Page 652 - ACCCN's Critical Care Nursing

Trauma Management 629

resultant compromise to coagulation on an ongoing Nursing a patient who undergoes damage-control surgery
basis. Alternatively, patients may be taking anticoagu- requires recognition of the principles and aims of the
lants, such as aspirin or warfarin, as treatment for other surgery, as well as flexibility in care of the patient after
health conditions. 37,41 the initial surgery but before definitive surgery. In the
emergency department setting there is a need to under-
Treatment of coagulopathy should focus first on preven-
tion of coagulopathy and then on the treatment as take a rapid, systematic evaluation of the patient and
required. Prevention strategies include: 40 prepare him or her for rapid transfer to the operating
room. It is essential to implement all measures possible
l maintaining normothermia in critically injured to preclude the components of the trauma triad, while
patients through the use of blankets, warming devices, avoiding any delays to surgery. When the patient is admit-
and minimisation of exposure and theatre time ted to the ICU postoperatively, the standard mechanisms
l administering as little resuscitation fluid as is neces- for the treatment of hypothermia, acidosis and coagu-
sary to maintain adequate circulation lopathy, as discussed above, should be implemented.
l achieving control of haemorrhage as soon as possible, After damage-control surgery, patients may also have an
through techniques such as low-pressure resuscitation open abdomen with temporary dressings, or skeletal frac-
and damage-control surgery. tures with external fixateurs in situ.
There is a strong need to ensure that patients are not SKELETAL TRAUMA
overtransfused, and regular monitoring of coagulation
factors including haematocrit, platelet count, prothrom- Skeletal trauma involves injury to the bony structure of
bin time (PT), activated partial thromboplastin time the body. While skeletal injuries alone rarely result in the
(APTT), thrombin time (TT) and fibrinogen levels will patient being admitted to critical care, damage to sur-
assist in achieving this aim. The international normalised rounding blood vessels and nerves, as well as potential
ratio (INR) should be measured at the beginning of the complications such as fat embolism syndrome (FES)
process and repeated if abnormal. and rhabdomyolysis, may cause the patient to become
seriously ill. Patients with skeletal trauma who require
Treatment includes transfusion of platelets, fresh frozen admission to ICU include those with multiple injuries,
plasma (FFP) and cryoprecipitate, as well as the plasma severe pelvic fractures (often associated with significant
35
derivatives showing promise in this area of treatment. blood loss), long bone fractures (often associated with
While transfusion of platelets is specifically directed FES) and thoracic injuries such as flail segment. A small
towards increasing the circulating concentration of plate- number of people with crush injuries that cause signifi-
lets, administration of FFP is directed at increasing the cant damage to muscles, often resulting in rhabdomyoly-
levels of fibrinogen and other coagulation factors. Cryo- sis, also require admission to the ICU. 44,45
precipitate is made by freezing and thawing individual
units of FFP and collecting the precipitate, a process that Skeletal trauma is the form of trauma that causes the
concentrates fibrinogen, von Willebrand factor, factor highest number of patients to be admitted to hospital for
VIII and factor XIII. 24 hours or more, with approximately 50% of patients
28
experiencing a fracture as their main injury. Of those
patients admitted to an ICU, fractures are the second
Damage-control Surgery most common type of injury (after head injury), with
Damage-control surgery can be defined as a four-stage approximately 20% of patients experiencing this type of
procedure, involving early recognition of relevant patients injury.
and ‘rapid termination of an operation after control of
life-threatening bleeding and contamination followed by Pathophysiology
correction of physiological abnormalities and definitive Bone is composed of an organic matrix as well as bone
management’. 42,43 This approach to surgical correction of salts. The majority of the organic matrix is collagen fibres
traumatic injuries gained favour through the latter part of and the remainder is ground substance, a homogeneous
the 1990s and is intended to reduce the development gelatinous medium composed of extracellular fluid plus
46
of the triad of complications of hypothermia, acidosis proteoglycans. Calcium and phosphate are the primary
and coagulopathy. The intention is that surgery is initi- bone salts, although there are smaller amounts of magne-
ated rapidly, only the most rapid and simplest interven- sium, sodium, potassium and carbonate ions. These ions
tions that are required to stop bleeding and contamination combine to form a crystal known as hydroxyapatite.
are undertaken, then surgery is completed and the patient A fracture is simply defined as a break in the continuity
42
moved to definitive care, usually in the ICU. Care can of a bone. Fractures generally occur when there is force
then be undertaken to ensure that hypothermia, acidosis applied that exceeds the tensile or compressive strength
and coagulopathy do not develop or, if present, are of the bone. In patients sustaining a major injury (injury
rapidly reversed, thereby ensuring correction of physio- severity score [ISS] ≥16) fractures are the primary injury
logical abnormalities as quickly as possible. Definitive in more than 15% of cases, although many patients expe-
surgical correction of injuries is undertaken during the rience a fracture in addition to other serious injury result-
ensuing days when the patient is physiologically stable. ing in ICU admission. 28
Damage-control surgery can apply to a range of patients,
including those with abdominal, skeletal and thoracic Fractures are classified as either complete or incomplete.
trauma. A complete fracture is where the bone is broken all the