Page 655 - ACCCN's Critical Care Nursing

632 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

l Fractures of the spinal column. (see also Chapter 17). Given the potential for extensive blood loss, as well as
The spinal column includes all of the bony compo- the frequent close proximity of nerves and blood vessels
nents in the cervical, thoracic and lumbar vertebral to bones, neurovascular assessment of the patient with
regions. Fractures of the vertebra are common in skeletal trauma is essential (see Table 23.4).
trauma patients, but the actual incidence of fracture
without spinal cord injury in multitrauma patients is Collaborative practice: splinting
not well described. Not all fractures cause vertebral One of the major emergent management strategies for
column instability with the subsequent risk of spinal haemorrhage control in the patient with skeletal trauma
cord damage. A spine column fracture will be diag- is splinting. Splinting is a potentially lifesaving interven-
nosed as mechanically stable or unstable and this tion and is generally undertaken by nursing staff. The
will affect the positioning and possible activity of the purpose of splinting is to align and immobilise the bone,
patient. which alone has remarkable haemorrhage control
l Discoligamentous injuries of the spinal columns (see properties. Every fractured bone that has not undergone
also Chapter 17). The soft tissue components of the definitive orthopaedic management requires splinting.
spinal column include the spinal cord, the inter- Examples of intermediate stabilisation of fractures
vertebral discs and the spinal ligaments. An injury to include:
the spinal column can disrupt one or more of these
structures with or without fracture. These injuries can l Positioning of injured limbs. All patients who have
be highly unstable and the nurse must be vigilant with any form of splint in situ should not have the affected
spinal precautions and the fitting and management limb below the level of the patient’s body, and may
of the patient requiring a spine orthoses (refer to need to have it elevated to promote venous return and
Figure 23.1). minimise tissue oedema. In the ICU the trauma
Nursing Practice
There are several major considerations for the nurse man-
aging the critically ill patient with skeletal trauma. These TABLE 23.3 Potential blood loss caused by fractures 76
include appropriate assessment as well as application of
traction, management of any amputated parts and stabi- Fracture Blood loss (mL)
lisation of pelvic fractures and spine precautions. These Humerus 500–1500
latter aspects of care will be conducted in collaboration
with medical and allied health colleagues. Elbow 250–750
Radius/ulna 250–500
Independent practice
Pelvis 500–3000
Bones are very vascular structures and can be the cause
of substantial blood loss in the trauma patient. The Femur 500–3000
critical care nurse should therefore be cognisant of the Tibia/fibula 250–2000
potential for extensive blood loss in common fractures
(see Table 23.3). Ankle 250–1000

TABLE 23.4 Neurovascular observations of the skeletal trauma patient
Should be undertaken on all injured limbs both pre- and postoperatively as required
Observation Process Comments
Skin colour State the skin colour of the area inspected Pink: normal perfusion
as it compares with the unaffected part. Pale: reduced perfusion
NB: Distal limb pulses may be difficult to Dusky, purple or cyanotic discolouration: usually indicating
palpate in the injured limb; a warm significantly reduced perfusion
pink limb is a perfused limb.
Demarcated: a distinct line where the skin colour changes to
dusky (usually follows the vessel path)
Skin temperature to touch State the ambient temperature of the skin Normal: not discernibly cold to touch. Reduced skin
to touch as it compares with normally temperature indicates reduced perfusion.
perfused skin at room temperature.
Voluntary movement The patient should be able to move the It is important to assess range of motion where that is
non-immobilised distal part of any possible, provided this will not aggravate the injury.
injured limb (i.e. fingers and toes of a Reduced movement may indicate compromise to either the
plastered limb). nerve or blood supply to the limb.
Sensation The patient should be able to report Sensation should be assessed in nerve distributions (i.e. all
normal sensation to touch. fingers and toes). Reduced sensation may indicate
compromise to either the nerve or blood supply to the limb.