Page 662 - ACCCN's Critical Care Nursing

Trauma Management 639

financial and social problems. Early referral of selected
TABLE 23.7 Assessment of chest drainage patients to allied health professionals has the potential
to significantly influence patient outcome.
Characteristic Description
ABDOMINAL TRAUMA
Water seal Ensure there is sufficient water in the
water seal chamber. Any organ or structure in the abdominal cavity can be
Bubbling Continued bubbling indicates an air leak. injured. Abdominal trauma presents unique challenges
to clinicians due to the abdominal cavity’s high diversity
Drainage Observe the nature and volume of fluid of organs and structures. The morbidity and mortality
exudate (NB: >1500 mL stat or
200/mL/hour for 2–4 hours; surgical associated with abdominal injuries are high, so the need
exploration may be required. for early, accurate diagnosis and treatment is paramount.
Abdominal trauma accounts for approximately 15% of
Patency Ensure the intercostal catheter is not
blocked, remove any blood clots. all trauma deaths, with haemorrhage being the major
cause in the first 48 hours. Latent trauma deaths after
Swinging Oscillation of fluid in the ICC confirms abdominal injury are usually related to sepsis and
patency, as this reflects the changes in
intrapleural pressure with respiration; complications.
such oscillation should continue even Recent advances in diagnostic and treatment techniques
when the lung has re-expanded.
for abdominal trauma have seen an increased emphasis
Suction If suction is ordered, check the on non-operative management for solid organ injury,
appropriate level is being delivered.
with more recent increases in the use of angioembolisa-
tion. These two clinical treatment innovations place an
emphasis on excellent patient monitoring and, in some
instances, higher ICU utilisation for selected cases. 62,63
Collaborative practice: ventilatory support
Ventilatory support is often required for patients with Patients who experience abdominal trauma as their main
chest trauma (see Chapter 15 for general principles). The injury comprise only 3–5% of injured patients requiring
following specific considerations apply: admission to ICU, although up to a quarter of trauma
28
patients experience some form of abdominal injury. Of
l Non-invasive ventilation: care should be taken based all patients who present to the emergency department
on associated injuries, with contraindications includ- with serious injury, approximately 15–20% have abdomi-
ing fractured base of skull or facial fractures. nal injury. 26
l Intubation: haemoptosis is relatively common in
patients with lung injury, and care must be taken to Pathophysiology
ensure removal of blood clots from the ETT. Heated, The abdominal cavity consists of a range of tissues and
humidified air and regular suctioning will assist with organ structures, including musculoskeletal, solid and
maintaining ETT patency. hollow organs, vessels and nerves. Musculoskeletal struc-
l Airway injury: initiation of positive pressure ventila- tures include the major abdominal muscle groups forming
tion in the chest trauma patient may identify damage the abdominal wall, as well as the lumbar vertebrae and
to a small airway that previously went unnoticed pelvis. Solid organs include the liver, spleen, pancreas,
(damage to a large airway will usually have been kidneys and adrenal glands (and ovaries in women).
detected early in the assessment phase). Treatment Hollow organs include the stomach, small and large
will depend on the severity and location of the rupture, intestines, gallbladder and bladder (and uterus in
but usually requires decompression of the pleura with women). Finally, the vessels and nerves include a complex
an ICC, possibly surgical intervention and advanced array of all abdominal blood vessels (arterial and venous),
respiratory support such as independent lung lymphatics, and nerves including neural plexuses and the
ventilation. spinal cord. Traumatic abdominal injuries are classified
l Use of tracheostomy: this may be required for patients as being extraperitoneal, intraperitoneal and/or retroperi-
with injury to the trachea and is managed using toneal. Importantly, a patient can have any mix or mul-
the same principles as with any patient with a tiples of these. The classification of injury guides clinical
tracheostomy.
decision making.
Collaborative practice: allied The pathophysiology of abdominal trauma is largely
health interventions related to the structure(s) injured. Careful serial assess-

Physiotherapy is generally required for chest trauma ments are essential to identify changing clinical manifes-
tations. The most common clinical manifestation of
patients. The primary aspects of care include chest phys- abdominal trauma is haemorrhage and/or signs of an
iotherapy, given the often extended episodes of mechani- acute abdomen, such as pain, tenderness, rigidity and
cal ventilation and bedrest that are required, as well bruising. Importantly, these are life-threatening signs and
as mobility exercises. Occupational therapy particularly require immediate surgical intervention.
offers benefits to the long-term ventilated patient in terms
of diversion activity, while social work is often beneficial The most significant sign of abdominal trauma in
for patients with long-term disability and ongoing the conscious patient is pain. Where hollow viscus