Road Traffic Accident - Essay Example

Road Traffic Accident Introduction Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems (“About Critical Care Nursing”, AACN). A licensed professional nurse who is responsible for ensuring that all critically ill patients and their families receive optimal care is known as a critical care nurse. The nurse relies upon a specialized body of knowledge, skills, and experience to provide care to patients and families and create environments that are healing, humane, and caring and they practice in settings where patients require complex assessment, high intensity therapies and interventions, and continuous nursing vigilance (“Critical Care Nurse”). The case that is undertaken for discussion is a 26 year old pedestrian male who is struck by a high speeding car, consequent to which he suffers multiple injuries which includes deep 5cm laceration on his forehead, sharp pain to the back of the neck, unequal chest movements, abdominal injury and injury to the pelvis and right femur. The 3 main injuries which will be specifically discussed are sharp pain to the back of the neck, unequal chest movement and injury to the pelvis. Sharp pain to the back of the neck The sharp pain to the back of the neck of the patient hints at probable spine injury at that area. Most cervical spine fractures occur predominantly at 2 levels -at the level of C2 and at the level of C6 or C7 (Mueller 2006). The normal cervical spine has 3 distinct columns- the anterior column is composed of anterior longitudinal ligament and the anterior 2/3rds of the vertebral bodies, the middle column consists of the posterior longitudinal ligament and the posterior 1/3rd of the vertebral bodies, the annulus and intervertebral discs and the posterior column includes all of the bony elements formed by the pedicles, transverse processes, articulating facets, laminae, and spinous processes. Disruption of more than one of these columns makes the spine move as 2 separate units, increasing the likelihood of spinal cord injury. Based on the mechanism of injury, cervical spine injury can be classified into flexion, flexion-rotation, extension, extension-rotation, vertical compression, lateral flexion, and imprecisely understood mechanisms (Mueller 2006). The patient can present with spinal shock which manifests as flaccidity, areflexia, loss of anal sphincter tone, fetal incontinence, priapism and loss of bulbocavernosus reflex. He can also manifest with signs of neurogenic shock like hypotension, paradoxical bradycardia and flushed but dry skin. Signs of autonomic dysfunction like ileus, urinary retention and poikilothermia are usually seen (Mueller 2006). Besides spinal and neurogenic shock, the complications of cervical spine injury include complete and incomplete spinal cord syndromes. Anterior spinal cord syndrome is caused by compression of the anterior spinal artery and involves complete motor paralysis and loss of temperature and pain perception distal to the lesion with preservation of light touch, vibration, and proprioceptive input. Central spinal cord syndrome is caused by damage to the corticospinal tract during extension injury which causes bucking of the ligamentum flavum into the spinal cord and presents as weakness which is greater in the upper extremities than the lower extremities. Injury to only one side of the spinal cord is known as Brown- Sequard Injury. It is caused by hemisection of the spinal cord from penetrating trauma or by a lateral mass fracture of a cervical vertebra. It manifests as paralysis, loss of vibration sensation, and loss of proprioceptive input ipsilaterally, with contralateral loss of pain and temperature perception. High cervical spinal syndromes manifest as onion skin pattern of anesthesia in the face and occur due to damage to the spinal tract of the trigeminal nerve in the high cervical region. Horner syndrome results from damage to the cervical sympathetic chain and manifests as ptosis, miosis, and anhydrosis. Direct injury to the upper cervical level and/or cervicomedullary junction results in posterior cerebellar artery syndrome which includes dysphagia, dysphonia, hiccups, vertigo, vomiting, or cerebellar ataxia, may occur (Mueller 2006). Case management Since cervical spine injury was suspected in this patient, the patient was transported by minimizing neck injury. This was done by transporting the patient on a backboard with a semi rigid collar, with the neck stabilized on the sides of the head with sand bags or foam blocks taped from side to side (of the board), across the forehead. In the emergency room, since spinal malignment was identified, the patient was placed in skeletal traction with tongs as soon as possible, even though there was no evidence of neurologic deficits. The tongs were placed finger width above the ear lobes in alignment with the external auditory canal. The patient was then admitted to the intensive care unit and referred to neurosurgical consultation. Along with stabilizing the spine, care was taken to establish airway, breathing and circulation. The oral secretions were cleared to prevent aspiration and assist breathing. The patient required modified jaw thrust and insertion of an oral airway. However, the emergency team got ready in case intubation and mechanical ventilation was needed (Schreiber, 2006). The patient was started on methyprednisolone. It was started at a dose of 30mg/kg intravenous as a bolus over 30 minutes, followed by continuous drip at the rate of 5.4mg/kg/hy for one day. This drug is useful because of its anti-inflammatory properties. It is contraindicated in cases of hypersensitivity and associated viral, fungal or tubercular infections. Potassium levels must be monitored when administered along with digitalis because of possible hypokalemia which can cause digitalis toxicity. Phenobarbitone, phenytoin and rifampicin decrease methyl prednisone levels (Mueller 2006). Nursing care included monitoring vital signs and observation for progressive neurological damage. The patient’s breathing pattern was continuously observed. Even the strength of cough effort was observed. The patient's motor and sensory changes were continuously observed. The nurses recorded these aspects serially so that monitoring would be better and deterioration or improvement could easily be noted. The initial vital signs at the time of admission included normal blood pressure, tachycardia and normal respiratory rate. However the GCS score was only 13/15. The GCS was probably because of minor head injury or initial neurogenic shock. Soon the patient deteriorated and was sent to the intensive care. The initial tachycardia was due to shock. After admission to the ICU, care was taken to maintain systolic blood pressures above 90 - 100 mmHg (Schreiber, 2006). Ionotropic support with dopamine infusion was provided to maintain these pressures and prevent hypotensive episodes. Heart rate was maintained around 60-100 per minute (Schreiber, 2006). Whenever there was bradycardia, atropine was given. Also, care was taken to maintain adequate oxygen levels. The aim of saturations was above 90%. Urine output was maintained above 30ml per hour (Schreiber, 2006). Monitoring of urine output was possible by placement of Foley's catheter. Care was taken to prevent hypothermia. In this patient, the investigations which were done to evaluate the cause for sharp pain at the neck include radiography and computed tomography (CT Scan). Radiography in the lateral view can demonstrate cervical spine injuries in about 85-90% of cases (Mueller 2006). It shows all 7 vertebral bodies and the cervicothoracic junction. CT scan is useful because of its high sensitivity rates. It can also evaluate soft tissue injuries. MR scan is actually less dangerous and more useful in evaluating soft tissue injuries. The patient was treated in supine position. Since those with spinal cord injuries following an accident usually have other injuries including head injury, these were also taken care of. Also efforts were made to prevent further complications. Since ileus is common in spinal cord injuries, continuous nasogastric aspiration was done to prevent aspiration pneumonia (Schreiber, 2006). Use of antiemetics was liberal. Symptomatic relief of pain with analgesics was provided. Fluids and electrolytes were administered intravenously based on urine out put, serum electrolytes, renal function and cardiac function. Oral diet was gradually introduced. Since this patient with spinal paraplegia tends to be in bed for a long time, care was taken to prevent bed sores. The patient was turned every 1 to 2 hours and all extensor surfaces were padded (Schreiber, 2006). This patient was given aggressive physical and occupational therapy once the acute phase settled and he was shifted to the ward (Schreiber, 2006). The main concern in cervical spine injuries is prognosis. While in spinal shock, complete resolution may be expected, in a patient with complete spinal cord lesion, permanent paraplegia can occur. However, patients with an incomplete lesion can expect to regain some degree of function. Spinal cord injury may have a psychological impact on the person. The patient may have difficulty in adjusting to the injury leading to decreased quality of life, poor self care and costly multiple medical problems. The patient may go into depression and even develop suicidal tendencies. Depression may lead to difficulties in rehabilitation and adjustment. The patient not only has psychosocial adjustment problems but also have financial stress (Baker 1993). Being a young person the aspects which may worry him and his family members are about recovery, disability, sexual performance and return to day-to-day work. He may continue to have urinary and fecal incontinence which embarrass him socially. The nurses ensured that these psychosocial aspects were dealt with while the patient was in the hospital itself. The patient may need cognitive and behavioral therapy and even antidepressants. Unequal chest movements Injuries to the chest are common in road traffic accidents. Blunt injuries to the chest can affect any one or all components of the chest wall and thoracic cavity. These injuries may damage the chest wall, the blood vessels lining the chest wall, the lung tissue, pleurae, tracheobronchial tree, esophagus, heart, great vessels of the chest, and the diaphragm. The 3 main structures within the chest are the mediastinum and the right and left pleural cavities. In the mediastinum lie the heart, the aorta, the superior venacava, the lower esophagus and the lower part of trachea. The pleural cavities contain lungs within them. All these structures lie within the thoracic cage which is made up of 12 thoracic vertebrae, 12 pairs of ribs, and the sternum. During breathing, the chest movements occur by the action of the diaphragm, intercostal muscles and accessory muscles of respiration. During inspiration, the diaphragm and the intercostal muscles contract while during expiration, the muscles relax. Whenever there is fracture of ribs on one side or when there is accumulation of air or blood in one of the pleural cavities, both the sides of the chest cannot move simultaneously resulting in unequal chest movements. Unequal chest movements, damage to lungs and other important structures like heart and great vessels can cause massive changes in hemodynamics and respiration. The patient under study has unequal chest movement. Causes of unequal chest movements include pneumothorax, hemothorax, flail chest or even aortic rupture (“Chest injuries” 2005). The patient initially did not have respiratory distress and the patient was thrown off suddenly. Hence the most probable cause of unequal chest movement could be aortic rupture (Jones 1995) or simple pneumothorax. The major pathophysiology encountered in blunt chest trauma includes derangements in the flow of air, blood, or both in combination. . A chest radiograph is an important adjunct in the diagnosis of many conditions, including chest wall fractures, pneumothorax, hemothorax, and injuries to the heart and great vessels. Helical CT scanning and CT angiography (CTA) are necessary to confirm possible blunt aortic injuries. The criterion standard for diagnosing traumatic thoracic aortic injuries is aortography. Ultrasound may be necessary to study pericardium, heart, and thoracic cavities in the emergency room. Laboratory investigations include complete blood count to gauge blood loss, arterial blood gas analysis as an objective measure of ventilation, oxygenation, and acid-base status, serum electrolytes, and coagulation profile. Case management Initial management included maintenance of airway, breathing and circulation. Chest X-ray in this patient revealed pneumothorax. The patient was managed in the intensive care unit with continuous monitoring of vital signs, saturation levels and ECG. He was started on continuous oxygen. Intercostal tube was placed to drain air in between the pleura. Fluid and electrolytes support was given as needed. Arterial blood gases were done regularly to monitor oxygenation. The position of the tube was monitored using chest X-ray. The nurses took care of oro-pharyngeal suction, hypotension, nasogastric aspiration, bladder catheterisation, tubes hygiene, bandaging and splinting, and monitoring of vital signs and urine output (“General Emergencies and Major Trauma.”). Complications following chest injury can occur early or late. Most complications relate to the circumstances of wounding, the treatment choices made and the procedures performed. Technical problems with tube thoracostomy placement, position and function, delay in placement of the chest tube, the presence of a large hemothorax, incomplete re-expansion of injured lung, incomplete obliteration of the space between the pleural surfaces, delayed recognition of a diaphragmatic injury, pulmonary parenchymal contusion, extrathoracic hematoma, unstable chest wall injury with multiple rib fractures, all predispose a patient to complications with the chest injury (Fallon, “Injury to the chest, complications and management”). Outcome in chest injury depends on the diagnosis. Simple pneumothorax and uncomplicated frail chest have excellent prognosis. But tension pneumothorax and aortic rupture may have guarded prognosis. Like any other traumatic injury, those who suffer from chest injury suffer a great deal of psychosocial stress. They may suffer from sadness or even depression (Shalev 1993). Pelvic injury Injuries to the pelvis are common in road traffic accidents. The clinical features include sudden onset of pain with an inability to weight bear. The causes of pain following road traffic accident include fractures and muscle strains. The most common fracture associated with pelvic injury is fracture neck of femur. The test which helps in the diagnosis of fracture is radiograph. MRI may be necessary to stage the extent of a femoral neck stress fracture. In incomplete fracture neck of femur, non-weight bearing on the affected leg helps. In complete fractures, surgical fixation is necessary (‘Operational Medicine”). Pelvis consists of the ileum, ischium, and pubis, which form an anatomic ring with the sacrum. Disruption of this ring requires significant energy and this amount of energy frequently causes injury to the organs within the pelvis. Also, pelvis contains major blood vessels which may also be injured during pelvic injury. Bleeding from these vessels can cause significant blood loss and shock. Also accumulation of blood in the pelvis causes significant amount of pain. Investigations involve radiographs in various views to look for fractures. CT scan is the best imaging study for evaluation of pelvic anatomy and degree of pelvic, retroperitoneal, and intraperitoneal bleeding. This scan also confirms hip dislocation associated with an acetabular fracture. Ultrasound is a useful tool to assess injury in the intensive care unit. Since the patient is a male, retrograde urethrography may be necessary if blood is seen in the urethral meatus. If the patient is hemodynamically unstable due blood loss, arteriography determines the site of bleeding. If urethral damage has already occurred, suprapubic catheterisation will be necessary (Sheppard 2005). Case management This patient was managed in the intensive care unit. Investigations revealed fracture of the neck of femur and bleeding in the peritoneum. The bleeding in the peritoneum was managed with blood transfusion which included whole blood and packed red blood cells. Hemoglobin was monitored. The plan was to determine the site of bleeding only if there was worsening. But since there was no further drop in hemoglobin and he responded to transfusion, no further interventions were done as far as peritoneal bleeding was concerned. The patient was managed nil orally in the acute phase. Fracture neck of femur was managed conservatively by immobilizing the affected leg. Pelvic injury causes lot of pain. Also, the fact that the patient needs to be nil oral for some time is distressing. Immobilization of the leg makes the patient depressed and anxious and dependent on others. The multiple injuries have burden not only on the patient but also on the family. The family members need to help the patient for physical activities and there is also a great deal of financial burden involved. Conclusion The 26 year old man who met with a road traffic accident was admitted with multiple injuries involving the spine, chest and the pelvis. He was managed in the intensive care with continuous monitoring of his vital signs. He was given appropriate fluids, electrolytes, blood transfusion, diet and medications. The main concern in this patient is the prognosis of spinal cord injury which is poor. Hence it is obvious that the patient and his family members are worried about his prospects in terms of recovery, day-to-day activities, employment, social and married life. The patient and the relatives will need emotional and psychological help before discharge. In addition the patient will also need rehabilitation measures including physiotherapy and occupational therapy. References About Critical Care Nursing. AACN. Retrieved on 12th October, 2007 from http://www.aacn.org/AACN/mrkt.nsf/vwdoc/AboutCriticalCareNursing?opendocument Baker, J., Cairns, D. (1993). Adjustment to spinal cord injury: a review pf coping styles contributing to the process. The Journal of Rehabilitation. Retrieved on 12th October, 2007 from: http://www.encyclopedia.com/doc/1G1-16514148.html Chest injuries. (2005). Primary Clinical Care Manual. Retrieved on 12th October, 2007 from: http://www.health.qld.gov.au/pccm/pdfs/sec1emerg/trauma_injur/1.18chest.pdf. Critical Care Nurse. Nurses for a healthier tomorrow. Retrieved on 12th October, 2007 from: http://www.nursesource.org/critical_care.html Fallon, W.F., Barnoski, A.L., & Mancuso, C. Injury to the chest, complications and management. Experience at Level-1 trauma Center. Retrieved on 12th October, 2007 from: http://www.panamtrauma.org/journal/Injuy%20to%20the%20Chest.pdf. General Emergencies and Major Trauma. Clinical Practice Guidelines for Nurses in Primary Care. Retrieved on 12th October, 2007 from: http://www.hc-sc.gc.ca/fnih-spni/pubs/nursing-infirm/2000_clin-guide/chap_14a_e.html Jones, L.L. (1995). CE Credit: Meeting the Challenge of Chest Trauma. The American Journal of Nursing, 95 (9): 22-30 Mueller, J,B. (2006). Fractures, Cervical Spine. eMedicine from Web MD. Retrieved on 12th October, 2007 from: http://www.emedicine.com/emerg/topic189.htm Nochols, K., Brown, A., Sett, P. (2005). Spinal cord injury. Hospital Pharmacist, 12: 91-94. Operational Medicine. (2001). Hip and Pelvis Injuries. Retrieved on 12th October, 2007 from: http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/SickCall/HipandPelvisInjuries.htm Sawyer, M.A.J. (2006). Blunt Chest Trauma. eMedicine from WebMD. Retrieved on 12th October, 2007 from: http://www.emedicine.com/med/topic3658.htm Schreiber, D. 2006. Spinal Cord Injuries. eMedicine from WebMD. Retrieved on 24th October, 2007 from: http://www.emedicine.com/emerg/topic553.htm Shalev, A.Y., Schreiber, S., & Galai, T. (1993). Early psychological responses to traumatic injury. Journal of Traumatic Stress, 6(4): 441-450. Sheppard, C. (2005). Fractures, Pelvis. eMedicine from WebMD. Retrieved on 12th October, 2007 from: http://www.emedicine.com/emerg/topic203.htm Spinal Cord Injuries. Nursing Care for Neurological Patients. Retrieved on 12th October, 2007 from: http://www.free-ed.net/sweethaven/MedTech/NurseCare/NeuroNurse01.asp?iNum=41 Read More