death. It involves the assessment, diagnosis, and treatment of perceived,
actual or potential, sudden or urgent, physical or psychosocial problems that are primarily episodic or
acute.

Emergency Medical Services

 Responsible for establishing, regulating, coordinating, and monitoring the components involved in
the provision of emergency care.
 Team of healthcare providers that provides emergency care.

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1. Emergency Medical Technician (EMT). Also known as an ambulance technician, is a health
professional that provides emergency medical services. EMTs are most commonly found working in
ambulances. They are also the most common type of providers in all of EMS.

2. Emergency Medical Technician Intermediates (EMTI). EMTIs are next to EMTs. Intermediates
maintain a critical skill set that can often be life-saving to those involved in accidents, emergencies, and
complicated procedures.

3. Emergency Medical Technician Paramedics (EMTP). EMTPs are the highest level of EMTs.
Paramedics are advanced providers of emergency medical care and are highly educated in anatomy and
physiology, cardiology, medications, and medical procedures.

FOUR BASIC STEPS FOR EMERGENCIES

1. Know your facility. It is important to know what emergency resources are available in each location
and the equipment’s placement, such as overhead sprinkler systems, fire extinguishers, and defibrillators.
Healthcare providers, especially nurses, should know where the E-carts and E-kits are placed in the
hospital setting. They need to be available to providers very easily.

2. Know the proper scope of your emergency care.

The nurse should know their role, accountability, and responsibility when dealing with emergencies.
The nurse is responsible for the following:

 Deciding when to call the doctor

 Coordinating care
 Assisting with other emergency procedures
 Performing emergency assessment and interventions
Primary and Secondary Assessment

 Primary Assessment. A primary assessment allows for the recognition of potentially life threatening
conditions and the correct management to be implemented. The acronym ABCDE provides the basis
of the primary assessment and it is an easy way to remember the correct order for assessing patients
presenting to the emergency department.
 Airway. The most important component to be established and maintained to
prevent hypoxia and ultimately death.
 Breathing. Assessed after the airway. During times of acute injury and stress,
the respiratory system can be compromised.
 Circulation. Adequate circulation is needed to maintain tissue perfusion and
cellular oxygenation. This system involves the heart, vessels,
and blood volume.
 Disability. A neurological assessment to assess for motor or sensory deficits
is vital as a decrease in level of consciousness can affect ABC.
 Exposure. Once the patient is exposed for full body assessment, their privacy
needs to be respected by providing a gown and blanket.
 Secondary Assessment. When all life threatening conditions have been found and corrected, the
secondary assessment is undertaken.
 The main focus of the secondary assessment is to explore specific medical conditions the patient may
have.

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 The components of the secondary are continuous with the primary assessment A,B,C,D,E,F,G,H,I.
 Full set of vital signs. Vital signs such as temperature, respiration rate, heart
rate, blood pressure, and pain should be assessed.
 Give comfort. For many patients in the emergency department, levels of pain
may be quite high.
 History. Understanding the complexity and processes involved in history
taking allows nurses to gain a better understanding of patients’ problems.
 The mnemonic AMPLE is a useful tool to guide history taking.
 Allergies
 Medications
 Past medical history
 Last meal
 Events surrounding injury
 Inspect posterior surfaces.
3. Know your patients. Nurses are responsible for identifying if the patient is in an emergency and
recognizing patients’ symptoms, taking measures within their scope of practice to administer medications,
providing other measures for symptom alleviation, and collaborating with other professionals to optimize
patients’ comfort and families’ understanding and adaptation.

4. Stay prepared. Preparing for unexpected occurrences is only part of the equation. Being fast, ready,
and accurate for an emergency also involves practicing good mental health strategies that can develop
one’s level of competency in the event of a crisis.

Emergency Equipment, Drugs, and Procedures.

 Ambu Bag. An Ambu bag is a medical tool used to force air into the lungs of patients
who are not breathing or who are not breathing adequately so still need assistance. The
term AMBU comes from the acronym for “artificial manual breathing unit.”
 Epinephrine. Epinephrine injection is used along with emergency medical treatment to
treat life-threatening allergic reactions caused by insect bites or stings, foods,
medications, latex, and other causes.
 Atropine Sulfate. Atropine is a prescription medicine used to treat the symptoms of low
heart rate or bradycardia, reduce salivation and bronchial secretions before surgery or as
an antidote for overdose of cholinergic drugs or mushroom poisoning.
 Heparin. Heparin is used to decrease the clotting ability of the blood and help prevent
harmful clots from forming in blood vessels.
 Protamine Sulfate. When bleeding requires reversal of heparinization, protamine sulfate
(1% solution) by slow infusion will neutralize heparin sodium. No more than 50 mg
should be administered, very slowly in any 10 minute period. Each mg of protamine
sulfate neutralizes approximately 100 USP heparin units.
 Tracheostomy Tray. Emergency tracheostomy is needed when breathing is obstructed
and emergency personnel can’t put a breathing tube through your mouth and into your
trachea.
 General instruments (tissue tweezers, mosquito forceps, Cooper
scissors, muscle retractors, and Mayo needle holder).
 Scalpel
 14-gauge sheath
 Dilator
 Guidewire dilating forceps

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  Tracheostomy tube
 Endotracheal Tube. Endotracheal intubation is a medical procedure in which a tube is
placed into the windpipe or trachea through the mouth or nose. In most emergency
situations, it is placed through the mouth.
 CVP Kits. There are many different indications for placing a central venous line, but in
emergency medicine, the most common indications include fluid resuscitation, drug
infusions that could otherwise cause phlebitis or sclerosis, central venous pressure
monitoring, emergency venous access, and transvenous pacing wire placement.
 IV Equipment. Intravenous access is used when therapies cannot be used or are less
effective by alternative routes.
 Gloves
 Skin disinfectant (alcohol swab)
 16-18 gauge IV catheter (smaller catheters may be used for pediatric patients,
but larger is better in critical cases)

GUIDELINES FOR GIVING EMERGENCY CARE

1. Getting Started

A. Planning of action.

B. Gathering of materials needed.

2. Emergency Action Principles

A. Survey the scene. First, survey the scene for any possible hazards. Stop. Look. Listen. Feel. Safety
first!

B. Perform Primary Assessment. If the area appears safe, check the victim for life-threatening
conditions such as:

 Level of Consciousness
I. Assess for ABC.

 Airway. The most important component to be established and maintained to prevent

hypoxia and ultimately death.
 Breathing. Assessed after the airway. During times of acute injury and stress, the
respiratory system can be compromised.
 Circulation. Adequate circulation is needed to maintain tissue perfusion and cellular
oxygenation. This system involves the heart, vessels, and blood volume.
 The central pulse of choice for adults is the carotid pulse. In children, the carotid pulse is
usually used, although the femoral pulse is also an option. Infants (<1 year) have short
necks and so the carotid is not palpated. Instead, the brachial or femoral pulses are used.
 Do not move to the next step if the client is unstable.

C. Call for help. After checking the victim, call for help. Remain calm, and be prepared to describe the
situation and the exact location where responders are needed.

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Also, contact local site security and emergency response.

D. Perform Secondary Assessment. The main focus of the secondary assessment is to explore specific
medical conditions the patient may have.

I. Neurologic Assessment

Level of Consciousness. The normal state of consciousness comprises either the state of

wakefulness, awareness, or alertness in which most human beings function while not
asleep or one of the recognized stages of normal sleep from which the person can be
readily awakened.
 Alert. Mentally quick, active, and aware.
 Lethargic. Quality of dullness, prolonged sleepiness, sluggishness, and
serious drowsiness.
 Stuporous. State of unresponsiveness and unaware of surroundings.
 Semi-Comatose. Stupored but can be aroused.
 Comatose
 Glasgow Coma Scale. The Glasgow Coma Scale (GCS) is a neurological scale which
aims to give a reliable and objective way of recording the state of a person’s
consciousness for initial as well as subsequent assessment.
Glasgow Coma Scale

1 2 3 4 5 6

Does not Opens eyes in Opens eyes in Opens eyes

Eye N/A N/A
open eyes response to pain response to voice spontaneously

Oriented,
Makes no Confused,
Verbal Makes sounds Words converses N/A
sounds disoriented
normally

Extension to Abnormal flexion

Flexion / Withdra Localizes to
Makes no painful stimuli to painful stimuli Obeys
Motor wal to painful painful
movements (decerebrate (decorticate commands
stimuli stimuli
response) response)

 Interpretation:
 Severe, GCS < 8–9
 Moderate, GCS 8 or 9–12
 Minor, GCS ≥ 13.
 Eye response (E)
Four grades are starting with the most severe:

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1. No opening of the eye
2. Eye opening in response to pain stimulus. A peripheral pain stimulus, such as squeezing the lunula area
of the person’s fingernail, is more effective than a central stimulus, such as a trapezius squeeze, due to a
grimacing effect.
3. Eye opening to speech. Not to be confused with the awakening of a sleeping person; such people
receive a score of 4, not 3.
4. Eyes opening spontaneously

 Verbal response (V)

Five grades are starting with the most severe:

1. No verbal response
2. Incomprehensible sounds. Moaning but no words.
3. Inappropriate words. Random or exclamatory articulated speech, but no conversational exchange.
Speaks words but no sentences.
4. Confused. The person responds to questions coherently, but there is some disorientation and confusion.
5. Oriented. The person responds coherently and appropriately to questions such as their name and age,
where they are and why, the year, month, etc.

 Motor response (M)

There are six grades:

1. No motor response
2. Decerebrate posturing accentuated by pain (extensor response: adduction of the arm, internal rotation
of the shoulder, pronation of forearm and extension at the elbow, flexion of wrist and fingers, leg
extension, plantar flexion of the foot)
3. Decorticate posturing accentuated by pain (flexor response: internal rotation of the shoulder, flexion of
forearm and wrist with a clenched fist, leg extension, plantar flexion of the foot)
4. Withdrawal from pain (absence of abnormal posturing; unable to lift hand past chin with supraorbital
pain but does pull away when nail bed is pinched)
5. Localizes to pain (purposeful movements towards painful stimuli; e.g., brings a hand up beyond chin
when supraorbital pressure applied)
6. Obeys commands (the person does simple things as asked)

AVPU ASSESSMENTS BY DEFINITION

The AVPU scale (Alert, Voice, Pain, Unresponsive) is a system by which a first aider, health care
professional, or bystander can measure and record a patient's responsiveness, indicating their level of
consciousness.

It is a simplification of the Glasgow Coma Scale, which assesses a patient response in three measures –
Eyes, Voice, and Motor Skills. The AVPU scale should be assessed using these three identifiable traits,
looking for the best response of each.

Meaning of the mnemonic The AVPU scale has only 4 possible outcomes for recording.

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The assessor should always work from best (A, or Level 1) to worst (U, or Level 4) to avoid unnecessary
tests on patients who are clearly conscious.

The four possible recordable outcomes are:

Alert - a fully awake (although not necessarily orientated) patient. This patient will have spontaneously
open eyes, will respond to voice (although may be confused) and will have bodily motor function.

Voice - the patient makes some kind of response when you talk to them, which could be in any of the
three component measures of Eyes, Voice or Motor - e.g. patient's eyes open on being asked "are you
okay?!". The response could be as little as a grunt, moan, or slight move of a limb when prompted by the
voice of the rescuer.

Pain - the patient makes a response on any of the three component measures when pain stimulus is used
on them. Recognized methods for causing the pain stimulus include a Sternal Rub (although in some
areas, it is no longer deemed acceptable), where the rescuers knuckles are firmly rubbed on the
breastbone of the patient, pinching the patient's ear and pressing a pen (or similar instrument) in to the bed
of the patient's fingernail. A fully conscious patient would normally locate the pain and push it away,
however a patient who is not alert and who has not responded to voice (hence having the test performed
on them) is likely to exhibit only withdrawal from pain, or even involuntary flexion or extension of the
limbs from the pain stimulus.

The person assessing should always exercise care when performing pain stimulus as a method of
assessing levels of consciousness, as in some jurisdictions, it can be considered assault. This is a key
reason why voice checks should always be performed first, and the person assessing should be suitably
trained. •

Unresponsive - Sometimes seen noted as 'Unconscious', this outcome is recorded if the patient does not
give any Eye, Voice or Motor response to voice or pain.

In first aid, an AVPU score of anything less than A is often considered an indication to get further help, as
the patient is likely to be in need of more definitive care. In the hospital or long term healthcare facilities,
caregivers may consider an AVPU score of less than A to be the patient's normal baseline

PERRLA. The list includes Pupils, Equal, Round, Reactive to, Light, Accomodation.
 Pupils. Pupils are the black hole in the middle of the colored part of your eye
(the iris).
 Equal. Normal pupils are about the same size. But, for about one in five
people, one is bigger than the other. This condition is called anisocoria and
may be harmless.
 Round. Pupils should be perfectly round circles. Abnormal pupils may look
like a keyhole or a cat’s eye.
 Reactive to. The muscles in the iris open and close the pupil in response to
light. Normal pupils get smaller in brighter light and larger in the dark.
 Light. Normal pupils shrink in reaction to bright light. Both pupils should
get smaller together, even when only shining direct light into one eye at a
time. Both pupils should get bigger once it’s dark again.

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  Accommodation. Pupils change size as they switch from looking at
something far away to something very near.
 Motor movement and strength of muscles.
 AVPU. Alert, Verbal, Pain, Unresponsive
II. History

 Chief complaint.
 Duration of the problem.
 Mechanism of injury.
 Associated manifestations.
 Past medical history.
 Current treatment and compliance.
 Use of OTC drugs.
 Routine use of alcohol or drugs.
 Medication allergy.
 Immunization history.
 Pregnancy.
III. Pain Assessment. OPQRST is a useful mnemonic used by EMTs, paramedics, nurses, medical
assistants, and other allied health professionals to learn about the patient’s pain complaint.

 Onset of the event. What the patient was doing when it started (active, inactive, stressed,
etc.), whether the patient believes that activity prompted the pain and whether the onset
was sudden, gradual or part of an ongoing chronic problem. “Did your pain start
suddenly or gradually get worse and worse?”
 Provocation or palliation. Whether any movement, pressure such as palpation or other
external factor makes the problem better or worse. This can also include whether the
symptoms relieve with rest. “What makes your pain better or worse?”
 Quality of the pain. This is the patient’s description of the pain. Questions can be open
ended (“Can you describe it for me?”) or leading. “What does your pain feel like?”
 Region and Radiation. Where the pain is on the body and whether it radiates (extends)
or moves to any other area. “Point to where it hurts the most. Where does your pain go
from there?”
 Severity. The pain score (usually on a scale of 0 to 10). Zero is no pain and ten is the
worst possible pain. Remember, pain is subjective and relative to each individual patient.
 Timing. How long the condition has been going on and how it has changed since onset.
IV. General Appearance. Gait, unusual skin markings, affect, posture, skin color.

V. Head to toe Assessment. Establishing a good assessment would, later on, provide a more accurate
diagnosis, planning, and better interventions and evaluation. That’s why it’s important to have a good and
strong assessment.

VI. Diagnostic Tests. A diagnostic procedure is an examination to identify an individual’s specific areas
of weakness and strength to determine a condition, disease, or illness.

E. Diagnosis. Nursing diagnoses represent the nurse’s clinical judgment about actual or potential health
problems/life processes occurring with the individual, family, group, or community.

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F. Management. The nurse implements the nursing care plan, performing the determined interventions
that were selected to help meet the goals/outcomes that were established.

G. Evaluation. The nurse evaluates the progress toward the goals/outcomes identified in the previous
phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the care
plan accordingly.

H. Client Disposition. Understanding the patient’s readmission risk stratification, the needs of the patient
upon discharge, and the ability of the receiving facility to meet those needs all have a role in the patient’s
well-being and can help prevent readmission.

I. Documentation. The entire process is recorded or documented to inform all members of the health care
team.

3. Golden Rules of Emergency Care

 Obtain consent whenever possible

 Be as calm and as direct as possible
 Care for the most serious injuries first
 Keep onlookers away from the injured person
 Handle victim to a minimum
 Loosen tight clothing
 Do not leave the victim alone
 Do not assume that the obvious injuries are the only ones
 Don’t give false reassurance
 Do not require the victim to make decision
Triage

Triage

 Trier in French, battlefield screening, to sort out, to categorize, to classify.

 The prioritization of patient care based on the severity of injury/illness, prognosis, and
availability of resources.
Purpose:

 To sort or classify all patients

 Set priorities of care
Descriptions of a few Emergency Nurse roles:

Triage Nurse

 An emergency nurse is assigned to triage patients as they arrive in the emergency

department, and as such, is the first professional patients will see.

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 This emergency nurse must be skilled at rapid, accurate physical examination and early

recognition of life-threatening conditions.
ED Charge Nurse

 An experienced emergency nurse is put in the role of charge nurse or team leader.
 This nurse is responsible for the overall flow of the department.
 He or she assigns nurses to patients, assures patients are being transported to and from
tests outside the ED, addresses patient complaints and concerns, communicates with the
house supervisor, takes phone calls, and assures nurses get their breaks.
Trauma Nurse

 Trauma Nurses work in Trauma Centers and run the show when trauma patients come in
by ambulance, helicopter, or personal vehicle.
 This role requires specialized training and usually two years of experience.
Code Nurse

 Code Nurses run the Code Rooms where the sickest of the sick patients go in the ED. No
pulse, not breathing? No problem! The Code Nurse will run the ACLS-based codes and
provide emergency care for these critically ill patients.
Disaster Response or Emergency Preparedness Nurse

 In theory, all ED nurses are first-responders during a disaster.

 All ED nurses should have annual training in disaster response per the policy of their
facility.
Critical-Care Transport (CCT) Nurse (Ambulance)

CCT Nurses that work on ambulances are responsible for transporting critical care
patients from one facility to another.
Burn Center Nurse

Emergency Nurses that work in Burn Centers are specially trained in burn victim
resuscitation and burn care. Most major metropolitan areas will have at least one
designated burn center with an emergency department.
Emergency Department Triage System (Three-Tier System)

EMERGENT (RED)

 Priority 1
 Injuries are life threatening
 Needs immediate attention and continuous evaluation
 Severe head injury or comatose state
 Active seizures
 Sustain chemical splashes to the eye
 Severe respiratory distress or cardiac arrest
 Chest pain with acute dyspnea or cyanosis
 Trauma
 Severe chest or abdominal wound

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  Limb amputation
 Severe shock
 Excessively high temperature (40.6 °C)
URGENT (YELLOW)

Priority 2

Injuries have complications that are not life threatening

Needs to be treated within 1 to 2 hours (evaluation 30-60 minutes thereafter)

 Asthma without respiratory distress
 Persistent nausea and vomiting and/or diarrhea
 Hypertension
 Other types of severe pain
 Simple fracture
 Abdominal pain
 Client with renal stone
 Fever above 38.9 °C
NONURGENT (GREEN)

Priority 3

Injuries do not have immediate complications

Can wait for several hours for medical treatment (evaluation every 1-2 hours)

 Mild headache
 Cold symptoms
 Minor laceration
 Sprain
 Strains
NO CATEGORY or BLACK CATEGORY

Includes dead or even catastrophically injured patients who have a minimal chance for
survival despite optimal medical care.
Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary Resuscitation (CPR) incorporates rescue breathing with chest compression to

circulate oxygen around the body while anticipating further emergency help. CPR does not normally
restart a person’s heart, but it can save many lives when combined with early emergency help, early
defibrillation, and early advanced hospital care. Ribs may be broken during CPR, but this is preferable
to dying.

Basic Life Support (BLS)

 Basic Life Support (BLS) is a specific level of prehospital, noninvasive emergency lifesaving
medical care that attempts to give a person in cardiopulmonary arrest an open airway, adequate
ventilation, and mechanical circulation (via chest compression) to the vital organs.
 BLS includes recognition of signs of sudden cardiac arrest (SCA), heart attack, stroke, and foreign-
body airway obstruction (FBAO); cardiopulmonary resuscitation (CPR); and defibrillation with an
automated external defibrillator (AED).
Elements of Basic Life Support (BLS)

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  Maintain an open airway
 Support the breathing
 Support the circulation
Four Age Categories in Basic Life Support (BLS)

 Newborn. First hour after birth until discharge from the hospital
 Infant. Less than one year of age
 Child. One to eight years of age
 Adult. Age beyond that of a child

Procedures in Doing Cardiopulmonary Resuscitation (CPR)

Before Giving CPR

 Check the scene and the person. Ensure the scene is safe, then tap the person on the shoulder and
shout “Are you OK?” to ensure that the person needs help.

 Call 911 for assistance. If it’s evident that the person needs help, call (or ask a bystander to call) 911,
then send someone to get an AED. (If an AED is unavailable, or there is no bystander to access it,
stay with the victim, call 911 and begin administering assistance.

 Open the airway. With the person lying on their back, tilt the head back slightly to lift the chin.

 Check for breathing. Listen carefully, for no more than 10 seconds, for sounds of breathing.
(Occasional gasping sounds do not equate to breathing.) If there is no breathing, begin CPR.

CPR Steps according to Red Cross

 Push hard, push fast. Place your hands, one on top of the other, in the middle of the chest. Use your
body weight to help you administer compressions at least 2 inches deep and delivered at a rate of at
least 100 compressions per minute.

 Deliver rescue breaths. With the person’s head tilted back slightly and the chin lifted, pinch the nose
shut and place your mouth over the person’s mouth to make a complete seal. Blow into the person’s
mouth to make the chest rise. Deliver two rescue breaths, then continue compressions.
Note: If the chest does not rise with the initial rescue breath, re-tilt the head before delivering the
second breath. If the chest doesn’t rise with the second breath, the person may be choking. After each
subsequent set of 30 chest compressions, and before attempting breaths, look for an object and, if
seen, remove it.

 Continue CPR steps. Keep performing chest compressions and breathing cycles g until the person
exhibits signs of life, such as breathing, an AED becomes available, or EMS or a trained medical
responder arrives on the scene.

Note: End the cycles if the scene becomes unsafe or you cannot perform CPR due to exhaustion.

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Automated External Defibrillation (AED)
Its an equipment used to shock the heart with specialized electrical current in an attempt to stop the
chaotic, disorganized contraction of the myocardial cells and allow them to start again in a synchronized
fashion to restore a normal rhythmic heartbeat.
Indicated for pulseless patients and mostly for patients with ventricular fibrillation
Two Types of Machine

1. Monophasic. Monophasic AEDs are devices that emit a type of shock. It sends an electrical current in
a single direction from one side of the chest to an electrode on the other side.

2. Biphasic. Biphasic waveform defibrillators utilize bidirectional current flow as opposed to monophasic
AED, where the current flows are in one direction.

Contraindications:

While it’s important to know when to use a defibrillator, it’s just as important to know when not to use a
defibrillator.

 Patients with traumatic cardiac arrest. They have a window of about 10 minutes to be resuscitated.
With each minute that goes by, their odds of survival decline by about 10%.
 Children younger than one year of age
 Absence of hospital protocols in defibrillating patients between the ages 1 and 7 years old or those
who weigh less than 55 lbs (25 kg).
Advanced Cardiac Life Support (ACLS)

 Advanced Cardiac Life Support (ACLS) involves lifesaving procedures, such as cardiac
monitoring, administration of intravenous fluids and medications, and use of advanced airway
adjuncts.
Criteria for Not Starting Cardiac Life Support

 The patient has a valid Do Not Attempt Resuscitation (DNAR) Order

 The patient has signs of irreversible death
 No physiologic benefit can be expected because viral functions have deteriorated despite maximal
therapy
 Attempts to perform CPR would place the rescuer at risk of physical injury
 Newborn: If gestation, birth weight, or congenital anomalies are associated with almost certain early
death.

When to terminate BLS in Out-of-Hospital Setting

 Restoration of effective, spontaneous circulation and ventilation.

 Care is transferred to a more senior-level emergency medical professional who may determine that
the patient is unresponsive to the resuscitation attempt.
 Presence of reliable criteria indicating irreversible death.
 The rescuer is unable to continue because of exhaustion, or the presence of dangerous environmental
hazards, or because continuation or resuscitative efforts places other lives in jeopardy.
 A valid DNAR(do not attempt resustation) order is presented to rescuers.

15
 There is a high degree of certainty that the patient will not respond to further ACLS.
 Newborn: After 10 minutes without signs of life despite continuous and adequate resuscitation
efforts.

FRACTURE
A fracture is a partial or complete break in the bone.
When a fracture happens, it's classified as either open or closed: Open fracture (also called compound
fracture): The bone pokes through the skin and can be seen, or a deep wound exposes the bone through
the skin. Closed fracture (also called simple fracture).
10 Common Types of Bone Fractures
Bone Fracture Basics
There are several types of bone fractures, and each type can have slight variations. Many of the types of
fractures we’ll talk about later may also be described by one of the following terms:
 Open Fracture: A fracture in which the bone breaks through the skin and can be seen
outside the leg. Or there is a deep wound that exposes the bone through the skin. This is also
called a compound fracture.
 Closed Fracture: A fracture that does not break the skin. This is also called a simple
fracture.
 Partial Fracture: An incomplete break of the bone
 Complete Fracture: A complete break of the bone causing it to be separated into two or
more pieces
 Stable Fracture: The broken ends of the bone line up and have not moved out of place.
 Displaced Fracture: There is a gap between the broken ends of the bone. Repairing a
displaced fracture may require surgery.

Types of Bone Fractures
Different types of bone fractures can be open, closed, stable, displaced, partial, or complete.
1. Transverse Fracture
Transverse fractures are breaks that are in a straight line across the bone. This type of fracture may be
caused by traumatic events like falls or automobile accidents.
2. Spiral Fracture
As the name suggests, this is a kind of fracture that spirals around the bone. Spiral fractures occur in long
bones in the body, usually in the femur, tibia, or fibula in the legs. However, they can occur in the long
bones of the arms. Spiral fractures are caused by twisting injuries sustained during sports, during a
physical attack, or in an accident.
3. Greenstick Fracture
This is a partial fracture that occurs mostly in children. The bone bends and breaks but does not separate
into two separate pieces. Children are most likely to experience this type of fracture because their bones
are softer and more flexible.
4. Stress Fracture
Stress fractures are also called hairline fractures. This type of fracture looks like a crack and can be
difficult to diagnose with a regular X-rays. Stress fractures are often caused by repetitive motions such as
running.
5. Compression Fracture
When bones are crushed it is called a compression fracture. The broken bone will be wider and flatter in
appearance than it was before the injury. Compression fractures occur most often in the spine and can

16
 cause your vertebrae to collapse. A type of bone loss called osteoporosis is the most common cause of
compression fractures.
6. Oblique Fracture
An oblique fracture is when the break is diagonal across the bone. This kind of fracture occurs most often
in long bones. Oblique fractures may be the result of a sharp blow that comes from an angle due to a fall
or other trauma.
7. Impacted Fracture
An impacted fracture occurs when the broken ends of the bone are driven together. The pieces are
jammed together by the force of the injury that caused the fracture.
8. Segmental Fracture
The same bone is fractured in two places, leaving a “floating” segment of bone between the two breaks.
These fractures usually occur in long bones such as those in the legs. This type of bone fracture may take
longer to heal or cause complications.
9. Comminuted Fracture
A comminuted fracture is one in which the bone is broken into 3 or more pieces. There are also bone
fragments present at the fracture site. These types of bone fractures occur when there is a high-impact
trauma, such as an automobile accident.
10. Avulsion Fracture
An avulsion fracture occurs when a fragment is pulled off the bone by a tendon or ligament. These types
of bone fractures are more common in children than adults. Sometimes a child’s ligaments can pull hard
enough to cause a growth plate to fracture.

 Greenstick. This is an incomplete fracture. ...

 Transverse. The break is in a straight line across the bone.
 Spiral. The break spirals around the bone; common in a twisting injury.
 Oblique. The break is diagonal across the bone.
 Compression. The bone is crushed. ...
 Comminuted. ...
 Segmental.
 Fracture

Open reduction and internal fixation (ORIF) is a type of surgery used to stabilize and heal a broken bone.
You might need this procedure to treat your broken ankle. Three bones make up the ankle joint. These are
the tibia (shinbone), the fibula (the smaller bone in your leg), and the talus (a bone in your foot)

Complications of Fractures
 Blood vessel damage. Many fractures cause noticeable bleeding around the injury. ...
 Pulmonary embolism. Pulmonary embolism is the most common severe complication of serious fractures
of the hip or pelvis. ...
 Fat embolism. ...
 Compartment syndrome. ...
 Infections. ...
 Joint problems. ...
 Uneven limbs. ...
 Osteonecrosis.

17
Introduction

Most bone injuries heal normally. But some patients do experience complications during the healing
process. Complications of fractures fall into two categories: early and delayed.

1. Early complications include wound healing problems,[1] shock, fat embolism, compartment
syndrome, deep vein thrombosis, thromboembolism (pulmonary embolism), disseminated
intravascular coagulopathy, and infection.
2. Delayed complications include delayed union and nonunion, avascular necrosis of bone,
reaction to internal fixation devices, complex regional pain syndrome, and heterotrophic
ossification.[2]

Early Complications

Early complications include wound healing problems, shock, compartment syndrome, fat embolism,
thromboembolism (pulmonary embolism), deep vein thrombosis, disseminated intravascular
coagulopathy, and infection.

ntroduction

Most bone injuries heal normally. But some patients do experience complications during the healing
process. Complications of fractures fall into two categories: early and delayed.

1. Early complications include wound healing problems,[1] shock, fat embolism, compartment
syndrome, deep vein thrombosis, thromboembolism (pulmonary embolism), disseminated
intravascular coagulopathy, and infection.
2. Delayed complications include delayed union and nonunion, avascular necrosis of bone,
reaction to internal fixation devices, complex regional pain syndrome, and heterotrophic
ossification.[2]

Early Complications of Fractures

Early complications include:

wound healing problems,

shock, compartment syndrome,

fat embolism, thromboembolism (pulmonary embolism),

deep vein thrombosis, disseminated intravascular coagulopathy, and infection.

Intervention Description Signs and Symptoms Action to Take

Shock Hypovolemic or traumatic  Anxiety or  Urgent Medical

18
 shock resulting from Agitation. Team Review
hemorrhage and from loss  Cool, Clammy  Management
of extracellular fluid into Skin or Sweating, includes
damaged tissues may occur Moist Skin restoration of
in fractures of the  Confusion blood volume
extremities, thorax, pelvis,  Decreased or No and circulation,
or spine. Because the bone Urine Output relieving the
is very vascular, large  Generalised patient’s pain,
quantities of blood may be Weakness providing
lost as a result of trauma,  Pale Skin Color adequate splinti
especially in fractures of (Pallor) ng, and
the femur and pelvis.  Rapid Breathing protecting the
patient from
further injury
and other
complications.

Rhabdomyolysis Risk Factors:  Significant  Urgent Medical

Muscle Pain Team Review
 Crush Injury  Swelling Requires
(resulting in muscle  Fever immediate
damage with  Vomiting action from the
byproducts  Confusion medical team
damaging the  Tea-colored urine  Management
kidneys)  Irregular heartbeat includes fluid
resuscitation and
the management
Timeframe: of associated
renal failure
 Usually occurs in
the very acute
phase (around 1-3
days) post-injury

y
Compartment Risk Factors:  Pain out of  MEDICAL
Syndrome proportion to the EMERGENCY
 Tibial or Forearm associated injury  Inform the
Fractures  Pain on passive surgeon
 High-energy Wrist movement of the immediately.
Fractures muscles of the Requires
 Crush Injuries involved immediate
compartments action.
 Severe Swelling  Remove any
Timeframe:  Neurovascular cast, splint of
Changes - 5P’s circumferential
 Usually occurs in dressing and
the very acute elevate limb to

19
 heart level.
phase, post-injury  May require
emergency
fasciotomy

Fat Embolism Risk Factors:  Hypoxia  Urgent Medical

Syndrome  Tachypnea Team Review.
 Long Bone  Tachycardia Requires
Fractures  Pyrexia immediate
 Pelvic Fractures action.
 Multiple Fractures  Check
 Crush Injuries Observations
 Young Adults (20 to  Administer
30 years of age) oxygen if
 Older required and if
Adults with Proxim this is within
al Femur Fracture your
 scope of practice

Timeframe:

 Occurs Very Acute

Phase Post-injury
(24 to 72 hours)
 Rapid Onset

Pulmonary Risk Factors  Pyrexia  Urgent Medical

Embolism  Dyspnea and/or Team Review.
 Serious Limb Tachypnea Requires
Injury Surgery  Crackles immediate
 Prolonged Bed Rest  Second Heart action.
 Static Lower Limb Sound  Check
Posture for more  Pleuritic Chest Observations
than 6 hours Pain  Administer
 Trauma and Spinal  Profuse Sweating oxygen if
Cord Injury  Haemoptysis required and if
 Smoking  Tachycardia this is within
 Oral Contraceptives  Hypotension your scope of
 Hormone  Lightheaded / practice
Replacement Dizzy
Therapy  Syncope
 Cancer  Cyanosis
 Chemotherapy
 Pregnancy and
Post-Partum Period
 Advanced Age (>40
years old)

20
  Immobilizer or Cast
 Central Venous
Catheterization

Timeframe:

 Patient is most at
risk in the acute
phase and first three
months post-injury

Deep Vein Usually in the calf but can  Swollen, Hard,  Inform Medical
Thrombosis also occur in upper limbs. Painful Limb Team
This can progress to a  Tender to Touch  Check whether
Pulmonary Embolism,  Heat the team is
which may cause death  Discolouration happy for the
several days to weeks after (usually red but patient to
injury. (see above) can be blueish- mobilise
Risk Factors grey)

 Reduced Skeletal
Muscle
Contractions
 Bed Rest.
 Lower Limb
Fractures
 Pelvic Fractures

Timeframe:

 Patient is most at
risk in the acute
phase and first three
months post-injury

Disseminated Group of bleeding disorders  Ecchymoses  Urgent Medical

Intravascular with diverse causes,  Unexpected Team Review.
Coagulopathy including massive tissue Bleeding after Requires
(DIC) trauma. Surgery immediate
 Bleeding from action.
Mucous  May require
Membranes, plasma, red
Venipuncture blood cell and
Sites, platelet
Gastrointestinal transfusion and
and Urinary Anti-coagulant
Tracts. medication to
prevent blood

21
 clotting.

Infection Risk Factors  New or Increasing  Inform the

Pain Medical Team
 Open Fractures  Heat Infections must
 Internal Fixation  Redness be treated
 Surgical Wound  Swelling promptly.
 Pin Sites  Green or Cloudy  Antibiotic therap
Oozing/Discharge y must be
 Tenderness appropriate and
adequate for
prevention and
treatment of
infection[2].

DELAYED COMPLICATIONS

Intervention Description Signs and Symptoms Action to Take

Osteomyelitis An acute or chronic  Fever  Urgent Medical
inflammatory process  Lethargy, Team Review
involving the bone and Malaise or
its structures secondary Irritability in
to infection with Children
pyogenic organisms  Pain
including bacteria  Swelling
(mostly  Redness
Staphylococcus), fungi,  Warm
and mycobacteria. Sensation Over
Acute osteomyelitis is an Area of
the clinical term for a Bone
new infection in bone  Loss of Range
that can develop into a of Movement
chronic reaction when
intervention is delayed
or inadequate.
Delayed Union Occurs when the bone  Discomfort  Orthopaedic
does not heal at a  Pain Review
normal rate for the  Reduced  In low resource,
location and type of Function in disaster or
fracture. Delayed union Affected Area conflict settings
may be associated with where surgical
distraction of bone patients may
fragments, systemic or not be routinely
local infection, poor followed up
nutrition, then arrange for
or comorbidity (eg, dia orthopaedic
betes; autoimmune

22
 disorders). Eventually, review
the fracture heals.
Malunion Occurs when bone  Discomfort  Orthopaedic
heals but not in the  Pain Review
right position. You may  Deformity  In low resource,
have never had  Reduced disaster or
treatment for the Function in conflict settings
broken bone. Or, if you Affected Area where surgical
did have treatment, the  Swelling patients may
bone moved before it not be routinely
healed. followed up
then arrange for
orthopaedic
review

Non-Union Results from failure of  Discomfort  Orthopaedic

the ends of a fractured  Pain Review
bone to unite. The  Continued  In low resource,
patient complains of Movement at disaster or
persistent discomfort Fracture Site conflict settings
and abnormal beyond where surgical
movement at the Expected patients may
fracture site. Factors Healing Times not be routinely
contributing to union  Reduced followed up
problems include Function in then arrange for
infection at the fracture Affected Area orthopaedic
site, interposition of  Swelling review
tissue between the bone
ends, inadequate
immobilization or
manipulation that
disrupts callus
formation, excessive
space between bone
fragments (bone gap),
limited bone contact,
and impaired blood
supply resulting in
avascular necrosis.

Complex Regional Pain Abnormally severe pain  Continuing  Consult with

Syndrome (CRPS) and reduced function Pain, Allodynia, Medical Team
that develops following or Hyperalgesia  Develop Joint
injury. in which the Treatment Plan
Type 1 following injury pain is
or immobilisation disproportionat
without nerve injury e to any known

23
 Type 2 following injury inciting event
with nerve injury)
Diagnosis is based on  Oedema
the exclusion of other
conditions that would  Changes in skin
otherwise account for blood flow
the degree of pain and
dysfunction  Abnormal
Sudomotor
Activity
(Sweating,
Abnormal Hair
or Nail Growth)

 Reduced Range
of Movement in
the Region of
Pain

Avascular Necrosis The death of bone due  Gradually  Urgent

to loss of blood supply. worsening pain, Orthopaedic
It may occur after a in particular on Review
fracture with disruption weight bearing
of the blood supply,  Reduced range
especially in femoral of movement in
neck. The patient the affected
develops pain and joint
experiences limited
movement. X-ray
reveal calcium loss and
structural collapse.
Treatment generally
consists of attempts to
revitalise the bone with
bone
grafts, prosthetic replac
ement, or arthrodesis
(joint fusion).
Reaction to Internal Some patient may have  Discomfort  Orthopaedic
Fixation Device a reaction to the  Pain Review
Internal fixation
devices. The device  Reduced
may be removed after Function in
bony union has taken Affected Area
place. In most patients,
however, the device is
not removed unless it
produces symptoms.
Pain and decreased
function are the prime

24
 indications that a
problem has developed.
[2]

Signs and Symptoms

It’s important to know the warning signs of a bone healing complication. Receiving prompt care is
critical to treating complications. S &S include:

 Chronic pain
 Drainage from a Wound
 Fever
 Swelling
 Limping[3]

Patient-Related Risk Factors

Certain patient-related characteristics influence the development of fracture-healing complications in

general, even though specific healing complications may differ by their mechanism.

 Diabetes, NSAID use, and a recent motor vehicle accident are most consistently associated with
an increased risk of a fracture-healing complication, regardless of fracture site or specific
fracture-healing complication. [4]
 In delayed union and non-union identified risk factors include: age; lower limb > upper limb;
open fractures; infection; diabetes; smoking; poor blood supply[5].
 Fractures in obese children have a higher rate of complications independently from
conservative or surgical treatment. Surgical indications are more common than in normal
weighted children and are generally more invasive.

HEAD INJURY
Head injury is defined as any trauma to the head other than superficial injuries to the face
The World Health Organisation estimates that 300 people per day are killed due to trauma on Africa’s
roads.
Etiology

25
 Motor vehicle accidents account for the largest percentage of traumatic brain injuries.
 Falls, sports-related injuries,
 violence are also common causes of traumatic brain injuries
Classification of head injury
 Closed head injury or nonpenetrating injury- when there has been rapid back and forth
movement of the brain causing bruising and tearing of brain tissues and vessels, but the skull is
intact.
 Open head injury or penetrating injury - refers to a break in the skull.
 Acceleration injury is the term used to describe a moving object hitting a stationary head. An
example of this type of injury is a patient who is hit in the head with a baseball bat.
 A deceleration injury occurs when the head is in motion and strikes a stationary surface. This type
of injury is seen in patients who trip and fall, hitting their head on furniture or the floorcombination
of
 Acceleration -deceleration injury occurs when the stationary head is hit by a mobile object and the
head then strikes a stationary surface. A soccer player who sustains a blow to the head and then hits
the ground with his or her head may sustain an acceleration-deceleration injury
Twisting of the brainstem can damage the reticular activating system, causing loss of consciousness
Types of Brain Injury and Signs and Symptom
Concussion Cerebral
Concussion is considered a mild brain injury. If there is a loss of consciousness, it is for 5 minutes or less.
Concussion is characterized by headache, dizziness, or nausea and vomiting. The patient may complain of
amnesia of events before or after the trauma.
On clinical examination there is no skull or dura injury and no abnormality detected on CT or MRI.
Contusion Cerebral
Contusion is characterized by bruising of brain tissue, possibly accompanied by hemorrhage.
There may be multiple areas of contusion, depending on the causative mechanism. Severe contusions can
result in diffuse axonal injury (DAI).
The symptoms of a cerebral contusion depend on the area of the brain involved. Brainstem contusions
affect level of consciousness.
Decreased level of consciousness may be transient or permanent.
Respirations, pupil reaction, eye movement, and motor response to stimuli may also be affected. The
autonomic nervous system may be affected by edema or by hypothalamic injury, causing rapid heart rate
and respiratory rate, fever, and diaphoresis.
Hematoma

26
SUBDURAL HEMATOMA.
Subdural hematomas are classified as acute or chronic based on the time interval between injury and
onset of symptoms. Acute subdural hematoma is characterized by appearance of symptoms within 24
hours following injury.
The bleeding is typically venous in nature and accumulates between the dura and arachnoid membranes.
Approximately 24% of patients who sustain a severe brain injury develop an acute subdural hematoma.
Damage to the brain tissue may cause an altered level of consciousness. Therefore, it can be difficult to
recognize a subdural hematoma based only on clinical examination.
As the subdural hematoma increases in size, the patient may exhibit one-sided paralysis of extraocular
movement, extremity weakness, or dilation of the pupil.
Level of consciousness may deteriorate further as ICP increases.
The patient with a chronic subdural hematoma may be
Forgetfu, lethargic, or irritable or may complain of a headache.
If the hematoma persists or increases in size, the patient may develop hemiparesis and pupillary
changes.
The patient or significant other may not associate the symptoms with a previous injury and
therefore may delay seeking medical care

EPIDURAL HEMATOMA.
Approximately 10% of patients with severe brain injuries develop epidural hematomas.
This collection of blood between the dura mater and skull is usually arterial in nature and is often
associated with skull fracture.
Arterial bleeding can cause the hematoma to become large very quickly. Patients with epidural hematoma
typically exhibit a progressive course of symptoms.
The patient loses consciousness directly after the injury; he or she then regains consciousness and is
coherent for a brief period.
The patient then develops a dilated pupil and paralyzed extraocular muscles on the side of the hematoma
and becomes less responsive. If there is no intervention, the patient becomes unresponsive. Seizures or
hemiparesis may occur.
Airway management and control of ICP must be instituted immediately. If ICP is not controlled, the
patient will die

27
Diagnostic Tests
CT scan- usually the first imaging test performed on the brain-injured patient. It is faster and more
accessible than MRI
This is particularly important for unstable patients or those with multiple injuries. It is easier to identify
skull fractures on CT than on MRI.
MRI may be used later to identify damage to the brain tissue. Neuropsychological testing can be useful in
assessing the patient’s cognitive function.
This information helps direct rehabilitation placement, discharge planning, and return to work or school.
Neuropsychological testing identifies problems with memory, judgment, learning, and comprehension.
Compensation strategies can be suggested to the patient and significant others based on the results

therapeutic Interventions
1. Surgical Management
Surgical treatment of hematomas is discussed under intracranial surgery later in this chapter.
2. Medical Management
Medical management of traumatic brain injury involves control of ICP and support of body functions.
Brain-injured patients may be partially or completely dependent for maintenance of
 Respiration
 Nutrition
 Elimination
 Movement
 Skin integrity
Techniques used to control intracranial pressure in the patient with moderate or severe brain injury.
The first step is to insert an ICP monitor to allow measurement of the ICP.
If ICP remains elevated despite drainage of cerebrospinal fluid,
the next step is use of an osmotic diuretic.
commonly used drug is intravenous mannitol (Osmitrol).
Mannitol utilizes osmosis to pull fluid into the intravascular space and eliminate it via the renal system.
Serum osmolarity and electrolytes must be carefully monitored when mannitol is being administered.
Some patients experience a rebound increase in ICP after the mannitol wears off.

28
Mechanical hyperventilation is the next step if the patient is still experiencing increased ICP.
Hyperventilation is effective in lowering ICP because it causes vasoconstriction. Vasoconstriction allows
less blood into the cranium, thereby lowering ICP.
Research has demonstrated, however, that aggressive hyperventilation, particularly within the first 24
hours after injury, may induce ischemia in the already compromised brain.
Therefore, hyperventilation is now reserved for increased ICP that does not respond to other treatments.
High-dose barbiturate therapy may be used to induce a therapeutic coma, which reduces the metabolic
needs of the brain during the acute phase following injury.
These patients are completely dependent for all their needs and care.
They will be mechanically ventilated and cared for in an ICU setting. Vasopressors may be required to
maintain blood pressure, and the patient’s temperature should be kept as normal as possible

TRAUMATIC BRAIN INJURY SUMMARY

Signs and Symptoms
Loss or decrease in level of consciousness, depending on severity and type of injury Loss of memory
before or after the injury Increased ICP Headache, dizziness Nausea and vomiting Unequal pupils
Tachycardia, tachypnea Diaphoresis Hemiparesis
Diagnostic Tests
CT scan, MRI Skull x-rays Routine laboratory tests (hemoglobin, electrolytes, coagulation studies, type
and crossmatch) Neuropsychological testing
Therapeutic Interventions
Control intracranial pressure,Surgical management of hematoma, Maintain respiratory function, Maintain
diet/nutrition, Maintain skin integrity, Prevent complications and Education

COMPLICATIONS
Increased intracranial pressure
Brain Herniation
If interventions to control ICP are unsuccessful, the patient may experience uncontrolled edema or
herniation of brain tissue
Herniation is displacement of brain tissue out of its normal anatomical location. This displacement
prevents function of the herniated tissue and places pressure on other vital structures, most commonly the
brainstem. Herniation usually results in brain death.
Diabetes insipidus,
Edema or direct injury affects the posterior portion of the pituitary gland or hypothalamus.

29
Inadequate release of antidiuretic hormone results in polyuria and, if the patient is awake, polydipsia.
Fluid replacement and intravenous vasopressin are used to maintain fluid and electrolyte balance
Acute hydrocephalus
Cerebral edema can interfere with cerebrospinal fluid circulation, causing hydrocephalus.
Initial treatment is with an external ventricular drain, followed by a ventriculoperitoneal shunt if
necessary.
A shunt drains excess CSF into the peritoneum, where it is reabsorbed into circulation and excreted

Labile Vital Signs

Direct trauma to or pressure on the brainstem can cause fluctuations in blood pressure, cardiac rhythm, or
respiratory pattern. Treatment is aimed at control of intracranial pressure
Posttraumatic syndrome
Posttraumatic Syndrome Patients who sustain a concussion may experience ongoing, somewhat vague
symptoms.
They complain of headache, fatigue, difficulty concentrating, depression, or memory impairment.
Symptoms may be severe enough to interfere with work, school, and interpersonal relationships.
Neuropsychological testing may provide objective evidence of cognitive dysfunction and establish the
need for cognitive rehabilitation.
Symptoms may take 3 to 12 months to resolve.
Cognitive and personality changes
The patient may have significant shortterm memory impairment. This limits his or her ability to learn new
information and may interfere with ability to function at work or school. Impaired judgment can make the
patient a safety risk to self or others. It also affects social functioning
Emotional lability, loss of social inhibitions, and personality changes may occur. These consequences of
traumatic brain injury have a profound effect on the patient and significant others. Spouses may state,
“This is not the person I married.
Possible nursing Diagnosis
Disturbed thought processes related to cerebral edema or increased intracranial pressure
Self-care deficit related to increased intracranial pressure
Pain related to cerebral edema

Foreign body airway obstruction

Foreign body airway obstruction, is when a small item gets stuck in a child's/ adult throat or upper airway
and makes it hard for the to breathe.

30
According to the National Safety Council's statistics, foreign-body airway obstruction (FBAO) is the
fourth leading cause of unintentional death,

Adults management

MILD OBSTRUCTION,

encourage the patient to continue coughing;

do nothing else except monitor for deterioration.

SEVERE OBSTRUCTION IN A CONSCIOUS PATIENT:

Stand to the side and slightly behind the victim,

support the chest with one hand and lean the victim well forwards

(so that the obstructing object comes out of the mouth rather than going further down the airway).

Give up to five sharp back blows between the shoulder blades with the heel of your other hand (checking
after each if the obstruction has been relieved).

If unsuccessful, give up to five abdominal thrusts.

Stand behind the victim (who is leaning forward),

Put both arms around the upper abdomen and clench one fist,

Grasp it with the other hand and pull sharply inwards and upwards.

Continue alternating five back blows and five abdominal thrusts until successful or the patient becomes
unconscious.

In an unconscious patient:

 Lower the patient to the floor.

 Call an ambulance immediately.

 Begin CPR (even if a pulse is present in the unconscious choking victim).

Children

If coughing effectively,

Just encourage the child to cough, and monitor continuously.

If coughing is, or is becoming, ineffective, shout for help and assess the child's conscious level.

If the child is conscious,

Give up to five back blows,

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followed by five chest thrusts to infants or

Five abdominal thrusts to children

(repeat the sequence until the obstruction is relieved or the patient becomes unconscious):

For infants (<1 year old) - back blows and chest thrusts:

In a seated position, support the infant in a head-downwards, prone position to let gravity aid removal of
the foreign body.

Support the head by placing the thumb of one hand at the angle of the lower jaw, and one or two fingers
from the same hand at the same point on the other side of the jaw.

Do not compress the soft tissues under the jaw, as this will aggravate the airway obstruction.

Deliver up to five sharp blows with the heel of your hand to the middle of the back (between the shoulder
blades).

After each blow, assess to see if the foreign body has been dislodged and, if not, repeat the manoeuvre up
to five times.

After five unsuccessful back blows, use chest thrusts: turn the infant into a head-downwards supine
position by placing your free arm along the infant's back and encircling the occiput with your hand.
Support the infant down your arm, which is placed down (or across) your thigh. Identify the landmark for
chest compression.

This is the lower sternum, about a finger's breadth above the xiphisternum. Deliver five chest thrusts.
These are similar to chest compressions for CPR, but sharper in nature and delivered at a slower rate.

 For children (1 year old to puberty) - back blows and abdominal thrusts:
 Blows to the back are more effective if the child is positioned head down. A small child can be
placed across the lap as with an infant. If this is not possible, support the child in a forward-leaning
position.
 Deliver up to five sharp back blows with the heel of one hand in the middle of the back between the
shoulder blades.
 After five unsuccessful back blows, abdominal thrusts may be used in children over 1 year old:
 Stand or kneel behind the child, placing arms around torso. Place a clenched fist between the
umbilicus and xiphisternum (ensuring no pressure is applied to either landmark).
 Grasp this hand with your other hand and pull sharply inwards and upwards, repeating up to five
times.
 If the child becomes unconscious, place him or her on a flat, firm surface, shouting for help if none
has arrived. Open the mouth and look for any obvious object. If one is seen, make an attempt to
remove it with a single finger sweep (don't do blind finger sweeps).
 If unsuccessful, begin CPR as for paediatric basic life support. Begin with five rescue breaths,
checking for rise and fall of the chest each time (reposition the head each time if a breath does not
make the chest rise, before making the next attempt).

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EPISTAXIS
 Nosebleeds usually happen when a small blood vessel inside the nose lining bursts and bleeds.
 The lining of the nose has lots of tiny blood vessels that warm the air as it enters the nose.
 This lining is very fragile and may break easily, causing bleeding.
 Epistaxis can occur at any age but are twice as common in children.
 Predominantly affects children between the ages of 2 and 10 years and
 It also affects older adults between the ages of 45 and 65
 Most nosebleeds are harmless and do not require treatment.
 Successful treatment requires knowledge of nasal anatomy, possible causes, and a step-wise
approach.
 Many presentations are spontaneous and self-limiting; often all that is required is proper first aid.

Anatomy of the nasal cavity -blood supply

The nasal cavity has a rich and highly varied blood supply arising from the internal and external
carotid arteries
with multiple anastomoses and a crossover between the left and right arterial systems.
The internal maxillary artery (IMAX) supplies 80% of the nasal vault
The sphenopalatine artery (SPA) supplies most of the nasal septum and the turbinates,
The greater palatine artery (GPA) supplies the floor of the nasal septum.
The ethmoidal arteries course through the cribriform plate to supply the roof of the nasal cavity.
The ethmoidal arteries communicate with branches of the SPA posteriorly and several branches
anteriorly

Classification of epistasis
i. Anterior
ii. Posterior
This based on the arterial supply and the location of the bleed in relation to the piriform
aperture.2
Anterior epistaxis occurs in >90% of patients and arises in Little’s area.6
Posterior epistaxis arises from Woodruff’s plexus in the posterior nasal septum or lateral nasal
wall.
It occurs in 5% to 10% of patients, is usually arterial in origin, and leads to a greater risk of
airway compromise, aspiration, and difficulty in controlling the hemorrhage

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Further classification of Epistaxis
can be classified further as
primary hemorrhage
secondary hemorrhage.

Primary epistaxis is idiopathic, spontaneous bleeds without any precipitants.2 Blood vessels
within the nasal mucosa run superficially and are relatively unprotected.
Damage to this mucosa and to vessel walls can result in bleeding.4 Spontaneous rupture of vessels may
occur occasionally, during, say the Valsalva maneuver or when straining to lift heavy objects.4 Secondary
epistaxis occurs when there is a clear and definite cause (eg trauma, anticoagulant use, or surgery).

Etiology of epistaxis2
Local factors
 Trauma
 Mucosal irritation
 Septal abnormalities (eg septal perforation)
 Inflammatory diseases
 Illicit drug use
 Iatrogenic causes
 Neoplasia
SYSTEMIC FACTORS
 Age (2-10 years and 45-65 years)
 Hypertension
 Alcohol use
 Circadian rhythms (morning and late afternoon)
 Genetic disorders (eg HHT, hemophilia, and von Willebrand’s disease)
 Juvenile nasopharyngeal angiofibroma (males)
MEDICATIONS
 Antiplatelet agents (eg aspirin and clopidogrel)
 NSAIDs
 Anticoagulant therapy (eg warfarin and NOACs)
 Complementary and alternative medicines (eg garlic, gingko, and ginseng)
ENVIRONMENTAL FACTORS
 Temperature (cooler months)
 Low humidity
Idiopathic causes
HHT, hereditary hemorrhagic telangiectasia; NSAIDs, nonsteroidal anti-inflammatory drugs;
NOACs, novel oral anticoagulants CAUSES of NOSEBLEEDing ?
The common ones include:
 Fragile blood vessels that bleed easily, mostly in warm to hot, dry weather
 An infection of the lining of the nostrils, sinuses or adenoids (lymph nodes in the throat behind the
nose)
 Colds flu, allergy or hay fever
 Bumps or falls
 An object pushed up the nostril
 Nose picking
 Constipation causing straining
 Medications such as warfarin, aspirin, clopidogrel (also known as ‘blood thinners’) and anti-
inflammatory tablets
 A bleeding or clotting disorder (this is rare).

34
 FIRST AID FOR NOSEBLEEDING
 Stay calm. Crying will make the bleeding worse.
 Sit upright and bend slightly forwards
 Use the thumb and forefinger to pinch the nose.
 Squeeze firmly over the soft part of the nose just above the nostrils (pressure applied to the hard or
bony part of the nose does not stop the bleeding).
 Hold for 10 minutes and then release the grip slowly. You may have to repeat this step until the
bleeding stops. 
 Do not keep checking whether the bleeding has stopped because the blood needs time to clot. 
 Do not blow your nose once the bleeding has stopped otherwise it may bleed again. 
 Breathe through your mouth while the nostrils are pinched. 
 Spit out any blood that comes into your mouth.
 Do not swallow the blood. It may help to put a cold pack or cold cloth over your forehead or the
bridge of the nose.

Other CARE 
 Rest quietly for the next 12–24 hours. 
 Avoid hot liquids for at least 24 hours after a nosebleed. 
 Do not pick or blow your nose for 12 hours. 
 Avoid strenuous exercise, straining or lifting heavy items for seven days. If constipatipated,get stool
softener (such as Coloxyl) to prevent straining. 
 Avoid aspirin and related drugs if possible.
 Some people with dry skin in the nose may find ointment (such as Vaseline) or nasal sprays may
help.
 Some people may have several nosebleeds over a period of a few weeks.
 In the elderly, the bleeding can come from the back of the nose.
 This can be serious.
Sometimes the bleeding is due to an underlying bleeding problem. This is rare. Rarely do people lose so
much blood that it causes anaemia (a serious reduction in the number of red blood cells).

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PREVENTION
If the bleeding happens often,there will be need to investigate for the underlying problem.
 cautery (a procedure to seal the blood vessels inside the nose) to stop the nosebleeds for good. This
only works if one blood vessel is involved.
 Using a humidifier
 drinking plenty of fluids 
 using an ointment on the affected area (such as Vaseline) 
 using a saline nasal spray 
 using headgear when playing sports 
 Avoiding cigarette smoke

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