Multisystem Trauma, Shock, Multisystem Organ Dysfunction Syndrome and Systemic Inflammatory Response Syndrome

Introduction to Trauma Unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical or chemical energy Leading cause of critical illness and death in the USA. Average ICU stay is days !is" of morbidity and death is increased in older patients and those #ith comorbidities $alls are the most common cause of trauma in older adults Legal Issues in %mergency Care A highly litigious area &a lot of la#suits come out of emergency care' All ( states have )*ood Samaritan La#s+ you can give care that is in good faith and #ithout charge for the good Samaritan la# ,urses are accountable to the public for -udgment and conse.uences of -udgment /elegation to unlicensed personnel is our responsibility Confidentiality and privacy issues are critical $ederal and state la#s mandate that %/s have a duty to provide service to those see"ing care &no )dumping+' cant send people to other places 0andated !eporting &1ave to be reported to some official organi2ation' Any death in the %/ and deaths #ithin 34 hours of hospital admission Suspected abuse Communicable diseases &1I5, hepatitis, T6' C/C %lopement of psychiatric patients %xtensive burns 1omicide

Infectious outbrea"s !ape7sexual assault Serious in-ury related to a medical device ST/s Suicide or attempt Some states mandate that sei2ures be reported to /05 *iving Consent Express consent8 oral or #ritten Implied consent8 if patient is unconscious or #here immediate decisions must be made to prevent loss of life or limb Emergent treatment of minors: if necessary to protect life or limb if guardian not available Involuntary consent: physician or police officer determine the individual is a threat to self or others Translation services: must be provided to spea"ers of other languages /ocumentation !e.uirements Initial assessment date7time Time #hen each intervention occurs %vidence that unstable patients are receiving intensive care Identified problems and procedures are performed All interventions Use of translator 9atient responses to interventions ,ursing observations

Communications #ith other health team members Communications #ith family members 9atient teaching7discharge instructions Any refusal of care !estraints : $alse Imprisonment; 0a"e sure you have an order for restraints /ocument reason #hy you are using restraints Forensics: %vidence Collection and 9reservation Collection, analysis, and interpretation of medical evidence presented in legal cases ,urses are involved in evidence collection, preservation, and chain of custody 6lood, urine, photographs, clothing, *S!, #eapons7missiles, nail scrapings, fluid collection *uidelines for %vidence Collection ,ever discard clothing 9lace #et or bloody clothing in a paper bag /o ,<T #ash the hands of a patient #ith *un shot #ound &cover #ith paper bags' gun shot residue #ill be on the hands of the person #ho shot the gun Cut around bullet holes, po#der mar"s and "nife cuts in clothing $old clothing #ithout sha"ing it &do not cross=contaminate clothing' 9recisely document #hat the patient says /escribe appearance of #ounds and presence of blood 9hotograph #ounds /ocument behavior in ob-ective terms

Unless a procedure is essential, delay cleaning the patient or #ounds until police see it /o not handle bullets or other solid evidence &place in sealed container and label #ith location found, date, time, initials' Chain of evidence is critical>.must remain #ith the collector or be loc"ed in a secure area until released to la# enforcement All parties sign the evidence label #ith date, time, time of exchange If moisture is needed to collect biological samples &blood, tears', slightly moisten tip of cotton s#ab #ith saline. /ry in separate containers7envelopes %ach victim has -ust one opportunity to have evidence collected properly Triage &to sort or to choose' The rapid sorting of patients #ho present to the %/ ?ho needs immediate medical attention; ?ho can safely #ait to be seen; The most experienced nurse on duty should be the triage nurse !apid, brief assessment is done by an experienced nurse #ithin minutes of arrival to the %/ Chief complaint, vital signs, focused assessment related to symptoms, brief history 0ust be non-udgmental and empathetic &)I bet that really hurts+ or )@ou donAt loo" li"e you feel #ell+ can have a positive impact on the patientAs experience in the %/' 9urpose is to put the right person in the right place at the right time for the right reason Small hospitals may have a )sic" or not sic"+ system. Three=level triage is most commonly used. 0ay be color coded or I, II, III %mergent 9atients !e.uire immediate care 9resenting problem is a threat to life, limb or organ Cardiac arrest

0a-or trauma !espiratory failure Stro"e Loss of pulse in an extremity Unconsciousness #ith inability to maintain air#ay Anaphylaxis Arterial bleeding Sexual assault evidence needs to be collected soon Urgent 9atients !e.uire prompt care, but may safely #ait several hours if necessary Abdominal pain $ractured hip Bidney stone 5omiting and diarrhea Asthma 6lood in urine or stool $ractured extremity &if pulse is present' ,on=Urgent 9atients Could have been seen in a doctorAs office ,eed care, but time is not critical 9atient can #ait safely

Sore Throats !ash Con-unctivitis Simple fractures Lacerations not bleeding profusely but #ill need stitches $lu ,, 5 C / Reassess these patients at least every 2 hours ?ho #ould you treat first; DD year old college soccer player #ho has an obviously fractured tibia7fibula EF year old #oman #ho had a syncopal episode t#o hours ago #hile standing at her "itchen sin" 3( year old man #ith history of sei2ures #ho is semi=conscious and post=ictal E4 year old man #ho experienced sudden chest pain during the final minutes of the U*A=*T game and drove himself to the %/ Gst Triage in 0ultiple Casualty Situations Treat the most seriously #ounded #ho have the potential to be saved The $ocused Triage Assessment Chief Complaint &#hy did you come today;' Allergies Current medications 9ast medical history &Including Last 0enstrual 9eriod for #omen' %vents surrounding the illness or in-ury

5ital signs, pulse ox, accuchec" if diabetic Last tetanus shot If an in-ury, speed of vehicle, direction of impact, patient position in the vehicle, use of restraints, airbags, e-ection, rollover, fatalities, entrapment7prolonged extrication; 5ictims of Abuse Separate patient from others. 5ictim #ill not spea" honestly if abuser is there The abuser #ill normally not step out of the room let that be a red flag to you /ocument every little thing you see, every #ord spo"en 6e a#are of mismatches bet#een physical SCS and #hat victim says &)tripped and fell do#n the steps+' Loo" for areas that donAt )sho#+ for in-uriesH Loo" for perineal trauma 0echanisms of Traumatic In-uries Bno#ledge about the mechanism can help explain type of in-ury, predict outcome, identify common in-ury combinations, and indicate diagnostic testing needed In-ury occurs #hen force deforms tissue $orce : 0ass I Acceleration 6lunt Trauma &not penetrating= #ont see any blood' 0ay be 05C, falls, assaults, contact sports 0ultiple in-uries common>force is distributed over a large area Acceleration in-uries are due to an increase in the velocity &speed' of a moving ob-ect /eceleration in-uries are due to a decrease in velocity of a moving ob-ect &car hits tree'>.body "eeps moving for#ard #hen the car has come to an abrupt stop Shearing in-uries occur #hen structures )slip+ relative to each other &brain vs s"ull' li"e a carpet burn Crush in-uries occur #hen continuous pressure is applied to a body &pinned bet#een a vehicle and garage #all'

Acceleration7/eceleration in-uries most often occur in 05CAs and are most common In-ury occurs #hen soft tissue hits a hard ob-ect &such as bone' 9enetrating In-ury 9roduced by foreign ob-ects &bullets, "nife blades, debris' entering tissue %xternal appearance of #ound does not reflect extent of internal in-ury Lo#=velocity missiles cause little cavitation and blast effect, essentially only pushing tissue aside 1igh=velocity missiles &rifles, semi=automatic' produce greater energy and cavitation The main in-ury determinants in stab #ounds or impalements are length, #idth, and tra-ectory of the penetrating ob-ect and presence of vital organs in area of #ound. Initial Assessment and 0anagement of Trauma 9re=1ospital Care 6est chance of survival if advanced care is given within one hour of accident. )The *olden 1our+ 9rincipal factor is transport time to a trauma center $e# interventions #ill be provided if transport time is short. %xtensive interventions if transport time is longer $ocus on maintaining air#ay, ventilation, controlling external bleeding and preventing shoc", maintaining spine immobili2ation, .uic" transport. ,euro assessment after A6Cs Primary Survey in hospital!""""TEST #$S Life=threatening in-uries identified and managed. A6C first. C:circulation. Circulation:bleeding. *ive fluids Assessing for hypovolemia &hemorrhagic shoc"'>compression of artery and area of in-ury, elevate, surgery, replacing lost volume. Two large%&ore I' lines inserted 0onitor, vital signs . E= mins, pulse ox, blood #or" sent, type and cross match, urinary catheter inserted, ,* placed Assess for hypothermia &#ill cause clotting'

9rimary survey determines diagnostic tests hypovolemic shoc" paleness, poor s"in turgor, diaphoresis, tachycardia, oliguria, and hypotension "idney is the least forgiving organnot uncommon for trauma patients to go through a time of "idney failure b7c of hypoperfusion Secondary Survey 0ore detailed head=to=toe assessment to detect life or limb=threatening in-uries 9atient history is obtained Information about mechanism of in-ury &#as person on foot or bi"e; Si2e of vehicle; $atality; Length of "nife; ?as assailant male or female; Caliber of bullet; /istance of *S?; 1o# far #as fall;' 0en stab deeper than #omen do 0a"e an assumption that there is a spinal cord in-ury until proven other#ise $luid !esuscitation in Trauma *oal is to perfuse vital organs #ithout inducing complications of fluid overload Aggressive fluid resuscitation puts patient at ris" of hypothermia and coagulopathy Crystaloids &isotonic, hypertonic, or hypotonic' Isotonics most commonly used in trauma. Closely mimics bodyAs extracellular fluid. E liters of crystaloids for each liter of blood lost. 0ost commonly used is ,ormal Saline (ypertonics remain in vascular space and shift #ater into plasma. Causes rapid increase in blood volume. 0ost common is EJ saline 0ore #hole particles than blood (ypotonics not often used in trauma. / ? is example Colloids &albumin, dextran, hetastarch' Creates oncotic pressure #hich encourages fluid retention and movement of fluid into vascular space Colloids have huge protein molecules in them $luid pulls from tissue into blood

Large molecules stay in intravascular spaces longer Less volume is needed to achieve hemodynamic stability Complications8 anaphylaxis, coagulopathy 6lood products 9ac"ed !6Cs increase oxygen=carrying capacity and is the mainstay of treatment for trauma. 9rovides hgb #ithout a huge amount of fluid If no time for cross=match, )%*egative &lood is preferred for women of child&earing age+ )%Positive may &e used in men and post%menopausal women $resh $ro2en 9lasma &coagulation factors' and platelets 0assive transfusions put patient at ris" for SI!S, A!/S, and /IC systemic inflammatory response syndrome, adult resp distress syndrome Autotransfusion especially for chest trauma victims /elayed Complications of Trauma 1eme8 hemorrhage, coagulopathy, /IC Cardiac8 arrhythmias, heart failure, aneurysm !esp8 atelectasis, pneumonia, emboli, A!/S *I8 peritonitis, paralytic ileus, bo#el obstruction, anastomosis lea"s, fistulas, bleeding, compartment syndrome 1epatic8 liver abscess, failure !enal8 hypertension, myoglobinuria, A!$ <rtho8 compartment syndrome S"in8 #ound infections, dehiscence, brea"do#n Systemic8 sepsis, SI!S

Shoc" A state of cellular hypo=perfusion, hypercoagulability, activation of the inflammatory response system Anaerobic metabolism occurs in hypo=perfused areas and lactic acid is produced &acidosis' Cell death occurs if oxygen is not ade.uate As more cells die, tissues and organs become dysfunctional and end=organ failure occurs Time is tissue #hen it comes to saving organs Stage I of Shoc" Syndromes The body activates compensatory mechanisms in an effort to maintain circulatory volume, blood pressure, and cardiac output. 1! goes up !elatively normal 5S and cerebral perfusion may continue and shoc" not recogni2ed. Stage II of Shoc" Syndromes Compensatory mechanisms begin to fail and metabolic and circulatory abnormalities become noticeable Inflammatory and immune responses activate Signs of dysfunction on one or more organs may become apparent 6U, and Cr begin to rise Stage III of Shoc" Syndromes $inal, irreversible damage is done Cellular and tissue in-ury are so severe that life may not be sustainable 0ultisystem <rgan /ysfunction &0</S' occurs 5ery first sign of hypoxia:agitation /ecreased urine output

/octor loo"s at lactic acid to investigate shoc" *eneral 9rinciples for Shoc" Care %stablish ade.uate organ perfusion and oxygenation ASA9 in order to lessen inflammatory responses Bey assessments include neuro, urine output, pulse ox, A6* measurements loo"ing for acidosis and oxygenation, vital signs 1ypovolemic Shoc" Inade.uate circulating volume Acute loss doesnAt allo# normal compensatory mechanisms to occur Cellular hypoperfusion, anaerobic metabolism, lactic acidosis, electrolyte and acid=base disturbances occur %xisting volume is shunted to heart, lung, brain #hich ma"es hypo=perfusion to other organs #orse !enal damage and cerebral anoxia can cause death 1C1, lactic acid levels determine fluid replacement Large=bore I5 needles &GF guage' and #armed fluids Septic Shoc" Septic shoc", SI!S, and 0</S are progressive stages of sepsis <ccurs due to complex interactions among invading microorganisms and the immune system, inflammatory system, and coagulation Activated ?6Cs release mediators that cause endothelial cells to lose their tight -unctions : vascular permeability 5asodilation occurs, blood flo# is maldistributed, heart muscle is depressed /ilated veins decrease preload *et blood cultures before beginning antibioticsK !emove all potential sources of infection 0aintain 0A9 greater than F mm 1g, C59 4=GD and blood glucose belo# G ( mg7dl.

,utrition must be provided due to the high metabolic rate and need for protein Tube feedings Cardiogenic Shoc" /ue to loss of contractility of the heart An extreme form of heart failure %xtensive L5 damage from an 0I is most common cause <ther causes are papillary muscle rupture, ventricular septal rupture, cardiomyopoathy 0ore common in advanced age, e-ection fraction belo# E J, large anterior 0I, history of diabetes. Individuals #ith preexisting cardiac disease are li"ely to develop cardiogenic shoc" after a trauma ,eurogenic Shoc" /isruption of sympathetic tone, most often due to cervical or upper thoracic cord in-ury 9arasympathetic symptoms including hypotension, bradycardia, #arm dry s"in $luid resuscitation is most helpfulH vasoconstrictions may help a little %xternal pacema"er

Anaphylactic Shoc" Allergic reaction to an allergen that evo"es a life=threatening hypersensitivity response Antibody=antigen reaction causes ?6Cs to secrete mediators that cause vasodilation, increased capillary permeability, bronchoconstriction, coronary vasoconstriction, urticaria 5asodilation : decreased preload : decreased cardiac output 0ultiorgan System /ysfunction Syndrome &0</S' The end=point of shoc"

9hysiologic failure of several organ systems such that homeostasis cannot be maintained #ithout intervention ,o organ is independent of any other <nce one organ fails, others are li"ely to fail ,ge is a &ig ris- factor due to progressive changes in body systems even before a ne# illness or in-ury have occurred. Lungs and "idneys are usually first organs to fail Assessment and 0anagement of Specific Traumatic In-uries8 Thoracic

Tracheobronchial Trauma Can be blunt or penetrating <ften associated by esophageal and vascular damage !uptured bronchi are often present #ith upper rib fractures and pneumothorax Symptoms may be subtle8 dyspnea, hemoptysis, cough, SL emphysema, anxiety, hoarseness, stridor, air hunger, hypoventilation, accessory muscle use, retractions, apnea, cyanosis ,ursing8 oxygenationK 6ony Thorax $ractures !ibs and sternal fractures &flail chest' multiple rib fractures Indicate serious intrathoracic and abdominal in-ury Significant pain #hen breathing or coughing, and .uic"ly cause pulmonary deterioration 9leural space in-uries &see /r. StreitAs notes' In-ured side do#n #hen possible stabili2es bro"en bones and inhaling on the good sided 9ulmonary Contusions 6ruising of lung tissue is potentially lethal

!uptured capillary #alls cause hemorrhage and lea"age of plasma and protein into alveolar spaces : 9ulm %dema and hypoxia Suspect this in any patient #ho has a high=energy blunt chest trauma 9resence of scapular fracture, rib fractures, or flail chest raises suspicion 0ay ta"e F hours for contusion to sho# on I=ray /yspnea, crac"les, hemoptysis, tachypnea, increasing pea" air#ay pressure, hypoxia, respiratory al"alosis &loosing carbon dioxide', poor response to increasing $i(D Cardiac Contusion Usually caused by blunt chest trauma &heart impacts sternum or heart is compressed bet#een sternum and bac"' %B* abnormalities, %C1< may sho# myocardial depression %n2ymes may be abnormal bruised heart #ill release en2ymes Cardiac monitor, hemodynamic monitoring, en2ymes, treat pain

Cardiac Tamponade Life=threatening and can be from blunt or penetrating trauma 9roblem is #ith filling heart cant expand to fill #ith blood 6lood fills pericardial space and compresses the heart /ecreases cardiac filling #hich decreases cardiac output, contractility, and leads to shoc" %ven (=G(( ml of blood can create increased pericardial pressure )6ec"As Triad+===decreased 69, muffled heart sounds, distended nec" veins 9ulsus 9aradoxus &inspiratory decrease in systolic 69 of G( mm1g' %cho ma"es the diagnosis sho#s if there is fluid around the heart /rain blood #ith long needle

9enetrating Cardiac In-ury 0ortality rate (=4(J If people survive it is because a tamponade saved them <ccasionally a small stab #ound to right ventricle #ill seal itself off because of lo# pressure in that chamber Aortic Transection &tearing or rupturing' Leading cause of death from blunt trauma 0ost die at the scene or before reaching hospital /ue to sudden deceleration forces &05C or fall' Thoracic aorta is very mobile and tears occur at points of fixation &descending arch' Aorta continues to travel for#ard but can -ust go so far. 5essel #all tears If outer layer of the aorta remain intact, aneurysm or hematoma may form and prolong live for a short time 9oor perfusion beyond the tear, pulse deficit in lo#er extremities or left arm, hypotension, upper arm hypertension relative to leg 69, pain, systolic murmur, hoarseness, resp distress7dyspnea ,ursing8 hemodynamic monitoring and 69 management, preservation of organ function Septic Shoc" or sepsis is primary concern for penetrating ob-ects into body The older a person is the more li"ely the are to develop multi organ system failure Aortic Transection7/issection

Abdominal Trauma

$acts about Abdominal Trauma Can be blunt or penetrating

Can rapidly lead to death due to hemorrhage, shoc", sepsis Single=organ in-uries are rare>.usually several are involved /etection of in-uries can be difficult and missed in-uries are fre.uent cause of death 9enetrating in-uries are )dirty+ Suspect if there is abdominal tenderness or guarding, hemodynamic instability, lumbar spine in-ury, pelvic fracture, or retroperitoneal or intraperitoneal air 6lunt trauma compression forces can fracture solid organ capsules and they bleed. 1ollo# organs #ill collapse and absorb force but #ill lea" their fluids 1igh 1!, lo# 69 1ypovolemic shoc" /iagnostic Tests for Abdominal Trauma $AST &$ocused Abdominal Sonography for Trauma' done in %! $irst A6C, then if there is any free fluid in abd cavitiy straight to the <! 9eritoneal lavage loo"ing for discolored or bloody fluid CI! to detect organ displacement or free air Abdominal CT !egions of the Abdomen 9eritoneal Area8 diaphragm, liver, spleen, stomach, transverse colon !etroperitoneal Area8 aorta, vena cava, pancreas, "idney, ureters, duodenum and part of colon 9elvic Area8 rectum, bladder, uterus, iliac vessels %sophageal Trauma 9enetrating is the most common cause 0ost often it is the cervical esophagus

Symptoms are subtle, but hemothorax or pneumothorax #ithout rib fractures raise suspicion CT of chest, abdomen and pelvis #ill be done, esophagoscopy, s#allo# studies Beep ,9< #ith an ,* tube to continuous suction Aggressive antibiotic therapy Air#ay, oxygenation, hemodynamic support !upture of /iaphragm 0ore common in blunt in-uries Allo#s movement of abdominal organs into thorax, #hich can cause bo#el strangulation !espiratory compromise due to displacement of lung tissue CI!, ultrasound, CT !espiratory distress, dyspnea, decreased breath sounds on affected side, bo#el sounds in the chest, abdominal fluid #hen inserting a chest tube Stomach Trauma 6lunt gastric in-uries can present #ith blood in the ,* aspirate or hematemesis <ther signs are often absent and CT findings may be subtle 0ay not be diagnosed until peritonitis develops !e.uires surgery #ith ,* after#ards to "eep stomach emptyH -e-unostomy tube for feedings 9ancreatic Trauma Usually due to penetrating trauma Acute abdomen, increased serum amylase7lipase levels, epigastric pain radiating to bac", nausea, vomiting Small lacerations may only re.uire drainsH larger #ounds re.uire surgery $istula formation common due to en2ymes )eating a#ay+

!est the pancreas8 ,9<, ,* to lo# suction, patency of drains, monitor fistula development Colon Trauma 0ost often due to penetrating trauma Spillage of contents creates intra=abdominal sepsis and abscess formation %xploratory lap is done and peritoneal cavity )#ashed out+ Sometimes colostomy needed ?ound may be left open ?atch for infection, dressing changes, antibiotics Beep open abdomen moist #ith saline=soa"ed dressings, drainage bags, tegaderm Spleen In-uries The most commonly in-ured organ, usually from blunt trauma 5ery vascular, so blood loss is rapid CT to diagnose Left upper .uadrant pain radiating to left shoulder &)BehrAs sign+', hypovolemic shoc", elevated ?6C 0inor in-uries may be observed #ith ,* to decrease pressure on spleen %arly complications include recurrent bleeding, subphrenic abscess, pancreatitis Late complications8 thrombocytosis and over#helming sepsis Liver Trauma Second most common in.ury Can be due to blunt or penetrating trauma 0ay result in hematoma or laceration

Signs C Symptoms !ight upper .uadrant pain !ebound tenderness 1ypoactive or absent bo#el sounds 1ypovolemic shoc" Can cause huge blood loss into peritoneum If stable, can observe #ith serial CT scans, 1C1 every F hours Unstable patients re.uire surgery to ligate or emboli2e bleeding vessels, repair lacerations, or resect part of liver 0ay need to give platelets or fresh fro2en plasma ?hen hemorrhage is uncontrollable, liver is pac"ed to tamponade the bleeding open abdomen. !is" is great for /IC, A!/S, sepsis Bidney Trauma 0ay lead to )free+ hemorrhage, a contained hematoma, intravascular thrombus, laceration or contusion of renal tissue, or ruptured bladder Signs C Symptoms8 1ematuriaK 9ain, flan" hematoma, ecchymosis over flan" Treatment8 Some in-uries can be resolved #ith bedrest but vascular in-ury #ill need surgical repair or nephrectomy <ptimal fluid balance and lo#=dose dopamine /ilates renal arteries and promotes renal perfusion Complications that may develop8

Acute "idney failure, bleeding, urinary fistula formation, late=onset hypertension may occur 6ladder Trauma Can be lacerated, ruptured, or contused Usually due to blunt trauma #hen the bladder is full at the time of impact $re.uently associated #ith pelvic fractures In-uries to urethra, scrotal hematoma, or displaced prostate gland must be ruled out before inserting foley <n $AST assessment you #ill see fluid Urine #ill enter the intraperitoneal space and cause peritonitis Supra=pubic cystostomy tube may be placed to drain urine out until area can heal 0usculos"eletal In-uries $emur fracture higher priority than tibia or fibula fracture due to muscle7vascular damage

05Cs, falls, industrial, farming, home in-uries, and assaults cause musculos"eletal in-uries !e.uire prompt recognition and stabili2ation $ractures are classified according to type, cause, anatomical location. <pen fractures are classified grade I,II, or III depending on the amount of tissue, nerve, and vascular damage has occurred Amputations )Cut+ or guillotine amputation clean lines and #ell=defined edges )Crush+ amputation ill=defined edges and more soft tissue damage )Avulsion+ amputation occurs #hen part of the body is stretched and torn a#ay

Assessment This is part of the S%C<,/A!@ survey unless there is arterial bleeding If limb s#elling, echymosis, or deformity is noted> Chec" for capillary refill, pulses, crepitus over bone or -oint Chec" for muscle spasm, movement, sensation and pain 9elvic fractures often associated #ith abrasions, lacerations, contusions, asymetry of lo#er extremities. )!oc"+ the pelvis to loo" for instability !ectal exams, vaginal exams done to assess for urethral tears. Treatment8 9elvic binder, external fixator Compartment Syndrome 9ressure #ithin the fascia=enclosed muscle compartment is increased This compromises blood flo# to muscle and nerves !esult is tissue ischemia, and prolonged elevation of pressure causes necrosis Caused 6y8 /ecreased compartment si2e d7t restrictive dressing, splints, casts or excessive traction Increased compartment contents r7t bleeding, edema, or I5 infiltration Signs8 Increased pain in the affected area that is )out of proportion+ to in-ury /ecreased sensation and parasthesia $irmness of tissue

MMM9aleness and pulselessness are late signs and extremity may be lost !emember F 9As pallor, parathesia, pain, paralysis and pulselessness Treatment $asciotomy surgical decompression of the affected compartment 0axillofacial Trauma

$ractures of facial bones can cause sudden, deadly air#ay obstruction and death MM9rimary concern after facial in-ury in to establish C maintain a patent air#ayKK <nly after primary survey, maxillofacial in-uries are assessed Loo" for facial symmetry then palpate to observe for any movement of bony structures This coincides #ith a head in-ury, so thorough neuro exam is indicated Careful assessment of ocular muscles C cranial nerve involvement &C, III, I5 C 5I' 0any in-uries re.uire multiple surgeries before patient is definitively treated 9lastic surgical consult for best body image Continuously assess neuro status, air#ay, relieve pain and anxiety Conclusion 9lease #ear your seatbelt 9lease stay a#ay from motorcycles 9lease be careful #hen driving an AT5 La#n mo#ers can be deadly 6e a#are of your environment and donAt travel alone, especially at night Anticipate #hat you #ould do if assaulted &0ace; !aid; ?histle;' LetAs all teach our young people that their ris"=ta"ing behaviors are not cool

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