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EMERGENCY NURSING

 Care given to patients with urgent and critical needs

 Also for non-urgent cases or whatever the patient or family considers an emergency

 Serious life-threatening cardiac conditions (Myocardial infarction, Acute heart

failure, Pulmonary edema Cardiac dysrhythmias)

The Emergency Nurse

 Applies the ADPIE on the human responses of individuals in all age groups whose

care is made difficult by the limited access to past medical history and the episodic

nature of their health care

 Triage and prioritization.

 Emergency operations preparedness.

 Stabilization and resuscitation.

 Crisis intervention for unique patient populations, such as sexual assault survivors.

 Provision of care in uncontrolled and unpredictable environments.

 Consistency as much as possible across the continuum of care

The Nursing Process

 Provides logical framework for problem solving in this environment

 Nursing assessment must be continuous, and nursing diagnoses change with the

patient’s condition

 Although a patient may have several diagnoses at a given time, the focus is on the

most life-threatening ones

 Both independent and interdependent nursing interventions are required

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Emergency Nursing in Disasters

 The emergency nurse must expand his or her knowledge base to encompass

recognizing & treating patients exposed to biologic and other terror weapons

 The emergency nurse must anticipate nursing care in the event of a mass casualty

incident.

Documentation of Consent

 Consent to examine and treat the patient is part of the ER record.

 The patient must consent to invasive procedures unless he or she is unconscious or

in critical condition and unable to make decisions.

 If the patient is unconscious and brought to the ER without family or friends, this

fact should be documented

 After treatment, a notation is made on the record about the patient’s condition on

discharge or transfer and about instructions given to the patient and family for

follow-up care.

Exposure to Health Risks

 All emergency health care providers should adhere strictly to standard precautions

for minimizing exposure.

 Early identification and adherence to transmission-based precautions for patients

who are potentially infectious is crucial.

 ER nurses are usually fitted with a personal high-efficiency particulate air (HEPA)-

filter mask apparatus to use when treating patients with airborne diseases.
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Providing Holistic Care

 Sudden illness or trauma is a stress to physiologic and psychosocial homeostasis

that requires physiologic & psychological healing.

 When confronted with trauma, severe disfigurement, severe illness, or sudden

death, the family experiences several stages of crisis beginning with anxiety, and

progress through denial, remorse & guilt, anger, grief & reconciliation.

 The initial goal for the patient and family is anxiety reduction, a prerequisite to

recovering the ability to cope.

 Assessment of the patient and family’s psychological function includes evaluating

emotional expression, degree of anxiety, and cognitive functioning.

Nursing Diagnoses

 Possible nursing diagnoses include: Anxiety related to uncertain potential outcomes of

the illness or trauma and ineffective individual coping related to acute situational crises

 Possible diagnoses for the family include: Anticipatory grieving and alterations in

family processes related to acute situational crises

Patient-Focused Interventions

 Those caring for the patient should act confidently and competently to relieve

anxiety.

 Reacting and responding to the patient in a warm manner promotes a sense of

security.

 Explanations should be given on a level that the patient can understand, because an

informed patient is better able to cope positively with stress.

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 Human contact & reassuring words reduce the panic of the severely injured person

and aid in dispelling the fear of the unknown.

 The unconscious patient should be treated as if conscious (i.e. touching, calling by

name, explaining procedures)

 As the patient regains consciousness, the nurse should orient the patient by stating

his or her name, the date, and the location.

Family-Focused Interventions

 The family is kept informed about where the patient is, how he or she is doing, and

the care that is being given.

 Allowing the family to stay with the patient, when possible, also helps allay their

anxieties.

 Additional interventions are based on the assessment of the stage of crisis that the

family is experiencing.

 Helping Them Cope With Sudden Death

 Take the family to a private place.

 Talk to the family together, so they can mourn together.

 Reassure the family that everything possible was done; inform them of the

treatment rendered.

 Show the family that you care by touching, offering coffee, and offering the

services of the chaplain.

Helping Them Cope With Sudden Death

 Encourage family members to support each other & to express emotions freely.
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 Avoid giving sedation to family members; this may mask or delay the grieving

process, which is necessary to achieve emotional equilibrium and to prevent

prolonged depression.

 Encourage the family to view the body if they wish; this action helps integrate the

loss.

 Spend time with the family, listening to them and identifying any needs that they

may have.

 Allow family members to talk about the deceased and what he or she meant to them;

this permits ventilation of feelings of loss.

 Avoid volunteering unnecessary information.

Discharge Planning

 Instructions for continuing care are given to the patient and the family or significant

others.

 All instructions should be given not only verbally but also in writing, so that the

patient can refer to them later.

 Instructions should include information about prescribed medications, treatments,

diet, activity, and contact info as well as follow-up appointments.

Principles of Emergency Room Care

Triage: comes from the French word trier, which means "to sort;” A method to quickly

evaluate and categorize the patients requiring the most emergent medical attention.

ER Triage

 Emergent (immediate): patients have the highest priority; must be seen

immediately
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 Urgent (delayed or minor): patients have serious health problems, but not

immediately life-threatening ones; seen w/in 1 hour

 Non-urgent (minor or support): patients have episodic illnesses addressed within

24 hours.

Determination of Priority in ER Triage: Classified based on principle to benefit the

largest number of people

Determination of Priority in Field Triage

 Critical clients are given lowest priority

 Victims who require minimal care and can be of help to others are treated first.

1. Red – Emergent (immediate)

2. Yellow – Immediate (delayed)

3. Green – Urgent (minor)

4. Blue – Fast track or psychological support needed

5. Black – Patient is dead or progressing rapidly towards death

 Triage Tags should be used on all calls involving 3 or more patients.

 The general placement location should be on one of the patient’s arms.

 When a triage tag has been utilized, remember to document the tag number in the

history portion of your run report.

“E”– Cart

 Located in designated areas where medical emergencies and resuscitation is needed

 Purpose: to maximize the efficiency in locating medications/supplies needed for

emergency situations.
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 Drawer 5: Contains respiratory supplies such as oxygen tubing, a flow meter, a face

shield, and a bag-valve-mask device for delivering artificial respirations

 Drawer 4: Contains suction supplies & gloves

 Drawer 3: Contains intravenous fluids

 Drawer 2: Contains equipment for establishing IV access, tubes for laboratory tests,

and syringes to flush medication lines.

 Drawer 1: Contains medications needed during a code such as epinephrine, atropine,

lidocaine, CaCl2 and NaHCO3

 The back of the cart usually houses the cardiac board.

Assessment and Intervention in the ER

The Primary Survey: Focuses on stabilizing life-threatening conditions; employs the

ABCD Method

The ABCD Method

 Airway - Establish the airway

 Breathing - Provide adequate ventilation

 Circulation - Evaluate & restore cardiac output by controlling hemorrhage,

preventing & treating shock, and maintaining or restoring effective circulation

 Disability - Determine neurologic disability by assessing neuro function using the

Glasgow Coma Scale

Eye opening Spontaneous 4

response To voice 3

To pain 2
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None 1

Verbal Oriented 5

response Confused 4

Inappropriate words 3

Incomprehensible 2

sounds 1

None

Motor Obeys command 6

response Localizes pain 5

Withdraws 4

Flexion 3

Extension 2

None 1

Assess and Intervene: The Secondary Survey includes:

 A complete health history & head-to-toe assessment

 Diagnostic & laboratory testing

 Application of monitoring devices

 Splinting of suspected fractures

 Cleaning & dressing of wounds

 Performance of other necessary interventions based on the patient’s condition.

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Airway Obstruction

 An acute upper airway obstruction is a blockage of the upper airway, which can be in

the trachea, laryngeal (voice box), or bronchi areas

 Causes: Viral and bacterial infections, fire or inhalation burns, chemical burns and

reactions, allergic reactions, foreign bodies, and trauma.

Clinical Manifestations

1. Choking

2. Apprehensive appearance

3. Inspiratory & expiratory stridor

4. Labored breathing

5. Flaring of nostrils

6. Use of accessory muscles (suprasternal & intercostal retractions)

7.  anxiety, restlessness, confusion

8. Cyanosis & loss of consciousness develops as hypoxia worsens.

Assessment and Diagnostics

 Involves simply asking whether the patient is choking & requires help

 If unconscious, inspection of the oropharynx may reveal the object.

 X-rays, laryngoscopy, or bronchoscopy may also be performed.

 For elderly patients, sedatives & hypnotic medications, diseases affecting motor

coordination, & mental dysfunction are risk factors for asphyxiation of food.

 Victims cannot speak, breath or cough.

 If victim can breathe spontaneously, partial obstruction should be suspected; the victim

is encouraged to cough it out.

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 If the patient has a weak cough, stridor, DOB & cyanosis, do the Heimlich.

 After the obstruction is removed, rescue breathing is initiated; if the patient has no

pulse, start cardiac compressions.

Head-Tilt-Chin-Lift Maneuver

1. Place the patient on a firm, flat surface.

2. Open the airway by placing one hand on the victim’s forehead, and apply firm

backward pressure with the palm to tilt the head back.

3. Place the fingers of the other hand under the bony part of the lower jaw near the

chin and lift up.

4. Bring the chin and teeth forward to support the jaw.

Jaw-Thrust Maneuver

1. Place the patient on a firm, flat surface.

2. Open the airway by placing one hand on each side of the victim’s jaw, followed by

grasping and lifting the angles, thus displacing the mandible forward.

Oropharyngeal Airway Insertion

A semicircular tube or tube-like plastic device inserted over the back of the tongue into the

lower pharynx

Used in a patient who is breathing spontaneously but unconscious.

ET Intubation: Indications

1. To establish an airway for patients who cannot be adequately intubated with an

oropharyngeal airway.

2. To bypass an upper airway obstruction

3. To prevent aspiration
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4. To permit connection of the patient to a resuscitation bag or mech. ventilator

5. To facilitate removal of tracheobronchial secretions

Cricothyroidotomy

 Used in the following emergencies in w/c ET intubation is contraindicated:

1. Extensive maxillofacial trauma

2. Cervical spine injuries

3. Laryngospasm

4. Laryngeal edema

5. Hemorrhage into neck tissue

6. Laryngeal obstruction

Nursing Diagnoses For Airway Obstruction

1. Ineffective airway clearance due to obstruction of the tongue, object, or fluids (blood,

saliva)

2. Ineffective breathing pattern due to obstruction or injury

Hemorrhage

 Bleeding that may be external, internal or both

 External: Laceration, avulsion, GSW, stab wound

 Internal: Bleeding in body cavities and internal organs

Assessment

 Results in reduction of circulating blood vol., w/c is the principal cause of shock

 Signs and symptoms of shock:

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1. Cool, moist skin

2. Hypotension

3. Tachycardia

4. Delayed capillary refill

5. Oliguria

Management

 Fluid Replacement

 Two large-bore intravenous cannulae are inserted to provide a means for fluid and

blood replacement, and blood samples are obtained for analysis, typing, & cross-

matching.

 Replacement fluids may include isotonic solutions (LRS, NSS), colloid, and blood

component therapy.

• Packed RBCs are infused when there is massive hemorrhage

• In emergencies, O(-) blood is used for women of child-bearing age.

• O(+) blood is used for men and postmenopausal women.

• Additional platelets and clotting factors are give when large amounts of blood is

needed.

Control of External Hemorrhage

 Physical assessment is done to identify area of the hemorrhage.

 Direct, firm pressure is applied over the bleeding area or the involved artery.

 A firm pressure dressing is applied, and the injured part is elevated to stop venous &

capillary bleeding if possible.

 If the injured area is an extremity, it is immobilized to control blood loss.

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Control of Bleeding: Tourniquets

 Applied only as a last resort just proximal to the wound and tied tightly enough to

control arterial blood flow; tag the client with a “T” stating the location and the time

applied

 Loosened periodically to prevent irreparable vascular on neuro damage

 If still with arterial bleeding, remove tourniquet and apply pressure dressing

 If traumatically amputated, the tourniquet remains in place until the OR.

Control of Internal Bleeding

 Watch out for tachycardia, hypotension, thirst, apprehension, cool and moist skin, or

delayed capillary refill.

 Packed RBC are administered at a rapid rate, and the patient is prepped for OR.

 Arterial blood is obtained to evaluate pulmonary perfusion & to establish baseline

hemodynamic parameters

 Patient is maintained in a supine position and closely monitored.

Hypovolemic Shock

 A condition where there is loss of effective circulating blood volume due to rapid fluid

loss that can result to multi-organ failure

 Causes

1. Massive external or internal bleeding

2. Traumatic, vascular, GI and pregnancy related

3. Burns

Nursing Diagnoses for Hypovolemic Shock

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1. Altered tissue perfusion related to failing circulation

2. Impaired gas exchange related to a V-P imbalance

3. Decreased cardiac output related to decreased circulating blood volume

Clinical Manifestations

1. Weakness, lightheadedness, and confusion

2. Tachycardia

3. Tachypnea

4. Decrease in pulse pressure

5. Cool clammy skin

6. Delayed capillary refill

Hypovolemic Shock: Management

1. Rapid blood and fluid replacement; blood component therapy optimizes cardiac

preload, correct hypotension, & maintain tissue perfusion

2. Large-bore intravenous needles or catheters are inserted into peripheral vv.

3. A central venous pressure catheter may also be inserted in or near the RA.

4. LRS approximates plasma electrolyte composition and osmolarity

5. A Foley catheter is inserted to record urinary output every hour; urine volume indicates

adequacy of kidney perfusion

Wound Healing: By First Intention

 Occurs when tissue is cleanly incised and re-approximated and healing occurs without

complications.

 The incisional defect re-epithelizes rapidly and matrix deposition seals the defect.
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Wound Healing: By Second Intention

 Healing occurs in open wounds.

 When the wound edges are not approximated and it heals with formation of granulation

tissue, contraction and eventual spontaneous migration of epithelial cells.

Wound Healing: By Third Intention

 Occurs when a wound is allowed to heal open for a few days and then closed as if

primarily.

 Such wounds are left open initially because of gross contamination.

Trauma

 The unintentional or intentional wound or injury inflicted on the body from a

mechanism against w/c the body cannot protect itself

 Leading cause of death in children and in adults younger than 44 y/o

 Alcohol & drug abuse are implicated in both blunt & penetrating trauma

 Collection of Forensic Evidence: Included in documentation are the ff:

1. Descriptions of all wounds

2. Mechanism of injury

3. Time of events

4. Collection of evidence

5. Statements made by the patient

 If suicide or homicide is suspected in a deceased patient, the medical examiner will

examine the body on site or have it moved to the medico-legal office for autopsy.

 All tubes & lines are left in place.

 Patient’s hands are covered with paper bags to protect evidence.

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Injury Prevention Components

1. Education: Provide information and materials to help prevent violence, and to

maintain safety at home and in vehicles.

2. Legislation: Provide universal safety measures without infringing on rights

(Seatbelt Law).

3. Automatic Protection: Provide safety without requiring personal intervention

(Airbags, seatbelts).

High incidence of injury to hollow organs, particularly the small intestines. The liver

is the most frequently injured solid organ. High velocity missiles create extensive tissue

damage.

Trauma: Assessment

1. Inspection of abdomen for signs of injury (bruises, abrasions)

2. Auscultation of bowel sounds

3. Watch out for signs of peritoneal irritation like distention, involuntary guarding,

tenderness, pain, muscular rigidity, or rebound tenderness together with absent BS.

Trauma: Diagnostic Findings

1. Urinalysis to detect hematuria

2. Serial hematocrit to detect presence or absence of bleeding

3. WBC count to detect elevation associated with trauma

4. Serum amylase to detect pancreatic or GIT injury

PE for Internal Bleeding

 Inspect body for bluish discoloration, asymmetry, abrasion, & contusion

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 FAST (Focused Assessment for Sonographic Examination of the Trauma Patient)

exam through CT scan to assess hemodynamically unstable patients and detect

intraperitoneal bleeding

 Pain in the left shoulder is common in a patient with bleeding from a ruptured

spleen.

 Pain in the right shoulder can result from a laceration of the liver.

 Administration of opioids is avoided during the observation period.

Trauma: Genitourinary Injury

 A rectal or vaginal exam is done to determine any injury to the pelvis, bladder, and

intestinal wall.

 To decompress the bladder & monitor urine output, a Foley catheter is inserted AFTER

DRE.

 A high-riding prostate gland indicates a potential urethral injury.

Trauma: Management of Intra-abdominal Injuries

1. A patent airway is maintained.

2. Bleeding is controlled by applying direct pressure to any external bleeding wounds &

by occlusion of any chest wounds.

3. Circulating blood vol. is maintained with intravenous fluid replacement including

blood component therapy.

4. In blunt trauma, cervical spine immobilization is maintained until cervical x-rays have

been obtained & injury is ruled out.

5. All wounds are located, counted & documented.

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6. If abdominal viscera protrude, the area is covered with sterile, moist saline dressing to

prevent drying.

7. Oral fluids are withheld and stomach contents are aspirated with an NGT in anticipation

of surgery.

Tetanus and broad-spectrum antibiotics are given as prescribed.

8. If still with evidence of shock, blood loss, free air under the diaphragm, evisceration,

hematuria or suspected abdominal injury, transport to OR.

Management of Fractures

 ABCD Method & evaluation for abdominal injuries is performed BEFORE an

extremity is treated unless a pulseless extremity is seen.

 If the extremity is pulseless, repositioning of the extremity to proper alignment is

required.

Pulseless Extremities

 If the pulseless extremity involves a fractured hip or femur, a Hare traction may be

applied to assist w/ alignment.

 If repositioning is ineffective in restoring the pulse, a rapid total body assessment is

completed, followed by a transfer to the operating room for arteriography and possible

arterial repair.

Management of Fractures

 After the 1° survey, the 2° survey is done using a head-to-toe approach.

 Observe for lacerations, swelling & deformities including angulation, shortening,

rotation, & symmetry.

 Palpate all peripheral pulses.

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 Assess extremity for coolness, blanching, decreased sensation & motor function.

Splinting of Extremities

 Before moving the patient, a splint is applied to immobilize the joint above & below

the fracture

 Relieves pain, restores circulation, prevents further tissue injury

 Procedure:

1. One hand is placed distal to the fracture & some traction is applied while the other

hand is placed beneath the fracture for support.

2. The splint should extend beyond the joints adjacent to the fracture.

3. Upper extremities must be splinted in a functional position.

4. If a fracture is open, moist, sterile dressing is applied.

5. Check the vascular status by assessing color, temperature, pulse, and blanching of

the nail bed.

6. If there is neurovascular compromise, the splint is removed and reapplied.

7. Investigate complaints of pain or pressure.

People at Risk:

 those not acclimatized to heat

 elderly and very young people

 those unable to care for themselves

 those w/ chronic & debilitating dse

 those taking tranquilizers, diuretics, anticholinergics, and beta blockers.

 exertional heat stroke occurs in healthy individuals during sports or work activities.
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Heat Stroke

 An acute medical emergency caused by failure of the heat-regulating mechanisms.

 Usually occurs during extended heat waves, especially when accompanied by high

humidity

Pathophysiology

 Hyperthermia results because of inadequate heat loss, which can also cause death.

 Monitor weight and fluid losses during workouts; replace fluids

 Use a gradual approach to physical conditioning; allow acclimatization

FROSTBITE

 Trauma from exposure to freezing temperatures that results to actual freezing of the

tissue fluids in the cell and intracellular spaces

 Results in cellular and vascular damage

 Body parts most frequently affected are the feet, hands, nose and ears

 Ranges from 1st (erythema) to 4th degree (full-depth tissue destruction)

Assessment

 Frozen extremity may be cold, hard, and insensitive to touch

 Appears white or mottled blue-white

 Extent of injury from exposure to cold is not initially known; assess for concomitant

injury

 History includes environmental temperature duration of exposure, humidity, and

presence of wet conditions

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Management

 The goal is to restore normal body temperature; controlled yet rapid rewarming is

instituted

 Constrictive clothing and jewelry that could impair circulation are removed.

 Patient should NOT be allowed to ambulate if the lower extremities are involved.

 Place extremity in a 37° to 40°C circulating bath for 30- to 40-min.

 Repeat treatment until circulation is effectively restored.

 Early rewarming  amount of tissue loss.

 Analgesic is given during rewarming since process may be very painful.

 Avoid handling of body part to prevent further injury.

 ELEVATE to prevent further swelling.

 Sterile gauze or cotton is placed between affected fingers or toes to prevent maceration.

 A foot cradle is used to prevent contact with bedclothes.

 Blebs are left intact and not ruptured, especially if they are hemorrhagic.

 Risk for infection is great; strict aseptic technique is used during dressing changes, and

tetanus prophylaxis & anti-inflammatory medications are given

 Whirlpool bath for affected extremity to aid circulation, debride necrotic tissue and

prevent infection

 Escharotomy to prevent further tissue damage, allow normal circulation and permit

joint motion; fasciotomy

 After rewarming, hourly active motion of affected digits is done to promote maximal

restoration of function and to prevent contractures.

 Refreezing is avoided
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Hypothermia

 A condition in which core temperature is 35°C or less as a result of exposure to cold

 Occurs when patient loses ability to maintain body temperature

 Urban hypothermia is associated with a high mortality rate affected are the elderly,

infants, patients with concurrent illnesses, and the homeless.

 Alcohol ingestion  susceptibility due to systemic vasodilation.

 Trauma victims are at risk resulting from treatment with cold fluids, unwarmed oxygen,

and exposure during examination.

 Hypothermia takes precedence in treatment over frostbite.

Assessment

 Watch out for progressive deterioration, with apathy, poor judgment, ataxia, dysarthria,

drowsiness, pulmonary edema, acid-base abnormalities, coagulopathy & coma

 Shivering may be suppressed below 32.2°C due to ineffective mechanism

 Peripheral pulses are weak and become undetectable; cardiac irregularities, hypoxemia

and acidosis may occur.

Management: Monitoring

 VS, CVP, urine output, arterial blood gas levels, blood chemistry and chest xray are

frequently evaluated.

 Body temp is monitored with a rectal, esophageal, or bladder thermometer.

 Continuous ECG monitoring is done because cold-induced myocardial irritability can

lead to v. fibrillation.
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Management: Core Rewarming

 Include cardiopulmonary bypass, warm fluid administration, warm humidified oxygen

by ventilator, and warm peritoneal lavage

 Done for severe hypothermia

 Monitoring for ventricular fibrillation as the patient passes through 31° to 32°C is

essential.

Management: Passive External Rewarming

 Includes the use of warm blankets or over-the-bed heaters

 Increases blood flow to the acidotic, anaerobic extremities

 Cold blood returning to the core can cause cardiac dysrhythmias & electrolyte

imbalances

Supportive Care

 External cardiac compression

 Defibrillation of v. fibrillation (ineffective if core temp is <31°C)

 Mechanical ventilation and heated, humidified oxygen

 Warmed IVF to correct hypotension and maintain urine output and core rewarming

 Sodium bicarbonate to correct metabolic acidosis if necessary

 Antiarrhythmic medications

 Insertion of Foley catheter to monitor fluid status

Near-Drowning

 Survival for at least 24 hours after submersion

 Most common consequence is hypoxemia

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 One of the leading causes of death in children younger than 14 y/o; children younger

than 4 y/o account for 40% of all drownings

Risk Factors

1. Alcohol ingestion

2. Inability to swim

3. Diving injuries

4. Hypothermia

5. Exhaustion

Rescue

 Successful resuscitation with full neurologic recovery has occurred in drowning

victims after prolonged submersion in cold water.

 After surviving submersion, ARDS resulting in hypoxia, hypercarbia, & respiratory or

metabolic acidosis can occur.

Pathophysiology

 Fresh water aspiration results in loss of surfactant, hence the inability to expand the

lungs.

 Salt water aspiration leads to pulmonary edema from the osmotic effects of the salt

within the lungs.

 Treatment Goals

 Maintaining cerebral perfusion and adequate oxygenation to prevent further damage to

vital organs

 Immediate CPR is the factor with the greatest influence on survival

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 Prevention of hypoxia by ensuring an adequate airway and respiration, thus improving

ventilation and oxygenation

Management

 ABG analyses are performed to evaluate O2, CO2, HCO3 and pH

 If the patient is not breathing spontaneously, ET intubation with positive-pressure

ventilation improves oxygenation, prevents aspiration, and corrects intrapulmonary

shunting and V-P abnormalities

 If the patient is breathing spontaneously, supplemental O2 may be given by mask

 Because of submersion, the patient is usually hypothermic; use a rectal probe to assess

 Prescribed warming procedures such as corporeal rewarming, warmed PD, inhalation

of warmed aerosolized O2, and torso warming depends on the severity & duration of

hypothermia.

 Intravascular volume expansion & inotropic agents are used to manage hypotension &

impaired tissue perfusion; ECG monitoring is done to monitor dysrhythmias.

 A Foley catheter is used to measure output; NGT intubation is used to decompress the

stomach & prevent aspiration of gastric contents.

 Close monitoring continues with serial VS, serial ABG’s, ECG monitoring, ICP

assessments, serum electrolyte levels, I & O, & serial CXR.

 Complications include hypoxic or ischemic cerebral injury, ARDS, pulmonary damage

2° to aspiration, & cardiac arrest.

Decompression Sickness (DCS)

 Occurs in patients who have engaged in diving, high-altitude flying, or flying in a

commercial aircraft 24 hrs after diving

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 Results from nitrogen bubbles trapped in joint or muscle spaces, resulting in

musculoskeletal pain, numbness, & hyperesthesia

 Bubbles can become emboli in the bloodstream & cause stroke, paralysis, or death.

 A rapid history & recompression is done ASAP & may necessitate a low altitude flight

to the nearest hyperbaric chamber.

Assessment

Evidence of rapid ascent, loss of air in the tank, buddy breathing, recent alcohol intake

or lack of sleep, or a flight within 24 hours after diving are risk factors.

Signs and symptoms:

1. Joint/extremity pain

2. numbness, hypesthesia

3. loss of ROM

4. neuro Sx mimicking CVA

5. CP arrest in severe cases

Management

 A patient airway and adequate ventilation are established & 100% O2 is given

throughout treatment & transport

 A CXR is obtained to identify aspiration, and at least 1 IV line is started with LRS

or NSS.

 If a head injury is suspected, the head of the bed is lowered.

 Wet clothing is removed and the patient is kept warm.

 Transfer to the closest hyperbaric chamber is done.

 Antibiotics may be prescribed if aspiration is suspected.

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Anaphylaxis

 An acute systemic hypersensitivity reaction that occurs w/in seconds or min. after

exposure to foreign substances such as medications & other agents

 Repeated administration of oral & parenteral therapeutic agents may cause this when

initially only a mild allergic response occurred

Pathophysiology

 Antigen-antibody interaction

 Antigen – allergen

 Antibody – IgE previously sensitized basophils and mast cells

 Release of mediators like histamine and prostaglandin cause the systemic reactions

Causes

 Penicillins – most common

 Contrast media

 Bee stings

 Food

Anaphylaxis Signs and Symptoms

1. Respiratory Signs:

 nasal congestion

 itching, sneezing, coughing

 bronchospasm & laryngeal edema

 chest tightness, dyspnea

 wheezing & cyanosis

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2. Skin:

 flushing with sense of warmth & diffuse erythema;

 generalized itching over entire body (systemic reaction)

 urticaria (hives);

 massive facial angioedema (with accompanying upper respiratory edema)

3. Cardiovascular:

 Tachycardia or bradycardia

 Peripheral vascular collapse indicated by pallor, imperceptible pulse,  BP,

circulatory failure, coma & death

4. GIT:

 nausea & vomiting

 colicky abdominal pains, diarrhea

Anaphylaxis Management

 Establish an airway & ventilation while another gives epinephrine.

 Early ET intubation avoids loss of the airway, & oropharyngeal suction removes

secretions.

 If glottal edema occurs, a crico-thyroidotomy is used to provide an airway.

Anaphylaxis: Epinephrine Administration

 Subcutaneous injection for mild, generalized symptoms

 IM injection for more severe & progressive reactions with the possibility of vascular

collapse

 IV route for rare instances where there is LOC & severe cardiovascular collapse; may

cause dysrhythmias
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Anaphylaxis: Additional Treatments

 Antihistamines are given to block further histamine release

 Aminophylline by slow IV trans-fusion for severe bronchospasm & wheezing

refractory to treatment

 Albuterol inhalers or humidified treatment to  bronchoconstriction

 Crystalloids, colloids, or vasopressors for prolonged hypotension

 Isoproterenol or dopamine for reduced cardiac output; O2 to enhance tissue perfusion

 IV benzodiazepines for seizure control; corticosteroids for prolonged reaction with

persistent hypotension or bronchospasm

Anaphylaxis Prevention

 Be aware of the danger signs of anaphylaxis.

 Ask the patient about previous allergies (e.g. allergies to eggs)

 Before giving antigenic agents, ask caregiver whether agent was received at an

earlier time.

 Avoid giving medications to patients with allergic disorders unless necessary.

 Perform a skin test before administration of certain agents; have epinephrine readily

available.

 If dealing with outpatients, keep them in the clinic for at least 30 min after injection

of any agent.

 Caution patients who are highly sensitive to carry medical kits.

 Encourage wearing of medical IDs.

Poisoning: Ingested Poisons

 May be corrosive (alkaline and acid agents that cause tissue destruction)
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 Alkaline products: Lye, drain and toilet bowl cleaners, bleach, non-phosphate

detergents, button batteries

 Acid products: toilet bowl and metal cleaners, battery acid

Poisoning Management

 Control the airway, ventilation and oxygenation.

 ECG, VS, and neurologic status are monitored for changes.

 Shock resulting from the cardio-depressant action of the ingested substance, or from 

circulating blood volume due to  capillary permeability, is treated.

 A Foley catheter is inserted to monitor renal function and blood examinations are done

to test for poison concentration.

 The amount, time since ingestion, signs and symptoms, age and weight and health

history are determined.

 Patient who ingested a corrosive poison is given water or milk to drink for dilution (not

attempted if patient has acute airway obstruction, or if with evidence of gastric or

esophageal burn or perforation.

 The following procedures may be done:

 Ipecac syrup to induce vomiting in the alert patient

 Gastric lavage for the obtunded patient; aspirate is tested

 Activated charcoal administration if poison can be absorbed by it

 Cathartic, when appropriate

 Ingested Poison Warnings

 Vomiting is NEVER induced after ingestion of caustic substances or petroleum

distillates.
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 The area poison control center should be called if an unknown toxic agent has been

taken or if it is necessary to identify an antidote for a known toxic agent.

Gastric Lavage Guidelines

1. Remove dentures and inspect for loose teeth.

2. Measure the distance between the bridge of the nose and the xiphoid process and

mark tube with indelible pencil or tape.

3. Lubricate tube with KY-Jelly.

4. If comatose, patient is intubated with cuffed nasotracheal or endotracheal tube

before placement of NGT.

5. Place patient in a left lateral position with head lowered 15°.

6. Pass the tube orally while keeping the head in neutral position. Pass tube to

marking (50 cm).

7. Aspirate gastric contents with the syringe attached to the tube before instilling

water/antidote & save specimen.

8. Remove syringe and attach funnel to the end of the tube or use a 50mL syringe to

instill solution into tube.

9. Elevate funnel above patient’s head and 150-200mL of solution into it.

10. Lower funnel and siphon the gastric contents, or connect to suction.

11. Save the samples of the first two washings.

12. Repeat the lavage until the returns are clear and no particulate matter is seen.

13. The stomach may be left empty, and an absorbent or saline cathartic is instilled and

allowed to remain inside.

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14. Pinch out the tube during removal or suction while withdrawing and keep head

lower than the body.

15. Warn patient that stools will turn black from the charcoal.

Management

 The specific chemical is given as early as possible to reverse effects.

 Procedures include administration of charcoal, diuresis, dialysis, and hemoperfusion.

 If poisoning is due to a suicide attempt, psychiatric evaluation is requested; if

accidental, home poison-proofing directions are given

Inhaled Poisons: CO Poisoning

 A result of industrial or household incidents, or attempted suicide

 Implicated in more deaths than any other toxins, except alcohol.

 CO exerts its toxic effects by binding to circulating hemoglobin, reducing its oxygen-

carrying capacity. Hemoglobin absorbs CO 200x more readily than O2.

 Carboxyhemoglobin doesn’t have O2

 CNS symptoms predominate with CO toxicity. Watch out for headache, muscle

weakness, palpitation, dizziness, and confusion, which rapidly leads to coma.

 Skin color ranges from cherry-red to pale and is not a reliable sign.

 Pulse oximetry will record false (+)’s.

CO Poisoning Management

Goal: to reverse cerebral and myocardial hypoxia and hasten elimination of CO by:

1. Carrying the patient to fresh air immediately and opening doors and windows

2. Loosening all tight clothing

3. Initiate CPR if required; give O2.

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4. Prevent chilling; wrap in blankets.

5. Keep patient as quiet as possible.

6. Do NOT give alcohol in any form.

7. Upon arrival at the ER, analyze carboxyhemoglobin levels and give 100% O2 until

level is <5%.

8. Watch out for psychoses, spastic paralysis, ataxia, visual disturbances, and

deterioration in mental status and behavior which may be symptoms of brain

damage.

9. If accidental poisoning occurs, the DOH should be informed so that the dwelling

could be inspected.

Food Poisoning

 A sudden illness that occurs after ingestion of contaminated food or drink

 Some of the most common diseases are infections caused by bacteria, such as

Campylobacter, Salmonella, Shigella, E. coli O157:H7, Listeria, and botulism

Campylobacter

 A bacterium that causes acute diarrhea

 Transmitted through ingestion of contaminated food, water, or unpasteurized milk, or

through contact with infected infants, pets or wild animals.

Salmonella

 Transmitted by drinking unpasteurized milk or by eating undercooked poultry and

poultry products such as eggs

 Any food prepared on surfaces contaminated by raw chicken or turkey can also become

tainted
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 May also stem from food contaminated by a food worker

Shigella

 Transmitted through feces. It causes dysentery, an infection of the intestines causing

severe diarrhea. The disease generally occurs in tropical or temperate climates,

especially under conditions of crowding, where personal hygiene is poor

E. Coli O157:H7

 Associated with eating undercooked, contaminated ground beef. Drinking

unpasteurized milk and swimming in or drinking sewage-contaminated water can also

cause infection

Listeria

 Found in many types of uncooked foods, such as meats and vegetables, as well as in

processed foods that become contaminated after processing, such as soft cheeses (such

as feta and crumbled blue cheese) and cold cuts.

 Unpasteurized milk or foods made from unpasteurized milk may also be sources of

listeria infection.

Botulism

 Linked to home-canned foods with a low acid content

 Foods include asparagus, green beans, beets, and corn.

 Other sources include chopped garlic in oil, chili peppers, tomatoes, improperly

handled baked potatoes cooked in aluminum foil, and home-canned or fermented fish

(such as sardines)
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Food Poisoning: MC Foods

 Honey should NOT be given to children younger than 12 months of age, as it can

contain spores of C. botulinum and is known to cause infant botulism

 Staphylococcus aureus in spaghetti

 Bacillus cereus in fried rice

 Toxins in mushrooms, shellfish, including the puffer fish

Assessment

1. How soon after eating did the symptoms occur?

2. What was eaten in the previous meal? Did the food have an unusual odor or taste?

3. Did anyone else become ill from eating the same food?

4. Did vomiting occur? What was the appearance of the vomit?

5. Did diarrhea occur?

6. Any other neurologic symptoms?

7. Does the patient have a fever?

8. What is the client’s appearance?

Management

 Determine the source and type of food poisoning.

 Food, gastric contents, vomitus, serum and feces are collected for examination.

 Patient’s VS, sensorium and muscular activity are closely monitored.

 Special attention to the hands, head, neck, chest, ears, face, perineum and feet

 Prevention of contractures in these areas is crucial to good healing.

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 Any time there is soot around the nose or mouth, burned nasal hairs, stridor, hoarseness,

decreased breath sounds, upper airway damage should be suspected.

Burns in the Extremes of Age

 In pediatric clients under age 2, the immunologic response to stress and trauma is

not fully developed, and a burn injury can be overwhelming.

 In the elderly, these responses are diminished and the person's general health may

be compromised by existing medical problems.

Burn Management

Maintenance of Airway Patency

A. Assess the airway.

B. Auscultate the trachea, and monitor for adventitious breath sounds or decreased

breath sounds.

C. If client is dyspneic or if there is carbon monoxide poisoning, a high liter flow of 8

to 10 liters of oxygen is recommended.

D. If compromise is suspected, the victim may be intubated and ventilated.

 Indications for intubation are airway obstruction and a PaO2 of less than 60

mm Hg.

 The continuous monitoring by means of a pulse oximeter assists in assuring

adequate oxygenation.

E. The client's level of consciousness should be carefully monitored. Burn victims are

most often alert, oriented and cooperative even with extensive injuries.

Fluid Resuscitation
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 The maximum loss of fluid occurs within 12 to 18 hours after the burn.

 The total quantity of fluid required to correct this volume deficit is replaced in the

first 24 hours following the burn injury.

 The amount of fluid required to correct the deficit is calculated to be 2 to 4 mL per

cent burn per kilogram of body weight.

 Administration of the fluids takes place over a 24-hour period with half the amount

given in the first 8 hours and the remainder over the next 16 hours.

Fluid Loss Management

1. Consensus Formula: 2-4 mL x body weight (kg.) x % body surface area burned. Half

to be given in first 8 hours, remaining half to be given over next 16 hours.

2. Evans Formula

 Colloids: 0.5 mL x body weight (kg.) x %BSA burned

 Electrolytes: 1.5 mL x body weight (kg) x % BSA burned

 Glucose: 2000 mL for insensible loss

 Day 1: Half to be given in the first 8 hours; remaining half over next 16 hours

3. Parkland Formula

 Lactated Ringer’s Solution: 4 mL x body weight (kg) x % BSA burned

 Day 1: Half to be given in first 8 hours; half to be given over next 16 hours

 Day 2: Varies. Colloid is added (e.g. albumin, dextran)

Burn Management

 Obtain laboratory data

 Monitor urine output and vital signs

 Administer tetanus antitoxin/toxoid

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 Hypertonic Saline Solution

 Goal: to increase serum sodium level and osmolarity to reduce edema and prevent

pulmonary complications

 Concentrated solutions of sodium chloride (NaCl) and lactate are given sufficiently

to maintain a desired volume of urinary output.

Phases of Burn Care: Emergent

1. Airway

2. Breathing

3. Circulation

4. Disability

5. Exposure

6. Fluid Resuscitation

 Assess for Acute Respiratory Failure

 Assess for Acute Renal Failure

 Assess for Distributive Shock

 Assess for Compartment Syndrome (Assess peripheral pulse, capillary refill.)

 Assess for Paralytic Ileus (Auscultate bowel sounds, abdominal distention.)

 Assess for Curling’s Ulcer (Assess gastric pH, occult blood in stools.)

Burn Care: Acute Phase

 Begins 48 to 72 hours post-injury

 Assess for edema, jugular vein distention, crackles, increased arterial pressure
 39

 Use asepsis & reverse isolation.

 Give high-calorie, high-protein diet

 Assess the graft sites. Report signs of poor healing, graft take or trauma.

 Prevent flexed position in burned areas.

 Burn Care: Rehabilitation Phase

 Wound healing, psychosocial support, and restoring maximal functional activity

remain priorities.

Chemical Burn

 Most chemicals that cause burns are either strong acids or bases

 The severity of a chemical burn is determined by the mechanism of action, the

penetrating strength and concentration, & the amount and duration of exposure of the

skin to the chemical.

Management

 The skin should be continuously drenched immediately with running water from a

shower, hose or faucet as the patient’s clothing is removed.

 The skin of the health care professional assisting should also be appropriately protected.

Chemical Poison Warnings

 Water should NOT be applied on burns from lye or white phosphorus because of a

potential for an explosion or for deepening of the burn.

 All evidence of these chemicals should be brushed off the patient before any flushing.

Management

 Determine the identity and characteristics of the chemical agent for future treatment.
 40

 The standard burn treatment for the size & location of the wound (antimicrobials,

debridement, tetanus toxoid) is instituted.

 The patient may require plastic surgery for further wound management

 The patient is instructed to have the affected area re-examined at 24 & 72 hours and in

7 days because of the risk of under-estimating the extent & depth of these types of

injuries.

 All evidence of these chemicals should be brushed off the patient before any flushing.

Management

 Determine the identity and characteristics of the chemical agent for future treatment.

 The standard burn treatment for the size & location of the wound (antimicrobials,

debridement, tetanus toxoid) is instituted.

 The patient may require plastic surgery for further wound management

 The patient is instructed to have the affected area re-examined at 24 & 72 hours and in

7 days because of the risk of under-estimating the extent & depth of these types of

injuries.