Female Suffering After Blunt Trauma and the Need to be Cared for and Cared About.

Using a phenomenological design, the researcher repeated a previous study of males, this time exploring the question of what is the experience of suffering voiced by female patients 6-12 months after hospitalization for blunt trauma. Eleven female volunteers were interviewed and asked questions about how they suffered, what made their suffering more or less bearable, and how they were transformed through their suffering. Like the males, female participants experienced changes in patterns resulting in perceptions of suffering. Participants reported mostly experiencing physical, emotional, and social forms of suffering, whereas fewer participants experienced economic and spiritual suffering. Experiences of suffering resulted from the threat to their sense of wholeness because of their injuries. Intrinsic and extrinsic factors made participants' suffering more or less bearable as they regained or revised their shattered wholeness. Positive attitude and motivation were significant intrinsic factors, whereas quality supportive care was the most significant extrinsic factor. Feeling cared about emotionally was as important as feeling cared for physically in helping participants better bear their suffering. Poor quality care was a significant negative extrinsic factor resulting in suffering being made more unbearable. Through their experiences of suffering and finding meaning in that suffering, participants were transformed, amending their previous state and resulting in a new state of wholeness. Knowledge gained through this phenomenological study may help nurses understand suffering and guide their care and caring to alleviate it or make it more bearable.

The Use of Clinical Cervical Spine Clearance in Trauma Patients: A Literature Review.

INTRODUCTION: Five million patients in America are placed in spinal immobilization annually, with only 1% to 2% of these patients suffering from an unstable cervical spine injury. Prehospital agencies are employing selective and limited immobilization practices, but there is concern that this practice misses cervical spine injuries and therefore possibly predisposes patients to worsening injuries. METHODS: A systematic review was conducted that examined literature from the last 5 years that reviewed cervical spine immobilization application and/or clearance in alert trauma patients. RESULTS: Prehospital selective immobilization protocols and bedside clinical clearance examinations are becoming more commonplace, with few missed injuries or poor outcomes. Prehospital providers can evaluate patients in the field safely to assess who needs or does not need cervical collars; similar criteria can be used in the emergency department. Harm from cervical collars is increasingly documented, with concerns that risks exceed possible benefits. DISCUSSION: The literature suggests that alert trauma patients can be cleared from cervical spine immobilization safely through a structured algorithm in either the prehospital or ED setting. The evidence is primarily observational. Thus, many providers who fear missing cervical injuries may be reluctant to follow the recommendations despite few or no published cases of sudden deterioration from missed cervical spine injuries.

Recognising and assessing blunt abdominal trauma.

Blunt abdominal trauma is common following major traumatic injury but may not be recognised quickly enough and is therefore a cause of preventable death in trauma patients. Emergency department nurses have a major role to play in reducing the incidence of unrecognised abdominal trauma by enhancing their knowledge and skills. They can do this by attending trauma-related courses, taking on more expanded roles, carrying out full and comprehensive physical assessments, and ensuring that members of the multidisciplinary team use the wide range of diagnostic adjuncts available to them. This article reviews the anatomy and physiology of the abdominal cavity, explains abdominal trauma, gives an overview of advanced abdominal assessment techniques and diagnostic adjuncts, and reviews some management strategies for uncontrolled haemorrhage that have been adopted in the UK.

Blunt chest trauma.

Blunt chest trauma is associated with a wide range of injuries, many of which are life threatening. This article is a case study demonstrating a variety of traumatic chest injuries, including pathophysiology, diagnosis, and treatment. Literature on the diagnosis and treatment was reviewed, including both theoretical and research literature, from a variety of disciplines. The role of the advance practice nurse in trauma is also discussed as it relates to assessment, diagnosis, and treatment of patients with traumatic chest injuries.

Blunt mechanism chest wall injury: initial patient assessment and acute care priorities.

Blunt mechanism chest wall injury (CWI) is commonly seen in the emergency department (ED), since it is present in around 15% of trauma patients. The thoracic cage protects the heart, lungs and trachea, thereby supporting respiration and circulation, so injury to the thorax can induce potentially life-threatening complications. Systematic care pathways have been shown to improve outcomes for patients presenting with blunt mechanism CWI, but care is not consistent across the UK. Emergency nurses have a crucial role in assessing and treating patients who present to the ED with blunt mechanism CWI. This article discusses the initial assessment and acute care priorities for this patient group. It also presents a prognostic model for predicting the probability of in-hospital complications following blunt mechanism CWI.

The incidence of fever in US Critical Care Air Transport Team combat trauma patients evacuated from the theater between March 2009 and March 2010.

INTRODUCTION: Most critically ill injured patients are transported out of the theater by Critical Care Air Transport Teams (CCATTs). Fever after trauma is correlated with surgical complications and infection. The purposes of this study are to identify the incidence of elevated temperature in patients managed in the CCATT environment and to describe the complications reported and the treatments used in these patients. METHODS: We performed a retrospective review of available records of trauma patients from the combat theater between March 1, 2009, and March 31, 2010, who were transported by the US Air Force CCATT and had an incidence of hyperthermia. We then divided the cohort into 2 groups, patients transported with an elevation in temperature greater than 100.4°F and patients with no documented elevation in temperature. We used a standardized, secure electronic data collection form to abstract the outcomes. Descriptive data collected included injury type, temperature, use of a mechanical ventilator, cooling treatment modalities, antipyretics, intravenous fluid administration, and use of blood products. We also evaluated the incidence of complications during the transport in patients who had a recorded elevation in temperature greater than 100.4°F. RESULTS: A total of 248 trauma patients met the inclusion criteria, and 101 trauma patients (40%) had fever. The mean age was 28 years, and 98% of patients were men. The mechanism of injury was an explosion in 156 patients (63%), blunt injury in 11 (4%), and penetrating injury in 45 (18%), whereas other trauma-related injuries accounted for 36 patients (15%). Of the patients, 209 (84%) had battle-related injuries and 39 (16%) had non-battle-related injuries. Traumatic brain injury was found in 24 patients (24%) with an incidence of elevated temperature. The mean temperature was 101.6°F (range, 100.5°F-103.9°F). After evaluation of therapies and treatments, 80 trauma patients (51%) were intubated on a mechanical ventilator (P < .001). Of the trauma patients with documented fever, 22 (22%) received administration of blood products. Nineteen patients received antipyretics during their flight (19%), 9 received intravenous fluids (9%), and 2 received nonpharmacologic cooling interventions, such as cooling blankets or icepacks. We identified 1 trauma patient with neurologic changes (1%), 6 with hypotension (6%), 48 with tachycardia (48%), 33 with decreased urinary output (33%), and 1 with an episode of shivering or sweating (1%). We did not detect any transfusion reactions or deaths during flight. CONCLUSION: Fever occurred in 41% of critically ill combat-injured patients evacuated out of the combat theater in Iraq and Afghanistan. Fewer than 20% of patients with a documented elevated temperature received treatments to reduce the temperature. Intubation of patients with ventilators in use during the transport was the only factor significantly associated with fever. Serious complications were rare, and there were no deaths during these transports.

Long-term outcomes after blunt injury to the boney thorax: an integrative literature review.

Management of blunt injury to the boney thorax centers on the hospital; yet, these injuries continue to impact patients long after hospitalization. The purpose of this literature review was to identify long-term outcomes associated with this injury. A literature search found 616 studies and, after screening, yielded 6 articles for review. Patient and injury characteristics and postinjury assessment findings were explored. The impact of this injury can be prolonged and life altering, prompting the need for further investigation. A greater understanding of injury-specific posthospitalization outcomes could elucidate the impact of these injuries on patients, families, and society.

Traumatic distal pancreatic transection: beware of the horses.

Blunt pancreatic trauma is rare; however, if missed, it can lead to devastating consequences such as fistula, pancreatitis, and pseudocyst. Blunt trauma accounts for 30% of all pancreatic injuries. High-speed motor vehicle collisions make up the greatest proportion of blunt pancreatic trauma, whereas other causes could be easily overlooked because of being so rare. In this case report we present a case of full-thickness transection of pancreatic tail after being kicked by a horse. The injury was timely identified and successfully treated by completing transection with a stapler. Considering that delay in diagnosis leads to a morbidity rate of 20%, physicians must have high level of suspicion and knowledge of invasive and noninvasive modalities to ensure early detection of pancreatic trauma and a positive outcome.

Oral contrast omission in the computed tomographic evaluation of blunt abdominal trauma: a literature review.

The purpose of this review is to examine existing research on oral contrast administrating as it pertains to the computed tomographic (CT) evaluation of blunt abdominal trauma, as well as to determine the necessity of oral contrast as part of a CT scanning universal protocol. Many hospitals routinely administer both oral and intravenous contrast prior to abdominal CT scan. There have been found to be numerous disadvantages and risks associated with oral contrast administration prior to CT scan. There has been a shift in many hospitals over the years from traditional CT scanners to multidetector row helical scanners, which allow for thinner collimation and higher spatial resolution. With the advances in technology, from single detector row to multidetector row helical CT scanners, the question whether oral contrast is necessary, useful, or dangerous presents itself. There is a significant lack of research on this topic over the past 10 years. All of the studies referenced support no longer administering oral contrast for the initial evaluation of the patient with blunt abdominal trauma. However, the findings of the studies cited in this article are based on small sample sizes and low incidences of solid organ, bowel, or mesenteric injuries. The current level of available research has significant limitations to support a recommendation to eliminate the administration of oral contrast before obtaining the initial CT scanning for blunt abdominal trauma. Further research is necessary before any conclusion or practice change can be made.

Overview of genitourinary trauma.

Genitourinary trauma is a common finding in the patient with multi-trauma, and includes injuries to the kidneys, bladder, ureters, urethra, penis, and scrotum. This article describes the care of the patient with genitourinary trauma focusing on assessments, diagnostic testing, and patient care. Nurses working with trauma patients need to monitor these patients carefully for genitourinary involvement because the signs and symptoms are not always clear.

Damage Control Resuscitation of a Patient With Traumatic Aortic Rupture: A Case Report.

Traumatic aortic rupture (TAR) is a highly fatal injury mechanism resulting from blunt deceleration forces against the descending aorta. The mechanism of TAR is directly attributed to the aorta suffering damage by indirect shearing forces. The descending aorta remains fixed to the posterior chest wall, while the heart and ascending aorta are exerted forward, thus causing the intimal tear. A characteristic triad presents as increased blood pressure in the upper extremities, decreased blood pressure in the lower extremities, and a widened mediastinum on radiography. Early recognition of signs and symptoms of the mechanism of injury is key to initiating early damage control surgery and ultimately decreasing morbidity and mortality. This case report describes the intraoperative management of an elderly female patient with TAR following a motor vehicle collision in a remote location in rural Pennsylvania.

Duodenal hematoma from a fall down the stairs.

Blunt abdominal trauma is not a common finding in abused children. However, there is a high rate of mortality associated with this type of injury. Recognizing the presentation of a child with abusive abdominal injuries is crucial for healthcare providers. Often these children are too young to provide a history of the injury, the caretaker accompanying the child may provide you with a misleading history or a history of minor trauma, and the child's symptoms may range from abdominal pain to vomiting to septic shock, making the diagnosis difficult. The child's anatomy puts him/her at risk for intra-abdominal injury from blunt force. They have less musculature and fat than adults and their rib cage is horizontally oriented, allowing organs to extend beyond the costal margin. Duodenal injuries are extremely uncommon in children because of the retroperitoneal location and a substantial amount of force is necessary to injure this area of abdomen. Understanding the different injury patterns and various mechanisms required to cause abdominal injury is important in determining accidental injury from nonaccidental injury.

Cervical spine clearance in the nonalert, noncommunicative, or unreliable pediatric blunt trauma patient.

Currently, there is no nationally recognized evidence-based guideline or protocol for cervical spine clearance in nonalert, noncommunicative, or unreliable pediatric blunt trauma patients. This descriptive survey study sought to identify current practices and elicit expert opinion data regarding pediatric cervical spine clearance in a specialized population of children in trauma centers in the United States. A 93-item electronic Pediatric Cervical Spine Clearance Survey was sent to 309 members of the Pediatric Special Interest Group of the National Society of Trauma Nurses. The main areas of interest in the survey included trauma verification, annual volume of pediatric trauma cases, and sequence and time frames of diagnostic testing for cervical spine clearance by age group. Additional areas of interest were perceived supports and barriers to meeting target time frames for diagnostic testing and outcomes to evaluate the impact of a cervical spine clearance guideline for pediatric blunt trauma. The results from 44 respondents demonstrate that trauma centers are using a variety of diagnostic testing sequences and time frames when clearing children for suspected cervical spine injury.

ChIP: An early activation protocol for isolated blunt chest injury improves outcomes, a retrospective cohort study.

BACKGROUND: Blunt chest injuries not treated in a timely manner with sufficient analgesia, physiotherapy and respiratory support are associated with increased morbidity and mortality. The aim of the study was to determine the impact of a blunt chest injury early activation protocol (ChIP) on patient and hospital outcomes. METHODS: In this pre-post cohort study, the outcomes of patients with blunt chest injury who received ChIP were compared against those who did not. Data including injury severity, patient outcomes, hospital treatments and comorbidites were extracted from medical records. The primary outcome was pneumonia. Secondary outcomes evaluated health service delivery. Logistic and multiple regressions were used to adjust for potential confounding variables. RESULTS: 546 patients were included, 273 in the before-ChIP cohort and 273 in the after-ChIP cohort. The incidence of pneumonia following the introduction of ChIP was reduced by 4.8% (95% CI 0.5-9.2, p=0.03). In the after-ChIP cohort, more patients received a pain team review (32% vs. 13%, p<0.001), physiotherapy (93% vs. 86%, p=0.005) and trauma team review (95% vs. 39%, p<0.001). There was no difference in length of stay (p=0.50). CONCLUSIONS: ChIP improved the delivery of healthcare services and reduced the rate of pneumonia among patients with isolated chest trauma.

From the trauma surgeon's viewpoint: multiple injuries--which cavity to open first?

Trauma patients with multiple complex problems pose critical management challenges. Clinical decisions are rarely straightforward. One of the biggest challenges in the care of the severely injured patient is how to deal with the issue of competing injuries; the process involved in the decision of what the trauma team should do first and then the next step. The ultimate goal is to transform a very complex situation into a simple problem by following straightforward algorithms to achieve a good outcome. The dilemma is that common algorithms used for "single body area" injury are usually not applicable for multisystem or multi-cavitary injuries. The first 5 or 10 minutes of trauma resuscitation are critical for the patient's outcome. The goal of nursing and the trauma surgical team during that short time frame is to address injuries and clinical situations that are life threatening. We routinely use the "ABCs" resuscitation strategy to achieve that goal; whenever that sequence is changed, a bad outcome ensues. It is proposed that the trauma team addressing complex problems in patients with multiple injuries can follow the same principles. Several challenging scenarios are common in clinical practice. For discussion purposes these will be divided according to the mechanism of injury either penetrating or blunt.

Case report: stroke versus carotid artery injury.

A potentially serious consequence associated with blunt force trauma to the neck is an injury to the carotid artery. Initially the blunt carotid injury may be missed or it may be delayed in presentation; therefore one must have a heightened index of suspicion when considering the patient's mechanism of injury. The purpose of this article is to present a case report of blunt carotid injury and implications for healthcare workers.

Blunt chest trauma: case report.

Care of patients with blunt cardiac trauma is challenging for bedside nurses because of the potentially elusive and subtle nature of clinical findings associated with such trauma. An understanding of the forces exerted during the trauma episode will assist nurses in the assessment and search for hidden injuries. A high index of suspicion and continued cautious assessment and attention to subtle changes in the patient's physical condition are essential. Keen attention to changes in the patient's vital signs, cardiac output, ECG findings, pulses, and fluid volume status alert nurses to potential injuries associated with blunt cardiac trauma ranging from myocardial contusion to cardiac tamponade, aortic tears, and cardiac rupture. Survival of patients with blunt cardiac trauma depends on early intervention.

Blunt renal trauma.

Severe blunt renal injuries threaten the patient's life with severe complications such as hemorrhage, infection, and the loss of renal function. The critical care nurse's role in the assessment of the patient focuses on evaluating the patient's response to the initial injury, the ongoing assessment of the patient's urinary function, assessing the degree and quality of the patient's pain, and observing the patient's trend in vital signs. The nurse is also responsible for determining the patient's response to diagnostic procedures, providing emotional support, and explaining diagnostic tests and procedures. By supporting compensatory mechanisms, the critical care nurse minimizes the potential for hemodynamic compromise, infection, and diminished renal function. Another important patient care consideration is the maintenance of urinary drainage, to allow assessment of urine and promote excretion of wastes. In all of these aspects of patient care, the critical care nurse is a key member of the trauma team who has a strong impact on the recovery of the patient with blunt renal trauma.