10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 491 J Wound Ostomy Continence Nurs. 2006;33(5):491-500. Published by Lippincott Williams & Wilkins O OSTOMY CARE When Trauma Means a Stoma Susan E. Steele Trauma is a leading cause of death and disability. When trau- injuries were sustained can assist the nurse in planning care matic injuries require ostomy surgery, the wound, ostomy, and and identifying the potential for complications during the continence nurse acts as a crucial part of the trauma team. This recovery period. Traumatic injuries occur when the human literature review describes mechanisms of injury associated body is exposed to physical forces causing tissue destruc- with creation of a stoma, key aspects of wound, ostomy, and tion. In most trauma situations, the physical forces are continence nursing care in trauma populations and presents kinetic in nature, and injury occurs when the energy of suggestions for future research. movement is transformed into other forms of energy, such as compression, shearing, and cavitation.4 Trauma nurses categorize mechanisms of injury into two broad cate- rauma affects all ages, races, and socio-economic classes gories: blunt injuries in which the skin surface is unbroken Tand ranks globally as a leading cause of morbidity and and penetrating injuries, which include a break in the skin mortality for all age groups except for persons aged 60 years integrity.5,6 In both mechanisms of injury, the mass of the or older.1 In 2003, more than 105,000 deaths in the United object striking the body and the velocity of the strike de- States were attributed to unintentional injuries.2 In that termine the amount of kinetic energy to which the body is same year, nearly half a million U.S. hospital discharges subjected and therefore the amount of damage. were attributed to injury treatment, with an estimated ag- gregate cost of over $8 billion.3 When an injured individual Blunt requires ostomy surgery, the wound, ostomy, and conti- Blunt trauma comprises the largest majority of nonmilitary nence (WOC) nurse becomes an integral part of the trauma injuries. The most common sources of blunt trauma in the team. United States are motor vehicle crashes (MVC) and falls. Working with trauma patients provides many unique These two categories comprised nearly 70% of all traumas challenges. Often, adaptation of both pouching techniques reported to the National Trauma Data Bank till 2003.7 and educational strategies is necessary to effect successful rehabilitation. During the recovery period, the trauma pa- tient is dependent upon a number of different profession- als to meet his or her needs, and the WOC nurse must The most common sources of blunt trauma collaborate with a team of specialist physicians, nurses, re- in the United States are motor vehicle habilitation therapists, social workers, and mental health crashes and falls. professionals. Although family involvement may occur to some degree with all ostomy patients, the family of a trauma patient may become overwhelmed with fear, grief, Blunt trauma may result in tearing, crushing, or rupture and anger, impairing ability to support the rehabilitation of internal abdominal organs.5 When an individual in mo- process. Trauma recidivism, the phenomenon of patients tion suddenly stops, deceleration causes shearing and tear- who repeatedly sustain trauma, may provoke feelings of ing of internal organs. The abdominal wall and the spine or anger and frustration in the WOC nurse, and repeated ex- posure to the stories and affect of trauma survivors can im- pose tremendous stress upon the nurse. Ⅲ Susan E. Steele, MS, RN, CWOCN, is WOC Clinical Nurse Specialist, Bayfront Medical Center, St. Petersburg, Florida, and a Doctoral Student, University of South Florida College of Nursing, ■ Mechanisms of Injury Tampa, Florida. Correspondence: Susan E. Steele, MS, RN, CWOCN, 376 18th Avenue Knowledge of the mechanism is critical to the care of a Northeast, St. Petersburg, FL 33704 (e-mail: susan.steele@bayfront. trauma patient with an ostomy. An understanding of how org). Copyright © 2006 by the Wound, Ostomy and Continence Nurses Society J WOCN ■ September/October 2006 491 10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 492 492 Steele J WOCN ■ September/October 2006 posterior ribs exert crushing forces on intrabdominal or- resulting in fecal contamination. A more recent trend in the gans, and if there is a sudden rise in the intrabdominal pres- surgical treatment of abdominal trauma is the use of dam- sure, hollow organs, such as the colon, may rupture.4 There age control or staged laparotomy. This approach requires an is some anecdotal evidence that traumatic intestinal rup- initial laparotomy for the control of contamination and he- ture may be more likely in individuals suffering from in- morrhage, an intensive care unit stay for hemodynamic, flammatory bowel disease.8 Although the ribs, sternum, and thermal, and ventilatory stabilization, and a second surgery pelvis normally serve to protect vital organs, a displaced for definitive abdominal repairs and wound closure.10,11 The fracture incurred from blunt trauma in these bones may re- impact of this approach on the overall survival is not clear. sult in severe organ injury. Johnson and associates12 identified a significant difference in the mortality between a cohort of 24 damage control pa- Penetrating tients and historical controls. Acensio and associates13 re- Penetrating trauma comprises a small percentage of all civ- ported no difference in mortality rates but did identify a ilian traumas. The high incidence in military combat in- decrease in the use of blood products, intensive care unit, juries and the successful treatment of penetrating injury and hospital days, and incidence of abscess and infection with diverting colostomy during World War II were re- with damage control surgery. However, bowel edema and sponsible for its acceptance as the primary treatment for abdominal compartment syndrome pose significant post- 14,15 penetrating colon trauma for the second half of the 20th operative complications with this approach. Various century.9 Penetrating trauma occurs most often as a result techniques for the management of open abdomen and fas- 16 of interpersonal violence such as gunshot, stabbing, or sex- cial closure have been identified in the literature, and there is evidence that the use of vacuum-assisted closure results in ual assault, and impalement from MVC. Perforation of early successful closure of the abdominal defect with less solid organs, such as the liver or spleen, results in bleeding ventral herniation.17,18 Regardless of the management and hypovolemia. If bowel is perforated, peritonitis and in- method chosen, the open abdomen in combination with a fection are potential life-threatening consequences. fecal diversion stoma presents significant challenges to the WOC nurse in attaining and preserving an intact pouch seal. Although previously considered the standard of care for penetrating abdominal trauma, the need for fecal diversion Penetrating trauma occurs most often as a has been repeatedly challenged in the past 2 decades. A sub- result of interpersonal violence. stantial body of evidence supports the use of primary repair over fecal diversion for penetrating colon injuries in both adult9,19-22 and pediatric trauma,23 primarily due to a higher incidence of infection in patients with a stoma.24 Delay Cavitation occurs whenever external kinetic forces dis- in performing primary repair does not preclude this ap- place tissues. In penetrating trauma, the cavitation becomes proach,25 and the approach has been deemed safe and ef- permanent as a hole is formed within the skin and the tis- fective even when studied with subjects sustaining war sues. The extent of cavitation depends upon the velocity injuries26 and in trauma within a developing nation.27 with which the object penetrates into the skin, the size of the object, and the path taken by the object after entering Pelvic Trauma 4 the body. Often, the full extent of injury is impossible to The bladder and the rectum, both well protected by the determine by external visual inspection, and surgical ex- bony pelvic ring, are rarely injured by blunt trauma in the ploration is necessary to assess and control the damage. absence of pelvic fracture. Surgical treatment is not usually necessary. Intraperitoneal bladder rupture caused by a sud- ■ Anatomical Location of Injury den, forceful blow to the lower abdomen or pelvis, results in an increased intravesical pressure and rupture of the weak- To properly educate, counsel, and rehabilitate the patient, est portion, the dome of the bladder. Approximately 15% a WOC nurse must also be aware of the anatomical location of all bladder ruptures in adults occur in this manner,28 of the injury that results in ostomy surgery. Three general although chronic alcohol abuse has been linked to intra- anatomic sites of trauma may result in urgent ostomy sur- peritoneal bladder rupture in minor blunt trauma.29 The gery: abdominal, pelvic, and perineal. In addition, spinal currently accepted standard of care for bladder dome rupture cord injury may be treated on a long-term basis with fecal is the operative repair with absorbable suture and postoper- or urinary diversion for the management of neurogenic ative drainage with urethral and suprapubic catheters;30-32 bowel and/or bladder. Each anatomical region is associated however, successful nonoperative management in children with challenges that complicate pouching