Ureteral injuries: CT diagnosis.

Ureteral injury is a rare, yet very serious, complication of various abdominal, pelvic, and even spinal procedures. It is often clinically unsuspected as symptoms are nonspecific and the patient may present weeks and even months after the injury. Therefore the diagnosis of ureteral injury is often delayed, leading to more serious morbidity. A ureteral injury may be first diagnosed on CT in a patient evaluated after surgery. A high index of suspicion is essential and a CT study should then include a delayed scan in order to establish the diagnosis of ureteral injury resulting in a urinoma. This may obviate the need for additional invasive imaging studies or unnecessary exploration.     

Hypothermic cardiac arrest far away from the center providing rewarming with extracorporeal circulation

A transorbital penetrating intracranial injury is a rare and severe traumatic brain injury. Patients with this type of injury may present dramatically, but often the injury is subtle and therefore easily overlooked and not recognized in the first place. We present the case of a 45-year-old female admitted to the emergency department after she fell with her bike and the bicycle brake handle penetrated her left eye. A computerized tomography of the cerebrum showed a fracture of the superior orbital roof with multiple bone fragments extending into the brain near the circle of Willis. A pneumocephalus and traumatic frontobasal, intraventricular and subdural hemorrhage was seen. The patient deteriorated suddenly and was transferred to a neurosurgical center where she underwent an emergency craniotomy with evacuation of the intracerebral hematoma and an intraventricular drain was placed. After surgery, the patient’s condition deteriorated, and total compression of the brain stem occurred, upon which the patient was declared brain dead. Our case report shows that the Glasgow Coma Scale score at admission is not always a good predictor of the severity of the injury. Even when there is minimal suspicion of a penetrating intracranial injury, a computerized tomography should be performed immediately, independent of the patient’s Glasgow Coma Scale score. A direct transfer to a specialized neurosurgical center is recommended because this injury often results in death due to fatal complications such as intracerebral hemorrhage, pneumocephalus and brain stem injury.     

Splenic Rupture Manifesting Two Years after Diagnosis of Injury

The entity of delayed splenic rupture is often challenged. This case report describes a patient who presented with splenic rupture 2 years after a prior splenic injury from blunt trauma. The pathology report confirmed previous splenic injury. Delayed splenic rupture is possible for extended periods following splenic injury managed conservatively.     

Management of the agitated and aggressive head injury patient in an acute hospital setting

The agitated and aggressive head injury patient poses a challenge to the nurse because this recovery stage is often misunderstood. Behavior can be dramatic and frightening to the patient, family and health care professionals. This article discusses the behavior, nursing management, family education and pharmacologic interventions for the patient exhibiting agitated and aggressive behavior.     

Lower extremity peripheral nerve assessment

Lower extremity peripheral nerve function is essential for normal mobility and protection of the feet and legs from further trauma. The common causes of such injuries predispose the patient to a more serious injury and prolonged morbidity. It is therefore essential that a careful assessment be done as often as necessary to protect the patient from complications that may cause long-term disability.     

Decisions made by family members of patients with severe head injury

An acute injury in which a family member requires critical care creates a period of intense stress for families. During such time, family members are often faced with decisions about the patient or the family. The ability of families to make decisions during this stressful period is not addressed in the literature. The purpose of this study was to determine what decisions families made in the one-month period after a patient's admission. Families of patients with severe head injury were chosen because these families are often forced to make decisions quickly and to act as proxy decision-makers for the injured person. Nurses can make important contributions to assist family members in making decisions about the patient or the family. Nurses need to understand what decisions family members need to make and the circumstances surrounding the decision-making process to intervene appropriately.     

Back injury in primary care: three sides of the coin

Low-back pain is the most common job-related injury in the United States. This diagnosis is often accompanied by complexities that make effective treatment options varied and inconclusive. The primary care nurse practitioner who manages industrial injuries must consider 3 perspectives: the patient, the employer, and the practitioner providing care. This research study compares 2 treatment options: conservative and active physical rehabilitation for the patient with an acute first-time low-back injury. Recommendations are made for customizing treatment plans to individual practice settings.     

Fractures of the axis: a review of pediatric,adult, and geriatric injuries

Fractures of the second cervical vertebra (C2, axis) are common in adult spine surgery. Those fractures occurring in younger adult patients are often associated with high-energy mechanism trauma, resulting in a “Hangman’s Fracture.” Management of these fractures is often successful with nonoperative means, though surgery may be needed in those fractures with greater displacement and injury to the C2-C3 disc. Older patients are more likely to sustain fractures of the odontoid process. The evidence supporting surgical management of these fractures is evolving, as there may be a mortality benefit to surgery. Regardless of treatment, longer-term mortality rates are high in this patient population, which should be discussed with the patient and family at the time of injury. Pediatric patients may suffer fractures of the axis, though differentiation of normal and pathologic findings is necessary and more difficult with the skeletally immature spine.     

Patient restraints. Protection for whom?

Healthcare providers often face the decision of whether to restrain a patient. If the patient suffers an injury based on the decision not to restrain, will the provider be held liable? Healthcare providers express concern about the legalities of using restraints to prevent patient injuries and about which circumstances would be considered appropriate to restrain patients. This article presents case law that delineates what standard of nursing care generally must be breached before nurses will be held liable for injury from the use or nonuse of restraints. Policies and guidelines for consideration by nurse executives in the use of patient restraints are presented.     

Therapeutic positioning of the multiply-injured trauma patient in ICU

Critically-ill patients who have sustained multiple traumatic injuries have complex, and often conflicting, physiological needs. These have profound implications on the way in which nursing staff approach the physical positioning of these patients to minimize the risks of further physiological injury and damage, maintain homeostasis and promote optimum recovery. This article reviews and discusses the evidence base underpinning therapeutic positioning of the multiply-injured trauma patient within the intensive-care unit (ICU), focusing on patients with a known or suspected unstable spinal injury, pelvic injury, traumatic brain injury, chest injury, or multiple limb fractures. Included are guidelines on the therapeutic positioning of the multiply-injured trauma patient within the ICU, based on the current available evidence and also drawn from practical experience within the author's own place of work. There is also a brief discussion of how such guidelines may be introduced into clinical practice.     

Mild head injury in children: Identification,clinical evaluation,neuroimaging, and disposition

Pediatric head injury presents in various degrees of severity. Early intervention in the patient with a severe head injury is the key to preventing secondary central nervous system damage. Patients with a head injury are easily identified, often by clinical examination alone. However, patients with a mild head injury present a challenge to practitioners, particularly in identification, knowing what is important in the clinical evaluation, deciding whether to use neuroimaging, and knowing where to send the child for observation. Use of the Glasgow Coma Score, primary survey, and identification of historic and clinical features that are suggestive of severe head injury may guide pediatric nurse practitioners in providing appropriate medical care and disposition.     

Exploring the guidelines for the management of severe head injury.

A significant improvement in patient outcomes can be achieved by in-hospital interventions aimed at the prevention of secondary brain injury. The Guidelines for the Management of Severe Head Injury is a scientific, evidence-based document that evaluates the current evidence for practice and interventions to reduce secondary brain injury and improve outcome for traumatic brain injury (TBI) patients. The Guidelines covers a wide range of topics including trauma systems, oxygenation and blood pressure resuscitation, intracranial pressure monitoring, intracranial hypertension, nutrition, and pharmacological interventions for the severe TBI patient in the intensive care environment. Head injury care requires an interdisciplinary approach involving emergency room personnel, trauma nurses, and critical care nurses. Critical care nurses will find this document especially applicable because secondary brain injuries are often the result of events that occur in the ICU setting: hypoxemia, hypotension, and intracranial hypertension.     

The daunting task of "clearing" the cervical spine

The evaluation of the cervical spine in the emergency department is a common and often challenging task. We report the case of a 70-year-old female who presented intoxicated with evidence of a recent fall. A 64-slice computed tomographic (CT) scan with sagittal and coronal reconstructions revealed no acute injury. The patient was re-examined when alert and had persistent neck pain. Flexion-extension static views revealed severe subluxation of C5 on C6 with jumped facets, and subsequent magnetic resonance imaging confirmed significant ligamentous injury. The evidence available suggests that although CT with reconstruction is highly sensitive for clinically significant cervical injury, the possibility of severe injury remains.     

The Daunting Task Of "clearing" The Cervical Spine

ABSTRACTThe evaluation of the cervical spine in the emergency department is a common and often challenging task. We report the case of a 70-year-old female who presented intoxicated with evidence of a recent fall. A 64-slice computed tomographic (CT) scan with sagittal and coronal reconstructions revealed no acute injury. The patient was re-examined when alert and had persistent neck pain. Flexion-extension static views revealed severe subluxation of C5 on C6 with jumped facets, and subsequent magnetic resonance imaging confirmed significant ligamentous injury. The evidence available suggests that although CT with reconstruction is highly sensitive for clinically significant cervical injury, the possibility of severe injury remains.     

Cervical spondylosis

The "hard" cervical disc, a bony ridge resulting from periosteal activity, usually occurs in the patient with a previous neck injury. The "soft" disc is the bulging or extruded disc itself, often manifested by acute radicular pain in the younger patient. Causes of spondylotic myelopathy include a congenitally narrow spinal canal, disc degeneration and impaired vascularity. Disc syndromes include dysphagia and vertebral artery compression.     

The importance of maintaining spinal precautions

Spinal injuries are devastating, often leaving the patient paralyzed or with a permanent deficit. Aspiring athletes may not be able to persue their dreams secondary to a spinal injury; families are often left without a major wage earner to support them; and individuals are dependent upon others for the fulfillment of their basic needs. Education is essential for the prevention of primary and secondary spinal injuries; nurses play a key role in both these areas.     

Pulmonary problems following multiple trauma in children

Acute respiratory failure (ARF=hypoxemia and/or hypercapnia) is a frequent finding in the polytraumatized patient. Multiple injury is often accompanied by injury of the central nervous system, and the presence or absence of ARF may play a key role for survival and late morbidity. This paper reviews the incidence of pulmonary problems after severe head injury and the possible dysfunctions of the respiratory apparatus following single or multiple trauma. Diagnostic work-up in ARF includes consideration of the mechanisms of injury, clinical examination, determinations of arterial blood gases and chest radiographs which are all essential for the choice of an effective treatment. This frequently includes supportive treatment by continuous positive pressure ventilation.     

Pulmonary problems following multiple trauma in children

Acute respiratory failure (ARF=hypoxemia and/or hypercapnia) is a frequent finding in the polytraumatized patient. Multiple injury is often accompanied by injury of the central nervous system, and the presence or absence of ARF may play a key role for survival and late morbidity. This paper reviews the incidence of pulmonary problems after severe head injury and the possible dysfunctions of the respiratory apparatus following single or multiple trauma. Diagnostic work-up in ARF includes consideration of the mechanisms of injury, clinical examination, determinations of arterial blood gases and chest radiographs which are all essential for the choice of an effective treatment. This frequently includes supportive treatment by continuous positive pressure ventilation.     

In patients with head injuries who undergo rapid sequence intubation using succinylcholine,does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review

A literature search was undertaken for evidence of the effect of succinylcholine (SCH) on the intracranial pressure (ICP) of patients with acute brain injury and whether pretreatment with a defasciculating dose of competitive neuromuscular blocker is beneficial in this patient group. The authors could find no definitive evidence that SCH caused a rise in ICP in patients with brain injury. However, these studies were often weak and small. For those patients suffering acute traumatic brain injury the authors could find no studies that investigated the issue of pretreatment with defasciculating doses of competitive neuromuscular blockers and their effect on ICP in patients given SCH. There is level 2 evidence that SCH caused an increase in ICP for patients undergoing neurosurgery for brain tumours with elective anaesthesia and that pretreatment with defasciculating doses of neuromuscular blockers reduced such increases. It is unknown if this affects neurological outcome for this patient group.     

Blunt traumatic rupture of the pericardium with cardiac herniation

Traumatic rupture of the pericardium with cardiac herniation is rare. Clinicians are often unfamiliar with the clinical and radiological manifestations of the injury, and the diagnosis is frequently missed preoperatively. This case report describes a patient with multiple trauma following a fall from a height, who developed this injury. The diagnosis was not made preoperatively despite suggestive clinical, electrocardiographic and radiological findings. Clinicians need to be aware of the presentation of this potentially fatal injury so that the diagnosis can be made and treatment instituted at an earlier stage. Pericardial rupture with cardiac herniation presents as cardiogenic shock, mimicking cardiac tamponade.