Page 667 - ACCCN's Critical Care Nursing

644 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

in that the injury is largely localised to a single body maintain adequate perfusion to essential organs until
region. Exceptions to this may occur, for example, with definitive repair of the wound can be undertaken. 43
firearm wounds if there are multiple bullet-entry wounds l Psychosocial care of the patient and family. It is pos-
or multiple knife-stab sites. sible that patients with penetrating injury will need
specific psychosocial care, particularly when the injury
Care must be taken when caring for patients with pene-
trating injury to prevent injury to staff. This is particularly has occurred as a result of assault.
important when the patient presents with a knife in situ †
or a large, protruding foreign object in their body. It BURNS
should also be noted that some penetrating trauma Recent improvements in both shock and sepsis manage-
occurs as a result of a criminal act, and it is essential ment have resulted in patients with severe and extensive
to observe rules governing forensic evidence. Police burn injuries spending long periods of time in the critical
should be notified by the senior clinician involved in care environment. Burn injuries occur as a result of
providing care. thermal, electrical or chemical injury and cause both local
and systemic changes to a patient. An understanding of
Clinical Manifestations these changes will assist with planning appropriate care
The clinical manifestations of penetrating injuries are for this group of patients.
dependent on where in the body the penetrating injury In recent years, improved survival, reduced hospital
has occurred, the underlying organs and the amount of length of stay and a decrease in morbidity and mortality
force and dispersion caused by the injury. For example, a has been seen in burns patients. This is primarily due to
high-velocity bullet will cause substantial tissue damage a better understanding of burns pathophysiology and
in a wider area than just the bullet’s track. The clinical advancements in care that include improvements in
manifestations of penetrating trauma can be divided into resuscitation protocols, improved respiratory support,
two broad types: management of the hypermetabolic response, rigid infec-
tion control monitoring, early excision and burn wound
1. conspicuous: where the penetrating article is closure, use of skin substitutes and early nutritional
grossly visible (e.g. a shard of glass, a branch or a support.
knife). Care must be taken not to focus solely on
the visible cause of injury but to continue to under- Burn injuries are highly variable and individual injuries
take a systematic trauma assessment affect all ages and social groups. In general terms, assess-
2. inconspicuous: where the penetrating article is not ment is based on the size, depth and anatomical site of
immediately visible and may become apparent the injury, mechanism of injury and the presence of coex-
only during the systematic trauma assessment of isting conditions. The World Health Organization esti-
the patient (e.g. with gunshot wounds and projec- mates that more than 300,000 deaths are fire-related
tiles). In these injuries the visual signs on the exter- every year, the majority occurring in developing
nal skin may not reflect the catastrophic injury countries. 70
underlying it (e.g. ventricle lacerations or serious Burn injuries occur as a result of thermal, electrical or
vascular injury).
chemical injury and cause both local and systemic changes
to a patient. An understanding of these changes will assist
Nursing Practice with planning appropriate care for this group of patients.
Patients with penetrating injury will be cared for based All patients with a serious burn injury should be referred
on the severity and area of injury they have sustained. to a specialised burns unit that is staffed and equipped
Surgical intervention is usually more urgent than that appropriately to manage burns. The Australian and New
seen with blunt injury, as bleeding may be occurring from Zealand Burns Association (ANZBA) criteria outline
a ruptured organ or vessel either into a body cavity or which burns patients require treatment in a specialised
externally. For this reason, the incidence of procedures burns unit (see Box 23.1).
such as laparotomy and thoracotomy is high in patients
with a penetrating injury. PATHOPHYSIOLOGY
In the emergency setting the following considerations are The skin is the largest organ in the human body and
generally unique to the patient with a penetrating injury: accounts for 15% of its weight. The skin has multiple
purposes, including protection from infection, regulation
l Stabilise the foreign object. This may require padding of body heat and functioning as a vapour barrier.
and/or taping an object, for example a knife, to ensure
minimal movement and prevent further damage until The skin consists of three layers: the epidermis, the dermis
68
definitive care to remove the object. and subcutaneous tissue. The epidermis is the outer
l Care for the patient in a non-standard position. This layer, and is composed of stratified epithelial cells that
will be dependent on how and where any foreign protect against infection and conserve moisture. This
object is protruding from the body. For example, it layer is characterised by having regenerative ability. The
may be necessary to care for a patient in the side-lying dermis, as the middle layer, is between 1 and 4 mm thick,
or prone position until the object is removed.
l Minimal volume resuscitation. This describes the † This section has been prepared with the assistance of Yvonne Singer RN, Victorian
practice of only resuscitating a patient sufficiently to State Burns Education Program Coordinator, Victorian Adult Burns Service.