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Eye Care
The potential for damage to the eyes is a recognised risk for the ICU patient due to sedation and paralysing agents, reduced or absent blinking, infection and the environment. Rosenberg (2008) state that 20-42% of ICU patients develop exposure keratopathy.

To start, take a look at these resourcesː


 * The Eye


 * | How The Eye Works

Eye Assessment
Part of routine practice as part of initial thorough assessment at the start of each shift. Assess forː


 * Eye & eyelid general cleanliness
 * Signs of infection or red eyes (Viral or bacterial conjunctivitis)
 * Risk factors for Ocular Surface Disorder (OSD)
 * Keratopathy (corneal damage)
 * Corneal dryness, discolouration or ulceration
 * Lagopthalmus (incomplete eye closure)
 * Ocular surface disorder
 * Conjunctival Oedema (Chemosis)

==Eye care interventions==

Sedated patient- eye lubricant (also may add moisture chamber with polyethene film) Awake patient- Artificial tears
 * Sterile technique
 * Saline soaked gauze (some ICU’s may use sterile water) to clean. This is also known as “eye toilet”.
 * Patient sedation level:

Resources

[http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/239733/eyecare_11112013.pdf Johnson,K. & Rolls, K. (2013) Eye Care for Critically Ill Adults. NSW Agency for Clinical Innovation Intensive Care Coordination and Monitoring Unit] (Poster)

[http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/239731/ACI14_Man_EYE_care_2-3.pdf Johnson,K. & Rolls, K. (2013) Eye Care for Critically Ill Adults. NSW Agency for Clinical Innovation Intensive Care Coordination and Monitoring Unit] (Guideline)

Kam et al (2013) Eye Care in the Critically Ill: A National Survey and Protocol

[http://xa.yimg.com/kq/groups/17437113/480756053/name/eye%20care%20-%20rosemberg%20-%20ccm%20-12-08.pdf Rosenberg, J. B., & Eisen, L. A. (2008). Eye care in the intensive care unit: narrative review and meta-analysis. Critical care medicine, 36(12), 3151-3155.]

Cardiac-

The Heart https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg

ECG

Coronary Anatomy

https://commons.wikimedia.org/wiki/File:Coronary_arteries.png

CardiologySite http://www.cardiologysite.com/html/rca.html

Axis

http://www.ecgteacher.com/

http://lifeinthefastlane.com/axis-bold-love/

Pelvic Injury

Young Burgess

Pelvic Images- commons

Arterial Blood Gas Sampling Process

The collection of blood from an arterial cannula closed system.

Clinical Noteː Arterial lines are for sampling only, no medications are to be administered (ensure arterial line labelled to prevent incorrect use).

Indications For Sampling:

Determine acid/base balance, electrolytes, Haemoglobin, glucose levels Blood test analysis Measurement of respiratory gases on analysis of respiratory or ventilator changes Assess the response of therapeutic interventions (such as electrolyte replacement, glucose or insulin administration)

Contraindications: Rationale for sampling needs to be determined to prevent unnecessary levels of sampling and loss of blood. If checking respiratory gases after ventilation change, ensure an appropriate time period has elapsed (15-20 minutes or follow your unit policy). Legal and professional issues, such as consent or when practice limitations are in place.

Arterial Blood Gas Sample Process:

References:  AAGBI Safety Guideline: Arterial line blood sampling: preventing hyoglycaemic brain injury </li> <li> Dougherty, L., & Lister, Sara. (2015). The Royal Marsden Manual of Clinical Nursing Procedures (9th ed.). Hoboken: Wiley </li> <li> Order of Draw for Multiple Tube Collections – Quest Laboratories </li> </ul>

Dougherty, L., & Lister, Sara. (2015). The Royal Marsden Manual of Clinical Nursing Procedures (9th ed.). Hoboken: Wiley. ICU Stepping Stones Program YouTube Playlist. Retrieved from https://www.youtube.com/playlist?list=PL79cxMg7X2HclGPIxMIF02vc13m5gFzSi Order of Draw for Multiple Tube Collections – Quest Laboratories. (2014). Retrieved July 1, 2015, from http://www.questlabs.com.sg/clinicians/order-of-draw-for-multiple-tube-collections/

Note:this is not a formal guide or competency checklist for performing prone position procedure

ICUnurses (discuss • contribs) 11:12, 11 September 2014 (UTC)

Care of the Complex Trauma Patient

Motor Vehicle Crashes

When caring for patients received from the scene of a motor vehicle crash, it is important to look at the initial paramedics notes for information relating to the accident. This includes could include details such as;

The speed of the vehicles The points of impact The types of impact sustained Whether the patient was the driver or passenger Front or backseat occupant Whether any safety devices were used and/or deployed during the crash If the patient was ejected from a vehicle If so, where the patient was found in relation to the location of the vehicles The mortality rate greatly increases, and injury prediction becomes extremely difficult in the event of patient ejection from an enclosed vehicle. It is also important to determine if any other occupants in the same vehicle were killed.

In most motor vehicle crashes, four separate collisions occur, since the vehicle and occupants rapidly decelerate at different rates of speed.

Upon initial impact, as the vehicle abruptly stops, the occupants continue to move. Subsequently, the occupants hit objects within the vehicle, bringing their bodies to a sudden stop, while their internal organs keep moving. Next, the internal organs come into contact with the other internal organs, cavity walls or structures and abruptly stop. Finally, any loose items in the vehicle may become flying objects, which may inflict additional injuries. Each of these four collisions may produce their own separate injuries. car crash (Image from McQuillan, 2002)

Frontal impact

crash_test_z.jpg

Frontal impact collisions occur when a vehicle hits another object head on. The occupants of the vehicle will either be thrown up-and-over or down-and-under the dashboard, depending on whether a seatbelt was used or an airbag deployed. Each trajectory path produces its own specific injury pattern. The speed of the vehicles and the degree cabin intrusion contribute to the severity of the injuries. Image from http://www.dddilaw.com/library/head-on-collision-accident-in-new-york-ny-car-crash-lawyer.cfm

Up-and-over Trajectory This usually occurs when seatbelts are not used. As the person is thrown up- and-over, he hits the windshield and steering column. This can result in injuries to the head, neck, check, and/or abdomen.

A02786-20-03           Image form www.lbfdtraining.com/Pages/emt/sectionc/mechofinjury.html

Down-and-under Trajectory This usually occurs when a seatbelt is worn. As the person is thrown down-and-under, impact is made with the lower dashboard and steering wheel. This can result in posterior dislocation of the hip and injuries to the lower extremities, chest, and abdomen. A02786-20-02              Image form www.lbfdtraining.com/Pages/emt/sectionc/mechofinjury.html

Lateral impact

T-Bone.jpg              Image from http://www.missouriinjuryattorneysblog.com/

Lateral or “T-bone” impact occurs when two vehicles moving in perpendicular directions collide into each other.

lateral impact 2

Since occupants who have been hit from the side are initially thrown into the direction of the impact, injuries are expected to be more severe on the impact side. Secondary injuries may occur on the opposite side when the person strikes other areas within the vehicle. Lateral impact collisions often result in injuries to the cervical spine, same side shoulder and clavicle fractures, lateral abdominal injuries, and head and face injuries if thrown forward.

rear collision.jpg

Rear Impact

This type of impact occurs when a vehicle (usually stationary) is struck from behind by a moving vehicle.

neck-injury.jpgI   mage obtained from http://www.lehighvalleylive.com/easton/index.ssf/2009/11/route_22_east_reopened_followi.html

The occupant’s torso usually travels forward with the vehicle; the head and neck are hyperextended backwards, producing a “whiplash” injury if the headrest is not in correct position. At high speeds, this can cause fatal spinal cord and cervical spine injuries.

Pedestrian Injuries Adults tend to turn sideways in an attempt to protect themselves and get away from an approaching vehicle. Upon impact, there are three specific injury patterns that occur as the adult is struck and then thrown: Pedestrian-Crash-Test.jpg

1. When initially struck: Injuries to the knee and fractures of the tibia, fibula, femur and pelvis are most common.

Pedestrian-Crash-Test.jpg

2. When thrown on top of vehicle: Fractures of the femur and injuries to the chest and abdomen are most common.

3. When thrown to ground: Injuries to the head, neck, spine, and wrist are most common.

Images from http://crashteams.com/Services/Crash-Reconstruction/Pedestrian-Collisions.html

Motorcycle Crashes mba.jpg                   Image from http://www.roadskill.org/factshop-15facts.asp

Injuries are dependent on speed, type of impact, and the quality of the protective gear worn by the rider. Common injury patterns that are associated with specific types of impacts are: Head-on collision Femur fractures are common. Also if thrown over the handlebars, face and chest injuries. Angular collision Crush injuries of the lower extremities and open or closed leg fractures are commonly seen. “Laying the bike down” This is a self-protection maneuver used by experienced bikers to slow the speed of collision and separate the rider from the motorcycle. Injury patterns include leg fractures and significant soft tissue avulsion injuries, “road rash”, and de-gloving injuries.

Falls Severity of injury depends on the height of the fall, the body parts that are struck during the fall and the type of surface where the person lands.

fall-photography-02.jpg

When adults fall or jump landing directly onto their feet, a trio of injuries known as the “Don Juan Syndrome” occurs. The three injuries produced are: 1. Direct impact onto the feet produce bilateral calcaneus fractures, which transfers energy up the vertebral column (known as axial loading) 2. The axial loading produced compression fractures of the thoracolumbar spine 3. Then falling forward onto outstretched arms produces bilateral Colles fractures of the wrists

Image from http://www.foundshit.com/ladder-fall-photography/

xray knife.jpg

Stab Wounds Stab wounds are considered low-velocity injuries, and therefore generally produce minimal secondary trauma. Severity of the injury is dependent on the type of weapon, location, depth and angle of penetration and the length of blade that entered the body.

Image obtained from http://emj.bmj.com/content/22/5/386/F2.large.jpg

Gunshot Wounds The severity associated with gunshot wounds is dependent on the type of projectile, mass and shape. The amount of fragmentation, the type of tissue struck and the distance travelled by the bullet will contribute to the trauma sustained.gunshot wound CT 3D.jpg

Low-velocity gunshot wounds in which the bullet travels at a lower speed produce localised injury at the center of the bullet tract and a temporary cavity of 2-3 times its diameter. High velocity gunshot wounds are large cavities that compress and displace surrounding tissues. These cavities can be up to 30-40 times the actual diameter of the bullet. A negative pressure is produced behind the bullet, pulling foreign bodies and other contaminants directly into the wound. Shot guns bullets will shatter into hundreds of lead pellets on lodgment into tissue and scatter throughout the body. Tumble and yaw are other important factors that determine the severity of tissue destruction from the bullet.

Yaw refers to how far nose of the bullet deviates from a straight path (up and down or left and right) Tumble refers to the bullet turning 180þ in flips on entry to the tissue The degree of yaw or tumble will increase the destruction of tissue. Image obtained from http://radiology.rsna.org/content/240/2/522/F8.large.jpg

Explosion In an explosion, gas expands and a blast wave is produced as radiant energy is released. Injuries occur from three impact points: 1. The initial blast produces burns and concussion injuries. 2. These shock waves carry shrapnel fragments such as glass, rocks or metal debris, and fire that can produce further injury.

blast onjuries.jpg

3. There is a possibility the patient can then be thrown by the blast, producing additional secondary injuries.

Image obtained from http://www.orthosupersite.com/view.aspx?rid=21114

Missed Injuries Missed injuries are unfortunately sometimes inevitable given the complexity and multifaceted nature of trauma patients. It is up to all trauma clinicians to continually assess the patient and maintain a level of injury suspicion until proven otherwise (see section on primary and secondary assessments).

Summary Knowledge of the mechanisms involved in trauma allows the trauma clinician to have a good working knowledge of predicted injury patterns. This enables the critical care nurse to plan their care appropriately for trauma patients. Suspected injuries should be considered present until ruled out through definitive assessments and diagnostic procedures.

Introduction Patients presenting to the emergency department following a trauma require a knowledge and skills that support an approach that varies slight to the traditional model of care that is typically provided to a patient presenting with an illness or exacerbation of medical condition. In this topic we will be exploring the concepts that underpin a rapid and systematic response to trauma presentations, including identification of major trauma; systems of trauma management across the state of Victoria; recognition of the role mechanism of injury plays in producing trauma and injury; the importance of the pre-hospital period; and the approach to reception and resuscitation of major trauma patients. This online topic is complimented with practical workshop sessions. Pre Learning Concepts In order to complete this topic, it is expected that students have the knowledge and skills to assess a critically unwell patient in a timely manner. Prescribed Reading Curtis, K. &amp; Ramsden, C., (2011) ''Emergency and Trauma Care for nurses and paramedics. ''Sydney:Mosby Chapters 42, 43 &amp; 44 Estimated Student Learning Hours 6 hours (online and self directed readings and activities) Intended Student Learning Outcomes Following completion of the online topic and participation at the workshop session, it is expected that students will be able to: <ul> <li>Recognise a patient with major trauma using the major trauma criteria for adults and children</li> <li>Describe the structure and purpose of the State Trauma System</li> <li>Describe the role the students local hospital plays in the State Trauma System</li> <li>Discuss relationships between mechanism of injury and injury patterns</li> <li>Outline the initial reception and management a trauma patient</li> <li>Describe the primary and secondary survey undertaken on a trauma patient</li> <li>Identify resources available to assist in the initial management of major trauma</li> </ul>

Principles and practice of trauma nursing


 * 1) /Systematic Trauma Assessment/
 * 2) /Mechanism of Injury/
 * 3) /Head Trauma and Intracranial Pressure Management/
 * 4) /Spinal Management/
 * 5) /Thoracic Trauma/
 * 6) /Pelvic and Abdominal Trauma/
 * 7) /Musculoskeletal Trauma /
 * 8) /Shock- Care and Management/
 * 9) /Burns Management/

<iframe width="560" height="315" src="//www.youtube.com/embed/videoseries?list=PL79cxMg7X2Hdsp_31nEip33vTq-ARcxQW" frameborder="0" allowfullscreen>

Any sign of shortness of breath, chest pain or feeling of unwell- oxygen will likely be provided as one of the first interventions by health professionals. In Intensive Care speciality, questions remain regarding setting safe oxygen parameters, to maintain safety but also prevent the potential of oxygen toxicity.

Especially difficult in complex mechanical ventilation scenarios is setting appropriate oxygen aims (Sp02 and Pa02):

Is oxygen treatment safe? Oxygen is a classified as a drug, how often is it prescribed? Do we need to aim for normal for ICU patients or accept lower levels? What is considered a safe level? What is the impact of oxygen on the inflammatory process? Time for permissive hypoxaemia and target oxygen levels?

"Respiratory evidence focuses on volutrauma, barotrauma and biotrauma but the effects of high oxygen and hyperoxemia seem to have been forgotten" (Capellier, G. & Panwar, R, 2013).

The article raises some interesting discussion, take some of these concepts by the authors and discuss with nursing and medical colleagues to see what the concept of oxygen is in your clinical environment.

Readings

[http://rc.rcjournal.com/content/58/1/18.full Heffner, J. E. (2013). The story of oxygen. Respiratory Care, 58(1), 18-30. doi:10.4187/respcare.01831]

[http://www.cicm.org.au/journal/2011/september/ccr_13_3_010911-139.pdf%20 Capellier, G., & Panwar, R. (2012). [http://www.cicm.org.au/journal/2011/september/ccr_13_3_010911-139.pdf Is it time for permissive hypoxaemia in the intensive care unit? ] Critical Care and Resuscitation, 14(1), 139-141]

Kallet, R. H., & Matthay, M. A. (2013). Hyperoxic acute lung. Respiratory Care, 58(1), 123-140. doi:10.4187/respcare.01963

http://www.youtube.com/playlist?list=PL79cxMg7X2Hdsp_31nEip33vTq-ARcxQW

Intensive Care Uni video resource playlist [link here]

Indications:
 * Severe ARDS

Contraindications: <ul><li>C-spine precautions</li> <li>Haemodynamic instability (although can still perform CPR in prone position)</li> <li>Increased or concern with abdominal pressure</li> <li>Extreme obesity</li> <li>Increased intracranial pressure</li> <li>Staff not trained/skilled or not enough personnel to carry out safely</li></ul>

Initial Prone Position Manoeuvre:

Video Resources: <ul><li> UK 'Cornish Pasty' Critical Care approach from Tutorial WHH </li> <li> French approach from PROSEVA Trial prone instructional video in NEJMvideo </li> </ul>

Note: this is not a formal guide or competency checklist for performing prone position procedure

Any sign of shortness of breath, chest pain or feeling of unwell- Oxygen will likely be provided as one of the first interventions by health professionals. In the Intensive Care specialty questions remain with setting safe oxygen parameters, especially difficult with complex mechanical venitilation:

Is oxygen treatment safe? Its classified as a drug, how often is it prescribed? Do we need to aim for normal for ICU patients or accept lower levels? What is considered a safe level? What is the impact of oxygen on the inflammatory process? Time for permissive hypoxaemia and target oxygen levels? "Respiratory evidence focuses on volutrauma, barotrauma and biotrauma but the effects of high oxygen and hyperoxemia seem to have been forgotten" (Capellier, G. & Panwar, R, 2013). [link here]

The article raises some interesting discussion, take some of these concepts by the authors and discuss with nursing and medical colleagues to see what the concept of oxygen is in your clinical environment.

Readings
 * Heffner, J. E. (2013). The story of oxygen. Respiratory Care, 58(1), 18-30. doi:10.4187/respcare.01831
 * Capellier, G., & Panwar, R. (2012). Is it time for permissive hypoxaemia in the intensive care unit? Critical Care and Resuscitation, 14(1), 139-141 [link here]
 * Kallet, R. H., & Matthay, M. A. (2013). Hyperoxic acute lung. Respiratory Care, 58(1), 123-140. doi:10.4187/respcare.01963