Page 658 - ACCCN's Critical Care Nursing

Trauma Management 635

TABLE 23.5 Spinal precautions 56

Action Rationale Aim Method
Head hold To maintain the cervical spine in Prevent flexion, extension and 1. Nurse holds head from head of bed – the head is held
a neutral position during any lateral head tilting during any firmly by placing one hand around the patient's jaw
position change movement. with fingers spread to cup the jaw and hold the
endotracheal tube as necessary. The forearm is used
to support side of the head
2. Nurse holds head from side of bed – nurse stands on
side of bed that the patient will be rolled towards.
One hand is placed firmly under the patient's occiput.
Ensure to be in a position to support the weight of
the head
The other hand holds the jaw and endotracheal tube as
necessary. The patient is rolled onto the forearm of
the nurse holding the head which completes the
biomechanical support for the head thus
immobilising the cervical spine during the rolling.
Log roll To maintain the entire spine in To prevent rotational torsion on The patient is rolled in one smooth motion with
anatomical alignment position the spinal column by assistants supporting the shoulder and pelvic girdles.
during any position change minimising twisting of the Another assistant supports the legs so the patient
craniocervical, cervico- moves in one plane
thoracic and thoracolumbar The patient is rolled in one smooth motion with the
junctions of the spinal column nurse holding the head issuing the command to start
and stop the manoeuvre.

particularly in relation to stabilisation, remains approximately 20% of road traffic crash injuries occurring
controversial. 45,51,55 to the chest, 30% of stabbing injuries occurring to the
chest and only 10–15% of assault and fall injuries occur-
54
Collaborative practice: spine orthoses ring to the chest. Associated mortality ranges from 4%
28,55
The cervical collar or orthosis is the most commonly used to 9%.
splint to immobilise the cervical spine. It commonly Pathophysiology
remains in situ for >24 hours in an ICU setting. This
particular type of splinting is associated with an increased The chest consists of the thoracic cavity and the organs
32
risk of pressure ulceration in immobile patients. Collar contained within. The thoracic cavity is made up of two
care is an essential component of critical care practice. structures, including a bony cavity consisting of the ribs,
Any dirt, grit, glass and road grime must be removed as sternum, scapulae and clavicles; and the second muscular
soon as possible from under the collar, particularly in the structure of the respiratory muscles and diaphragm. The
occipital regions. The patient should side-lie as much as organs contained in the chest include the lungs, airways,
possible and the collar should be removed while main- heart, blood and lymph vessels and oesophagus.
taining spinal precautions (see Table 23.5) and the under- Like all trauma, chest trauma can be penetrating or blunt
52
lying skin integrity assessed at least every 8 hours. Other in nature. Penetrating trauma, generally caused by blades
examples of spine orthoses include a halothoracic brace or bullets, results in damage to the structures and organs
and thoracolumbar/truncal anti-flexion bracing. in the chest, as well as disruption of the normal negative
intrapleural pressure resulting in a pneumothorax. Blunt
CHEST TRAUMA chest trauma generally occurs as a result of road traffic
Chest trauma is recognised as a severe, potentially life- crashes, falls and assaults or collisions.
threatening form of injury that may require admission to Chest trauma can be separated into injury to the thoracic
the critical care areas. Chest trauma may be blunt in structure, including the ribs and diaphragm; injury to the
nature, often being experienced during road traffic crashes lung, airways and associated tissue; injury to the heart
and can be associated with injuries to other areas of the and associated tissue; or injury to the vascular or digestive
body or penetrating in nature. It is often experienced system located in the chest.
during gunshot or stabbing injuries.

Chest trauma represents approximately 10% of injuries Description
that require admission to hospital for more than 24 Chest trauma covers a broad array of injuries and severity,
28
hours, although this proportion grows to over 15% and ranges from relatively minor injuries (e.g. abrasions
when only patients with major injury (injury severity and fracture of a single rib) to major, immediately life-
score >15) are considered. 28,53 Chest trauma also repre- threatening injuries (e.g. cardiac rupture or tension pneu-
sents approximately 15% of the injured patients requir- mothorax). Chest trauma is often associated with injuries
28
ing admission to the ICU. The incidence of chest trauma to other regions of the body, including the head, neck,
varies, depending on the external cause of the injury, with spine, abdomen and limbs. 57