Page 672 - ACCCN's Critical Care Nursing

Trauma Management 649

tissue and burst blisters. Forceps and scissors may be l Skin substitutes: some products are available to
required to lift and remove smaller areas of tissue. cover partial-thickness wounds that provide a moist
Extensive areas of debridement will usually be under- environment that stimulates epithelialisation. These
taken in the operating room. are best reserved for ‘clean’ wounds. Some products
l Blisters: small blisters should be left intact, large blis- are able to act as full-thickness substitutes that provide
ters may be aspirated or deroofed during debride- wound closure, protection from mechanical trauma
ment, although it should be noted that evidence and bacteria and a vapour barrier. Once the new
regarding blister management is poor. Blisters over dermis is created the substitute is removed. 71
joints that are restricting movement should also be
debrided. SUMMARY
l Escharotomy: an escharotomy is undertaken to a limb
or side of the trunk for circumferential burns that are Care of the trauma patient presents the critical care nurse
contracting and creating vascular compromise to the with multiple challenges. With the introduction of
underlying and distal tissues. The escharotomy is an Trauma Systems the outcome and survival of injured
incision through the eschar, and does not involve patients has improved dramatically. The severity of injury,
opening muscle fascia. The escharotomy immediately and patient outcome, are dependent on effective prehos-
relieves the compression and is a limb/lifesaving sur- pital care, resuscitation, definitive surgical management
gical manoeuvre. The escharotomy is dressed as a burn on arrival at the hospital. Principles of resuscitation of
to prevent infection. the trauma patient are the same as that for all patients,
l Skin grafts: these are required to cover the skin defect. with a primary, secondary and tertiary survey being
They may be full-thickness or partial-thickness grafts, undertaken, and maintenance or correction of airway,
and may be harvested from the patient or, in some breathing and circulation taking precedence. Prevention
cases, obtained from a cadaver donor. Regardless of of the ‘trauma triad’ of hypothermia, acidosis and coagu-
the type of skin graft, nursing care remains the same, lopathy has the potential to significantly influence
with the aim being to maximise adherence. Specific patient outcome. Consideration of the specific injury,
nursing care of the graft site includes leaving the site with its resultant pathophysiological changes, is neces-
intact and immobilising the graft site, applying the sary to care effectively for patients with abdominal, chest,
appropriate wound care regimen, preventing shearing multiple or burn injuries. It is challenging work as trauma
injury to the graft site, and minimising the risk for patients are largely a young and healthy population
infection. With autografts, wound care will also be prior to injury and may experience significant ongoing
required for the donor site. 71 compromise.

Case study ‡

Chris was a 26-year-old, 120 kg, driver of a small sports car that ran l primary survey and associated resuscitation
a red light in rural Victoria. An oncoming delivery truck collided l intubation and mechanical ventilation
with the driver’s side at a high rate of speed. He was mechanically- l no cervical collar would fit him, so he was nursed with bilateral
trapped in the vehicle for over 80 minutes. On arrival of the emer- sandbag and head strapping
gency personnel his vital signs were as follows: l analgesia and sedation
l HR 110, RR not recorded, sBP 155 mmHg on palpation, GCS 15, l FAST exam gave a positive result
SpO 2 89% l CT of brain, cervical spine, chest, abdomen and pelvis.
l There was palpable surgical emphysema of the chest wall; a
tension pneumothorax was diagnosed. A pneumocath was Injuries included: C2 odontoid # (type 2) with 3.5 mm complete
inserted and an audible hiss was heard, with subsequent separation; a # R transverse process of C7 that extended into the
improvement in the patient’s vital signs. foramen transverserium; a # R transverse process of T1, bilateral rib
l IV cannula inserted with 1000 mL of Hartmann’s solution fractures with R sided flail segment in ribs 1–4, a # R pneumothorax
administered during extrication. Extrication was slow due to and sternal fracture. A Grade 3 Liver laceration, a fracture disloca-
the door of the car having to be removed and the patient’s tion of the R humeral head, right sided forearm degloving and
body habitatus, being 120 kg and 168 cm tall. scalp laceration injuries were also present.
l Chris met the major trauma triage criteria and was transferred In ICU the neurosurgical team documented that Chris was ‘not to
via helicopter, with a trauma team call activated prior to arrival. be moved’ as spinal stability could not be achieved due to the
When Chris arrived at the emergency department, a full team inability to fit an appropriate neck collar. A request was made for
was present to assess and treat him. This included a trauma an MRI, CT shoulder and angiogram to be completed before a
surgeon, emergency physician, trauma nurse leader, specialist halothoracic brace was to be fitted. After consultation with the
nurses and support staff. medical team 8 nurses log-rolled Chris with a head hold, and
placed a slide sheet and trauma spinal mat under him to facilitate
Treatment in the emergency department consisted of the movement between bed and radiology surfaces without further
following: movement.

‡ The authors acknowledge the assistance of Catherine Birch RN, Intensive Care Unit, The Alfred Hospital.