looking for opinons on this one Im pretty sure I have It right was just wondering.

allnurses Guide · Apr 13, 2012

Why don't you share your answers with us and then perhaps we can help you.

DSkelton711 · Apr 13, 2012

a 35-year-old married father of two. heis driving home from work on the interstate at 65 mph when a car crosses themedian and strikes his vehicle head on. marty, not wearing a seat belt, isthrown forward against the steering wheel. the front of the car is crushed, thesteering wheel traps his torso, and dashboard traps his lower extremities.extrication takes 45 minutes; he is then flown to a level i trauma center. hehas two iv lines in place and is immobilized on a backboard with a cervicalcollar. his knees are flexed. the flight nurses notes that he has severeabdominal pain and is unable to lay with his legs flat. vital signs during theflight are bp 90/60, p 120, r 36, oxygen saturation is 88%. supplemental oxygenis administered at 15 l.m via non-rebreather facemask. other obvious injuriesinclude contusions and edema in both knees. distal pulses in the lowerextremities are present.
focus questions:
1. what should marty's initial physical assessment include?indentify specific problems you are looking for and immediate actions.
2. which diagnostic tests should be obtained immediately andwhy?

i haven't worked in a hospital for nearly 20 years and worked ob/l&d but will take a stab:

physical assessment needs to include all systems with focus on neuro for sign of brain injury or cord injury; lungs for possible pneumothorax of some type; heart for abnormal heart sounds, muffling, abnormal rythym or mediastinal shift; abdomen for distention, rigidity, absence of bowel sounds-internal bleeding looks probable. check all pulses.

tests would possibly include ct of head--looking for bleeds; tests for various bleeding-ultrasound, bladder tap, u/a, laproscopic exam. blood work (inc abg); xrays to check for possible fractures--ribs, pelvis, etc. cxr-lungs/heart, etc.

i am so out of the loop now though that there is probably one machine that does all this and a robot to carry it out!!

daisy2012 · Apr 13, 2012

Sorry, I didnt think about that duhhh! (sometimes I think I would lose my head if it wasnt attatched)

1. first and foremost of course is determining wheather or not the patients airway was stable, checking for obstruction and the ability to pass air. if the patient was able to this then contacting anesthesia for an emergency intabation would be the next step. 2nd listen for breath sounds, determine how they sound and haow hard the patient is having to breath. a non rebreather mask at 100% oxygen is applied. 3rd assess heart sounds. patient is at risk for hypertension.look for any external hemmorage and apply pressure there if needed. 4th try to determine patients mental and moter status.

2. Chest x-ray to look for possiable pneumothrax, or pulmonary contussion. CT scan to look for internal bleeding and injuries. type and cross, blood gasses, H&H, urinalyis, cbc.

Im new at doing these sometimes I know what I want to say, but not sure how to put it. any advice would be greatly appreaciated. I am not looking for easy answers just opinons.

Columnist · Apr 13, 2012

Moved to Nursing Student Assistance.

Esme12, ASN, BSN, RN · Apr 13, 2012

you are given a ton of information. the vehicle is at a high rate of speed. he has sustained a injury to the chest/sternum (thrown into the steering wheel...heart/aorta/lungs). there is encroachment into the passenger compartment of the vehicle (increasing injury, evidence of force). he is pinned by the steering wheel (spleen/liver/kidneys/bowel). he is thrown (cervical injury/concussion, brain injury...coup contrecoup:whiplash injury of the brain.) in to the steering wheel (spinal chord injury without radiological abnormality:sciwora). he is unable to lie with his legs flat....his legs were trapped by the dashboard and has bilateral knee swelling( hip dislocations). time to extrication length is in direct correlation to severity of injury. you have 88% o2 sat on 100% nrb rr of 36 so he is in distress....you have lung/ribs/chest injury.

what to do first....abc...what to do first. remember you look listen and feel. auscultate, palpate and observe. are they awake? are they following you in the room? does the chest have equal expansion? is the trachea midline? is there crepitus? are the pulses equal? pupils?

the initial evaluation follows a protocol of primary survey, resuscitation, secondary survey, and either definitive treatment or transfer to an appropriate trauma center for definitive care. always remember your abc's first.

the steps of the primary survey are encapsulated by the mnemonic abcde (airway, breathing, circulation/hemorrhage, disability, and exposure/environment).

the airway is the first priority. assess it by determining the ability of air to pass unobstructed into the lungs. critical findings include obstruction of the airway due to direct injury, edema, or foreign bodies and the inability to protect the airway because of a depressed level of consciousness (see the image below).

next, evaluate the breathing to determine patient ability to ventilate and oxygenate. critical findings include the absence of spontaneous ventilation, absent or asymmetric breath sounds (consistent with either pneumothorax or endotracheal tube malposition), dyspnea, hyperresonance or dullness to chest percussion (suggesting tension pneumothorax or hemothorax), and gross chest wall instability or defects that compromise ventilation (in, flail chest, sucking chest wound).

evaluate the circulation by identifying hypokalemia, cardiac tamponade, and external sources of hemorrhage. inspect neck veins for distension or collapse, determine whether the heart tones are auscultated, and determine whether the external hemorrhage is identified and controlled. control any external hemorrhaging with direct pressure or surgery.

initial evaluation of the trauma patient

medscape: medscape access

you need to register for medscape and read this article it will answer all of your questions. it is free no strings.

so what tests do you think has to be done first? which would be the most life saving? (hint sat 88% on 100%o2). abgs does he really need intubation right now? next came he be moved? (c-spine) is his heart hurt?(tamponade/contusion) ekg his abdomen is of obvious importance (severe pain) ct chest/abd/pelvis. look at the hips last as their delay won't endanger his life...he has pulses.

what do you think?