Edited Emergency Nursing

8/9/2019 Edited Emergency Nursing

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Is a specialized education, training and

experience to gain expertise in assessingand identifying patients health care

problems in crisis situations.

ER NURSING


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Emergency nurse establish priorities,

monitors and continuously assesses

acutely ill and injured patients,supports and attends to families,

supervise allied health personnel and

teaches the patient and families within

a time limited, high pressured careenvironment.


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Issues in Emergency Nursing Care

Documentation of consent.

Limiting exposure to health risk. Providing holistic care


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Care given to clients with urgent and critical

needs

Care must be rendered without delay

Diversified situations

Consent (unless unconscious and without S.O.)

Common clients (elderly, stomach pain, chest

pain, fever, drug related, wound) Disaster Nursing (terrorism)

Principle: TRIAGE


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Triage

- a process use in sorting victims into

categories of priority for care and transport

based on severity of injuries and medicalemergencies.


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TRIAGE

French word trier to sort

Sorting of clients based on the severity of

health problems Hierarchy based on the potential for life

loss

Advanced skills


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TRIAGE

3 categories ofTRIAGE (Berners)

1. Emergent

2. Urgent3. Non-urgent


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TRIAGE

I Emergent

Highest priority

Life threatening conditions, limbs Must be treated immediately

Airway compromise

Cardiac arrest

Shock

Stroke

Major Burns


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TRIAGE

II Urgent

Threatening conditions

Not immediate Must be seen within 1 hour

Fever

Minor Burns Lacerations


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TRIAGE

III Non-urgent

Can be addressed within 24 hours

Chronic conditions Dental problems

Missed Menses

4th category

Fast track simple first aid


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TRIAGE

Assess and Intervene (Primary survey)

A airway

B breathing C circulation

D disability

E expose


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QUICK ASSESSMENT

HEAD

MOUTH , LIPS & TEETH

EYES NOSE & EARS

FACE

SPINE & TRUNK LIMBS


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GLASCOW COMASCALE

Eye opening response

spontaneous 4To voice 3

To pain 2

None 1


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Verbal response

oriented 5

Confused 4Inappropriate words 3

Incomprehensible 2

None 1


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Motor response

Obeys commands 6

Localized pain 5 Withdraw 4

Flexion 3

Extension 2 None 1


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Secondary Survey

done after the priorities has been addressed.

a. Complete History and PE

b. Diagnostic and laboratory testing

c. ECG, Arterial lines, urinary catheters

d. Splinting of suspected fractures

e. Cleaning and dressing of wounds

f. other necessary interventions


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WOUNDS

Laceration skin tearwith irregular edges


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Avulsion tearing

away from

supporting structure

Abrasion denuded

skin


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Ecchymosis/contusi

on blood trapped

Hematoma tumorlike

under the skin massof blood trapped

under the skin


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Stab incision with

well defined edges

Stab wound with

evisceration


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Gun shot wound

Entry

Exit


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Management:

wound cleansing

wound closure primary closure

delayed primary closure

Tetanus prophylaxis antibiotics


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Hemorrhage

Stopping bleeding is essential to the care andsurvival

Primary cause of shock Signs & Symptoms ofShock:

Cool moist skin

Falling blood pressure

Increasing heart rate Delayed capillary refill

Decreasing urine volume


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Management:

fluid replacement

control of external bleeding control of internal bleeding


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Management:

Fluid replacement & Blood replacement

Control of external hemorrhage:

Direct pressure

Temporal

Facial

Carotid

Subclavian

Brachial

Radial & Ulnar

Femoral

Pressure dressing

Tourniquets (last resort)


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Control ofInternal Bleeding

Signs & Symptoms:

tachycardia

Falling blood pressure

Thirst

Apprehension

Cool & moist skin

Delayed capillary refill

Packed Red Blood Cell transfusion Surgery

Pharmacologic therapy


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SHOCK


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SHOCK

a condition of profound hemodynamic

and metabolic disturbance due to

inadequate blood flow and oxygen

delivery to the capillaries and tissues ofthe body.


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1. Hypovolemic

Results from loss of circulating volume.

This ma be due to excessive blood loss,loss of body fluids or third spacing fluids,hemorrhage, dehydration, burns andtrauma.

2. Cardiogenic

Results from impaired or compromisedcardiac output.

Pump failure, decreased venous return(myocardial infarction, cardiac tamponade,dysrhythmias)


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3. Vasogenic

Results from profound and massive

vasodilation thatleads to disproportionbetween the size of vascular space and the

amount of blood contained in it.

Head injury, general anesthesia, drug

overdose

4. Septic

Results from severe and profoundcondition of generalized vascular collapse

secondary to a systemic infection.


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5. Anaphylactic

Profound peripheral vascular

collapsed induced by severe allergic

reaction mediated by histamine,

bradykinin, leukotrienes, and

prostaglandins.


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Signs and Symptoms

Early stage Restless, confusion

increase pulse rate, RR

cold, moist skin

decreased pulse pressure

pallor

thirst, dry mucous membrane diaphoresis

oliguria


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Late stage shallow respiration

Dec. BP

Oliguria, anuria

Cool, clammy skin ( hypovolemic, cardiogenic,

septic)

Cool, mottled skin ( neurogenic, vasogenic)

Lethargy

Cyanosis

Dilated pupils


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Nursing problems: altered tissue perfusion related to failing

circulation

impaired gas exchange related to ventilation-perfusion imbalance

decreased cardiac output related to decreased

circulating blood volume


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Management:

1. Promoting fluid balance and cardiac

output whole blood and blood products

colloid solutions (albumin, plasma)

plasma expanders

crystalloids solution

Isotonic solutions plain LR


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2. Assisting cardiac support modified trendelenburg position

3.Assisting with respiratory supports

oxygen therapy

mechanical ventilation

suctioning

deep breathing,coughing exercise


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4. Assisting with renal support monitor urine output

BUN, Creatinine

5. Assisting GI support histamine blockers, antacids

NGT

6. Promoting safety restraints

strict asepsis technique


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Drug Therapy in Shock:

1. Vasoconstrictors (with Chronotropic and

Inotropic effects)

a. Epinephrine, Dopamine, Dobutamine

2. Vasodilatorsa. Nitroprusside

b. Nitroglycerine, Isosorbide

3. Sodium Bicarbonate to reverse acidosis

4. Antibiotics to control sepsis.5. Heparin to treat DIC

6. Steroids to produce antiinflammatory effect

7. Glucagon to increase blood sugar


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8. Cimetidine to prevent Stress Ulcer.

9. Glucose 50% to meet increased demand

for energy during shock.10. Naloxone (Narcan) to block Endorphin-

mediated hypotension.

11. Diphenhydramine (Benadryl) forAnaphylaxis

12. Narcotic to relieve pain.

13. Cardiotonic Medications:

a. To treat Dysrhythmias-Lidocaine,

Bretylium, Quinidine

b. To treat Bradycardia-Isoproterenol,

Atropine SO4


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Trauma

Unintentional or intentional wound or injury

4th leading cause of death in the US

Leading cause of death in children & youngadults < 44 years of age

Injury prevention ( only way to reduce incidenceof trauma)

Education

Legislation

Automatic protection


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TRAUMA


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Stab Wound


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1. Intra-abdominal injuries:

Penetrating abdominal injuries

Gunshot wound, Stab wounds

Serious & requires surgery

Liver ( most frequently injured solid organ)

All abdominal gunshot wounds require

surgical exploration Stab wounds may be managed non-operatively


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Blunt Trauma


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Blunt Abdominal Injury

Result from motor vehicle crashes, falls,

blows or explosions Injuries may be hidden or difficult to

detect

Involves the liver, kidneys, spleen, blood

vessel


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Assessment & Diagnostic Findings

History & PE

Lab studies: Urinalysis

serial Hct. level

WBC count

Serum amylase analysis


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Internal Bleeding Inspection ( front of the body, flanks & back)

Bluish discoloration, asymmetry, abrasion,

contusion Abdominal CT Scan

Abdominal Ultrasound

Left shoulder pain ( ruptured spleen)

Right shoulder pain (liver laceration)


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Intraperitoneal Injury

Assess for tenderness, rebound tenderness,

guarding, rigidity,

spasm, increasing distention & pain

Referred pain ( intraperitoneal injury)


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Diagnosis: abdominal ultrasound

abdominal CT scan

Diagnostic peritoneal lavage 1 L LRS/ NSS

400 ml return

RBC > 100,000/mm3

WBC ct > 500/mm3

Bile, feces, food


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Sinography ( detection of peritoneal

penetration)

Purse string

Small catheter

Contrast agent

X-ray


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Genitourinary Injury

Rectal/vaginal

examination

pelvis Bladder

Intestinal wall

Indwelling catheter

inserted after rectal

exam


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Intraabdominal Injury Management:

Resuscitation procedure

Occlusion of chest wound

Direct pressure

Intravenous fluid replacement

Immobilization of the spine

Cervical spine immobilization

Tetanus prophylaxis

Broad spectrum antibiotics


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Crush Injuries

Caught between

objects

Run over by movingvehicle

Compressed by

machinery


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Management:

ABC

Fasciotomy

Wound debridement & fracture repair


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Multiple Injuries

Requires a team approach

Affects every body system

Assessment & Diagnostic

Depends on the body part involved


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MVA


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MVA


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MVA


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MVA


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MVA


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Management:

Determine the extent of injury

Establish priority of treatment


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Fracture

A break in the continuity of the bone and is

defined according to its type and extent


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Fracture

Severe mechanical Stress to bone

bone fracture

Direct Blows

Crushing forces

Sudden twisting motion

Extreme muscle contraction


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Fracture

TYPES OF FRACTURE

1. Complete fracture

Involves a break across the entire cross-

section

2. Incomplete fracture

The break occurs through only a part of the

cross-section


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Fracture

TYPES OF FRACTURE

1. Closed fracture

The fracture that does not cause a break in

the skin

2. Open fracture

The fracture that involves a break in the skin


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Fracture

TYPES OF FRACTURE

1. Comminuted fracture

A fracture that involves production of several

bone fragments

2. Simple fracture

A fracture that involves break of bone into two

parts or one


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Fracture

ASSESSMENT FINDINGS

1. Pain or tenderness over the involved area

2. Loss of function

3. Deformity

4. Shortening

5. Crepitus

6. Swelling and discoloration


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Fracture

ASSESSMENT FINDINGS

1. Pain

Continuous and increases in severity Muscles spasm accompanies the fracture

is a reaction of the body to immobilize the

fractured bone


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Fracture

ASSESSMENT FINDINGS

2. Loss of function

Abnormal movement and pain can resultto this manifestation


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Fracture

ASSESSMENT FINDINGS

3. Deformity

Displacement, angulations or rotation ofthe fragments Causes deformity


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Fracture

ASSESSMENT FINDINGS

4. Crepitus

A grating sensation produced when thebone fragments rub each other


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Fracture

DIAGNOSTIC TEST

X-ray


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Fracture

EMERGENCY MANAGEMENT OF FRACTURE

1. Immobilize any suspected fracture

2. Support the extremity above and below

when moving the affected part from a vehicle

3. Suggested temporary splints- hard board,

stick, rolled sheets

4. Apply sling if forearm fracture is suspectedor the suspected fractured arm maybe

bandaged to the chest


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Fracture

EMERGENCY MANAGEMENT OF

FRACTURE

5. Open fracture is managed by covering a

clean/sterile gauze to prevent

contamination

6. DO NOT attempt to reduce the facture


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Fracture

MEDICAL MANAGEMENT

1. Reduction of fracture either open or

closed, Immobilization and Restoration of

function

2. Antibiotics, Muscle relaxants such as

METHOCARBAMOL and Pain

medications


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Fracture

General Nursing MANAGEMENT

For CLOSED FRACTURE

1. Assist in reduction and immobilization

2. Administer pain medication and muscle

relaxants

3. teach patient to care for the cast

4. Teach patient about potential complicationof fracture and to report infection, poor

alignment and continuous pain

Fracture


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Fracture

General Nursing MANAGEMENTFor OPEN FRACTURE

1. Prevent wound and bone infection

Administer prescribed antibiotics Administer tetanus prophylaxis

Assist in serial wound debridement

2. Elevate the extremity to prevent edemaformation

3. Administer care of traction and cast


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Fracture

FRACTURE COMPLICATIONS Early

1. Shock

2. Fat embolism 3. Compartment syndrome

4. Infection

5. DVT


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Fracture

FRACTURE COMPLICATIONS Late

1. Delayed union

2. Avascular necrosis 3. Delayed reaction to fixation devices

4. Complex regional syndrome


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Fracture

FRACTURE COMPLICATIONS: FatEmbolism

Occurs usually in fractures of the longbones

Fat globules may move into the bloodstream because the marrow pressure isgreater than capillary pressure

Fat globules occlude the small bloodvessels of the lungs, brain kidneys andother organs

Fracture


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Fracture FRACTURE COMPLICATIONS: Fat

Embolism Onset is rapid, within 24-72 hours

ASSESSMENT FINDINGS

1. Sudden dyspnea and respiratorydistress

2. tachycardia

3. Chest pain 4. Crackles, wheezes and cough

5. Petechial rashes over the chest, axillaand hard palate


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Fracture


Nursing Management

1. Support the respiratory function

Respiratory failure is the most commoncause of death

Administer O2 in high concentration

Prepare for possible intubation andventilator support


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Fracture


Nursing Management

1. Support the respiratory function

Respiratory failure is the most commoncause of death

Administer O2 in high concentration

Prepare for possible intubation andventilator support


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Fracture

FRACTURE COMPLICATIONS: Fat Embolism Nursing Management

3. Institute preventive measures

Immediate immobilization of fracture

Minimal fracture manipulation

Adequate support for fractured bone during

turning and positioning

Maintain adequate hydration and electrolytebalance

Fracture


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Early complication: Compartment

syndrome A complication that develops when

tissue perfusion in the muscles is less

than required for tissue viability


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Fracture

Early complication: Compartment syndrome

ASSESSMENT FINDINGS

1. Pain- Deep, throbbing and UNRELIEVED

pain by opiods Pain is due to reduction in the size of the

muscle compartment by tight cast

Pain is due to increased mass in thecompartment by edema, swelling orhemorrhage


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Fracture

Early complication: Compartment syndrome

ASSESSMENT FINDINGS

2. Paresthesia- burning or tingling sensation 3. Numbness

4. Motor weakness

5.P

ulselessness, impaired capillary refilltime and cyanotic skin


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Fracture

Early complication: Compartmentsyndrome

Medical and Nursing management

1. Assess frequently the neurovascularstatus of the casted extremity

2. Elevate the extremity above the

level of the heart 3. Assist in cast removal and

FASCIOTOMY


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Fracture (open)

Strains


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Strains

Excessive stretching of a muscle or

tendon

Nursing management 1. Immobilize affected part

2. Apply cold packs initially, then heat

packs

3. Limit joint activity

4. Administer NSAIDs and muscle

relaxants


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Sprains

Excessive stretching of the LIGAMENTS

Nursing management

1. Immobilize extremity and advise rest 2. Apply cold packs initially then heat packs

3. Compression bandage may be applied to

relieve edema

4. Assist in cast application

5. Administer NSAIDS


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Head Injury


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Eye Injuries

FLAIL CHEST


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1. A blunt chest trauma from a steering wheel Injury.

2. Occurs when three or more adjacent ribs(multiple

contiguous ribs) are fractured at two or more sites,

free-floating segments.

3. During inspiration, the flail segment moves in

paradoxical manner (pendelluft movement), in that

it is pulled inward during inspiration

4. Results in hypoxemia, retained airway secretions,atelectasis, hypotension, inadequate tissue

perfusion, metabolic acidosis.


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Management:

a. Supportive

1. Provide ventilatory support

2. Clearing secretions from the lung

3. Controlling pain4. Positioning

5. Coughing

6. Deep breathing

7. Suctioning8. Endotracheal intubation

9. Mechanical ventilation

HEAD INJURIES


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HEAD INJURIES

May be an injury to the scalp, skull or

brain

It as the most common cause of death

from trauma in the US

Traumatic brain Injury- most serious

form of head injury

C f T ti B i I j


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Causes of Traumatic Brain Injury:

1. Motor vehicle crashes

2. Violence

3. Falls

Age group at risk:15 to 24 years, Males

The best approach to head injury

prevention

Two forms of brain damage from traumatic Injury:


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g j y

a. Primary Injury

1. Initial damage to the brain that results from

traumatic events

2. Contusions, lacerations, torn blood vessel

from impact, Acceleration/deceleration,

foreign object penetration

b. Secondary Injury

1. Ensuing hours and days after initial injury

2. Due to brain brain swelling or on-ongoing

bleeding, increasing ICP, ischemia,

infarction, irreversible brain damage &

brain death

1 Scalp injury


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1.Scalp injury

A minor head injury, bleeds profuselywhen injured

May result in abrasion, contusion,laceration or hematoma

Diagnosis is based on PE, inspection,palpation

2 Sk ll F t


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2. Skull Fracture

Break in the continuity of the skull

caused by forceful trauma

May occur with or without brain

damage

May be linear, comminuted, depressed,

basilar, open or closed


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Clinical Manifestations:

Persistent localized pain in the affected

area

X-rayBattles sign

CSF otorrhea

CSF RhinorrheaHalo sign

Assessment & diagnostic findings


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Assessment & diagnostic findings

CT Scan

MRICerebral angiography

Medical Management:Close obsevation

Surgery

Antibiotic treatmentBlood therapy

3. Brain Injury

Most important consideration In any head


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Most important consideration In any head

injury

Two types of Brain Injury:

1. Closed brain injury- occurs when the

head accelerates and rapidlydecelerates or collides with another

object, brain damage

2. Open Brain Injury - occurs when an

object penetrates the skull, enters the

brain, & damages the soft brain tissue

Clinical manifestations of brain injury:


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Clinical manifestations of brain injury:

1. Altered level of consciousness

2. Confusion

3. Pupillary abnormalities

4. Altered or absent gag reflex

5. Absent corneal reflex

6. Sudden onset of neurological deficits7. Changes in vital signs

8 Vision & hearing impairment

9. Sensory dysfunction

10. Spasticity

11. Headache12. Vertigo

13. Movement disorder

14. Seizure

Concussion


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Results in temporary loss of neurologic function with no

apparent structural damage.

Involves a period of unconsciousness from a few

seconds to a few Minutes.

Pt may be hospitalized overnight for observation

Signs & Symptoms:

1. Difficulty in awakening

2. Difficulty in speaking

3. Confusion

4. Severe headache

5. Vomiting

6. Weakness of the one side of the body

Contusion


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A more severe injury in which the brain is bruised

and hemorrhaged

Pt is unconscious for more than a few seconds or

minutes.

Clinical signs & symptoms depends on the size of

the contusion & amount of cerebral edema.

Poor prognosis

Abnormal motor functions, abnormal eye

movement, elevated ICP, brain damage, disability

or death.

Diffuse Axonal Injury


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Diffuse Axonal Injury

Involves a widespread damage to axons in thecerebral hemisphere,corpus callosum and

Brainstem.

May result in axonal swelling & dislocation.Immediate coma, decorticate & decerebrate

posturing and global cerebral edema.

Diagnosis: CT scan & MRI


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Intracranial Hemorrhage

Hematoma that develop within the

cranial vault.

Most serious brain injury.

May be epidural, subdural orintracerebral.


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Management of Brain Injury:

Initial PE & neurologic exam

CT Scan & MRIPET scan

All therapy is directed toward preserving

brain homeostasis & preventing

secondary brain Injury.

Spinal Cord Injury (SCI)


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Occurs 4 times common in males aged

16-30

Motor vehicle crashes (most common

cause of SCI)

Risk factors: age, gender, alcohol & Drugabuse

CS, C6, C7, T12, L1 (most frequently

involved vertebrae)Damage ranges from concussion to

contusion, laceration, compression of

the cord to complete transaction.


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Two categories:

1. Primary injury - initial insult or trauma,

usually Permanent.

2. Secondary Injury- contusion or tear injury,in which the nerve fibers begins to swell &

disintegrate, ischemia, hypoxia, edema,

hemorrhage, destruction of myelin &

axons. May be reversible 4-6 hoursafter injury.


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Clinical Manifestations depend on the type & level of

Injury:


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Central cord syndrome

Cause injury or edema of the central cord,

usually cervicalCharacteristics: motor deficit, sensory loss

varies, bowel/bladder dysfunction

variable or function maybe completely

preserved.


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Anterior Cord Syndrome

Cause acute disc herniation or hyperflexion

injuries associated with Fracture-

dislocation of vertebra, injury toAnterior spinal artery;

Characteristic loss of pain, temperature and

motor function; light touch, position& vibration senses intact.


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Brown-Sequard Syndrome (Lateral cord syndrome)

Cause Transverse hemisection of the cord from a knife

or missile injury, fracture dislocation

from a unilateral articular process or

an acute ruptured disc.

Characteristics: Ipsilateral paralysis or paresis,

ipsilateral loss of touch, position

and vibration senses intact,contralateral loss of pain &

temperature.


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Types of Injury:

1. Incomplete Spinal Cord Lesion - according to

area of spinal cord damaged: central, lateral,anterior, peripheral

2. Complete Spinal Cord Lesion - may result in

paraplegia & quadriplegia


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Assessment & DiagnosticFindings:

1. Detailed neurologic exam2. Diagnostic X-ray

3. CT

4. MRI

ASIA Impairment Scale

A l ( f i i d i


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A = complete ( no motor, sensory function is preserved in

the sacral segments S4,S5)

B = incomplete (sensory but not motor function is

preserved below the neurologic level, includes

S4,S5)

C = motor function is preserved below the neurologic level,

more than half of key muscles have a grade less

than 3)

D = incomplete motor function is preserved, half of keymuscle have a grade more than 3.

E = motor & sensory functions are normal


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Emergency Management:

o Rapid assessment

o Immobilization

o Extricationo Stabilization or control of life threatening

injuries.

o Transportation to appropriate medical facilities.


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Management of SCI (Acute Phase)

o Resuscitation

o Oxygenation

o Cardiovascular stability

o Pharmacologic therapy (high dose steroidsat 6 weeks, 6 mos., & 1 yr)

o Respiratory Therapy -

o Skeletal fracture reduction & fraction

o Surgical management:Laminectomy


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Complications:

O Spinal shock and Neurogenic shock.

O Deep vein thrombosisO Autonomic Dysreflexia


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Heat Stroke An acute medical emergency

Failure of the heat regulating mechanisms of thebody

Occurs during extended heat waves People at risk: Not acclimatized to heat

Elderly & very young

Unable to care for themselves

With chronic & debilitating diseases

Taking certain medications Causes thermal injury at the cellular level ( heart, liver, kidney,

blood coagulation)


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Assessment:

Exposure to elevated temperature

Excessive exercise during extreme heat

Signs & Symptoms:

Confusion, delirium, bizarre behavior, coma

Elevated body temperature ( 40.6 C or

higher)

Hot, dry skin

Anhydrosis

Tachynea, hypotension, tachycardia

Management:


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To reduce hightemperatureASAP

cool sheets & towels,TSB

Ice pack

Cooling blankets

Iced Saline Lavage Immersion in cold water

bath

Massage ( promotecirculation)

Pt monitoring ( VS,ECG, CVP)

Oxygenation (100%)

IV infusion therapy

Monitor urine output

Patient education

HEAT CRAMPS


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HEAT CRAMPS

Heat Cramps


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HeatCramps

- a muscular pain and spasm due largely

to loss of salt from the body in sweating or

too inadequate intake of salt.

Signs and Symptoms:

Muscle cramps, often in the abdomen or

legs.

Heavy perspiration.

Lightheadedness; weakness.

First Aid Management


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Have the victim rest with his/her feet.

Cool the victim. Do not use an alcohol

rub. Give the victim electrolyte beverages to

sip or make salted drink.

To relieve muscle cramps massage theaffected muscles gently but firmly untilthey relax.

Heat Exhaustion


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HeatExhaustion

- response to a heat characterized by fatigue, weakness, andcollapse due to inadequate intake of water to compensate for loss offluids through sweating.

Signs and Symptoms

Cool, pale or red, moist skin.

Dilated pupils. Headache.

Extreme thirst.

Nausea, vomiting.

Irrational behavior.

Weakness; dizziness Unconsciousness.



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Have the victim rest with his/her feet elevated.

Cool the victim.

Give the victim electroyte beverages to sip or

make a salted drink. Monitor the victim for signs of shock.

If the victim starts having seizures, protecthim/her from injury and give first aid for

convulsions. If the victim loses consciousness, give first aid

for unconsciousness.

Frostbite


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Trauma from

exposure to freezing

temperature

Actual freezing oftissue fluids

Results in cellular &

vascular damage

Feet, hand, nose,ears


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Assessment:

History of exposure to

cold

Frozen extremity,hard, cold ,

insensitive to touch

Management:R t l


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Restore normal

body

temperature

Circulating back

of 37 40 C

Sterile gauze or

cotton inbetween fingers

& toes

Massage is

contraindicated Whirlpool bath

Escharotomy

Fasciotomy


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Hypothermia


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The core (internal)

temperature is 35 C orless

Assessment and

Findings:

Progressive deterioration

Apathy

Poor judgement

Ataxia

Dysarthria

Drowsiness

Pulmonary edema

Coagulopathy

Management:


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Management:

Monitoring VS, CVP, UO, ABG, Bloodchem., ECG, Chest X-ray

Rewarming

a. core rewarming method, CP bypass,warm fluid, warm

humidified oxygen, warm peritoneal lavage

b. Passive external rewarming, warmblankets over the bed heaters

Supportive Care


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Near Drowning


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g

Survival for at least 24 hours after

submersion

Hypoxemia ( most common

consequence)

Leading cause of unintentional death in

children younger than 14 years old


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Factors:

Alcohol ingestion

Inability to swim

Diving injuries Hypothermia

Exhaustion

Fresh water aspiration (loss of surfactant) Salt water aspiration (pulmonary edema)

Management:


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Maintain cerebralperfusion

Adequate oxygenation

Immediate CPR

Monitor temperature by

rectal probe

Rewarming procedures

ECG monitoring

Indwelling urinary

catheter

NGT

. Decompression Sickness (DCS)


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Also called The Bends

Diving, high altitude flying or flying in commercial

aircraft within 24 hours after diving

Results from nitrogen bubbles trapped in thebody

Musculoskeletal pain, numbness/hypesthesia

Nitrogen bubbles become air emboli, stroke,

paralysis, death


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Assessment &

Diagnosis:

Detailed history

Rapid ascent, loss of

air in the tank, buddy

breathing, recent

alcohol intake, lack of

sleep or flight within 24

hours


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Management:

Patent airway

Adequate ventilation

Oxygenation (100%)Hyperbaric chamber

Anaphylactic Reaction


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p y

Acute systemic

hypersensitivity

reaction

Occurs withinseconds or minutes

after exposure to

certain foreign

substances Medications

Insect stings

Foods

Immunoglobulin E (IgE)


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Diagnosis:

Respiratory symptoms

DOB

Stridor secondary to laryngeal edema

Fainting, itching, swelling of mucus

membrane

Sudden drop in BP


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Management:

Patent airway & ventilation

ET intubation

Aqueous epinephrine

Crichothyroidotomy

Antihistamines

Aminophylines

Albuterol inhalers Isoproterenol or Dopamine

IV Benzodiazepines


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Latex Allergy

Affects healthcare

providers who uses

this product Management: Latex

free products

. Injected Poisons: Stinging Insects


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Venoms of the

hymenoptera (bees,

hornets, yellow

jackets, fire ants,

wasps)

Venom allergy ( IgE

mediated reaction)

Stinging


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ClinicalManifestations:

Generalized urticaria

Itching

Malaise

Anxiety

Bronchospasm

Shock Death


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Management:

Stinger removal

Wound care with

soap & water

Ice application

Oral Antihistamines

& analgesic

Aqueous

epinephrine SQ

Desensitization

therapy

Snake Bites


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Affects ages 1- 9 years

Pit vipers (most frequent poisonous snake in the

US) Cobra ( Philippines)

Upper extremity (most common site)

Envenomation (injection of a poisonous material

by sting, spine, bite)

Medical emergency


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Management:

Have victim lie down

Remove constrictive items

Provide warmth Cleanse & cover the wound

Immobilize the injured part below the level of

the heart Ice & tourniquet is contraindicated


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Corticosteroids are contraindicated in the first6-8 hours after bite

Observe for at least 6 hours

Administration of antivenin within 12 hoursafter the bite

Children requires more antivenin than adults

Skin or eye test to detect allergy to antivenin


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Measurement of circumference of theaffected part

before administration of antivenin and every 15minutes thereafter

After symptoms decrease, every 30-60 minutes forthe next 48 hours

Done to detect compartment syndrome (swelling,loss of pulse, increase pain, paresthesia)

Diphenhydramine & Cemetidine

Too rapid infusion ( most common caused ofallergic reaction)

Poisoning


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Any substance ingested, inhaled,

absorbed, applied to the skin or produced

within the body injures the body bychemical reaction


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Ingested orSwallowed Poisons(Corrosive)

Alkaline or acid agents caused tissue

destruction after in contact with mucusmembrane


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Management:

Airway, ventilation, oxygenation

Water or milk to drink for dilution

Syrup of Ipecac, Gastric lavage, Activated charcoal

and Catharsis are all Contraindicated.

Antidote as early as possible

Monitor VS, CVP, Fluid & Electrolytes

Psychiatric consultation

Inhaled Poisons : Carbon Monoxide

Poisoning


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Result of industrial or householdincidence or attempted suicide

Carbon monoxide exerts its toxic effect

by binding to circulating hemoglobin

thereby reducing O2 carrying capacity

of the blood

Carboxyhemoglobin does not transport oxygen


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Signs & Symptoms :

Headache

Muscle weakness

Palpitation

Dizziness

Confusion

Cyanosis

Coma


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Management:


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Reverse cerebral & myocardialhypoxia

Hasten elimination of carbon

monoxide

Oxygenation (100%) at atmospheric

or hyperbaric pressure

Substance Abuse


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Misused of specific

substances to alter

mood or behavior

Drug & alcohol

Acute Alcohol Intoxication


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Affects young adults or people older than 60years of age

Alcohol or ethanol is a direct multisystem toxin &

CNS depressant:

Drowsiness

Incoordination

Slurring of speech

Sudden mood changes, Aggression, belligerence,grandiosity

Uninhibited behavior


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Management:

Detoxification of

the acute

poisoning,

recovery,rehabilitation

Denial &

defensiveness

Alcohol Withdrawal

Syndrome/Delirium Tremens


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y

Acute toxic state that occurs as a result as a cessation ofalcohol intake

Signs & symptoms: Anxiety

Uncontrollable fear

Tremor

Irritability

Agitation

Insomnia

Incontinence

Visual, tactile, auditory, olfactory hallucination


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Management:

Adequate sedation & support

Allow pt to rest and recover

Place pt in a calm, nonstressful environment

Alcohol free environment

Refer pt to self help groups such as AA

Negative conditioning with

Disulfiram(Antabuse)

Naltrexone HCL (antidote)

Violence, Abuse, Neglect


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Family Violence, Abuse & Neglect


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Domestic violence is the leading cause ofdeath for young African American Women

Men & persons with disabilities are also

victims of domestic violence Elder abuse results physical,

psychological abuse, neglect, vilations of

personal rights & financial abuse


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Clinical Manifestation:

Unexplained bruises, laceration, abrasion,

head injuries & fractures

Malnutrition & Dehydration (most common inneglect)

Assessment:

Early detection & Intervention

Careful history


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Management:

Primary concern safety & welfare of

the pt.

Separation of the pt with the abuserMandatory reporting laws


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Sexual Assault


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Rape is force sexualact

Victims may either be

male or female


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Crisis Intervention: Assessment & diagnostic findings

rape trauma syndrome

phases of psychological reaction acute disorganization phase ( shock, disbelief,

fear, guilt, humiliation, anger)

Denial Phase: (anxiety, fear, flash backs, sleep

disturbances, hyperalertness & psychosomatic

reactions)

Phase ofReorganization: (Recovery)


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Management: Give sympathetic support

Reduce emotional trauma

Gather available evidence Goal: have pt. regain control over her/his life

. Violence in the Emergency Department


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Pts & families waiting for assistance at theED are sometimes dissatisfied resulting in

violence

Management: Safety is the first priority

Psychiatric Emergencies


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Is an urgent, serious disturbance ofbehavior, affect, or thought that makes the

pt. unable to cope with life situations &interpersonal relationships

Concern: Determining whether pt is at riskfor injuring self or others

Aim: Maintain pt self esteem whileproviding care

. Overactive Patients


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Display disturbed, uncooperative & paranoidbehavior

Management:

Reliable history about mental illness, hospitalization,

injuries, illnesses, use of alcohol or drugs

Immediate goal: Gain control of the situation

Restraint is used as the last resort

Psychotropic agent : Chlorpromazine, (Thorazine),

Haloperidol (Haldol)

Violent Behavior


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Usually episodic Means of expressing feelings of anger,

fear, or hopelessness

Management: Goal : bring the violence under control

Use calm & noncritical approach

Crisis intervention

Sedative

Restraint

Post Traumatic Stress Disorder (PTSD)


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. Development of characteristic symptomsafter a psychologically stressful event

Symptoms include intrusive thoughts &

dreams, phobic avoidance reaction,heightened vigilance, exaggerated startle

reaction, generalized anxiety, societal

withdrawal


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Assessment: Evaluation of the pts pretrauma history, the

trauma itself & post trauma functioning

Management: Crisis intervention

Establish a trusting & sharing relationship

Education of the pt and family

Underactive or Depressed

Patient


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Depression may be

masked by anxiety &

somatic complaints


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Clinical manifestations: Sadness

Apathy

Feeling of worthlessness

Self-blame

Suicidal thoughts

Anorexia, Weight loss

Decrease interest in sex Sleeplessness


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Management:

Ventilating personal feelings

Suicidal precaution

Antidepressant & antianxiety agentsPsychiatric consultation

Suicidal Patients


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.Attempted suicide is an act that stemsfrom depression

Viewed as a cry for help or intervention

Weight loss

Sleep disturbances

Somatic complaints

Suicidal preoccupation


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Management: Treat the consequences of suicidal attempt &

prevent further self injury

Crisis intervention

TOXICOLOGY


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POISONING & DRUG OVERDOSE

A. General Guidelines:

1. Maintain adequate airway, breathing and cardiac support.

2. If with mental status abnormalities (i.e. coma, stupor,

drowsy), give 50 ml ampule of 50% (1-2 mI/kg)

dextrose, followed by Naloxone (Narcan) 2 mg IV, or

endotracheally, and administer Thiamine 100 mg IV or

IM. Naloxone may be repeated in boluses of 1-2mg up

to 4mg IV. Obtain an immediate glucose level and

administer glucose if the glucose is


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4. Contact local poison center: Philippine General Hospital Poison CenterTelephone No. 524-1078, 521-8450 local 2311 or East Avenue Medical Center

Toxicology Center Telephone No. 928-0611 local 336 or 928-6233.

5. Consider possibility of suicide attempt or intentional poisoning in suspicious

overdoses.

6. All female patients with intentional ingestion should ideally have a pregnancy test

(check last menstrual period) following informed consent. And if found

positive, pregnancy outcome must be followed up.

7. Suicidal precautions should be instituted as needed: Always have a 24-hour

responsible watcher. There should be no access to sharp objects such asknives, razors, ropes, or belts inside the room. Always keep windows and

balcony locked. Never leave medications bedside. Limit visitors to prevent

possible supply of illicit substance.

B. Principles of Decontamination:

1. External Decontamination

a. Remove clothes.


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b. Wash skin with soap and water. Note also contamination ofhair and fingernails.

c. Keep warm; use blankets.

2. Gastric Lavage (Nasogastric tube)

a.Contraindications include ingestions of strong acids, alkalis,

petroleum distillates (unless volume is large because it may volatilizeand cause chemical pneumonitis).

b. Airway must be protected with endotracheal tube unless

patient is awake, alert and has a gag reflex. Place

patient in the Trendelenburg and left lateral decubitus position. Positionhead to one side to minimize aspiration. If patient has respiratory

difficulty, consider placing a cuffed endotracheal tube. Begin

mechanical ventilation and oxygenation if indicated.


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c. Perform gastric lavage unless overdose wasparenteral or distant in time. Lavage may be

useful if performed within 2 hours of drug

ingestion (unless dealing with a delayed

release preparation) and longer ifanticholinergic drugs (tricyclic

antidepressants) of other drugs that delay

gastric emptying were ingested.

3. Activated Charcoal


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a. Single dose activated charcoal: Always consider

giving charcoal after emesis or lavage unless

specifically contraindicated, such as if oral

antidote will be used or if endoscopy is

planned. For example, activated charcoal may

be detrimental in Paracetamol ingestion since it

binds to N-acetylcysteine. Adult dose of

activated charcoal is 50-1 00 grams (1 gram/kg

body weight) in 200 ml of tap water in a thickslurry. Instill slurry by lavage tube or have

patient ingest slurry.


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b. Multiple doses of charcoal: Giving activated charcoal 0.5 gram/kg/body

weight q 4-6 hours may be indicated for metamphetamine,

phenothiazines, digoxin, theophylline, phenobarbital and

organochlorine pesticides ingestion, because these substances

have enterohepatic recirculation kinetics. Note that activatedcharcoal may cause constipation or fecal impaction.

c. Activated charcoal is not effective for alkalis, cyanide, mineral acids,

ferrous sulfate and petroleum ingestion.

4. Cathartics (Sodium sulfate)

a. Contraindicated in infants, acid and alkali

ingestion patients who will receive an oral


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ingestion, patients who will 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

is contraindicated in hypertension and heart

failure.

b. Sodium sulfate 15-30 grams (or 250 mg/kg)

in 100 ml water given 30 minutes after the

activated charcoal. If still without bowel

movement within one hour, may repeat

procedure.

5. a. Forced Diuresis:

Maintain urinary flow rate of 5-7


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Maintain urinary flow rate of 5 7

ml/kg/hr by infusing normal

saline and intermittent boluses

of Furosemide 20 mg N doses.Alternatively, use mannitol 20-

100gm IV, maximum 300 gm.

Monitor electrolytes and state of

hydration.

b. Forced Alkaline Diuresis:

May be useful for phenobarbital,


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mephobarbital, primidone, salicylates,lithium, isoniazid. Adult dose: Sodium

bicarbonate 1-2 amp N, followed by

continuous N infusion of 1-2 ampules (50-100

mEq) of sodium bicarbonate in 1 liter of 0.25-0.45 and normal saline at 25 0-500 mI/hr the

first 1-2 hours.

Maintain the urine pH of 7.3-9.0. Addadditional 0.45% normal saline and intermittent

doses of Furosemide 20 mg N. Increase urine

output to 2-3 mi/kg/hour.

6. Miscellaneous Antidotes


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a. Extrapyramidal reaction to Phenothiazines orMetoclopromide Diphenhydramine 25- 50mg IV

or IM q 6 hours X 4 doses; followed by 25-50

mg IV or P0 q 6 hours for 24-72 hours PRN.

b. Benzodiazepine overdose (e.g. Diazepam,

Midazolam, Lorazepam) Flumazenil 0.5 mg/S ml

ampule: 0.2mg IV q 5-15 minutes until the patient

wakes up or until 1 mg is reached. Consider gastricemptying, activatedcharcoal. Administer cathartic

and conservative supportive therapy.

C. Guidelines for Nurses:


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1. When antidotes are ordered, it is

meant to be given immediately or at

least reasonably within the hour insome cases. They are not given

when it is the next convenient

dosing period for the nurses (i.e.TID, q 6 hours).


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2. Always check with the Pharmacy for the

available antidote or the Poison Center

before asking the patient to purchase these at

outside pharmacy outlets becausethese special drugs may not be commercially

available. Inform the doctor at

once when it is known that these drugs are not

available.

ACiD INGESTION

Admit to:Diet: NPO

Nursing: Monitor BP HR and abdomen for guarding & tenderness


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Nursing: Monitor BP, HR and abdomen for guarding & tenderness

Diagnostics: Serial CBC, Cross-matching, Esophago-

gastroscopy, Upright CXR & Abdominal films (check for

pneumothorax &

pneumoperitoneum)

Therapeutics:I. Provide airway control, ventilation, circulatory

support, & fluid resuscitation.

Wash the oral cavity copiously with cold water

(controversial).

2. Induction of emesis, lavage, or charcoaladministration is contraindicated, and

passage of nasogastric tube should not be performed in

most patients. Steroids have no proven benefit.

ALKALI INGESTION


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ALKALI INGESTION

Diet: NPO Nursing: Monitor BP, HR;

abdomen for guarding & tenderness

Diagnostics: Serial CBC,

Crossmatching; Monitor electrolytes

Upright CXR & Abdominal films (check

for perforation, pneumoperitoneum)


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Therapeutics:

1. Immediately rinse the oral cavity

copiously with cold water. Protect

airway, and administer oxygen andfluids if appropriate; antibiotics if

evidence of esophageal injury is

present.


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2. Esophagoscopy and gastroscopy should be

performed immediately if there is drooling,

stridor or painful swallowing; otherwise it may

be deferred for 12-24 hours. Hydrocortisonedose 1V is recommended for deep or

circumferential burns with tapering of dose

over three weeks.


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3. Emesis, neutralizing agents, gastric

lavage, cathartics and charcoal are allcontraindicated.

HYDROCARBON/ KEROSENE INGESTION

Diagnostics: CBC, ABG, CXR PA-L


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Treatment Considerations:

1. Respiratory support: Provide supplemental oxygen; ensure

adequate airway protection.

2. Treatment is not required in the absence of symptoms.

3. Gastric emptying: Gastric lavage is indicated for ingestion ofa compound containing pesticides, organophosphates, heavy metals

(including lead in gasoline) or other toxics.

4. Skin decontamination: Remove contaminated clothing and

wash affected skin with soap and water. Once patient has

defecated, wash the perianal area to prevent chemical burns.

5. For Seizures: Diazepam or Phenytoin6. Watch out for cardiac arrhythmias, since hydrocarbon is also

a stimulant.

ISONIAZID OVERDOSE


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Nursing: I & 0; Insert foley catheter

IVF: D5NM 1 liter x 8 hours

Diagnostics: CBC, WBC (Leukocytosis)ABG (Metabolic acidosis)

K (Hypokalemia)

RBS (Hypoglycemia); Toxicology Screen

CPK-Total (Rhabdomyolysis)


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Therapeutics:

1. Place NGT and do gastric lavage till clean. Administer

Activated charcoal.

2. Antidote: Pyridoxine HCI (Vit B6) I gm/10 ml given gram per

gram basis

Example: Ingestion of 10 tabs INH 400mg requires 4graIns of Pyridoxine HCl IV

3. Seizures: Diazepam 5 mg N for active seizure

4. Metabolic acidosis: If pH < 7.15-7.20, administer sodium

bicarbonate IV infusion to correct acidosis early.

5. Consider Mannitol 20% 100 ml now then 75 ml q 6 hours


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ORGANOPHOSPHATE POISONiNG(Insecticides / Pesticides)

Nursing: NPO; I & 0; Insert foley catheter

Diagnostics: CBC, Na, K, RBS, BUN, Creatinine, CBG q 12

hours SGOT, SGPT, Amylase, PT, AEG

RBC Cholinesterase

Urinalysis (if urine output is reddish check for

Myoglobin)CXR, ECG

Therapeutics:


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1. Decontaminationa. External decontamination:

Have the patient rinse gently with

alkaline soap or baking soda (10 gm

in100 ml water). Change clothes and wash

patient with soap using gloves.

b. Internal decontamination:

Insert NGT and do gastric lavage with

activated charcoal 100gm in 200-500 ml water

2. Activated charcoal 1 gm/kg P0 then sodium

sulfate 15-30 grams in water after 30 minutes.


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g

Repeat sodium sulfate after one hour if still nobowel movement.

3. Antidote: Atropine Sulfate 0.01-0.05 mg/kg IV q 5

minutes or 1mg IV usually Maintain the following

parameters: Dry mucosa, HR> 60 bpm (target

HR of around 100 bpm), hypoactive bowel

sounds, pupils >4 mm; watch Out for Atropine

toxicity such as temperature> 39 C, absence of

sweating, psychosis and restlessness.

4. Seizures: Diazepam 5 mg IV q 8 hours


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Consider Phenytoin IV5. D50-50 glucose 1 ampule q 6 hours

6. Mannitol at I ml/kg IV in 10 minutes as test dose

If with good urine output, give 2.5-5 mI/kg q 6 hours x

8 doses

7. If with arrhythmia, do not give beta-blockers or Lidocine;may give calcium-channel antagonists or Phenytoin

instead.

8. Avoid the following drugs: Furosemide, beta-blockers,

sulfa-containing drugs and aminoglycosides.9. Correct acidosis with sodium bicarbonate

PARACETAMOL OVERDOSAGE

Diet: NPO during initial treatment of gastric lavage, then may


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resume diet if patient is conscious and coherent.VS: Neuro vital signs q 1 hour

Nursing: I & 0; Aspiration and seizure precautions; Place

NGT then lavage with wate

Diagnostics: CBC with plateletRBS, BUN, Creatinine, SGPT, SGOT, PT, PiT,

Amylase

Alkaline Phosphatase (daily for at least 3 days),

UrinalysisSerum Paracetamol Concentration (Note time of

blood extraction and time

of Paracetamol ingestion)


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Therapeutics:

1. Nasogastric tube

2. Activated Charcoal 30-100 gram doses,

remove via NGT suction prior tooral acetylcysteine antidote.

3. Sodium sulfate

4. IV Antidote: N-acetylcysteine (Hidonac)200 mg/mI injection


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SALICYLATE OVERDOSE(ASPIRIN)

Diagnostics: CBC, Blood culture and sensitivity, PT, PTT

(48 hours post-ingestion) SGPT, SGOT, Alkaline

Phosphatase (48 hours post-ingestion)

RBS, Na, K, Cl, BUN, Creatinine, ABG

Urinalysis, Stool exam with occult blood

ECG, CXR

Therapeutics:

1. Stabilize respiratory and cardiac functions. Avoid


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diluting gastric contents since this mayincrease gastric absorption.

2. Nasogastric tube

3. Activated Charcoal: 1 gm/kg body weight q 6

hours for 2 days

4. Sodium sulfate 15-30 grams in 100 ml H2O orally

or per NGT with every other doses of

activated charcoal to prevent charcoal

Edited Emergency Nursing

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