Trauma: Mechanism of Injury and

Appropriate Nursing Assessment - 2 Nursing CEs

Course Description:

This course is designed to assist the nurse in completing an appropriate nursing assessment based on the trauma patient’s mechanism of injury. Understanding “How” someone was injured plays a key role in assuring that no injuries go undiagnosed. In addition to a complete physical assessment, understanding what signs and symptoms may be present, and what these discoveries mean, will not only help the nurse to focus in on key areas, but help produce quick and effective interventions. Discussion about the effect that trauma has on our society and on healthcare will also be presented.

Course Objectives: 

Upon completion of this course the student will be able to:

•  Verbalize the impact that Trauma has on healthcare
• List 3 mechanisms of injury related to Motor Vehicle Collisions, and discuss specific complications that are seen with each.
• Understand the difference between Low, Medium and High Velocity, Penetrating Injuries, and give examples of each.
• Be able to discuss the significance of different entrance/exit wounds
• Describe populations regarding “falls” and methods of avoidance
• Discuss the significance of such assessment findings as:

1. Battle Signs
2. Raccoon Eyes
3. Kehr’s Sign
4. Cullen’s Sign

Nursing Assessment Based on Mechanism of Injury

·        50,000 of those who sustain a traumatic brain injury from a MVC die each year.

·         235,000 of those who sustain a MVC are hospitalized and 1.1 million are treated and released from an Emergency Department.

·        Approximately 475,000 Traumatic Brain Injuries (TBI) occur among children ages 0 to 14 years; ED visits account for more than 90% of the TBIs in this age group annually.

·        Falls are the leading cause of TBI; rates are highest for children ages 0 to 4 years and for adults age 75 years or older.

·        In 2003 more than 1.8 million seniors age 65 and older were treated in emergency departments for fall-related injuries and more than 421,000 were hospitalized.

·        Trauma is the leading cause of death in people 1-44 years of age

·        Trauma is responsible for 80% of all teenage deaths

·        Trauma is responsible for 60% of all childhood deaths

·        Trauma is responsible for approximately 40% of all healthcare costs in the United States

Three Types of Traumatic MVC Impact:

Vehicle Impact - If a car is traveling 40 mph and hits a tree head on, the first “vehicle impact” will occur when the car hits the tree.

 Body impact – This will occur when the occupant hits some structure inside the car (i.e., windshield, steering wheel, or dashboard).

 Organ impact - This will occur within the body of the occupant, when movable organs such as the brain, heart, liver, spleen, or intestines impact with the supporting structures (i.e., the skull, sternum, ribs, spine, or pelvis).

Motor Vehicle Collisions:

Frontal Collisions:

Injuries - Head and neck, back, brain, spine, rib and clavicle, arms and legs, concussions, soft tissue, internal, dislocations, abrasions, cuts and bruises. Other internal injuries may surface as late as 48-72 hours after impact. Symptoms associated with delayed internal injury include but are not exclusive to; headache, blurred vision, dizziness and loss of taste, smell or hearing. Also, difficulty breathing, blood in urine or stool, swelling, loss of motion and visualized bruising can take place.

Nursing Assessment: Complete head to toe assessment, keep in mind that some symptoms may surface slowly

Side Impact Collisions (T-Bone):

Injuries – Head and C-spine injury (the combination of the flexion and rotation of the spine that occurs with lateral impact produces more frequent and severe cervical injuries; fractures of the spine are more common with this type of collision than with rear-end collisions). Chest and abdominal injuries to the side of impact (same as in head-on

collisions) upper arm, shoulder and clavicle injuries on the side of impact pelvic, hip, or femur injuries on the side of impact.

Nursing Assessment: In addition to complete head to toe assessment, special focus needs to be placed on C-Spine immobility and potential for cervical and spine injuries.

Rear Impact Collisions:

Injuries - Usually occur as the torso and seat shoot forward; if the headrest is too low, the neck will end up hyper-extended over the top of the headrest. This is how strains, torn ligaments, and more serious cervical injuries often occur.

Nursing Assessment: Focus on neck and potential cervical injuries.

Rollover Collisions:

Injuries – These injuries can be difficult to predict (expect anything), if the victim was ejected injuries usually result from the second impact. Hitting the ground outside of the car can be more severe then the first impact. The distance between the victim and the vehicle usually indicates how fast the car was traveling and, therefore, how much energy was absorbed by the patient. Note: ejected victims are 25% more likely to be killed.

Nursing Assessment: In addition to complete head to toe assessment, look for evidence of secondary impact (dirt, shrubs, paint from car, road rash), these findings will assist in determining the degree of possible injuries.

Incursion Collisions:

Injuries – Often when the need for extrication is apparent, you can assume that the victim will present with some type of crushing injury. The dashboard or steering wheel is often the source of entrapment, causing severe leg, pelvic and abdominal injuries. C-Spine injuries and face and neck trauma are also common.

Nursing Assessment: In addition to complete head to toe assessment, focus on possible internal/crushing signs such as Grey-Turner of Kehr’s signs.

Restraint Systems:

Seat Belts - Should be worn correctly (should be positioned across the pelvis above the femur and should be pulled tight enough to remain in this position). They also protect the occupants from impacting with the inside of the car and prevent ejection. If SEAT BELTS ARE WORN IMPROPERLY they may be a source of trauma. If worn too high, or the occupant has removed their arm from the shoulder harness they increase their risk for the following injuries:

·               Compression injuries to the abdominal organs

·               Burst injuries to the small intestines and colon

·               Rupture of the diaphragm due to increased intrabdominal  pressure

·               Compression fractures of the Lumbar Spine

Air Bags - Provide maximum protection during head-on collisions when used in addition to seat belts. They deflate immediately after impact so they provide no further protection with multiple-impact collisions.  They are not effective with lateral or rear-impact collisions and even at low impact, can cause death in children.

Motorcycle Accidents:

Injuries - Helmets help to prevent head trauma, but do not protect against spinal injury. 75% of motorcycle deaths are due to severe head trauma and high frequency of head, neck, and extremity trauma.  Injuries are similar to victims that are ejected from vehicles.

Nursing Assessment: In addition to complete head to toe assessment, focus should be placed on Head and Spinal injuries, Battle Signs or Raccoon eyes may lead to diagnosis of Basal Skull Fracture. (The presence of Gray Matter oozing from the nose is another assessment finding that will assist in determining extend of head trauma)

Auto vs. Pedestrian Collisions:

Injuries – With an adult, the first impact is made by the bumper to the lower extremities; in children contact is usually to the upper legs and pelvis. As the victim folds forward, the second impact occurs when the adult’s upper legs and trunk hit the hood of the car. For the child, it is usually the abdomen or thoracic region. The third impact occurs when the victim falls off the car and hits the ground (usually on their head).

Nursing Assessment: In addition to a complete head to toe assessment, make a judgment as to where primary impact occurred and focus on this area. Also look for second and third impact findings to further assist with identifying injury.

Penetrating Injury:

A penetrating injury is basically caused by an object, which has enough oomph to break through the body's surface. Once inside, the amount of trauma depends on the amount of energy transferred into the body, and the area over which it is transferred. Such injuries often draw a good crowd. Penetrating injury can be low, medium or high velocity; the difference is basically in the amount of energy that the victim endures.

Low-Velocity Injury:

These injuries usually involve such things as knife attacks, people going through plate glass or garden tool injuries. Open fractures, where the bone has broken and penetrated through from the inside, also fall into this category.

Medium-Velocity Injury:

These injuries usually involve handguns, arrows, long bladed knives or swords and objects that were impaled with great force. The bigger the area of contact, the bigger the trauma. The faster the object, the deeper it goes. If a medium-velocity projectile strikes

bone, it may knock many bits off and push them away from the original injury site. This also increases soft-tissue trauma by a sort of shrapnel effect. 

High-Velocity Injury:

These injuries usually involve a higher caliber shot gun or rifle. They use a fast, relatively long projectile that destabilizes in soft tissue. The projectile strikes at such great speed that it converts body fluids to steam, blasting apart a channel far wider than the projectile. This effect is called cavitation, and if carried on to the exit point forms a stellate or star-shaped exit wound. Any bone that is encountered by the projectile, literally shatters into small bits and will increase bleeding and tissue damage.

Stab Wounds – severity of wound depends on the following:

·               Location penetrated (upper abdomen may have reached thoracic

                cavity)

·               Blade length

·               Angle of penetration (chest wall wounds below the 4th intercostal

                space may have injured either the abdominal organs or the

                diaphragm.

Nursing Assessment: Do not underestimate the internal damage of simple entrance wounds, since the attacker may have moved the blade around inside.

Firearms – severity of injury affected by the following factors:

·               Type of weapon ( low velocity weapons are less destructive than high

                velocity weapons)

·               Caliber or size of bullet (larger bullets cause more resistance and

                 therefore a larger area  of damage)

·               Distance from which the weapon was fired (with increased distance,

                the bullet will decrease in velocity by the time it reaches the victim)

·               Bullet deformity (hollow point and soft nose bullets flatten out when

                they impact the victim, so the area damaged is greater)

·               Tumble and yaw of bullet (as the bullet travels forward, it can tumble

                and oscillate vertically or horizontally about its axis, resulting in a

                larger surface area meeting the surface of the body)

Wounds Caused by Firearms – consists of three parts:

·               Entrance wound (may be round or oval; shots from close range may

                have burns or smoke marks on the skin)

·               Exit wound (  if present, is larger and may be linear or stellate in

                appearance; not all entrance wounds will have an exit)

·               Internal wound (damage to the tissue in the direct path of the bullet

                will cause a permanent cavity; tissue on either side of the bullet's path

                will also be injured due to pressure from energy exerted outward from

                the path of the bullet which results in a temporary cavity (this

                temporary cavity is usually 3 to 6 times the size of the front surface

               area of the bullet)

 Note:  85 - 95% of wounds caused by firearms will require surgical intervention; only 30% of knife wounds will need to be explored.

Fall Injuries – For children under the age of 14 and for elders over the age of 55, falling is the most frequent cause of trauma.

In Children - Falls are the leading cause of unintentional injury for children. Falls are so common among children that they are the number one reason for trips to the emergency room. One in three emergency room visits among children ages 14 and under could have been prevented by parental supervision and the use of safety products.

Most falls occur from furniture, stairs, windows, baby walkers, shopping carts and playground equipment (trampolines). The injuries caused by a fall depend on the distance of the fall and the type of landing surface.

Falls from windows are the most likely to cause death or serious injuries. The majority of the deaths and severe injuries from falls are head injuries.

In Adults – Falls from height are the most common cause of fatal injury and the second most common cause of major injury to employees, accounting for 15% of all such injuries. All industry sectors are exposed to the risks presented by this hazard although the level of incidence varies considerably.

In Elders - More than one-third of adults ages 65 years and older fall each year.

Of those who fall, 20% to 30% suffer moderate to severe injuries such as hip fractures or head traumas that reduce mobility and independence, and increase the risk of premature death.

Falls are a leading cause of traumatic brain injuries. Among older adults, the majority of fractures are caused by falls (Bell 2000). Approximately 3% to 5% of older adult falls cause fractures. Based on the 2000 census, this translates to 360,000 to 480,000 fall-related fractures each year.

Additional Trauma Assessment Finding:

• Grey-Turner Sign – Subcutaneous bruising around the flanks and umbilicus, suggestive of a retroperitoneal hematoma.
• Hamman Crunch – A crunching sound synchronous with the heartbeat and heard on auscultation of the precordium, suggestive of hemothorax, pneumothorax and possibly fluid build up that can lead to respiratory failure. (This is not the same as subcutaneous air).
• Raccoon Eyes – Ecchymotic discoloration and swelling around either or both eyes, associated with head trauma and suggestive of basilar skull fracture or facial bone fracture.
• Battle Sign – Ecchymotic discoloration and swelling behind either or both ears, associated with a head trauma, and suggests a possible basilar skull fracture.
• Cullen Sign – A bluish “halo” surrounding the umbilicus, indicating bleeding into the tissues, associated with intra-abdominal bleeding and trauma (can also be a sign of ectopic pregnancy or pancreatitis).
• Kehr's Sign – Pain in the sub-scapular region of the shoulder, usually on the left side, referred from an irritated phrenic nerve, associated with a ruptured spleen (can also be a sign of ectopic pregnancy).

Understand the Mechanism of Injury and be Pro-Active in searching for probable signs and symptoms. These symptoms sometimes take several hours to appear, so assess and reassess on an ongoing and frequent basis.

References

*You don't have to pay until you pass the test!
 Go ahead and take the test now with no obligation!-->