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Acute biologic crisis Passive Drowning: face-down in the 6.

Seizures acute respiratory distress syndrome


water. resulting in hypoxia, hypercarbia,
Drowning & Near drowning 7. Death
Active Drowning: The victim is and respiratory or metabolic
 Drowning: Death due to submersion vertical in the water, not kicking, acidosis can occur.
in liquid (usually water) still breathing and usually moving
*The time that this takes is
the arms in the effort to bob out of
 Near Drowning: is survival for more variable, but it could be as little as
the water. The victim can’t call for
than 24 hours from suffocation by 12 to 20 seconds from the first Fresh water - results in a loss of
help.
submersion. panic to unconsciousness. surfactant, hence an inability to
expand the lungs.
Common complication: HYPOXEMIA
Causes
prolonged submersion in cold
 Attempted suicide Salt water: pulmonary edema from
Classes of drowning the osmotic effects of the salt
decrease in metabolic
 Blows to the head or seizures within the lung.
 Dry: demands or the diving reflex.
while in the water
laryngospasm -> Water doesn’t Successful resuscitation with
 Drinking alcohol while
enter the lungs full neurologic recovery Complications:
boating or swimming
 Wet: hypoxic or ischemic cerebral injury,
 Falling through thin ice acute respiratory distress
laryngospasm relaxes -> water
 Inability to swim or panicking syndrome, pulmonary damage
enters the lungs Hypoxia, cerebral injury,
while swimming secondary to aspiration, and
hypercarbia, ARDS, pulm.
lifethreatening
 Leaving small children and acidosis damage,
Dry: laryngospasm. The larynx unattended around bathtubs cardiac arrest cardiac arrest.
expand to block the airway, thus and pools
often preventing water from
entering the lungs in.
Therapeutic goals
Summary of the drowning process:
Fresh water: loss of surfactant.  maintaining cerebral
Wet: With many patients, the 1. Panic & violent struggle perfusion
laryngospasm relaxes as the person 2. Period of Calmness Salt water: pulmonary edema
loses consciousness, and water  adequate oxygenation
(osmosis)
enters the lungs at that point 3. Swallowing of fluid (vomiting) (prevent further damage to
vital organs)
4. Terminal Gasp
Types of Drowning 5. Unconsciousness
◦ Immediate CPR- ◦ warmed peritoneal Hymenoptera allergy
greatest influence on dialysis, aerosolized
survival. O2, torso warming) Drowning rescue, board assist  extreme sensitivity to the
venoms of : bees, hornets,
 hypotension and impaired If the water is calm and shallow yellow jackets, fire ants &
tissue perfusion enough (no higher than chest) you wasps
The treatment goal: prevention of can get into the water to reach the
hypoxia ◦ Intravascular volume victim  Venom allergy –IgE
expansion & inotropic
 serial vital signs agents  Clinical manifestations range

 ensure an adequate airway & Drowning rescue, reaching assist  generalized urticaria,
 dysrhythmias
respiration(ventilation)
If the victim is in deepo or
◦ ECG monitoring  Malaise
 ABGs (determine the type of dangerous water but there is a
ventilatory support needed) dock to stand on, try a reaching  laryngeal edema
 compromised renal function
assist with a long, sturdy object
 Supplemental O2, by mask ◦ indwelling urinary  severe bronchospasm
catheter
 ET intubation w/ +P  shock, and death.
Drowning rescue on ice, board
 decompress the stomach & assist
◦ improves oxygenation prevent the patient from NOTE: The shorter the time bet. the
aspirating gastric contents sting & the onset of severe Sx, the
If a person falls through ice, do not
◦ Prevents aspiration worse the prognosis.
go into ice to attempt a rescue.
◦ NG intubation From a safe place try a reaching
◦ corrects Management
intrapulmonary assist with a long, sturdy object
shunting  stinger removal
An indwelling urinary catheter is
◦ corrects Ventilation– inserted to measure urine output. ◦ venom is assoc. /sacs
Drowning rescue on the ice, human
perfusion Hypothermia and accompanying around the barb of the
chain
abnormalities (caused metabolic acidosis may stinger
by aspiration of water) compromise renal function. If a person falls through ice, and
 Wound care w/ soap and
there is more than one person on
N/I: water
solid ground, form a chain of bodies
from a secure location out to the  Scratching is avoided
 hypothermia Drowning rescue, throw assist
fallen person because (results in histamine
◦ rectal probe If the water is too deep or response.
dangerous to enter or if the victim
◦ rewarming procedures is too far out to reach with a long  Ice application (reduces
INJECTED POISONS: STINGING
(extracorporeal object, a throwing assist may be swelling & decreases venom
INSECTS
warming, wisest absorption)
 oral antihistamine &  immobilize the injured body  Do not use during the acute  15 mins. before & after: the
analgesic (itching and pain) part below the level of the stage (first 6 to 8 hrs): ice, circumference of the affected
heart. tourniquets, heparin, part is measured proximally
NOTE: stinger removal if the bite is Corticosteroids are
from a bee, because the venom is  Do not apply: Ice or a contraindicated in after the  Premedicate w/:
associated with sacs around the tourniquet bite diphenhydramine and
barb of the stinger itself. Scratching cimetidine
is avoided because (results in  may depress antibody
histamine response). prod’n  IV (slow), IM
Initial evaluation:
Severe Allergic Response  hinder the action of  diluted in 500 -1000 mL of
 Whether the snake was NSS
antivenin
 Epinephrine (aqueous) venomous or nonvenomous
 For hypotension: Parenteral  total dose :infused during the
◦ SC  if the snake is dead, it should first 4-6 hrs after poisoning
fluids & vasopressors (short-
be transported to the ED with
term)
◦ massaged to hasten the pt for ID NOTE: IV, IM Depending on the
absorption.  Surgical exploration of the
 Where and when the bite severity of the bite
SNAKE BITES bite
occurred
Premedicate w/: diphenhydramine
 Pt. is observed closely for at
 1 -9 y.o. high risk  Circumstances of the bite and cimetidine (decreases the
least 6 hours
allergic response to antivenin)
 daylight hrs. to early  Sequence of events
evening(summer)  Never left unattended After the symptoms decrease,
 S & Sx (fang punctures, pain,
 pit vipers edema, and erythema of the the circumference of the affected
bite and nearby tissues) ANTIVENIN (ANTITOXIN) part should be measured

 Severity of poisonous effects every 30 to 60 minutes for the next


 antitoxin manufactured from
Management 48 hours to detect symptoms
the snake venom
 V/s
 Initial first aid: Let victim lie of compartment syndrome
down  admin. w/n 12 hours after (swelling, loss of pulse, increased
 Circumference of the bitten the snake bite
extremity or area at several pain,
 Remove constrictive items
 Children may require more and paresthesias).
 Points (compare w/ the other dose
 Provide warmth
extremity) The most common cause of allergic
 cleanse the wound  Skin test reaction to the antivenin
 Laboratory data (CBC, UA &
 cover w/ a light sterile clotting studies)
dressing
is its too-rapid infusion, although nearly everything, allowing fluids,  oropharyngeal suction
about 3% of patients with proteins, and sometimes blood to (remove excessive
negChapter pass through into the interstitial secretions)
space. This causes massive
71 Emergency Nursing 2167 interstitial edema. The vasodilation  Resuscitative measures (pts
and fluid sequestration in the with stridor and progressive
ative skin test results develop pulmonary edema)
interstitium causes a relative
reactions not related to infusion
hypovolemia.
 O2 therapy
rate.
fullness in the face, urticaria,
pruritus, malaise, and
apprehension Pharmacologic mngt.
ANAPHYLACTIC REACTION
 • Antihistamines
 an acute systemic
hypersensitivity reaction that ◦ to block further
tachycardia, SOB,
occurs within seconds or histamine binding at
minutes after exposure to hypotension,
target cells
certain foreign substances
STOP!!!  • Aminophylline
 result of an antigen–Ig
interaction in a sensitized • Diphenhydramine ◦ slow intravenous
individual who, as a The immune system goes infusion for severe
consequence of previous “haywire” in anaphylactic shock in • vasopressors bronchospasm and
exposure, has developed a an extreme allergic reaction. At wheezing refractory to
special type of Ig that is some point, the individual is other treatment
specific for that particular exposed to the substance and
allergen. develops antibodies against it. On  • Albuterol inhalers or
subsequent exposure to the humidified treatments
substance (the antigen), these
antibodies will aggressively bind to ◦ to decrease
Anaphylactic Shock Management bronchoconstriction;
the antigen, forming an antigen-
Shock due to the severe allergic antibody complex. This complex  establishing a patent airway
causes the release of chemicals  crystalloids, colloids, or
antigen-antibody reaction to & ventilation
that cause vasodilation (in vasopressors
substances such as drugs, contrast
media, blood products, or insect or particular, histamine).  administer epinephrine ◦ to treat prolonged
animal venom is called hypotension
anaphylactic shock. Food products Both veins and arteries vasodilate,  Early ET intubation is
such as seafood, nuts, peanuts, leading to decreased blood essential (to avoid loss of the  • Isoproterenol or dopamine
peanut butter, and MSG can also returning to the heart. The airway)
cause anaphylactic shock capillaries become permeable to
◦ for reduced cardiac • To remove or inactivate the  cardiodepressant action of  depends largely on
output poison before it is absorbed the substance ingested successful mgnt. of
respiration and
 • Intravenous • To provide supportive care in  venous pooling in lower
benzodiazepines maintaining vital organ systems extremities circulation.

◦ control of seizures, • To administer a specific antidote  reduced circulating blood ECG, vital signs, and neurologic
to neutralize a specific poison volume (increased capillary status An indwelling urinary
 corticosteroids f permeability) catheter is inserted to monitor
• To implement treatment that renal function.
◦ for prolonged reaction hastens the elimination of the ASSESSMENT
with persistent absorbed poison  Blood specimens are
hypotension or  determine what substance obtained to test for
bronchospasm was taken; concentration of
Corrosive poisons include
 the amount; time since  drug or poison.
 alkaline and acid agents ingestion;
Poisoning The patient who has ingested a
 signs and symptoms, such as corrosive poison is given water or
poison ◦ cause tissue
pain or burning sensations milk
destruction after
 any substance that, when coming in contact with  dilution is not attempted if
 any evidence of redness or
ingested, inhaled, absorbed, mucous membranes the patient has acute airway
burn in the mouth or throat,
applied to the skin, or pain on swallowing edema or obstruction,
produced w/n the body in ◦ drain cleaners
esophageal, gastric, or
relatively small amounts,  inability to swallow, intestinal
injures the body by its ◦ toilet bowl cleaners
chemical action.  vomiting, or drooling;  burn or perforation.
◦ Bleach

◦ detergents  age and weight of the  The following gastric


patient; emptying procedures may be
◦ oven cleaners used as Prescribed:
 Pertinent health history.
INGESTED (SWALLOWED) POISONS
◦ button batteries ◦ Syrup of ipecac
Management (induce vomiting)
E. coli
◦ metal cleaners
Staph. aureus  Control of the airway, ◦ Gastric lavage for the
◦ Rust removers ventilation, and oxygenation obtunded patient
are essential.
◦ battery acid ◦ Gastric aspirate -senD
Emergency Tx goals:  (-) cerebral or renal damage, to the laboratory for
Shock, may result from: patient’s prognosis testing
◦ (toxicology screens) ◦ Dialysis NOTE: Carbon monoxide poisoning ◦ • Prevent chilling;
occurs as carbon monoxide mixes wrap the patient in
◦ • Activated charcoal ◦ Hemoperfusion and binds with hemoglobin in the blankets.
ADMIN. blood to form carboxyhemoglobin
 detoxification of (COHb). When carbon monoxide ◦ • Keep the patient as
◦ • Cathartic, when the blood by binds to hemoglobin, less oxygen quiet as possible.
appropriate processing it gets transported to body tissues
through an and vital organs such as the brain ◦ • Do not give alcohol
NOTE: Activated charcoal extracorporeal in any form.
and heart. The bond between
administration if poison is one that circuit and an carbon monoxide and hemoglobin
is absorbed by charcoal adsorbent  100% oxygen is
is approximately 250 times
cartridge stronger than the bond between administered at atmospheric
containing oxygen and hemoglobin. or hyperbaric pressures
NURSING ALERT: Vomiting is never charcoal or
resin, after ◦ to reverse hypoxia
induced after ingestion of caustic
substances (acid or alkali) or which the
Carbon monoxide poisoning ◦ To accelerate the
petroleum distillates cleaned blood is
elimination of carbon
returned to the
 Goals of management: monoxide.
patient.
 to reverse cerebral and  O2 is admin. until the
ANTIDOTE
myocardial hypoxia carboxyhemoglobin level
 The specific chemical or <5%.
physiologic antagonist;  hasten elimination of carbon
admin. as early as monoxide.
possible(to reverse or Symptoms of permanent brain
 Whenever a patient inhales a
diminish the effects of the damage
poison, the following general
toxin)
measures apply:
 Psychoses
 If these measures are
◦ • Carry the patient to
ineffective, procedures are Carbon monoxide poisoning  Spastic paralysis
fresh air immediately;
initiated
open all doors &
 CO2 High Hgb affinity:250x  Ataxia
to remove the ingested subs. windows.
stronger than O2
such as:  visual disturbances
◦ • Loosen all tight
 carboxyhemoglobin clothing.
◦ Admin. of multiple  deterioration of mental
doses of charcoal ◦ CO–bound Hgb status and behavior
◦ • Initiate CPR if
◦ diuresis (for required;
◦ Doesn’t transport O2
substances excreted
◦ Administer oxygen. Hemorrhage
by the kidneys)
 results in the reduction of  last resort when the external  platelets and clotting  a condition in which there is
circulating blood volume is hemorrhage cannot be factors loss of effective circulating
controlled in blood volume. Inadequate
 a primary cause of shock.  Packed RBCs are infused organ and tissue perfusion
any other way when there is massive follow, ultimately resulting in
 fluid volume deficit cellular metabolic
 Applied just proximal to the  blood loss. In emergencies: derangements.
 decreased cardiac output wound and tied tightly
enough to control arterial  O-negative blood is used for  Nrsg. Dx.:
blood flow. women of childbearing age
 Altered tissue perfusion
NOTE: Only a few conditions, such  Periodically, the tourniquet is  O-positive blood is used for related to failing circulation
as obstructed airway or a sucking loosened (to prevent men & postmenopausal
irreparable vascular or women  Impaired gas exchange
wound of the chest, take
neurologic damage.) related to a ventilation–
precedence over the immediate  ABG (evaluate pulmonary
control perfusion imbalance
 For arterial bleeding, the function and tissue perfusion
of hemorrhage. Stopping bleeding tourniquet is removed and to establish baseline  decreased cardiac output
is essential to the care and survival hemodynamic parameters) related to decreased
 and a pressure dressing is circulating blood volume
of patients in an emergency or applied.  index for determining the
disaster situation. amount of fluid replacement
 For traumatic amputation the patient can tolerate and
with uncontrollable the response to therapy.
hemorrhage,
Direct, firm pressure is applied over  supine position and
the bleeding area or the involved  the tourniquet remains in monitored closely
artery place until the patient is in
the OR NOTE: O-negative blood provides
 firm pressure dressing is safe administration of blood
applied, and the injured part immediately
is elevated (to stop venous &
capillary bleeding if possible) Management without sensitizing an Rh-negative
woman to Rh-positive
 immobilize AFFECTED  Replacement fluids may
extremity to control blood include: blood. Sensitization can result in
loss. difficulties during pregnancy
 isotonic electrolyte solutions
(LR, NSS), later.

Tourniquets.  colloid, and blood component


therapy:
Hypovolemic Shock
Venous return is decreased and normalizing vital signs without also avoided.
because of the lack of fluid in the ongoing hemorrhage.
vascular space, causing decreased NOTE: Serial hematocrit values
ventricular filling. The ventricles do
management are obtained if continued bleeding
not have as much blood as normal
is suspected.
to pump out, so the stroke volume
 indwelling urinary catheter is
is decreased. goals of treatment inserted
The heart rate will increase to 1. Establish Airway and ventilation
 to restore and maintain  Serial Hct values
compensate for the diminished
tissue perfusion
stroke volume and resulting poor 2. Control of hemorrhage
cardiac output and blood pressure.  Large-gauge IV needles or
Eventually, if the fluid or blood loss catheters are inserted into 1. Place the victim in shock position 3. Prevent ant treat hypovolemic
continues, the heart rate will not be peripheral veins. shock. Monitor UO.
able to compensate for the 2. Keep the person warm and
decreased stroke volume. comfortable 4. Assess for head and neck
 Two or more catheters
injuries. Maintain spine
are necessary for rapid
The end result of hypovolemic 3. Turn the victim’s head to one immobilization.
fluid replacement &
shock is inadequate tissue side if neck injury is not suspected
reversal of 5. Evaluate for other injuries –
perfusion. hemodynamic reassess head, neck, abdomen,
instability. back and extremities.
central venous pressure (CVP)
Lactic acidosis is a common  emphasis : volume catheter 6. Splint fractures
replacement.
side effect of hemorrhage and  Inserted (in or near the right 7. Carry out a more thorough and
injury. It is associated with  to correct physiologic atrium) to serve as a guide ongoing examination and
abnormalities. for fluid replacement. assessment
poor cardiac performance and
higher rates of morbidity and  Continuous CVP readings
mortality. give the direction & degree
NOTE: Also, the feet are SEIZURES
of change from baseline
Base deficit and lactate are readings.
measures of successful and elevated slightly to improve • the result of a sudden
complete cerebral circulation and promote disruption of orderly
 The catheter is also a vehicle
venous communication among nerve
for emergency fluid volume
resuscitation. End points for cells in the brain, called
return to the heart. However, this replacement.
resuscitation include a serum neurons.
position is contraindicated
 Infusion of LR (approximates
lactic acid level lower than 2.5 • can lead to a number of
for patients with head injuries. plasma electrolyte
mmol/L within 24 hours after injury symptoms, which vary
Unnecessary movement is composition & osmolality)
depending on where the
disruption occurs in the brain
and where the abnormal 3. Generalized seizures/grand mal Absence seizures Febrile Seizure
electrical activity spreads. seizures:
Vacant stare also known as a FEVER FIT or
• intense rigidity of the entire FEBRILE CONVULSION is a
body may occur, followed by Eyes roll upward generalized convulsion caused by a
alternating muscle relaxation fever in infants and small children.
Lack of Response
and contraction (generalized
tonic–clonic contraction), Loss of Consciousness and
simultaneous contractions of shakes
the diaphragm and chest
muscles may produce a
characteristic epileptic cry, Atonic seizures
tongue is often chewed, and
the patient is incontinent of • "drop attack," atonic seizures
1.simple partial seizures: urine and feces. cause a sudden loss of
muscle tone.
• finger or hand may shake,
mouth may jerk • After 1 or 2 minutes: • may result in the dropping of
uncontrollably, person may convulsive movements begin the head or a limb, or lead a
talk unintelligibly, may be to subside; patient relaxes student to fall to the ground.
dizzy, and may experience and lies in deep coma,
unusual or unpleasant sights, • There also may be a brief
breathing noisily.
sounds, odors, or tastes, but loss of consciousness.
Respirations at this point are
without loss of consciousness chiefly abdominal. Myoclonic seizures

Postictal state: patient is • typically affecting children


2. complex partial seizures: often confused and hard to and young adults.
arouse and may sleep for
• the person either remains hours. May report headache, • involves a sudden
motionless or moves sore muscles, fatigue, and contraction of muscles and
automatically but depression. can appear as a jerk of one
inappropriately for time and or both arms or sometimes
place, he or she may Tonic-clonic seizures the head.
experience excessive
a. Tonic Phase • may cause just a single jerk
emotions of fear, anger,
or several jerking
elation, or irritability. b. Clonic Phase movements.
Whatever the manifestations,
the person does not c. Post-ictal confusional fatigue • seizure is so brief that
remember the episode when although the pt. loses
it is over. consciousness, he or she
may appear conscious.

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