Page 656 - ACCCN's Critical Care Nursing

Trauma Management 633

patient will often be nursed flat, with the bed on tilt Collaborative practice: traumatic amputations
for a head-elevation position. In these circumstances, Traumatic amputation is the separation of a limb or
the injured dependent limb must be elevated on appendage from the body. During the prehospital phase
pillows so that it is no longer dependent. Care must it is hoped that any amputated body part will have been
be taken to ensure that elevation does not place pres- wrapped in a clean or sterile (if available) cloth. This
sure on any part of the limb: for example, a hand sack should then have been placed in a plastic, waterproof bag
made from a pillowcase tied to an IV pole should not and placed into an insulated cooler with ice. It is impor-
be used, as it places direct pressure on the path of tant that the ice does not come into direct contact with
the median nerve and can cause an iatrogenic the amputated part. When managed using these princi-
neurapraxia. ples, the amputated part may be viable for up to 6–12
l Wooden/air splints. These are padded appliances that hours before reattachment. Depending on any additional
are strapped to the injured limb. Ideally, no patient injuries, and the cardiovascular status of the patient,
should remain in wooden splints for longer than 4 surgery for limb salvage will be scheduled as soon as
hours, as pressure may build up on pressure points. possible.
l Plaster backslab. Limbs with fractures will often swell
as a physiological response to injury; a plaster back- Postoperative management will be guided by the type of
slab composed of layered Plaster of Paris is the pre- surgery that was performed, specifically whether or not
ferred treatment, as it accommodates swelling and can amputation occurred. Principles of postoperative care
easily be loosened by nursing staff at any time of day. include:
It is imperative that this be adequately padded within l appropriate positioning of the affected limb, usually
the limitations of providing structural support to the based on surgical orders
limb. Poorly made or ill-fitting backslabs can cause l frequent neurovascular observations, particularly
major complications, such as pressure sores or dis- observing for reperfusion injury, which manifests as
placement of fractures. an acute compartment syndrome or vascular trashing
l Traction. Traction may be required as part of fracture of distal vessels from a clot
management, and involves the application of a pulling l implementing changes in treatment initiated in
force to fractured or dislocated bones. There are three response to altered perfusion in a timely manner
types of traction: l psychological support to assist the patient in dealing
1. skeletal, where traction pins are anchored into the with the injury.
bone (i.e. Steinmann pin);
2. skin, where the body is gripped, as in the use of
slings and bandages;
3. manual, applied by a clinician pulling on a body Practice tip
part, such as in the reduction of dislocation. It may
also be applied to maintain the traction during Where there are any signs of deterioration of the reimplanted
such nursing care manoeuvres as log-rolling or part, communication should occur directly between the nursing
repositioning of the traction. staff and the surgical consultant to ensure timely implementa-
tion of changes to optimise salvage of the amputated part.
The principles of traction are to achieve the goal of align-
ment of bones whilst preventing complications. Remem-
ber that incorrectly-applied traction is painful and can
exacerbate the injury. The following should guide man-
agement of the patient with traction: Practice tip
1. The grip or hold on the body must be adequate For patients with amputations, on arrival in the emergency
and secure. department:
2. Provision for countertraction must be made. 1. Inspect the amputated part.
3. There must be minimal friction. 2. Clean with 0.9% saline solution and return to a clean plastic
4. The line and magnitude of the pull, once correctly bag wrapped in 0.9% saline-soaked gauze. Surround with
established, must be maintained. ice in a thermal cooler.
5. There must be frequent checks of the apparatus
and of the patient to ensure that: (a) the traction
set-up is functioning as planned; and (b) the Collaborative practice: pelvic stabilisation
patient is not suffering any injury as a result of the Pelvic fractures can be uncomplicated and require no
traction treatment.
surgical intervention, or they can be serious enough to be
the primary cause of death from exsanguination. Appro-
priate assessment and management of pelvic fractures is
Practice tip a major consideration for the management of any trauma
patient.
No patient should remain in a wooden splint longer than 4
hours. Wooden splints must be changed to a resting backslab The initial management of the patient with a fractured
that places the injured limb in anatomical fracture alignment. pelvis involves assessment and splinting. Assessment
should encompass the following two aspects: 45,51