Emergency Nursing~~~~~~~ Scope and Practice of Emergency Nursing
Emergencymanagement ± refers to urgent and critical care needs; however, the ED has increasingly been used for non-urgent problems, and emergency management has broadened to include the concept that an emergency is whatever the patient or family considers it to be
The emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations
Priority Emergency Measures for All Patients: Make safety the first priority Preplan to ensure security and a safe environment Closely observe patient and family members in the event that they respond to stress with physical violence Assess the patient and family for psychological function Patient and family-focused interventions ±
±
± ±
Relieve anxiety and provide a sense of security Allow family to stay with patient, if possible, to alleviate anxiety
Provide explanations and information Provide additional interventions depending upon the stage of crisis
Types of Emergency:
The types of emergencies indicated and their definitions, with the exception of terrorism, were selected in accordance with the categories for which the Centers for Disease Control and Prevention (CDC) provide specific emergency response and prevention information.
A. Bioterrorism - refers to the deliberate release of viruses, bacteria, or other agents used to cause illness or death in people, animals, or plants. These agents can be spread through the air, water, or in food. B. Chemical emergencies - occur when a hazardous chemical is released and the release has the potential for harming people s health. Chemical releases can be unintentional such as an industrial accident, or intentional such as in the case of a terrorist attack. C. Mass Casualties - refer to incidents such
as fires, explosions, mass transit accidents such as train crashes or bridge collapses that cause numerous deaths and injuries.
D. Natural Disasters - refer to such natural occurrences as earthquakes, extreme heat, floods, hurricanes, landslides and mudslides, tornadoes, tsunamis, volcanoes, wildfires, and winter weather. E. Outbreaks - refer to flu epidemics, viruses, or other contagious diseases; also could include food-borne outbreaks such as salmonella or E. coli. F. Radiation - emergency could be a nuclear power plant accident or a terrorist event such as a dirty bomb or nuclear attack, which would expose people to significantly higher levels of radiation than are typical in daily life, leading to health problems such as cancer or even death. G. Terrorism - refers to a deliberate act of murder and destruction which disrupts infrastructure and is directed towards civilians with the aim of meeting political ends.
Triage
Triage sorts patients by hierarchy based on the severity of health problems and the immediacy with which these problems must be treated collects data and classifies the illnesses and injuries to ensure that the patients most in need of care do not needlessly wait Protocols may be initiated in the triage
area ED triage differs from disaster triage in that patients who are the most critically ill receive the most resources, regardless of potential outcome trier - to sort To sort patients in groups based on the severity of their health problem and the immediacy with which these problems must be addressed
Triage in the E.R. Berner s 1. Emergent Patients have the highest priority
With life-threatening condition
2. Urgent Patients with serious health problems Not life-threatening, MUST be seen in 1 hour 3. Non-urgent Episodic illness that can be addressed within 24 hours Triage in DISASTER! NATO 1. Immediate 2. Delayed 3. Minimal 4. Expectant
Establishing an airway
Airway Obstruction~~~~~~~ Acute upper airway obstruction is a lifethreatening medical emergency
Pathophysiology
Airway may partially or completely occluded Partial can lead to progressive hypoxia, hypercarbia & resp & cardiac arrest Complete causes permanent brain injury, death will occur within 3 to 5 minutes secondary to hypoxia. ± ±
Air movement is absent Oxygen saturation rapidly decreases
Causes Aspiration of foreign body Anaphylaxis Viral or bacterial infection Trauma Inhalation or chemical burns Narcotic analgesic (morphine) in elderly
Repositioning the head to prevent hypopharyngeal obstruction
Abdominal thrusts ± Elevating diaphragm can force air from the lungs to create artificial cough intended to expel foreign object Head tilt chin lift manuever Jaw thrust maneuver Oral airway/ intubation
Inserting an oropharyngeal airway
Measure the oral airway alongside the head. The airway should reach from lip to ear.
Extend the patient s head by placing one hand under the bony chin. With the other hand, tilt the head back ward by applying pressure to the forehead while simultaneously lifting the chin forward.
Open patient mouth Insert oral airway, rotate the tip 180 degree to displace the tongue
depresses the respiratory center
Diseases affecting motor coordination (Parkinson) Mental dysfunction (dementia ) Asphyxiation by food In Adult aspiration of a bolus meat : most common Small toy in children Peritonsillar abscess epiglotitis
Clinical Manifestation
Cannot speak, breath, or cough. The patient may clutch the neck between thumb and fingers. Choking Apprehensive appearance Inspiratory & expiratory stridor Labored breathing Suprasternal & intercostal retraction Flaring nostrils Increase anxiety, restlessness and confusion. Cyanosis LOC as hypoxia worsen
Assessment and Diagnostic Findings Ins pection Laryngoscopy X-rays br onchos copy Management Partial: encourage the patient to cough forcefull Complete: After removal of obstruction if no pulse (CPR)
Indication
To establish an airway for a patient who cannot be adequately ventilated. To bypass an upper airway obstruction. To prevent aspiration T o permit connection to ambubag or
mechanical ventilator To facilitate removal of tracheobronchial secretions LARYNGEAL
OBSTRUCTION: Edema of the larynx is a serious fatal condition. Swelling of the laryngeal mucous
membrane, may close off the opening tightly leading to suffocation.
ETIOLOGY:
Rarely occurs in patients with acute laryngitis, occasionally with urticaria & more frequently in patients with severe inflammations of the throat as in scarlet fever. It is am occasional cause of death in severe anaphylaxis (angioneuritic edema).
Foreign bodies frequently are aspirated into the pharynx, the larynx or trachea & cause a two-fold problem, FIRST, they obstruct the air passageways & cause difficulty in breathing w/c may lead to asphyxia. SECOND, the FB may later be drawn farther down, entering the bronchi or a bronchial branch and causing symptoms of irritation, croupy cough, expectoration of blood or mucus or labored breathing.
MEDICAL MANAGEMENT:
When allergy is the etiology, administering
SQ epinephrine or a corticosteroid and applying an ice pack to the neck is done.
Hemorrhage~~~~~~~~~~~~
Hypotension
can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities or side effects of medications and anesthetics
Most Common Cause: loss of circulating volume thru blood and plasma loss.
If the amount of blood loss exceeds 500m L, replacement is usually indicated
Shock can result from hypovolemia. This is described as inadequate cellular oxygenation accompanied by the inability to excrete waste products of metabolism
Types of SHOCK:
Hypovolemic shock:
characterized by a fall in venous pressure, a rise in peripheral resistance and tachycardia, pale, cool diaphoretic skin, poor capillary refill, poor urine output
EarliestSign: Tachycardia Can be avoided by thetimely administration of IVF, blood products and medications that elevate blood pressure
INTERVENTION: volume replacement is the primary intervention for shock, with administration of cardiotonic drugs, proper patient positioning, vital sign monitoring Blood By-product
is extreme blood loss. A patient is this situation is apprehensive, restless and thirsty, the skin is cold, moist and pale, PR increases, temperature falls and respirations are rapid and deep (air hunger) if hemorrhage is not treated CO decreases, BP and Hgb/Hct decreases CLASSIFICATION OF HEMORRHAGE: see tables
Whole Blood
Management
Platelet Replace platelet 1unit=50ml usually 6 to 9 units or one single donor unit (250-300ml) are infused
FLUID REPLACEMENT ± Isotonic electrolyte solution such as lactated ringers, normal saline
BT
± ±
±
Colloid and blood component Packed RBC when there is massive blood loss
Additional platelets clotting factors are given when large amts of blood are needed, because packed RBC lacks clotting factor
Control of external hge:
Direct firm pressure If extremity immobilized to control blood loss Tourniquet is applied to an extremity only as a last resort, when the bleeding cannot be controlled in any other way and immediate surgery is not feasible.
Hypovolemic Shock
1unit=450ml(+50ml) Deficient in platelet & clotting factor V, VIII, XI
Rarely use Packed RBC 1unit= 300ml(+50ml) No platelet or clotting factor Can mixed with NS to infuse faster
Fresh Frozen Plasma Replaces clotting factor 1unit=200-250ml No R BC /W BC /Platelet
Cryoprecipitate Replaces fibrinogen & some clotting factor
1unit= 10 to 15ml CHANGES OCCUR INSTORAGE OF
WHOLE BLOOD
- Dec Ca, inc K, dec 2,3 DPG, inc H(dec pH), dec clotting factor V,VII,XI, dec PMN s
Neurogenic Shock: a less common cause of shock in the surgical patient, occurs as a result of decreased arterial resistance caused by spinal anesthesia Inadequate tissue perfusion due to loss of sympathetic vasoconstrictive reflexes There is fall of BP
Cardiogenic Shock: Unlikely to occur in a surgical patient except if the patient has severe pre-existing cardiovascular disease or experienced AMI during surgery. S/SX: dyspnea, Rales, gallop rhythm Anaphylactic Shock: Inadequate tissue perfusion due to increased vascular permeability; vasodilatation, smooth muscle constriction, as a result of exposure to an allergen in a previously sensitized patient S/SX: urticaria/angioedema, laryngeal edema Septic Shock: Decreased vascular resistance, decreased intravascular volume, causing increased capillary permeability, microvascular pooling and cardiac dysfunction Causes: Gram-negative microbes (E. coli, B. fragilis) S/SX: fever, hyperventilation, hyperglycemia, leukocytosis CLASSIC SIGNS OF SHOCK: pallor cool moist skin rapid breathing cyanosis- circumoral rapid, weak, thready pulse decreasing pulse pressure low BP and concentrated urine Management
Patent airway Fluid replacement ( rapid rate) ± IV infused at rapid rate until systolic blood prssure or CVP increases to satisfactory level ±
CVP
Lactated
Ringer s : bec it approximate plasma electrolyte composition osmolality
Serve as guide for fluid replacement Bloodcomponent Indwelling urinary catheter ± To record urinary output every hour ± Urine output indicates adequacy of kidney perfusion ±
WOUND~~~~~~~~~~~~~ 3 Phases of wound healing:
Inflammatory: Vasoconstriction, increased capillary permeability, Migration of cells
Proliferative: Macrophage migration, Fibroblast proliferation, epithelial maturation, Collagen formation Maturation phase: at 3 weeks the wound is said to be essentially healed MECHANISMS OF WOUND HEALING: First- Intention Healing (Primary Wound Healing)
wounds made aseptically with minimum tissue destruction
Granulation tissue is not visible and scar formation is minimal
Inflammatory phase lasts only for 1 week Post-operatively this type of wound is covered with dry sterile dressing Closure of the wound allows for the best result.
If a cyanoacrylate tissue adhesive is used a dressing is contraindicated
Second-Intention Healing (Secondary Healing)
Granulation occurs in infected wounds in which edges have not been approximated. There is large tissue defect that must be filled
GRANULATION TISSUE: a proliferation of fibroblasts and vascular endothelial cells formed 3-4 days after surgery/injury. Characterized by often edematous pinkish, and soft in appearance. Histologic features: Angiogenesis and fibroblast proliferation Healing is complete when the epithelial cells/ skin cells grow over these granulations. Skin contraction may result When the post-operative wound is allowed to heal by this mechanism, it is usually packed with saline moistened sterile dressings and covered with a dry sterile dressing Some wound are too large necessitating skin grafts Third- Intention Healing (Tertiary closure/ Delayed primary closure): Used for deep wounds that have either not been sutured early or that breakdown and are re-sutured later, thus bringing together 2 apposing granulation surfaces This results in a deeper, wider scar.
Wounds that are heavily contaminated
and are likely to develop an infection if closed may be left open for 3-5 days.
The wounds are packed postoperatively with moist gauze and covered with dry sterile dressing
FACTORS AFFECTING WOUND HEALING: ± age of patient ± handling of tissue ± hemorrhage and hypovolemia ± Edema ± Inadequate dressing technique ± Nutritional deficits ± Foreign body ± O2 deficit ± Drainage accumulation ± Medications ± Patient over activity ± Systemic disorders( hypoxia, acidosis, Renal and hepatic failure)
± ±
Immunocompromisedstate Wound stressor
TRAUMA--------------------------
or injury has been defined as damage to the body caused by an exchange with environmental energy that is beyond the body's resilience.
most common cause of death for individuals between the ages of 1 and 44 years, and the third most common cause of death for all ages.
accomplished with a hard (Philadelphia) collar or sandbags on both sides of the head taped to the backboard.
Patients who are conscious and have a normal voice do not require further evaluation or early attention to their airway.
Exceptions to this principle include patients with penetrating injuries to the neck and an expanding hematoma, evidence of chemical or thermal injury to the mouth, nares, or hypopharynx, extensive subcutaneous air in the neck, complex maxillofacial trauma, or airway bleeding.
These patients initially may have a satisfactory airway, but it may become obstructed if soft tissue swelling or edema progresses. In these cases, elective intubation should be performed before evidence of airway compromise is apparent.
Patients who have an abnormal voice or altered mental status require further airway evaluation.
Direct laryngoscopic inspection often reveals blood, vomit, the tongue, foreign objects, or soft tissue swelling as sources of airway obstruction. Suctioning can offer immediate relief in many patients. Altered mental status is the most common indication for intubation because of the patient's inability to protect the airway. Options for airway access include nasotracheal, orotracheal, or operative intervention.
INITIAL EVALUATION AND RESUSCITATION OF If intubation have failed because of extensive THE INJURED PATIENT facial injuries require a surgical airway Treatment of trauma patients often begins in Cricothyroidotomy the field by emergency medical services (EMS) personnel and completed by rehabilitation specialists. The initial treatment of seriously injured patients consists of a primary survey, resuscitation, secondary survey, diagnostic evaluation, and definitive care The ATLS course refers to this as the primary survey or the ABCs-Airway, with cervical spine protection, Breathing, and Circulation. ± Any life-threatening problem identified in the initial survey must be treated before advancing. Primary Survey A = airway B = Breathing C = Circulation Airway Management
Ensuring an adequate airway is the first priority in the primary survey. Efforts to restore cardiovascular integrity will be futile if the oxygen content of the blood is inadequate. All blunt-trauma patients require cervical spine immobilization until injury is ruled out. This can be
Breathing
Once a secure airway is obtained, adequate oxygenation and ventilation must be assured. All injured patients should receive supplemental oxygen therapy and be monitored by pulse oximetry. The following conditions may constitute an immediate threat to life because of inadequate ventilation: (1) tension pneumothorax, (2) open pneumothorax, or (3) flail chest/pulmonary contusion.
These diagnoses can be made with a combination of physical examination and chest x-ray.
Flail Chest:
Tension pneumothorax
Respiratory distress in combination with any of the following physical signs:tracheal deviation away from the affected side; lack of or decreased breath sounds on the affected side; distended neck veins or systemic hypotension; or subcutaneous emphysema on the affected side.
Immediate tube thoracostomy is indicated In tension pneumothorax the collapsed lung pressure becomes positive, depressing the ipsilateral hemidiaphragm and forcing the mediastinal structures into the contralateral chest. The contralateral lung is then compressed, and the heart is rotated about the superior and inferior venae cavae, decreasing venous return and cardiac output while distending the neck veins.
Open pneumothorax
or sucking chest wound occurs with fullthickness loss of the chest wall, permitting a free communication between the pleural space and the atmosphere.
Proper treatment in the field involves placing an occlusive dressing over the wound, which is taped on three sides. The occlusive dressing permits effective ventilation on inspiration while the untaped side allows accumulated air to escape from the pleural space, preventing a
Circulation With a secure airway and adequate ventilation
established, circulatory status is determined. A rough first approximation of the patient's cardiovascular status is obtained by palpating peripheral pulses. A systolic blood pressure of 60 mmHg is required for the carotid pulse to be palpable, 70 mmHg for the femoral pulse and 80 mmHg for the radial pulse. At this point in the patient's treatment, hypotension is assumed to be caused by hemorrhage. Blood pressure and pulse should be measured at least every15 min. External control of hemorrhage should be obtained before restoring circulating volume. tension pneumothorax. Definitive treatment Manual compression and splints frequently requires wound closure and tube control extremity hemorrhage as effectively as thoracostomy. tourniquets and with less tissue damage. Blind clamping should be avoided because of the risk to adjacent structures, particularly nerves. Flail chest Digital control of hemorrhage for penetrating Flail chest occurs when four or more ribs are injuries of the head, neck, thoracic outlet, groin, fractured in at least two locations. Paradoxical and extremities should be done with a gloved movement of this free-floating segment of finger placed through the wound directly on the chest wall may be sufficient to compromise bleeding vessel applying only enough pressure ventilation to control active bleeding.
Scalp lacerations through the galea aponeurotica tend to bleed profusely; these can be temporarily controlled with Rainey clips or a full-thickness large nylon continuous stitch.
falsely elevated if the patient is agitated and straining.
Blood should be drawn simultaneously and sent for typing and hematocrit measurement.
Tension pneumothorax is the most frequent cause of cardiac failure.
Intravenous access for fluid resuscitation is begun with two peripheral catheters, 16gauge or larger in an adult.
For patients requiring vigorous fluid resuscitation, saphenous vein cutdowns at the ankle or percutaneous femoral vein catheter introducers are preferred.
Venous access in the lower extremities
provides effective volume resuscitation in cases of abdominal venous injury.
In trauma patients the differential diagnosis of cardiogenic shock is indicated by: (1) tension pneumothorax, (2) pericardial tamponade, (3) myocardial contusion or infarction, and (4) air embolism.
Traumatic pericardial tamponade is most often associated with penetrating injury to the heart. As blood leaks out of the injured heart, it accumulates in the pericardial sac. The classic findings of Beck's triad (hypotension, distended neck veins, and muffled heart sounds)
Secondary Survey
When the conditions that constitute an
immediate threat to life have been attended to or excluded, the patient is examined in a systematic fashion to identify occult injuries.
Initial Fluid Resuscitation
Initial fluid resuscitation is a 1-L intravenous bolus of normal saline, lactated Ringer's solution, or other isotonic crystalloid in an adult, or 20 mL/kg of body weight lactated Ringer's solution in a child. fluid resuscitation is to reestablish tissue perfusion.
Classic signs and symptoms of shock are tachycardia, hypotension, tachypnea, mental status changes, diaphoresis, and pallor.
Normalization of vital signs, clearing of the sensorium, evidence of good peripheral perfusion (warm fingers and toes with normal capillary refill ) are presumed to have adequate perfusion. Urine output is a quantitative and relatively reliable indicator of organ perfusion. Adequate urine output is 0.5 mL/kg/h in an adult, 1 mL/kg/h in a child, and 2 mL/kg/h in an infant less than 1 year of age.
Persistent Hypotension
CVP determines right ventricular preload; in otherwise healthy trauma patients, its measurement yields objective information regarding the patient's overall volume status. A hypotensive patient with flat neck veins and a CVP less than 5 cmH2O is hypovolemic and is likely to have ongoing hemorrhage. A hypotensive patient with distended neck veins or a CVP more than 15 cmH2O is likely to be in cardiogenic shock. The CVP may be
Special attention should be given to the patient's back, axillae, and perineum because injuries in these areas are easily overlooked.
Patients should undergo digital rectal examination to evaluate sphincter tone and to look for blood,perforation, or a high-riding prostate. A Foley catheter should be inserted to decompress the bladder, obtain a urine specimen, and monitor urine output.
A nasogastric tube should be inserted to decrease the risk of gastric aspiration and allow inspection of the contents for blood suggestive of occult gastroduodenal injury.
Regional Assessment and
Special Diagnostic Tests Head
± A score based on the GlasgowComa Scale (GCS) should be determined for all injured patients. It is calculated by adding the scores of the best motor response, best verbal response, and eye opening. Scores range from 3 (the lowest) to 15 (normal). Scores of 13 to 15 indicate mild head injury, 9 to 12, moderate injury, and less than 9, a severe injury. ± The GSC is useful for triage and prognosis.
presence of lateralizing findings are important, e.g., a unilateral dilated pupil unreactive to light, asymmetric movement of the extremities either spontaneously or in response to noxious stimuli, or a unilateral
Babinski's reflex suggest a treatable intracranial mass lesion or major structural damage.
Otorrhea, rhinorrhea, raccoon eyes, and Battle's sign (ecchymosis behind the ear) can be seen with basilar skull fractures. head and face should be systematically palpated for fractures.
Cerebral pathologic lesions from blunt trauma include hematomas, contusions, hemorrhage into ventricular and subarachnoid spaces
± grossly positive if more than 10 m L of free blood can be aspirated after insertion of the catheter.
If less than 10 mL is withdrawn, 1 L of normal saline solution is instilled and the patient is gently rocked from side to side and up and down. ±
Pelvis
CT scan, plain skull films Neck
± Attention should be focused on signs and symptoms of an occult cervical spine injury. Because of the devastating consequences of quadriplegia
plain x-rays reveal gross abnormalities, but CT scanning may be necessary to assess the pelvis for stability. Sharp spicules of bone can lacerate the rectum or vagina. ±
Zone of the Neck Zone I is between the clavicles and the cricoid cartilage, and is also referred to as the thoracic outlet. Zone II is between the cricoid cartilage and the angle of the mandible. Zone III is above the angle of mandible. Chest
Blunt trauma to the chest may involve the chest wall, thoracic spine, heart, lungs, thoracic aorta and great vessels, and the esophagus. ±
Most of these injuries are assessable by physical examination and chest x-ray. ±
most threatening occult injury in trauma surgery is a tear of the descending thoracic aorta. ±
Abdomen
most authorities agree that the presence of abdominal rigidity or gross abdominal distention in a patient with truncal trauma is an indication for prompt surgical exploration. Diagnostic peritoneal lavage (DPL) remains the most sensitive test available for determining the presence of intraabdominal injury For stab wounds to the abdomen, its sensitivity for detecting intraabdominal injury exceeds 95 percent. ±
The results of DPL are
± The finding of gross blood on digital examination strongly suggests injury to these organs.
The bladder can be lacerated by sharp fracture fragments, or, if the bladder is full, a direct blow to the hypogastrium can generate sufficient intravesicular pressure to cause rupture. ±
Gross blood on urinalysis ± Urethral injuries are suspected by the findings of blood at the meatus, scrotal or perineal hematomas, and a high-riding prostate on rectal examination. ±
Extremities ± Injury of the extremities from any cause requires plain x-ray films to evaluate fractures. Transfusion packed red blood cells (pRBC), freshfrozen plasma (FFP), and platelet packs. Not all trauma patients requiring transfusions receive all three components. Most trauma patients receive between
1 and 5 units of pRBC and no other components, but major trauma centers have the capability of transfusing tremendous quantities of blood components.
Intra AbdominalInjuries Category
Penetrating: GSW, SW Blunt Trauma: VA, Fall, blow, explotion
Penetrating Injury to hollow organs Small bowel Liver the most common solid organ affected GSW velocity is a factor, high velocity create
Priorities of Care for the Patient With Multiple Trauma Use a team approach Determine the extent of injuries and establish priorities of treatment Assume cervical spine injury Assign highest priority to injuries interfering with vital physiologic function
extensive tissue damage
All GSW that crosses the peritoneum may require surgical exploration Blunt
Usually associated with extra abdominal injury to the chest, head, or extremities
Difficulttodetect The incidence of delayed trauma related complication is greater than penetrating injuries
Common organ injured liver, kidney, spleen, blood vessels
May cause massive blood loss into the peritoneal cavity
Assessment
Inspection: bruises, abrasions, abdominal distention
Auscultation: bowel sound Palpation: involuntary guarding, tenderness, pain, muscle rigidity or rebound tenderness,
shock
Management of Patients With Intra-Abdominal Injuries
Blunt trauma or penetrating injuries Abdominal trauma can cause massive lifethreatening blood loss into abdominal cavity
Assessment ± Obtainhistory ± Perform abdominal assessment and assess other body systems for injuries that frequently accompany abdominal injuries Assess for referred pain that may indicate spleen, liver, or intraperitoneal injury
Perform laboratory studies, CT scan, abdominal ultrasound (FAST), and diagnostic peritoneal lavage Assess stab wound via sonography Ensure airway, breathing, and circulation Immobilize cervical spine Continually monitor the patient Document all wounds If viscera are protruding, cover with a
sterile, moist saline dressing Hold oral fluids NG to aspirate stomach contents Provide tetanus and antibiotic prophylaxis Provide rapid transport to surgery if indicated
Priorities in the Management of the Patient With Multiple Injuries
TRAUMA to the GIT: -
Penetrating trauma: most commonly injured organ is the LIVER
Blunt trauma: the most commonly affected organ is the SPLEEN , others kidneys, blood vessels - DX: diagnostic peritoneal lavage, HX, PE, abdominal xray, CT scan, - DPL after instillation of I liter saline, >100,000 cubic meter/of RBC, > 500/cubic meter of WBC, presence of the food, fecal matter. Presence of bile,feces or food -
Crush Injury Run over a moving vehicle, compressed by machine, crushed between 2 cars, crushed under collapse building Shock Paralysis of body part involve Erythema, blister Renal dysfxn due to hypotension
Management ABC Observed acute renal isufficiency ( may damage the kidney)
Slint to control bleeding Monitor lactic acid if less than 2.5mmol/L indication for successful resuscitation Elevate extremity to relieve swelling and pressure
Fasciotomy to restore neurovascular function
Pain medication Stat surgery for wound debridement and fracture repair
Hyperbaric oxygen for hyperoxygenation of
injured tissues
Pulseless: repositioning to proper alignment is required
Fractured hip/ femur are pulseless Hare traction is use ± A portable in line traction device to assist alignment
If ineffective in restoring pulse stat OR for arteriography and possible arterial repair
Splints is applied before the px is moved Splinting immobilizes the joint at a site distal and proximal to the fracture, relieves pain, restores or improves circulation, prevents further tissue injury, and prevents a closed fx from becoming an open one To splint an extremity one hand is placed distal to the fx and some traction is applied while the other hand is placed beneath the fx for support. The splints should extend beyond the joints adjacent to the fracture
Fracture~~~~~~~~~~~~~~~~ Types
Close fx ± Intact skin over fx or hematoma Openfx ± Wound overlying fx ± High risk for infection Simple fx ± One fx line, 2 bone fragment Comminuted ± more than 2 bone fragment ± fragmentation Transverse ± fx line perpendicular to long bone Oblique ± Fx line creates an oblique angle with long axis of bone
Spiral
±
Severe oblique fx w/c plane rotates along the long bone axis caused by a twisting injury
Pathologic ± Fx through abn bone, ex osteoporotic bone, tumor laden
Greenstick ± incomplete fx in w/c cortex on only side is disrupted Assessment Handle body part gently and as little as possible Clothing is cut off to visualize the affected body part Assessment is conducted for pain over or near a bone, swelling, and exudates Assess echymosis, tenderness, crepitation
Management
ABC Evaluate neurologic or abdominal injuries before extremity is treated, unless pulseless extremity is detected
Upper extremities must be splinted in a functional position Open fracture moist sterile dressing is applied
After splinting re assess the vascular status Check nail bed cyanosis, color, temperature, pulse
Environmental Emergencies Heat Stroke
Aute medical Emergency, A failure of heat regulating mechanisms
Occur during heat wavws Elderly, very young, px w/ chronic debilitating diseases, on tranquilizer, etc are at risk In healthy individual occurs during sports or work activities
Most heat related deaths occur in elderly because systems are unable to compensate for stress imposed by heat
Types Exertional: occurs in healthy individuals during exertion in extreme heat and humidity Hyperthermia: the result of inadequate heat loss Elderly, very young, ill, or debilitated and persons on some medications are at high risk Can cause death Manifestations: CNS dysfunction, elevated temperature, hot dry skin, anhydrosis, tachypnea, hypotension, and tachycardia Management of Patients With Heat Stroke Use ABCs and reduce temperature to 39° C as quickly as possible
Cooling methods ± Cool sheets, towels, or sponging with cool water ±
± ± ±
Apply ice to neck, groin, chest, and axillae Cooling blankets Iced lavage of the stomach or colon Immersion in cold water bath
Monitor temperature, VS, ECG, CVP, LOC, urine output
Use IVs to replace fluid losses ± Hyperthermia may recur in 3 to 4 hours; avoid hypothermia
Environmental Emergencies Frostbite
Trauma from freezing temperature and actual freezing of fluid in the intracellular and intercellular spaces
Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances
Poisoning and Drug overdose Management of Patients With Poisoning
Poison is any substance that when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relativity small amounts injures the body by its chemical action Treatment goals: ± Remove or inactivate the poison before it is absorbed ±
±
Causes vascular damage Body parts frequently affected feet, hands, nose, ears Ranging frm 1st degree erythema, to 4th degree full depth tissue destruction
Manifestations: hard, cold, and insensitive to touch; may appear white or mottled; and may turn red and painful as rewarmed The extent of injury is not always initially known
Controlled but rapid rewarming; 37° to 40° C circulating bath for 30- to 40-minute
intervals
Administer analgesics for pain Do not massage or handle; if feet are involved, do not allow patient to walk
Environmental Emergencies
Hypothermia
Internal core temperate is 35° C or less Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk
Alcohol ingestion increases susceptibility Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence
Physiologic changes in all organ systems Monitor continuously
Management of Patients With Hypothermia Use ABCs, remove wet clothing, and rewarm
Rewarming ± Active core rewarming Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, and warm peritoneal lavage ±
Passive external rewarming Warm blankets and over-the-bed heaters
±
Provide supportive care in maintaining vital organ systems
Administer specific antidotes Implement treatment to hasten the elimination of the poison
General Guidelines
Maintain adequate ABC support. In large tricyclic antidepressant overdose intubate Comatose, stupor, drowsy px: give 50ml ampule of 50% dextrose followed by naloxone 2mg IV
Perform gastric lavage in most adult px with suspected oral ingestion Consider possible suicide attempts or intentional poisoning in overdoses.
All female px w/ intentional ingestion should ideally have a pregnancy test (check
following informed consent Suicide precautions should be instituted as needed, always have a 24hr possible watcher, no access to sharp object, keep balcony window lock, never leave medication at bed side LMP)
Assessment of Patients With Ingested Poisons Use ABCs Monitor VS, LOC, ECG, and UO Assess laboratory specimens Determine what, when, and how much substance was ingested Assess signs and symptoms of poisoning and tissue damage Assess health history Determine age and weight
Principles of decontamination
1. External Decontamination ± ± ±
Remove clothes Wash skin w/ soap n water Keep warm; use blankets
2. Gastric lavage ±
Contraindication strong acid, alkali, petroleum distilates
±
±
±
± ±
±
Airway must be protected w et unless px is awake, alert has gag Place px in trendelenburg n left lateral decubitus position Position head to one side to minimize aspiration
If w DOB ventilator n O2 is indicated Perform gastric lavage unless overdose was parenteral or distant time Lavage may be usefull w/in 2hrs of
drug ingestion
3. activated charcoal ±
±
±
±
Single dose, after emesis unless contraindicated such as if oral antidote will be use or if endoscopy is planned Dose Adult; 50-100grams (1g/kg body wt) in 200ml tap water in a thick slurry, instill slurry by lavage tube or have px ingest slurry
Multiple dose 0.5gr/kg/bw q 4-6hrs for metamphetamine, phenothiazines, digoxin, theophylline, phenobarbital, organophosphate bec these subs has enterohepatic recirculation kinetics
activated charcoal may cause constipation or fecal impaction
Not effective for alkali, cyanide, mineral acid, ferous sulfate, petroleum ingestion 4 cathartics (sodium sulfate) ±
±
±
±
±
Contraindicated in infants, acid n alkali ingestion, px who receive an oral antidote, adynamic ileus, severe diarrhea, abdominal trauma, surgery, suspected intestinal obstruction, severe electrolyte loss or dehydration
Magnesium sulfate cathartics are contraindicated in renal failure
Sodium sulfate contraindicated in hypertension n heart failure Dose: 15 to 30grams ( 250mg/kg) in 100ml water given 30 minutes after the activated charcoal. May repeat procedure if still w/o bowel movements w/in 1 hr
5. force diuresis ±
±
Attempted in treatment ctr that can monitor hydration n electrolyte status
Forceddiuresis Maintain urinary flow rate of 57ml/kg/hr by infusing normal saline and intermitent boluses of furosemide 20mg IV doses Alternative: manitol 20-100mg IV max 300mg Monitor electrolyte
Acid ingestion
Diet NPO Monitor BP, HR, and abdomen for guarding n tenderness Check for pneumothorax n pneumoperitoneum
Provide airway control, ventilation, circulatory support fluid resuscitation, wash oral cavity copiously w/ cold water
Induction of emesis, lavage or charcoal contraindicated ngt should not be perform in most px.
Alkali Ingestion
NPO Monitor BP, HR, abd. For guarding n tenderness
Check for perforation, pneumoperitoneum Immediately rinse oral cavity w/ cold water protect airway n administer O2 n fluid, antibiotic if w/ esophageal is present
Esophagoscopy n gastroscopy shld not be performed immediately if w/ drooling stridor, odinophagia
Hydrocortisone dose IV
deep burn
recommendedfor
Emesis, neutralizing agents, gastric lavage, cathartics charcoal contraindicated
Amphetamine/ metamphetamine
CBC c APC, PT, PTT, RBS, BUN, creatinine, na, k, urine amphetamine level, UA, ABG Activated charcoal, cathartics, emesis has no role
Further elimination with ± Mannitol 20% 50-100ml q 6hrs ± Acidification of urine w/ vi c at 1 grm q 6hr
Watch out for complication ±
±
Seizure: diazepam 5-10mg IV up to 20mg followed by loading dose of phenytoin 18mg/kg in nss IV
Psychosis or agitation: chlorpromazine or haloperidol, diazepam IV
±
Hypertensive crisis: alpha or beta
±
Arrythmias: propranolol, lidocaine
blocking agent
Anticoagulant overdose
CBC c APC, PT, PTT, creatinine Heparine ± Protamine sulfate 1mg I V for q 50100units of heparin infused in the preceeding 2 hrs, dilute in 25-50ml IV fluids over 10min Warfarin ±
± ±
Gastric lavage n activated charcoal if recently ingested
Vit k 5-10mg IV
or sq q 8-12 hrs Fresh frozen plasma 2-6units for severe bleeding
Diazepam overdose
I n o BP n respiration, pulse oximeter, aspiration n seizure precautions, monitor Cbc, rbs,abg Support bp n respiration Place ngt, gastric lavage protect airway w/ et
Instill 50-100g charcoal, followed repeated doses of 20-25gm via ngt q 4-6hr
Cathartics Flumazenil 200mcg iv q 5-15min until px wakes up or tot of 1mg is reached
Flumazenil may ptt withdrawal seizure on chronic user of diazepam
Watch out for hypotension, cns, respi
depression, withdrawal syndrome(seizure, agitation, restlessness, insomia Digoxin/ digitalis overdose IV, NGT, do gastric lavage DC digitalis preparation, correct hypokalemia, hypomagnesemia or hypercalcemia. Administer charcoal slurry q 4-6hrs & cathartics
Symptomatic sinus depression & lowdegree AV block; atropine 0.5mg IV q 15 maximum of 3mg
Ethanol toxicity
I & O, NGT followed gastric lavage Maintain adequate airway, ventilation, circulation, O2
Thiamine 100mg IV or IM q8hrs,followed by Glucose 25-50g IV
Seizures: ±
Diazepam or Phenytoin IV
Hydrocarbon/ kerosene
Adequate airway protection, respiratory support
Treatment not required in the absence of symptoms.
Gastric emptying: gastric lavage Skin decontamination: remove clothing & wash affected skin with soap & water, once defecated wash perianal area to prevent chemical burns
Isoniazid overdose I&O, foley catheter, D5NM 1 L x 8hrs NGT, lavage till clean, activated charcoal Antidote: pyridoxine HCl (VitB6) 1 gm/10ml given per gram basis
Seizures: diazepam 5mg IV for active seizure Metabolic acidosis: Na bicarbonate IV
Narcotic overdose
NGT gastric lavage Maintain airway, ventilation & circulation
Naloxone 2mg q 5min initially IV, IM, SQ, endotracheally or continuous IV untill px sensorium & respiratory patterns improves Activated charcoal if (+) bowel sounds & cathartics
Complication: seizure, pulmonary edema, hypotension
Organophosphate poisoning
NPO, I&O, foley catheter Decontamination: ± External: have the px rinse gently w/ alkaline soap or baking soda (10gm in 100ml water) change clothes ±
Internal: NGT do gastric lavage w/ activated charcoal 100gm in 200500ml water
Activated charcoal 1 gm/kg PO then Na sulfate 15-30grams in water after 30min repeat after 1hr if still no bowel movement Antidote: atropine sulfate 0.01-0.05 mg/kg IV q 5min ±
±
Maintain Dry mucosa, HR>60bpm (target HR 100), hypoactive BS, pupils >4mm
Toxicity: >39 deg C temp,absence of sweating, psychosis, restlessness
Seizure: diazepam 5mg IV Arrythmia: Calcium chanel or phenytoin
Management Patients With Carbon Monoxide Poisoning
Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen
Manifestations: CNS symptoms predominate ±
Skin color is not a reliable sign and pulse oximetry is not valid
Treatment ± Get to fresh air immediately ± Perform CPR as necessary ± Administer oxygen: 100% or oxygen
under hyperbaric pressure
Monitor patient continuously Management of Patients With Chemical Burns
Severity of the injury depends upon the mechanism of action of the substance, the penetrating strength and concentration, and the amount of skin exposed to the agent Immediately flush the skin with running water from a shower, hose, or faucet ±
Lye or white phosphorus must be
brushed off the skin dry
Protect health care personnel from the substance
Determine the substance Some substances may require prolonged flushing/irrigation
Follow-up care includes reexamination of the area at 24 hours, 72 hours, and 7 days
Management of Patients With Food Poisoning
A sudden illness due to the ingestion of contaminated food or drink
Food poisoning, such as botulism or fish poisoning, may result in respiratory paralysis and death
ABCs and supportive measures Determination of food poisoning: see Chart 71-12 Treat fluid and electrolyte imbalances Control nausea and vomiting Provide clear liquid diet and progression of
diet after nausea and vomiting subside
Management of Patients With Substance Abuse
±
±
± ±
±
Overactive, underactive, violent, and depressed or suicidal patients
Management ± Maintain the safety of all persons and gain control of the situation ±
±
±
Determine if the patient is at risk for injuring himself or others
Maintain the person s self-esteem while providing care
Determine if the person has a psychiatric history or is currently under care to contact the therapist
Crisis intervention Interventions specific to each of the conditions
BURN~~~~~~~~~~~~~
Acute alcohol intoxication: a multisystem toxin ±
Psychiatric Emergencies~~~
2nd leading cause of death in children ±
Alcohol poisoning may result in death
Maintain airway and observe for CNS depression and hypotension
±
Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated
Use a nonjudgmental, calm manner Patient may need sedation if noisy or belligerent Examine for withdrawal delirium, injuries, and evidence of other disorders
Commonly abused substances: see Table 71-1
Crisis Intervention
Victims~~~~~~~~~~
Rape
±
Diagnosis ± ±
±
Treatment ±
How the patient is received and treated in
the ED is important to his or her psychological well-being
Crisis intervention begins as soon as the patient enters the facility; the patient should be seen immediately
Goals are to provide support, reduce emotional trauma, and gather evidence for possible legal proceedings Patient reaction; rape trauma syndrome History taking and documentation Physical examination and collection of forensic evidence Role of the sexual assault nurse examiner (SANE)
±
1 degree st
2
nd
Only epidermis,painful, erythematous, blisters not present
degree
Epidermis & partial thickness of the dermis, painful, with blisters
3 degree rd
Epidermis, dermis, nerves, painless, white, charred
ABC
Vigilant for shock, inhalation
injury, carbon monoxide poisoning Evaluate BSA % Supportive measures, tetanus,, stress ulcer prophylaxis, IV narcotic analgesia nd rd 2 & 3 degree
Fluid repletion using Parkland formula Parkland Formula
Fluid for the 1st 24hrs.=4x pt s wt in kg. x %BSA. Give 50% of fluids over the 1st 8hrs, & remaining 50% over the following 16 hrs. ± Topical silver sulfadiazine,
mafenide
