Emergency Care Lecture: Other Traumatic Injuries

Introduction

Traumatic injuries are a significant problem in emergency care settings in the United Kingdom (UK). The previous chapter of this unit introduced the most common types of traumatic injuries - those involving the head, brain, bones, soft tissues, neurovascular structures and spine. However, there are also a number of other important traumatic injuries that nurses working in emergency care settings must be able to assess and manage - including those affecting the thoracic, abdominal, genitourinary and maxillofacial regions. This chapter introduces the knowledge and skills required to accurately and rapidly assess, and effectively manage, a variety of traumatic injuries affecting the thoracic, abdominal, genitourinary and maxillofacial regions. This chapter also considers the most common mechanisms of injury, and typical emergency presentation, of traumatic injuries in these regions. Finally, this chapter will discuss the principles of managing traumatic injuries in children and in obstetric patients - two populations which are particularly susceptible to trauma, and which require specialised nursing care.

Important note

This chapter assumes a basic knowledge of human anatomy and physiology. If you feel you need to revise these concepts, you are encouraged to consult a quality nursing textbook.

Thoracic trauma

The term 'thoracic trauma' is used to describe any traumatic injury affecting the chest area. Typically, traumatic thoracic injuries are caused by blunt forces (e.g. the sudden deceleration, compression and / or direct blows sustained in road traffic accidents) and, though less commonly, penetrating injuries (e.g. stabbings, gunshot wounds, etc.). Although they are less common, patients with penetrating chest injuries tend to deteriorate more rapidly and dramatically than those with blunt force injuries; therefore, rapid assessment and management is particularly important in these patients. Traumatic thoracic injuries account for a significant proportion of pre-hospital deaths in the UK, primarily due to the major disruption of the airway, impairments to breathing and / or problems with circulation they cause. Patients who arrive in emergency care settings with traumatic thoracic injuries are often considerably unwell, and require intensive nursing care.

The assessment of patients with actual or potential thoracic injuries focuses on the identification of the two main problems associated with these injuries: (1) hypoxia (i.e. a lack of oxygen in the blood), and (2) hypoventilation (i.e. a low respiratory rate). As with all assessment, the assessment of traumatic thoracic injuries begins with an assessment of the patient's airway, breathing and circulation. During assessment, there must be a particular focus on the patient's breathing; indeed, the nurse should pay particular attention to the rate, depth and effort of the patient's breathing, auscultate breath sounds, and the integrity and symmetry of the chest wall. There is also a focus on a patient's cardiac function, and continuous monitoring of the cardiac rhythm is often undertaken. A rapid assessment of the patient's circulation (e.g. peripheral pulses, skin colour / temperature, capillary refill time) is also completed. Assessment usually also includes imaging studies - such as X-rays or CT scans - to formally diagnose internal injuries.

During assessment, a nurse may identify one or more of a variety of injuries related to thoracic trauma. The most common injuries, and their management in the emergency care setting, are described following:

• Rib fractures - these may involve a single rib or multiple ribs, and most often occur in the fourth to the tenth rib. Severe rib fractures, those involving eight or more ribs, may result in a flail injury, where a section of the ribcage moves independently from the main ribcage during breathing. Although painful, rib fractures alone do not require urgent care (however, it is important to note that rib fractures are a common cause of pneumothorax and haemothorax, described following). Splinting, rest and pain management are all key interventions in the management of rib fracture.
• Pneumothorax - this involves an accumulation of air in the pleural space around the lung/s, and the resultant 'collapse' of the lung/s. A haemothorax is a similar condition where blood fills the pleural space.  Patients with a pneumothorax (or haemothroax) typically present with chest pain, dyspnoea and tachycardia; auscultation of the chest will demonstrate decreased or absent chest sounds on the side/s of the collapsed lung/s. In the emergency care setting, the management of a pneumothorax (or haemothroax) involves the insertion of a drain between the ribs to empty the pleural space; this is an emergency procedure usually completed using only local anaesthetic, whilst the patient is conscious.
• Cardiac tamponade - this occurs when there is a rapid accumulation of the blood in the pericardial sac, which surrounds the heart. As the pericardial sac is a closed space with a definite volume, blood in this space places pressure on the ventricles and prevents them from filling to capacity. This results in acute circulatory dysfunction, including cerebral hypoxia. Patients with cardiac tamponade present with a suite of symptoms referred to as 'Beck's triad': (1) hypotension, (2) muffled or indistinct heart sounds, and (3) distended neck veins; if untreated, the condition results in increasing dyspnoea, decreased level of consciousness (LOC) and eventual death. In the emergency care setting, cardiac tamponade is often managed using a procedure known as pericardiocentesis, which involves the insertion of a drain between the ribs to empty the pericardial space; this is an emergency procedure usually completed using only local anaesthetic, whilst the patient is conscious.

Consider the following case study:

The administration of high-flow oxygen via a non-rebreather mask is crucial in the management of the traumatic thoracic injuries described above. The management of pain is also important, as uncontrolled pain can result in disruptions to a patient's respiratory effort (thus further complicating the effects of the traumatic injury); most commonly in the emergency care setting, intravenous opioid analgesics are used. Reassurance - particularly for patients who may be severely dyspnoeic - is also an important consideration for nurses.

Abdominal and genitourinary trauma

Traumatic injuries to the abdominal region are a leading cause of disability and death among patients presenting to emergency care settings in the UK. Traumatic abdominal injuries are often associated with injuries to the genitourinary region. Most often, these injuries are caused by blunt force trauma; however, injuries involving penetrating forces may also be seen. In the UK, the most common causes of traumatic injuries to the abdominal and / or genitourinary regions are road traffic accidents (including pedestrian-versus-vehicle accidents), falls from height, and assaults.

Traumatic injuries to the abdominal and / or genitourinary regions are divided into two types: (1) injuries to the solid organs (e.g. the kidneys, pancreas, spleen, liver, etc.) and (2) injuries to the hollow organs (e.g. the stomach, urinary bladder, intestines, etc.). The most significant injuries tend to be those to the solid organs, particularly the liver and kidneys, as it is these injuries which may result in haemorrhage and rapid death. It is important to note that a patient may have injuries to both solid organ/s and hollow organ/s.

As with all assessment, the assessment of traumatic abdominal and genitourinary injuries begins with an assessment of the patient's airway, breathing and circulation. The assessment of the abdominal and genitourinary systems themselves can then commence. The assessment of these systems can be complex, because any injuries usually occur internally and are not immediately obvious on visual inspection. Severe bruising, lacerations or distention are all indications that a traumatic abdominal and / or genitourinary injury may be present. Percussion and palpation of all four abdominal quadrants, following the administration of an appropriate level of analgesia, may be useful in detecting the presence of free fluid (e.g. blood) in the abdomen - and, subsequently, of abdominal haemorrhage. However, these assessments are not diagnostic, therefore assessment usually also includes imaging studies - such as X-rays or CT scans - to formally diagnose internal injuries. Consider the following case study:

During assessment, a nurse may identify one or more of a variety of injuries related to abdominal and / or genitourinary trauma. The most common injuries, and their management in the emergency care setting, are described following:

• Lacerations to the solid organs - the liver and spleen are common sites of traumatic abdominal injuries. Because the liver holds up to 25% of the body's circulating blood at any given time, injuries to the liver are particularly significant, often resulting in major haemorrhage. The management of lacerations to the solid organs in the emergency care setting focuses on maintaining haemodynamic stability (e.g. using aggressive fluid resuscitation) whilst the patient awaits corrective surgery.
• Renal injuries - the kidneys are another solid organ which are commonly affected by traumatic abdominal injury. The majority of renal injuries are due to blunt force trauma. Typical signs of renal injury include ecchymosis on the flank/s, a palpable mass in the region of the kidneys, and haematuria (i.e. blood in the urine). Minor renal injuries usually only require supportive care; however, severe renal injuries, and particularly in patients who are haemodynamically unstable, may be treated with nephrectomy (i.e. the surgical removal of the affected kidney).
• Bladder injuries - as one of the largest hollow organs, the bladder is the most common site of traumatic genitourinary injury. Bladder injuries are usually associated with pelvic injuries (often pelvic fractures). A patient with a traumatic bladder injury may present with a range of non-specific signs - for example, gross haematuria, pain in the suprapubic area, difficulty voiding and abdominal tenderness; however, only imaging studies can definitively diagnose a bladder injury. Minor bladder injuries usually only require supportive care; however, severe bladder injuries, including rupture of the bladder, may be treated with surgical repair.

The administration of analgesic medication for pain is crucial in the management of the traumatic abdominal and genitourinary injuries described above; most commonly in the emergency care setting, intravenous opioid analgesics are used.

Maxillofacial trauma

Maxillofacial trauma involves injury of the bones, neurovascular structures, skin, subcutaneous tissues, muscles and glands of the face and upper neck. You studied traumatic orthopaedic and neurovascular injuries in the previous chapter of this module; however, traumatic maxillofacial injuries are quite distinct. Not only do maxillofacial injuries have the potential to cause significant problems with the function of the airway, they may also affect a person's physical appearance (both temporarily and permanently), and this can be a significant source of distress for some.

As with all assessment, the assessment of traumatic maxillofacial injuries begins with an assessment of the patient's airway, breathing and circulation. Ensuring patency of the patient's airway is particularly important; displacement of the mandible, avulsed teeth, naso-orbital haemorrhage and swollen tongue associated with maxillofacial may all occlude the airway. Strategies for managing a patient's airway in the emergency care setting were discussed in an earlier chapter of this module; you should revise this chapter now, if required. Suctioning to remove foreign objects, control of haemorrhage (e.g. by packing the nose and applying ice across the cheeks), and the administration of supplemental oxygen are particularly important; however, if the airway cannot be managed, sedation and the insertion of an artificial airway - usually a nasopharyngeal airway - may be required.

Once the patient's airway, breathing and circulation are stable, the assessment of the maxillofacial region itself can commence. Inspection and subsequent palpation, following the administration of an appropriate level of analgesia, of the facial bones can be important in identifying maxillofacial fractures; depressed irregularities in the bone and crepitus are both key indicators of maxillofacial fractures. However, these assessments are not diagnostic, therefore assessment usually also includes imaging studies - such as X-rays or CT scans - to formally diagnose internal injuries. If the patient is conscious, they may be asked about jaw pain, their ability to completely open their jaw, and the extent to which their teeth meet normally; problems in any of these areas may indicate a jaw fracture specifically. The patient's visual acuity should be assessed; for example, the patient may be asked to count fingers, or assess objects in their peripheral vision. The facial nerve and its branches should also be evaluated; consider the following case study:

Traumatic maxillofacial injuries are a type of traumatic head injury. For this reason, assessment of a traumatic maxillofacial injury must include a comprehensive assessment of a patient's neurological function using a tool such as the Glasgow Coma Scale (GCS). You studied the GCS and its role in neurological assessment in a previous chapter of this module; you should revise this chapter now, if required.

During assessment, a nurse may identify one or more of a variety of injuries related to maxillofacial trauma. The most common injuries, and their management in the emergency care setting, are described following:

• Soft tissue injuries - these include injuries to the skin (including the eyebrows and eyelids), subcutaneous tissues, intra-oral tissues (including the tongue), the eye and / or the ear. Although painful, these injuries do not usually require urgent care (however, it is important to note that they may result in haemorrhage, in which case urgent care is required). The management of these injuries in the emergency care context focuses on the use of direct pressure to control initial haemorrhage, and subsequent wound repair using sutures, staples or clips. Additionally, sometimes urgent ophthalmologic surgery may be provided to save a patient's sight.
• Fractures - the maxillary structures (i.e. those in the midface, such as the cheeks and nose), the mandible (i.e. the jaw) and the orbital region (i.e. the eye sockets) are common fracture sites. Maxillary fractures are particularly significant, as they may result in significant changes to normal anatomic structure of, and subsequent impairments to, airway functioning. Occasionally, maxillary fractures are so severe that oropharyngeal airways cannot be inserted; in such cases, a patient will be given a trachaeostomy. Minor fractures usually only require supportive care; however, severe fractures, including maxillary fractures, may be treated with surgical repair, including plating to restore normal anatomic structure.

Again, the administration of analgesic medication for pain is crucial in the management of the traumatic maxillofacial injuries described above; most commonly in the emergency care setting, intravenous opioid analgesics are used. The administration of high-flow oxygen via a non-rebreather mask is also important if a traumatic maxillofacial injury compromises the patient's airway. Although it is a fundamental aspect of nursing care in all settings, the psychosocial care of a patient with a maxillofacial is particularly important; as described earlier in this section, these injuries may significantly affect a person's physical appearance (both temporarily and permanently), and this can be a significant source of distress for some.

Trauma in children

Despite advances in the medical care provided to trauma patients in the UK, traumatic injury continues to be a leading cause of death in children aged over 1 year. Blunt force trauma resulting from traffic accidents (including pedestrian-versus-vehicle accidents), falls from height, and accidents involving bicycles, skateboards and scooters are among the most common causes of traumatic injuries in children in the UK; however, near-drowning injuries, which are caused by severe hypoxic insult to the brain, are becoming more common. Remember: as highlighted in the previous chapter of this module, abuse is a significant cause of trauma in children presented to emergency care settings in the UK; recognising the signs of, and responding appropriately to, suspected child abuse is a key role for emergency nurses.

There are a number of important considerations in the management of traumatic injuries in children. Children differ from adults developmentally, anatomically and physiologically, and these differences impact on how children are assessed and managed in the emergency care setting. Key considerations include:

• A child's airway is comparatively short and narrow, and can be easily obstructed.
• A child's ribs tend to be pliable, and contusion is seen more often than rib fracture.
• When a child is in respiratory distress, retractions of the tissue in the intercostal, substernal and supraclavicular spaces are more likely to be observed.
• A child has a thin chest wall which transmits breath sounds easily; therefore, respiratory assessment can be challenging, and diagnostic imaging is often required.
• A child's absolute blood volume is small; therefore, even small bleeds can significantly decrease their circulating blood volume, resulting in shock.
• Hypotension is not common in children; it is typically a late sign of hypovolaemia.
• Bradycardia is also uncommon; it is typically a late sign of cardiac decompensation.
• Prior to the age of 18 months, the natural 'sutures' in a child's skull have not fused and the skull is pliable; children are therefore at increased risk of neurologic injury.
• A child's head is disproportionately large and the muscles of their neck underdeveloped, increasing their vulnerability to flexion-extension injuries.
• A child's abdominal organs are comparatively larger, increasing their risk of injury.
• A child's periosteum is thicker than that of an adult; therefore, unique fracture patterns are found in children: plastic deformity (where the bone is deformed but not broken), torus fractures (where compression forces are applied and the bone buckles), greenstick fractures (an incomplete fracture where the periosteum remains intact), and physis fractures (where there is an injury to the growth plate).
• Children have a large body surface-to-weight ratio, and are prone to hypothermia.

Children of all ages in the emergency care setting are often very frightened of the strange and painful things that are happening to them. Encouraging the presence of a supportive parent, carer or significant other, or the use of a familiar pacifier or toy, during investigations and interventions can be very effective in calming young children in particular. Providing comfort measures - including explaining the situation to the child at their level of understanding, holding the child's hand or rubbing their back, and allowing a child to communicate their distress (e.g. permitting crying, screaming and struggling without scolding or threatening) - are all important strategies for nurses to consider. In the emergency care setting, it is important to remember that, because of the fundamental role parents play in their child's management, care of the parent is just as important as care of the child.

Trauma in obstetric patients

The management of trauma in pregnant women is very complex; nurses are essentially caring for two patients, the mother and the foetus, and both have very different needs. In the UK, aside from direct obstetric causes, trauma is a leading cause of maternal and foetal death. Most deaths in the obstetric context are caused by traumatic injuries which result in head injury, haemorrhagic shock (including following pelvic fracture), and abdominal injuries due to blunt force trauma; these injuries often result in the abruption of the placenta and / or premature delivery. Direct injury to the foetus may also occur; foetal skull fractures and intracranial haemorrhage are most often seen, though clavicular and long bone injuries have also been recorded. Road traffic crashes, falls and assaults are the most common mechanisms of traumatic injury for obstetric patients. 

There are a number of important considerations in the management of traumatic injuries in obstetric patients. Pregnant women differ from other adults anatomically and physiologically, and these differences impact how they and their foetuses are assessed and managed in the emergency care setting. Key considerations include:

• By the third trimester, the uterus is large and prone to injury and haemorrhage.
• If a woman in the third trimester lays supine, the uterus and fetus may suppress the great vessels (e.g. the abdominal aorta and vena cava); for this reason, women should always be positioned lying on their side or with a wedge under one hip.
• In response to traumatic injury, the maternal body releases catecholamines; this may result in vasoconstriction in the placenta and uterus, and foetal hypoxia.
• Cardiovascular changes on electrocardiogram (ECG), including flattened or inverted T and Q waves in some leads and ectopic beats, may be normal in pregnancy.
• Maternal blood volume, heart rate and cardiac output increase significantly by the second trimester; some changes in laboratory blood values are normal and expected.
• Maternal assessment must include foetal assessment (e.g. using a Doppler to determine foetal heart rate, cardiotocography to monitor cardiac patterns, ultrasonography to evaluate fetal position and activity, etc.).

In some situations where a pregnant woman sustains particularly severe traumatic injuries, including where the woman is expected to die, her foetus may be delivered early - via surgical caesarean section - in an attempt to save its life. Also, occasionally in emergency care settings, traumatic injuries will result in the onset of labour, and babies - particularly those of early gestations - may be born very rapidly. If a baby is born unexpectedly in the emergency care setting, regardless of its gestational age, it is important that nurses attempt to resuscitate the child (e.g. by drying, warming, suctioning, giving tactile stimulation, and administering positive-pressure ventilation); initiating an emergency call to a neonate team (if available) or paramedics is also important. In most cases, foetuses above the age of 24 weeks gestation are considered 'viable'; however, all foetuses born before term (37 weeks gestation) will require intensive nursing care.

Conclusion

Traumatic injuries are a significant problem in emergency care settings in the UK. This chapter has introduced the knowledge and skills required to accurately and rapidly assess, and effectively manage, a variety of traumatic injuries affecting the thoracic, abdominal, genitourinary and maxillofacial regions in the emergency care setting. This chapter has also considered the most common mechanisms of injury, and typical emergency presentation, of traumatic injuries in the thoracic, abdominal, genitourinary and maxillofacial regions. Finally, this chapter had discussed the principles of managing traumatic injuries in children and in obstetric patients - two populations which are particularly susceptible to trauma, and which require specialised nursing care. Along with the previous chapter of this module, this chapter has provided a thorough grounding to prepare you to provide quality emergency nursing care to patients affected by traumatic injury.

Reference list

Beyreuther, J., Wagener, S., Woodford, M., Edwards, A., Lecky, F., Boyamra, O. & Dykes, E. (2009). Paediatric trauma: Injury pattern and mortality in the UK. ADC Education and Practice, 94(2), 37-41.

British Association of Oral and Maxillofacial Surgeons. (2016). Trauma. Retrieved from: http://www.baoms.org.uk/What_is_Oral_and_Maxillofacial_Surgery/Sub_specialist_Areas/Trauma

British Medical Journal: Best Practice Series. (2016). Assessment of Abdominal Trauma. Retrieved from: http://bestpractice.bmj.com/best-practice/monograph/1187.html

Cullen, P.M. (2012). Paediatric trauma. Continuing Education in Anaesthesia, Critical Care and Pain, 1-5.

DiSabatino, A.J. & Bucher, L. (2007). Nursing Assessment: Cardiovascular System. In S. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O'Brien & L. Bucher (Eds.). Medical-Surgical Nursing: Assessment and Management of Clinical Problems - International Edition. (7th edn.): St Louis: Mosby-Elsevier.

Howard, P.K. & Steinmann, R.A. (Eds.). (2010). Sheehy's Emergency Nursing: Principles and Practice. Naperville, IL: Mosby Elsevier.

Jones, G., Endacott, R. & Crouch, R. (2007). Emergency Nursing Care: Principles and Practice. Cambridge: Cambridge University Press.

Murphy, N.J. & Quinlan, J.D. (2014). Trauma in pregnancy: Assessment, management and prevention. American Family Physician, 90(10), 717-724.

National Institute of Health and Clinical Excellence. (2016). Major Trauma: Assessment and Initial Management (NG39). Retrieved from: https://www.nice.org.uk/guidance/ng39