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- by wantccu Sep 19Reviewed our most recent respiratory test in class today. There was a question that had a patient in the ER with facial trauma and swelling and asked what the priority assessment was. Two of the options were to assess for patent airway and assess for a skull fracture. (Don't remember what the other two options are, they were irrelevant.). Anyways, I thought it was a no brainer and clearly airway, but the correct answer was skull fracture. My professor told us "I know that airway has been hammered into your brains, but that is old school".
I'm not really too concerned about one question on one test (although there was another-same deal, not airway), but I am concerned about the NCLEX. Are they moving away from ABC's as priority?
- Not in my ER....."if they aint breathing they aint leavin"
However in the presence of facial trauma one needs to be very careful of what type of fracture and knw how to secure the irway of that patient and not cause further harm
There are three types of Le Fort fractures:
- Le Fort I fractures (horizontal) may result from a force of injury directed low on the maxillary alveolar rim in a downward direction. It is also known as a Guérin fracture or 'floating palate', and usually involves the inferior nasal aperture. The fracture extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates.
- Le Fort II fractures (pyramidal) may result from a blow to the lower or mid maxilla and usually involve the inferior orbital rim. Such a fracture has a pyramidal shape and extends from the nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.
- Le Fort III fractures (transverse) are otherwise known as craniofacial dissociation and involve the zygomatic arch. These may follow impact to the nasal bridge or upper maxilla. These fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenoid. This type of fracture predisposes the patient to CSF rhinorrhea more commonly than the other types.
- According to medscape ...my go to medical resource......Maxillary and Le Fort Fractures Treatment & Management
Stabilize the patient and treat serious insults to the airway, neurologic system, cervical spine, chest, and abdomen prior to definitive treatment of the maxillofacial bones.
Address emergencies related to maxillofacial trauma prior to definitive treatment. These include airway compromise and excessive bleeding. If the airway is compromised and orotracheal intubation cannot be established, the midface complex may be impacted posteroinferiorly, causing obstruction.
Disimpaction may be attempted manually or with large disimpaction forceps around the alveolar arch and premaxilla. If the segments do not move readily and the airway is obstructed, an emergent tracheotomy or cricothyrotomy may be necessary. Severe bleeding may occur from soft tissue lacerations or intranasal structures. A combination of pressure, packing, cauterization, and suturing may be useful in such situations.
- Sep 19 by GrnTeaPatent airway never goes out of fashion. Ask your faculty for the rationale behind his/her desired answer.
Sure, knowing about a skull fx is important. But breathing is always more important-- think postpharyngeal bleeding, for one thing. Also, if loss of consciousness or seizure occurs (is there a brain injury? who knows yet?), there had better be a good airway.
- Sep 19 by wantccuThank you for the helpful responses. That was my thought process. Couple of weird rationales on this exam honestly. I don't want to be "that" person that argues over every question, but I do want to ensure that my critical thinking skills are being honed for licensure and my future career.
- Sep 19 by HouTxYeah - nothing trumps ABC. But the skull fracture may well be cause airway obstruction or decreased respiratory effort (due to neural damage), as well as cerebral edema/IICP that would eventually compromise cardiac function... so assessing that injury would actually be related to A, B & C!!!
- Sep 19 by GrnTeaYou know, think this faculty remark might be related to the recent changes in CPR, where airway is no longer emphasized for citizen (out of professional care) CPR and people are being taught to do chest compressions only. Of course it's not remotely related to this question, but I can see as someone might have gotten it as a sort of earworm and inappropriately generalized it to "ABCs are old-fashioned."
- Maybe, Maybe...but to teach these new nurses..... then they get out of school and say that then get ripped by staff..... But till if they aren't breathing they will lose circulation and brain cells with it so what is fractured doesn't matter.....I'd LOVE to ask that instructor the rational for that question.
- Sep 19 by Ashley, PICU RNI think your instructor is trying to get you to think more deeply about the scenarios. She doesn't want you to just see the word "airway" and automatically choose that option because it's the "A". Yes, airway is absolutely a priority, and assessing it will always be correct (in real life). But in the context of the question, is it your MOST correct response?
Let's see if I can think of an example...
Your 6 year old pediatric patient was admitted for observation after being stung on the neck by a bee while riding her bike 6 hours ago. The patient suffered a broken right radius after falling from the bike. A plaster cast was placed on the right lower arm. Upon assessment, the nurse notes swelling and redness of the neck in the area of the bee sting. The patient reports that her neck "hurts a little" but her arm "hurts a lot". She says it "feels like there are lots of needles poking her fingers and hand". She appears scared, is crying and having a hard time catching her breath. Vital signs are as follows: HR 113 BP 110/69 RR 36 SpO2 95% Ax Temp 98.3 What is the nurse's priority?
1. Administer prescribed pain medication
2. Assess for a patent airway
3. Instruct the patient in relaxation techniques to slow respiratory rate
4. Assess circulation of the extremities
In this example, all of the ABC's are addressed, as well as the 6th vital sign- pain. Every option is correct, but one is the MOST correct, and it's NOT the airway option OR the breathing option. Yes, airway is important. The neck has some swelling, the patient is having a hard time catching her breath. Yes, anaphylaxis is possible with bee stings, but remember it's been 6 hours since the sting. Anaphylaxis onset at this point is extremely unlikely.
Breathing- yes, the respiratory rate is high, and the breathing pattern is labored. Oxygen saturation is slightly decreased for an otherwise healthy child. But WHY are you seeing these symptoms? The patient is in pain and scared. All are expected findings in this situation.
Which brings us to our C- circulation. There's a few clues in this question. 1. The patient is reporting severe pain in the casted extremity. 2. The patient reports a pins and needles sensation in the hands and fingers (not just in the area of the break). These things are suggestive of compartment syndrome- a dangerous complication with serious consequences if left untreated. Assessing the circulation of this extremity compared to other extremities is definitely your priority.
I hope I helped explain why the ABC's aren't always the correct answer, and why it's important to evaluate your options in the context of the question. That being said, with the information provided about the facial trauma and swelling, I probably would have chosen airway as well.
- Sep 19 by wantccuThe rationale was pretty much "because I said so". I have an appointment to meet with her, though. Not to nit pick and argue points, but because I simply don't understand the rationale about a few answers. Another was a select all asking which patients were at risk for pneumonia. One of the patients that I selected as at risk was a comatose patient who is being turned q 2 hours and it was incorrect. I get that turning lessens the risk of developing pneumonia but is that comatose patient really NOT at risk for developing pneumonia at all simply because they're being turned?