Page 651 - ACCCN's Critical Care Nursing

628 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

TABLE 23.2 Position and mobility restrictions in trauma patients

Type of injury Restrictions
Traumatic brain injury l Nurse head up 15–30 degrees.
l Side-lying as tolerated.
l Full tilt on bed if cervical spine not yet cleared of injury.
l Occasionally nursed flat if ICP problematic.
Facial trauma l Generally nurse in head-elevated position to reduce swelling, using either full bed tilt or back rest elevation.
Chest trauma l Nurse in varying positions from semi-Fowler to side-lying.
l Postural drainage (head down) usually beneficial if not contraindicated by other injuries (e.g. head or facial).
Abdominal trauma l Nurse in varying positions from semi-Fowler to side-lying.
l Preferable to have some degree of hip flexion when lying supine to reduce abdominal suture line tension.
Pelvic trauma l Position restrictions are dependent on severity of fracture(s), use of external fixateurs and degree of stabilisation.
l Some patients may sit out of bed and ambulate with external pelvis fixateur in situ.
l Position restrictions require regular review, as changed or loss of fixation may affect recovery.
Extremity trauma l Significant position restrictions may include limb elevation, avoidance of side-lying or limited movement.
ICP = intracranial pressure.

Additionally, hypothermia is a common contributor to l ensuring the patient is adequately covered during
the exacerbation of both acidosis and coagulopathy. 33-38 transport and hospital care
Acidosis has been discussed in earlier chapters so is l warm intravenous fluids
reviewed here only as it interacts with hypothermia and l using warm blankets or electrical warming blankets
coagulopathy in the trauma setting. Low cardiac output, l adjusting the temperature in the operating room
hypotension, hypoxia, hypothermia and rhabdomyolysis where feasible. 39
are common causes of acidosis in the trauma setting. The
increased recognition of the importance of this triad in In extreme cases of hypothermia internal methods of
the trauma setting has led to the development of damage rewarming, such as cardiopulmonary bypass and perito-
control surgery. The principle of this surgery is reviewed neal dialysis or lavage, might be utilised.
below. Coagulopathy

Hypothermia Coagulation is widespread in the trauma setting, and
Hypothermia is defined as a core temperature <35°C and ranges from a mild defect in coagulation function to life-
is associated with high morbidity and mortality. Even in threatening coagulopathy. Defects in coagulation may be
sub-tropical environments, hypothermia is identified in caused by dilution, hypothermia, acidosis, tissue damage
34,35
approximately 10% of major trauma cases during the or the effects of underlying disease.
prehospital or in-hospital phase of care. 36,39 Dilution results from the transfusion of either crystalloid
or colloid fluids, and occurs as the concentration of coag-
Uncontrolled causes of hypothermia can be endogenous ulation factors in the patient’s blood is diluted with the
or accidental. 33,34,37,39 Endogenous causes include meta- transfused fluid. It should be remembered that transfu-
bolic dysfunction with decreased heat production, or sion of red blood cells has the same effect, as whole
central nervous system dysfunction with insufficient ther- blood or packed cells have undergone some dilution and
moregulation such as in neurological trauma. Dermal have reduced viability of platelets. Hypothermia causes
38
dysfunction, such as a burn, is another endogenous cause coagulopathy because many of the enzymatic reactions
of hypothermia.
in coagulation are temperature-dependent. Platelet and
Accidental hypothermia can occur without thermoregula- thromboplastin function both decline with even moder-
tory dysfunction, and generally occurs in the trauma ate (34°C) hypothermia, while hypothermia stimulates
patient as a result of environmental exposure either at the fibrinolysis. 34,40
injury site or during transport to, or between, healthcare
facilities, as a result of large-volume fluid resuscitation or Acidosis reduces the activity of both the extrinsic and the
during prolonged surgical procedures. The pathophysio- intrinsic coagulation pathways, as well as platelet func-
logical changes associated with hypothermia vary depend- tion. This is particularly pronounced with a pH below
34
ing on the severity, and are outlined in Chapter 22. Of 6.8. Tissue damage causes endothelial disruption and
particular relevance, shivering leads to increased oxygen defibrination, which promote the systemic activation of
consumption and acidosis, and platelet dysfunction leads coagulation; this is particularly profound in patients with
to impaired clotting. 33,36,39 brain injury due to the high level of thromboplastin in
brain tissue. 34,37,38 The final cause of coagulopathy in
Measures to reduce the incidence of hypothermia – or trauma is the underlying disease present in many patients.
to correct it when it is present – in the trauma setting Patients may have a coagulation defect such as haemo-
include: philia or von Willebrand’s disease, or liver disease with